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Baghi M, Kohansal E, Akbarian M, Adimi S, Bakhshandeh H, Firoozi A, Salehi P, Mehdizadeh K, Hesami H, Yousefi M, Erami S, Dehghani Y, Hosseini Z, Shojaeifard M. Percutaneous versus surgical closure of paravalvular leaks in prosthetic valves: A cross-sectional comparison of clinical outcomes. Health Sci Rep 2024; 7:e70001. [PMID: 39184853 PMCID: PMC11342078 DOI: 10.1002/hsr2.70001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 04/30/2024] [Accepted: 08/01/2024] [Indexed: 08/27/2024] Open
Abstract
Background and Aims Paravalvular leak (PVL) is a serious complication of prosthetic valve replacement. Both surgical and percutaneous closure techniques are used for PVL closure, but optimal strategies and comparative outcomes are uncertain. This study aimed to compare the efficacy and safety of percutaneous versus surgical PVL closure by analyzing changes in leak severity, functional status, echocardiographic parameters, and clinical outcomes. Methods A total of 72 patients were included in this retrospective cross-sectional single-center study comparing percutaneous (n = 25) and surgical (n = 47) PVL closure from 2015 to 2022. Demographics, medical history, echocardiograms, laboratory data, complications, and mortality data were extracted from the records. Changes in leak severity, NYHA class, echocardiographic parameters, and clinical outcomes were compared between the percutaneous and surgical groups. Results Both percutaneous and surgical PVL closure significantly reduced leak severity and improved NYHA class (both p < 0.01), with no difference between the quantity of changes in each group. The 30-day mortality was 4% after percutaneous and 6.4% after surgical closure (p = 0.65). At 90 days, mortality was 24% percutaneous versus 17% surgical (p = 0.48). The length of stay in the hospital and post-procedural decrease in hemoglobin were considerably lower in the percutaneous group. The rate of complication rates was similar between the groups. Echocardiographic changes were also comparable. Conclusion Percutaneous and surgical PVL closure had similar efficacy in reducing leaks and improving symptoms, with no significant difference in early outcomes. Both options should be considered viable for PVL repair after heart team evaluation.
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Affiliation(s)
- Mohammadsaleh Baghi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Erfan Kohansal
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Mahsa Akbarian
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Sara Adimi
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Hooman Bakhshandeh
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Ata Firoozi
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Pegah Salehi
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Kasra Mehdizadeh
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Hamed Hesami
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Mina Yousefi
- Student Research CommitteeShahid Sadoughi University of Medical SciencesYazdIran
| | - Sajjad Erami
- Student Research CommitteeShahid Sadoughi University of Medical SciencesYazdIran
| | - Yeganeh Dehghani
- Student Research CommitteeShahid Sadoughi University of Medical SciencesYazdIran
| | - Zahra Hosseini
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
| | - Maryam Shojaeifard
- Rajaie Cardiovascular Medical and Research InstituteIran University of Medical SciencesTehranIran
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2
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Ugwu JK, Ndulue JK, Sherif KA, Alliu S, Elbadawi A, Taskesen T, Hussein D, Ugwu Erugo JN, Chatila KF, Almustafa A, Khalife WI, Kumfa PN. Safety of Transcatheter Aortic Valve Replacement in Patients with Aortic Aneurysm: A Propensity-Matched Analysis. Cardiol Ther 2022; 11:143-154. [PMID: 35249199 PMCID: PMC8933596 DOI: 10.1007/s40119-022-00258-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/05/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) among patients with thoracic or abdominal aortic aneurysms (AA). Using the Nationwide Inpatient Sample (NIS) database, we explored the safety of TAVR among patients with a diagnosis of AA. Methods We queried the National Inpatient Sample database (2012–2017) for hospitalized patients undergoing