Mohammad Q. Raza

Degenerative Mitral Stenosis: Unmet Need for Percutaneous Interventions

Degenerative mitral stenosis (DMS) is an important cause of mitral stenosis, developing secondary to severe mitral annular calcification. With the increase in life expectancy and improved access to health care, more patients with DMS are likely to be encountered in developed nations. These patients are generally elderly with multiple comorbidities and often are high-risk candidates for surgery. The mainstay of therapy in DMS patients is medical management with heart rate control and diuretic therapy. Surgical intervention might be delayed until symptoms are severely limiting and cannot be managed by medical therapy. Mitral valve surgery is also challenging in these patients because of the presence of extensive calcification. Hence, there is a need to develop an alternative percutaneous treatment approach for patients with DMS who are otherwise inoperable or at high risk for surgery. In this review, we summarize the available data on the epidemiology of DMS and diagnostic considerations and current treatment strategies for these patients.

Effect of Shorter Door-to-Balloon Times Over 20 Years on Outcomes of Patients With Anterior ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Cardiovascular disease remains the most common cause of mortality. We studied the change in outcomes for anterior ST-elevation myocardial infarction (STEMI) between 1995 and 2014. Over the past 20 years, 1,658 patients presenting to our center with anterior STEMI underwent primary percutaneous coronary intervention within 12 hours of presentation. We divided these into 4 quartiles, 1995 to 1999 (n = 312), 2000 to 2004 (n = 408), 2005 to 2009 (n = 428), and 2010 to 2014 (n = 510). Across the 4 quartiles, mean age decreased (64.4, 62, 60.3, and 60 years, p <0.01). In all groups, there was a significant rise in prevalence of smoking, hypertension, and obesity. The median length of hospital stay decreased (6, 4.4, 4.2, and 3.6 days, p <0.01), as did the median door-to-balloon time (DBT) (217, 194, 135, and 38 minutes, p <0.01). Thirty-day and 1-year mortality improved over time (14.4%, 11.8%, 8.4%, and 7.8%; and 20.5%, 16.4%, 15.9%, and 13.9%) (p = 0.01 both). Also, 3-year mortality improved (25.3%, 21.6%, 21.3%, and 16.5%, p = 0.02). After adjusting for age, gender, co-morbidities, ejection fraction, clinical shock, and mitral regurgitation, shorter DBT was associated with lower long-term mortality (compared with DBT <60 minutes; 60 to 90 minutes hazard ratio [HR] 1.67, 95% confidence interval [CI] 0.93 to 3.00, p = 0.084; 90 to 120 minutes, HR 1.74, 95% CI 1.02 to 2.95, p = 0.04; >120 minutes, HR 1.91, 95% CI 1.23 to 2.96, p = 0.004). In conclusion, over the past 2 decades, long-term outcomes improved in patients presenting with anterior STEMI associated with shortening of DBT.

An alarming trend: Change in the risk profile of patients with ST elevation myocardial infarction over the last two decades

BACKGROUND Coronary artery disease (CAD) is the leading cause of mortality around the world. We sought to study changes in the risk profile of patients presenting with ST elevation myocardial infarction (STEMI). METHODS We retrospectively studied all patients presenting with STEMI to our center between 1995 and 2014. Patients were divided into four quartiles, 5years each. Baseline risk factors and comorbidities were recorded. Sub-analysis was done for patients with established CAD and their household incomes. RESULTS A total of 3913 patients (67.9% males) were included; 42.5% presented with anterior STEMI and 57.5% inferior STEMI. Ages were 64±12, 62±13, 61±13 and 60±13 in the four quartiles respectively. Obesity prevalence was 31, 37, 38 and 40% and diabetes mellitus prevalence was 24, 25, 24 and 31%, while hypertension was 55, 67, 70 and 77%, respectively, p<0.01 for all. Smoking prevalence was 28, 32, 42 and 46, p<0.01. When subgroup analysis was done for patients with history of CAD, prevalence of smoking, obesity, diabetes and hypertension significantly increased across the four quartiles. When patients were divided to four groups based on household income (poor, low middle, middle and high income), prevalence of diabetes, hypertension, smoking and obesity were significantly higher in patients with low income. CONCLUSION Despite better understanding of cardiovascular risk factors and more focus on preventive cardiology, patients presenting with STEMI over the past 20years are getting younger and more obese, with more prevalence of smoking, hypertension, and diabetes mellitus. This trend is greater in the lower income population.

AN ALARMING TREND: CHANGE IN RISK PROFILE OF PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION OVER THE LAST TWO DECADES

Cardiovascular disease is the leading cause of mortality around the world. We sought to study changes in risk profile of patients presenting with ST elevation myocardial infarction (STEMI). We retrospectively studied all patients presenting with STEMI to our center between 1995 & 2014. Patients

MitraClip Therapy for Mitral Regurgitation: Primary Mitral Regurgitation

Primary mitral regurgitation (MR) owing to degenerative changes in the structural components of the mitral valve is a common acquired valvular pathology in the elderly. Surgical correction with mitral valve repair (MVRe) or replacement (MVR) is the mainstay of therapy. A significant proportion of patients are ineligible for MVRe/MVR owing to prohibitive surgical risk from advanced age, poor ventricular function, or associated comorbidities. Percutaneous mitral valve repair techniques have been developed to fill this void. The edge-to-edge MitraClip has accrued the largest human experience. This paper reviews the available literature on the MitraClip device for treatment of primary MR.

Relationship of Mitral Valve Annulus Plane and Circumflex-Right Coronary Artery Plane: Implications for Transcatheter Mitral Valve Implantation.

