Mohammed Al-Hijji

Trends and predictors of repeat catheter ablation for atrial fibrillation.

BACKGROUND Atrial fibrillation (AF) ablation is superior to pharmacologic therapy in achieving maintenance of normal sinus rhythm in selected patient populations. However, the procedure is resource intensive, and repeat ablations are sometimes required. We examined the predictors and trends of repeat ablation using a large national administrative claims database. METHODS Privately insured and Medicare Advantage patients who underwent catheter ablation for AF between January 1, 2004, and September 30, 2014, were included in the study. The primary outcome was repeat AF ablation during enrollment. We examined the associations between repeat ablation and patient demographics (age, gender, socioeconomic demographics), comorbid conditions (CHA2DS2-Vasc score and Charlson index), and year of the index ablation. Cox proportional hazard models were used to identify predictors of repeat ablation. RESULTS We included 8,648 adult patients in the analysis. Median age was 61.0 (interquartile range [IQR] 54-68) years, and 70.9% were men. Median follow-up was 1.1 (IQR 0.5-2.3) years. A total of 1,263 patients underwent repeat ablation (14.6%) over a total of 14,280 person-years (12.1% at 1 year). The hazard ratio (HR) for repeat ablation was higher in younger patients (HR 0.75 [0.61-0.91; P < .01] for age 65-75 and 0.55 [0.4-0.75; P < .001] for age ≥ 75 compared with age 18-54), those with higher household income (HR 1.24 [1-1.54; P < .05] for household income ≥

Three-dimensional prototyping for procedural simulation of transcatheter mitral valve replacement in patients with mitral annular calcification

100,000 compared with household income <

Characteristics and outcomes of re-do percutaneous paravalvular leak closure: Re-Do percutaneous paravalvular leak closure

40,000), patients treated in the south (HR 1.15 [1-1.31]; P < .05), and those on antiarrhythmic medications (HR 1.15 [1.01-1.31]; P < .05). In particular, younger patients (ages 18-54 years) continued to undergo repeat ablations over the entire follow-up period, and the cumulative rate was approximately 40% among those followed for 5 years. Clinical characteristics including those included in the CHA2DS2-Vasc score and Charlson index did not predict likelihood of repeat ablation. The rate of repeat ablation remained constant over the available follow-up. CONCLUSION Approximately 1 in 8 patients treated with catheter ablation for AF will undergo a second procedure within 1 year, although the rate is as high as 40% in young patients at 5 years. The rate of repeat ablation appears to be associated with demographic characteristics (younger age and higher household income) rather than medical comorbidities.

Direct transatrial implantation of balloon-expandable valve for mitral stenosis with severe annular calcifications: early experience and lessons learned

Three‐dimensional (3D) prototyping is a novel technology which can be used to plan and guide complex procedures such as transcatheter mitral valve replacement (TMVR).

Non–ST‐Segment–Elevation Myocardial Infarction Among Patients With Chronic Kidney Disease: A Propensity Score–Matched Comparison of Percutaneous Coronary Intervention Versus Conservative Management

Percutaneous paravalvular leak (PVL) closure is an alternative treatment option for severely symptomatic, high‐surgical risk patients with PVL. Some patients require multiple percutaneous PVL closure procedures. However, the procedural characteristics and success rate of re‐do PVL closure have not been well studied.

Recellularization of a novel off-the-shelf valve following xenogenic implantation into the right ventricular outflow tract

OBJECTIVES Patients with symptomatic severe mitral annular calcification present a therapeutic challenge. Direct transatrial implantation of SAPIEN valve has emerged as an alternative to surgical mitral valve (MV) replacement for high-risk surgical candidates. METHODS This series includes 6 consecutive patients with symptomatic severe mitral annular calcification deemed to be at high risk for standard surgery. All patients underwent direct transatrial implantation of balloon-expandable SAPIEN valve in the mitral position. RESULTS Mean age was 81 years [3 (50%) female], with an average Society of Thoracic Surgeons score of 10.3%. All patients had at least New York Heart Association Class III symptoms. Procedure was performed using normothermic cardiopulmonary bypass. The MV was approached through a standard left atriotomy in 4 patients and via a vertical trans-septal approach in the remaining 2 patients. Resection of the anterior leaflet of the MV was performed in 4 patients. The valve was successfully deployed in all patients. The diastolic mean gradient across the MV decreased from an average of 14 ± 3 to 5 ± 1 mmHg post deployment. There was no left ventricular outflow tract obstruction. MV periprosthetic regurgitation was severe in 3 patients and moderate to severe in 1 patient. In-hospital mortality occurred in 3 (50%) patients due to a non-cardiac cause in 1 patient and cardiogenic shock in the other 2 patients. CONCLUSIONS Early experience with direct transatrial balloon-expandable implantation for severe mitral annular calcification revealed feasibility of this approach but significant morbidity and mortality primarily related to periprosthetic regurgitation that requires further refinement of the technique.