TAVR, using ICD-9 and ICD-10 codes for endovascular TAVR. Reports show that > 95% of endovascular TAVR in the US is via transfemoral access, so our population are mostly patients undergoing transfemoral TAVR. Using propensity score matching, we compared the trends and outcomes of TAVR procedures among patients with versus without AA. Results From a total sample of 29,517 individuals who had TAVR procedures between January 2012 and December 2017, 910 had a diagnosis of AA. In 774 matched-pair analysis, all-cause in-hospital mortality was similar in patients with and without AA OR 0.63 [(95% CI 0.28–1.43), p = 0.20]. The median length of stay was higher in patients with AA: 4 days (IQR 2.0–7.0) versus 3 days (IQR 2.0–6.0) p = 0.01. Risk of AKI [OR 1.01 (0.73–1.39), p = 0.87], heart block requiring pacemaker placement [OR 1.17 (0.81–1.69), p = 0.40], aortic dissection [OR 2.38 (0.41–13.75), p = 0.25], acute limb ischemia [OR 0.46 (0.18–1.16), p = 0.09], vascular complications [OR 0.80 (0.34–1.89), p = 0.53], post-op bleeding [OR 1.12 (0.81–1.57), p = 0.42], blood transfusion [OR 1.20 (0.84–1.70), p = 0.26], and stroke [OR 0.58 (0.24–1.39), p = 0.25] were similar in those with and without AA. Conclusions Data from a large nationwide database demonstrated that patients with AA undergoing TAVR are associated with similar in-hospital outcomes compared with patients without AA. Supplementary Information The online version contains supplementary material available at 10.1007/s40119-022-00258-6.
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Affiliation(s)
- Justin K. Ugwu
- Cardiovascular Disease Fellowship, MercyOne Des Moines Medical Center/Iowa Heart Center, 1111 6th Ave, Des Moines, IA 50314 USA
| | - Jideofor K. Ndulue
- Providence Medical Group, Chehalis Family Medicine, 931 S Market Blvd, Chehalis, WA 98532 USA
| | - Khaled A. Sherif
- Cardiovascular Disease Fellowship Program, University of Texas Rio Grande Valley, 5423 S McColl Rd, Edinburg, TX 78539 USA
| | - Samson Alliu
- Heart and Vascular Institute, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219 USA
| | - Ayman Elbadawi
- Interventional Cardiology Fellowship, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030 USA
| | - Tuncay Taskesen
- Cardiovascular Disease Fellowship, MercyOne Des Moines Medical Center/Iowa Heart Center, 1111 6th Ave, Des Moines, IA 50314 USA
| | - Doha Hussein
- University of Texas Medical Branch Medical School, 301 University Blvd, Galveston, TX 77555 USA
| | - Judith N. Ugwu Erugo
- Ebonyi State University Teaching Hospital, PMB 077, Abakaliki, 480001 Ebonyi State Nigeria
| | - Khaled F. Chatila
- Division of Cardiovascular Medicine, University of Texas Medical Branch, 301 University Blvd, 5.106 John Sealy Annex, Galveston, TX 77555 USA
| | - Ahmed Almustafa
- Division of Cardiovascular Medicine, University of Texas Medical Branch, 301 University Blvd, 5.106 John Sealy Annex, Galveston, TX 77555 USA
| | - Wissam I. Khalife
- Division of Cardiovascular Medicine, University of Texas Medical Branch, 301 University Blvd, 5.106 John Sealy Annex, Galveston, TX 77555 USA
| | - Paul N. Kumfa
- Division of Cardiovascular Medicine, University of Texas Medical Branch, 301 University Blvd, 5.106 John Sealy Annex, Galveston, TX 77555 USA
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3
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Pandey AK, Xu K, Zhang L, Gupta S, Eikelboom J, Lopes RD, Crowther M, Belley-Côté EP, Whitlock RP. Efficacy and safety of low intensity vitamin K antagonists in Western and East-Asian patients with left-sided mechanical heart valves. J Thromb Thrombolysis 2021; 53:697-707. [PMID: 34622377 DOI: 10.1007/s11239-021-02568-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2021] [Indexed: 11/24/2022]
Abstract