Transcatheter mitral valve implantation (TMVI) is a novel technology for patients with severe mitral valve disease but at high surgical risk. Imaging guidance during the procedure is critical for successful device deployment. Identification of the mitral annular plane (MAP) with fluoroscopy during the procedure is limited by lack of clearly defined landmarks. We hypothesized that a plane defined by left circumflex‐right coronary arteries (LCX‐RCA) would have a consistent relationship to MAP.

Management of Symptomatic Severe Aortic Stenosis in Patient With Very Severe Chronic Obstructive Pulmonary Disease

Transcatheter aortic valve replacement (TAVR) is a viable option for patients with severe chronic obstructive pulmonary disease (COPD) who are deemed inoperable or high risk for surgery. We sought to determine outcomes of patients with severe aortic stenosis (AS) and severe COPD referred for aortic valve replacement (AVR). One hundred thirty-one patients with severe AS and severe COPD (GOLD criteria) were evaluated at our center between 2008 and 2013 and were divided retrospectively into 4 groups: 1-medical management, 2-balloon aortic valvuloplasty, 3-surgical aortic valve replacement (SAVR), and 4-TAVR. Baseline, clinical, and echo data were recorded. Primary outcome was cardiovascular death. From the study cohort, 54 (41.2%), 29 (22.1%), 21 (16.0%), and 27 (20.6%) were included in groups 1-4, respectively; the age was 74.9 ± 8.8, 76.2 ± 8.8, 78.8 ± 7.4, and 82.8 ± 6.8 years, respectively (P < 0.01). There was no significant difference between the groups for hypertension, diabetes, aortic valve area or gradients, forced expiratory volume in first second, right ventricular systolic pressure, ejection fraction, and Society of Thoracic Surgeons predicted risk of mortality score. At 3 ± 1.5 years, death occurred in 87%, 97%, 47.7%, and 51.8% of patients in groups 1-4, respectively. Heart failure readmissions occurred in 43%, 42%, 9.6%, and 14.8% of patients in groups 1-4, respectively. When SAVR and TAVR groups were compared, there was no significant difference in survival (P = 0.719) or heart failure readmissions (P = 0.19). In patients with severe or very severe COPD and severe AS, replacing the severely stenotic aortic valve by either SAVR or TAVR improves survival and reduces rehospitalization compared with medical therapy or balloon aortic valvuloplasty.

Outcomes of ischaemic mitral regurgitation in anterior versus inferior ST elevation myocardial infarction

Background Ischaemic mitral regurgitation (IMR) is a detrimental complication of ST elevation myocardial infarction (STEMI). Objective We sought to determine patient characteristics and outcomes of patients with IMR with focus on anterior or inferior location of STEMI. Methods All patients presenting with STEMI complicated by IMR to our centre who underwent primary percutaneous coronary intervention within the first 12 hours of presentation from 1995 to 2014 were included. IMR was graded from 1+ to 4+ within 3 days of index myocardial infarction by echocardiography, divided into 2 groups based on infarct location and outcomes were compared. Results Overall, 805 patients were included. There were 302 (17.8%) patients with mitral regurgitation (MR) out of the 1700 patients with anterior STEMI while 503 (21.8%) had MR out of the 2305 patients with inferior STEMI. There was no significant difference between both groups in comorbidities, clinical presentation or door-to-balloon time (DBT; median 104 vs 106 min, p=0.5). 30-day and 1-year mortality were higher in anterior STEMI compared with inferior STEMI (14.9% vs 6.8% and 26.4% vs 14.3%, respectively, p<0.001 both), as well as 5-year mortality (39.7% vs 24.8%, p<0.01). When analysis was performed for each grade of IMR, anterior was associated with worse outcomes in every grade. On multivariate cox survival analysis, after adjustment for age, gender, comorbidities, grade of IMR, ejection fraction and DBT, anterior STEMI was still associated with worse outcomes (HR 1.62 (95% CI 1.23 to 2.12), p<0.001). Conclusions Although IMR occurs more frequently with inferior infarction, outcomes are worse following anterior infarction.

Percutaneous Tricuspid Repair Techniques

Percutaneous repair or replacement techniques for the aortic and mitral valves have widespread acceptance as effective alternatives for patients who are not surgical candidates. Similar techniques for the tricuspid valve are now on the rise. Tricuspid valve disease is prevalent in a diverse population of patients ranging from 8 to almost 80 years of age. Currently there is a substantial division between the treated and diseased population, with the latter increasing in number. Experience and studies have shown that surgery for moderate or severe tricuspid regurgitation (TR) has a significant negative impact on morbidity and mortality. Progressive TR in itself has been shown to be a risk factor for decreased survival. Percutaneous techniques for management of TR offer these patients an attractive and efficient option. Novel devices have been constructed with the intent to restore the anatomy and physiology of the tricuspid valve complex. TR is most commonly due to secondary causes like left heart failure. Results so far are promising for most devices, and some human trials are underway. In coming years, feasibility and safety data along with experience with these devices will grow. It is possible that percutaneous tricuspid repair may become an alternative for some patients with TR.

IMPACT OF MAJOR BLEEDING AS DEFINED BY NATIONAL CARDIOVASCULAR DATA REGISTRY ACROSS DIFFERENT BASELINE HEMOGLOBIN LEVELS IN PATIENTS UNDERGOING ELECTIVE PERCUTANEOUS CORONARY INTERVENTION

The National Cardiovascular Data Registry defines major bleeding after percutaneous coronary intervention (PCI) as an absolute drop of hemoglobin (Hb) ≥3 g/dL. We sought to study impact of this across different baseline Hb levels. 2238 patients who underwent elective PCI in our center from 2011-