Comparative outcomes of transcatheter aortic valve replacement in African American and Caucasian patients with severe aortic stenosis

Background Chronic kidney disease (CKD) remains an independent predictor of cardiovascular morbidity and mortality. CKD complicates referral for percutaneous coronary intervention (PCI) in non–ST‐segment–elevation myocardial infarction (NSTEMI) patients because of the risk for acute kidney injury and the need for dialysis, with American College of Cardiology/American Heart Association guidelines underscoring the limited data on these patients. Methods and Results Using the National Inpatient Sample to analyze hospitalizations in the United States from 2004 to 2014, we sought to assess PCI utilization and in‐hospital outcomes in NSTEMI admissions with CKD. NSTEMI admissions were identified by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‐9‐CM) code 410.7. CKD admissions were identified by ICD‐9‐CM code 585. Propensity score–matched cohorts of patients with NSTEMI were matched for age, sex, comorbidities, race, median household income, primary payer status, and hospital characteristics. Of 4 488 795 hospitalizations for NSTEMI, 31% underwent PCI. Overall, 89% of admissions had no CKD. In addition, 32% of NSTEMI admissions with no CKD and 23%, 14%, and 22% with CKD stages 3, 4, and 5 underwent PCI, respectively. Hospitalized NSTEMI patients with CKD stages 4 and 5 had 41% and 20% less likelihood, respectively, of undergoing PCI compared with those with no CKD. Among hospitalized NSTEMI patients with no CKD or CKD stage 3, 4, or 5, PCI‐treated groups had 63%, 57%, 39%, and 59% lower likelihood, respectively, of all‐cause, in‐hospital mortality compared with propensity score–matched medically managed groups. Conclusions PCI use decreased among hospitalized NSTEMI patients as CKD severity increased, and all‐cause, in‐hospital mortality was greater for NSTEMI patients admitted with more severe CKD regardless of treatment strategy.

Cardiac Myxoma: The Great Mimicker

Current research on valvular heart repair has focused on tissue-engineered heart valves (TEHV) because of its potential to grow similarly to native heart valves. Decellularized xenografts are a promising solution; however, host recellularization remains challenging. In this study, decellularized porcine aortic valves were implanted into the right ventricular outflow tract (RVOT) of sheep to investigate recellularization potential. Porcine aortic valves, decellularized with sodium dodecyl sulfate (SDS), were sterilized by supercritical carbon dioxide (scCO2) and implanted into the RVOT of five juvenile polypay sheep for 5 months (n = 5). During implantation, functionality of the valves was assessed by serial echocardiography, blood tests, and right heart pulmonary artery catheterization measurements. The explanted valves were characterized through gross examination, mechanical characterization, and immunohistochemical analysis including cell viability, phenotype, proliferation, and extracellular matrix generation. Gross examination of the valve cusps demonstrated the absence of thrombosis. Bacterial and fungal stains were negative for pathogenic microbes. Immunohistochemical analysis showed the presence of myofibroblast-like cell infiltration with formation of new collagen fibrils and the existence of an endothelial layer at the surface of the explant. Analysis of cell phenotype and morphology showed no lymphoplasmacytic infiltration. Tensile mechanical testing of valve cusps revealed an increase in stiffness while strength was maintained during implantation. The increased tensile stiffness confirms the recellularization of the cusps by collagen synthesizing cells. The current study demonstrated the feasibility of the trans-species implantation of a non-fixed decellularized porcine aortic valve into the RVOT of sheep. The implantation resulted in recellularization of the valve with sufficient hemodynamic function for the 5-month study. Thus, the study supports a potential role for use of a TEHV for the treatment of valve disease in humans.

Current Treatment Strategies for Tricuspid Regurgitation

Racial disparities in cardiovascular care have been extensively investigated. The introduction of transcatheter aortic valve replacement (TAVR) revolutionized the treatment of aortic stenosis (AS) in the last decade. Whether a racial disparity in the utilization and outcome of TAVR exists is unknown.

Percutaneous Stenting of a Left Ventricular Assist Device Outflow Kink

Cardiac myxoma is the most common primary cardiac neoplasm in adults. They most commonly arise within the left atrium, but may arise from other cardiac chambers, rarely from the valves. Histologically, cardiac myxomas consist of lepidic (“myxoma”) cells within a myxoid stroma. They can be of