The optimal INR target in patients with mechanical heart valves is unclear. Higher INR targets are often used in Western compared with East Asian countries. The objective of this systematic review and meta-analysis was to summarize the evidence for the efficacy and safety of lower versus higher INR targets in Western and East Asian left-sided mechanical heart valve patients. We searched Western databases including Cochrane CENTRAL, Medline, and Embase as well as Chinese databases including SinoMed, CNKI, and Wanfang Data in addition to grey literature for Randomized Controlled Trials (RCTs) and observational studies. We pooled risk ratios (RRs) using random-effects model. Low and high INR targets were defined by the individual studies. We identified nine RCTs, including six Western (n = 5496) and three East Asian (n = 209) trials, and 17 observational studies, including two Western (n = 3199) and 15 East Asian (n = 5485) studies. In the RCTs, lower compared with higher targets were associated with similar rates of thromboembolism (2.4 vs. 2.3%; RR: 1.14, 95% CI 0.82, 1.60, I2 = 0%) and lower rates of both total bleeding (21.9 vs. 40.9%, RR: 0.46, 95% CI 0.28, 0.78, I2 = 88%) and major bleeding. RCT data showed no statistical heterogeneity by region. These effects were consistent in the observational data. We downgraded the quality of evidence due to serious risk of bias and imprecision. In patients with left-sided contemporary mechanical heart valves, low quality evidence suggests lower INR targets are associated with similar rates of thromboembolism and moderate quality evidence suggests lower rates of bleeding.
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Affiliation(s)
- Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Ke Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Li Zhang
- Banner University Medical Center, Tucson, USA
| | - Saurabh Gupta
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada.,Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, USA.,Duke University School of Medicine, Durham, USA
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Canada.,Division of Hematology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Richard P Whitlock
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Canada. .,Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
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Nair VV, Das S, Nair RB, George TP, Kathayanat JT, Chooriyil N, Radhakrishnan R, Thanathu Krishnan Nair J. Mitral valve repair in chronic severe mitral regurgitation: short-term results and analysis of mortality predictors. Indian J Thorac Cardiovasc Surg 2021; 37:506-513. [PMID: 34511756 DOI: 10.1007/s12055-021-01160-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 01/24/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Mitral valve repair is the accepted treatment for mitral regurgitation (MR) but lack of resources and socioeconomic concerns delay surgical referral and intervention in developing countries. We evaluated immediate and short-term results of mitral valve repair for non-ischemic MR at our centre and aimed to identify the predictors of in-hospital and follow-up mortality. Materials and methods The study was conducted at a tertiary-level hospital in South India. All patients >18 years with severe non-ischemic MR who underwent mitral valve repair over a period of 6 years were included. Perioperative data was collected from hospital records and follow-up data was obtained by prospective methods. Results There were 244 patients (170 males). Most of the patients were in the age group 31-60 years (76.6%). Aetiology of MR was degenerative (n = 159; 65.2%), rheumatic (n = 34; 13.9%), structural (n = 42; 17.2%), or miscellaneous (n = 9; 3.7%). All patients underwent ring annuloplasty with various valve repair techniques. One hundred patients (44.7%) underwent additional cardiac procedures. At discharge, MR was moderate in 4 patients; the rest had no or mild MR. The mean hospital stay of survivors was 7.1 days (SD 2.52, range 5-25 days). There were 9 in-hospital deaths (3.68%) and 10 deaths during follow-up (4.2%). The mean follow-up period was 1.39 years, complete for 87.6%. Pre-operative left ventricle ejection fraction (LVEF) <60% (p = 0.04) was found to be significantly associated with immediate mortality. Logistic regression analysis detected age (p = 0.019), female sex (p = 0.015), and left ventricular (LV) dysfunction at discharge (p = 0.025) to be significantly associated with follow-up mortality. Conclusion Pre-operative LV dysfunction was identified as a significant risk factor for in-hospital mortality. Female sex, age greater than 45 years, and LV dysfunction at discharge were found to be significantly associated with follow-up mortality. Hence, it is important to perform mitral valve repair in severe regurgitation patients before significant LV dysfunction sets in for a better outcome.
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Affiliation(s)
| | - Syam Das
- Government Medical College, Kottayam, India
| | | | | | | | - Nidheesh Chooriyil
- Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, India
| | - Ratish Radhakrishnan
- Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, India
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Kim J, Jang I. Predictors of bleeding event among elderly patients with mechanical valve replacement using random forest model: A retrospective study. Medicine (Baltimore) 2021; 100:e25875. [PMID: 34106641 PMCID: PMC8133181 DOI: 10.1097/md.0000000000025875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 12/25/2020] [Indexed: 11/25/2022] Open
Abstract
Available classification tools and risk factors predicting bleeding events in elderly patients after mechanical valve replacement may not be suitable in Asian populations. Thus, we aimed to identify an accurate model for predicting bleeding in elderly patients receiving warfarin after mechanical valve replacement in a Korean population. In this retrospective cohort study, a random forest model was used to determine factors predicting bleeding events among 598 participants. Twenty-two descriptors were selected as predictors for bleeding. Steroid use was the most important predictor of bleeding events, followed by labile international normalized ratio, history of stroke, history of myocardial infarction, and cancer. The random forest model was sensitive (80.77%), specific (87.67%), and accurate (85.86%), with an area under the curve of 0.87, suggesting fair prediction. In the elderly, drug interactions with steroids and overall physical condition had a significant effect on bleeding. Elderly patients taking warfarin for life require lifelong management.
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Park S, Jang I. Factors Affecting Medication Adherence in Patients with Mechanical Heart Valves Taking Warfarin: The Role of Knowledge on Warfarin, Medication Belief, Depression, and Self-Efficacy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5214. [PMID: 34068932 PMCID: PMC8156383 DOI: 10.3390/ijerph18105214] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/06/2021] [Accepted: 05/09/2021] [Indexed: 01/04/2023]
Abstract
Non-adherence is highlighted as one of the main contributors to the occurrence of adverse events and negative clinical outcomes in patients treated with warfarin. The aim was to examine knowledge on warfarin, medication belief, depression, and self-efficacy as factors influencing medication adherence for anticoagulation control. This was a cross-sectional study. The participants in this study were patients who visited an outpatient clinic of cardiovascular surgery to administer anticoagulants after mechanical valve replacement surgery at a tertiary hospital in Seoul. Responses of 154 participants on questionnaires were analyzed from 10 September to 26 December 2020. Multiple regression analyses were performed to assess the factors influencing medication adherence among the patients with anticoagulation control. Factors influencing medication adherence were consuming warfarin for 3 to 5 years, awareness of target prothrombin time international normalized ratio, knowledge of warfarin, and depression. Medication beliefs and self-efficacy had no significant influence on medication adherence. The most important factors associated with medication adherence in patients with mechanical heart valves were knowledge about warfarin and depression. In the control of oral anticoagulants that require continuous management, education and providing accurate guidance is more important than personal preferences. Clinical nurses should facilitate educational programs tailored to the characteristics of the patient, including their purpose and method of taking warfarin, specific diets, their knowledge on warfarin's interaction with other drugs, symptoms of adverse events, and self-management. In addition, healthcare providers should check whether warfarin therapy is being controlled by evaluating medication adherence and depression levels among patients.
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Affiliation(s)
- Soohyun Park
- Department of Nursing, Asan Medical Center, Seoul 05505, Korea;
| | - Insil Jang
- Department of Nursing, Chung-Ang University, Seoul 06974, Korea
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7
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Rullo CA. Transcatheter aortic valve replacement: An alternative for severe aortic stenosis. JAAPA 2021; 34:39-44. [PMID: 33600109 DOI: 10.1097/01.jaa.0000733244.57997.fe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Transcatheter aortic valve replacement (TAVR) is considered a lower-risk procedure for patients with severe aortic valve stenosis. Several FDA-approved trials performed in the United States support TAVR to be beneficial over surgical aortic valve replacement in certain patient populations. An optimal TAVR program consists of a multidisciplinary team that selects candidates for the procedure based on shared decision-making and the patient's anatomy and risk factors, and follows the patients through the Transcatheter Valve Therapy National Registry.
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Affiliation(s)
- Christine A Rullo
- Christine A. Rullo practices in cardiothoracic surgery at Beacon Medical Group in South Bend, Ind. The author has disclosed no potential conflicts of interest, financial or otherwise
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Chandra S, Gupta A, Chaudhary G, Narain VS, Dwivedi SK, Sethi R, Pradhan A, Vishwakarma P, Sharma A, Bhandari M, Cassese S. Safety and feasibility of same-day discharge after elective percutaneous balloon mitral valvotomy: a prospective, single-center registry in India. Acta Cardiol 2021; 76:30-37. [PMID: 31703542 DOI: 10.1080/00015385.2019.1686558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Percutaneous mitral balloon valvotomy (PBMV) is an alternative to surgery for patients with severe mitral valve (MV) stenosis. However, the safety and feasibility of same-day discharge (SDD) in patients undergoing elective PBMV for severe MV stenosis is yet to be investigated. This study aimed to assess safety and feasibility of SDD in patients undergoing elective PBMV because of severe MV stenosis in a tertiary-care hospital in India. METHODS From January 2018 to November 2018, patients with a diagnosis of severe MV stenosis were treated with PBMV at our institution. Among these patients, those suitable for SDD were prospectively included in this registry. Vascular access was achieved in forearm arteries and femoral veins. Clinical, echocardiographic and hemodynamic features were collected before and after PBMV. The primary outcome was 30-day mortality. The secondary outcome was incidence of in-hospital complications. Other outcomes of interest were arterial spasm and forearm haematoma. RESULTS A total of 98 patients scheduled for SDD after elective PBMV were included in the registry. Mean MV area increased from 0.8 ± 0.1 to 1.6 ± 0.2 cm2 (p < .001). Severe MV regurgitation after PBMV occurred in 3 patients, and 1 patient developed pericardial tamponade. Severe arterial spasm occurred in 2 patients. None of the included patients developed a clinically relevant haematoma of forearm. A total of 94 (96%) were discharged on the same day. No patient died up to 30-day follow-up. CONCLUSION PBMV from the venous access site can reduce the hospital stay of patients to less than a day with less local site complications.
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Affiliation(s)
- Sharad Chandra
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | - Abhishek Gupta
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | - Gaurav Chaudhary
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | - VS Narain
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | - SK Dwivedi
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | - Rishi Sethi
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | | | - Akhil Sharma
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | - Monika Bhandari
- Department of Cardiology, King George’s Medical University, Lucknow, India
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munchen, Germany
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9
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Hancock HC, Maier RH, Kasim A, Mason J, Murphy G, Goodwin A, Owens WA, Akowuah E. Mini-sternotomy versus conventional sternotomy for aortic valve replacement: a randomised controlled trial. BMJ Open 2021; 11:e041398. [PMID: 33514577 PMCID: PMC7849899 DOI: 10.1136/bmjopen-2020-041398] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To compare clinical and health economic outcomes after manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care). DESIGN A single-blind, randomised controlled trial. SETTING Single centre UK National Health Service tertiary hospital. PARTICIPANTS Adult patients undergoing aortic valve replacement (AVR) surgery. INTERVENTIONS Intervention was manubrium-limited mini-sternotomy performed using a 5-7 cm midline incision. Usual care was median sternotomy performed using a midline incision from the sternal notch to the xiphisternum. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the proportion of patients who received a red cell transfusion postoperatively and within 7 days of index surgery. Secondary outcomes included proportion of patients receiving a non-red cell blood component transfusion and number of units transfused within 7 days and during index hospital stay, quality of life and cost-effectiveness analyses. RESULTS 270 patients were randomised, received surgery and contributed to the intention to treat analysis. No difference between mini and conventional sternotomy in red-cell transfusion within 7 days was found; 23/135 patients in each arm received a transfusion, OR 1.0 (95% CI 0.5 to 2.0) and risk difference 0.0 (95% CI -0.1 to 0.1). Mini-sternotomy reduced chest drain losses (mean 181.6 mL (SD 138.7) vs conventional, mean 306·9 mL (SD 348.6)); this did not reduce red-cell transfusions. Mean valve size and postoperative valve function were comparable between mini-sternotomy and conventional groups; 23 mm vs 24 mm and 6/134 moderate or severe aortic regurgitation vs 3/130, respectively. Mini-sternotomy resulted in longer bypass (82.7 min (SD 23.5) vs 59.6 min (SD 15.1)) and cross-clamp times (64.1 min (SD 17.1) vs 46·3 min (SD 10.7)). Conventional sternotomy was more cost-effective with only a 5.8% probability of mini-sternotomy being cost-effective at a willingness to pay of £20 000/QALY (Quality Adjusted Life Years). CONCLUSIONS AVR via mini-sternotomy did not reduce red blood cell transfusion within 7 days following surgery when compared with conventional sternotomy. TRIAL REGISTRATION NUMBER ISRCTN29567910; Results.
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Affiliation(s)
- Helen C Hancock
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Rebecca H Maier
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Adetayo Kasim
- Wolfson Research Institute for Health and Wellbeing, Durham University, Stockton-on-Tees, Durham, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gavin Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew Goodwin
- Department of Cardiothoracic Surgery, James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - W Andrew Owens
- Department of Cardiothoracic Surgery, James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Enoch Akowuah
- Department of Cardiothoracic Surgery, James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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10
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Fanous EJ, Mukku RB, Dave P, Aksoy O, Yang EH, Benharash P, Press MC, Rabbani AB, Aboulhosn JA, Rafique AM. Paravalvular Leak Assessment: Challenges in Assessing Severity and Interventional Approaches. Curr Cardiol Rep 2020; 22:166. [PMID: 33037927 DOI: 10.1007/s11886-020-01418-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW With increasing use of prosthetic valves to treat degenerative valvular heart disease (VHD) in an aging population, the incidence and adverse consequences of paravalvular leaks (PVL) are better recognized. The present work aims to provide a cohesive review of the available literature in order to better guide the evaluation and management of PVL. RECENT FINDINGS Despite gains in operator experience and design innovation, significant PVL remains a significant complication that may present with congestive heart failure and/or hemolytic anemia. To date, clear consensus or guidelines on the evaluation and management of PVL remain lacking. Although the evolution of transcatheter valve therapies has had a tremendous impact on the management of patients with VHD, the limitations and complications of such techniques, including PVL, present further challenges. Incidence of PVL, graded as moderate or greater, ranges from 4 to 7.4% in surgical and transcatheter valve replacements, respectively. Improved imaging modalities and the advent of novel surgical and percutaneous therapies have undoubtedly yielded a better understanding of PVL including its anatomical location, mechanism, severity, and treatment options. Echocardiography, used in conjunction with cardiac computed tomography and cardiac magnetic resonance, provides essential details for diagnosis and management of PVL. Transcatheter intervention has become a favored approach in lieu of surgical intervention in select patients after previous surgical or percutaneous valve replacement. PVL treatment with vascular plugs, balloon post-dilation, and the valve-in-valve methods have shown technical success with promising clinical outcomes in appropriately selected patients.
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Affiliation(s)
- Elias J Fanous
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Roy B Mukku
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Olcay Aksoy
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Marcella Calfon Press
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Amir B Rabbani
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jamil A Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Center Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Asim M Rafique
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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Theriault-Lauzier P, Alsosaimi H, Mousavi N, Buithieu J, Spaziano M, Martucci G, Brophy J, Piazza N. Recursive multiresolution convolutional neural networks for 3D aortic valve annulus planimetry. Int J Comput Assist Radiol Surg 2020; 15:577-588. [DOI: 10.1007/s11548-020-02131-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 02/18/2020] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW As the number of surgical and transcatheter valve replacements continue to increase in the aging population, so does the incidence of paravalvular leak (PVL). Given its impact on morbidity and mortality, this article will focus on the epidemiology, clinical presentation, diagnostic assessment, and available treatments for PVL. RECENT FINDINGS Despite being performed on inoperable and typically higher risk patients, short-term complication rates of transcatheter PVL closure appear relatively low (< 10%). When indirectly compared with surgical PVL closure, long-term mortality, reoperation rates and degree of symptom improvement are similar. Nonetheless, current transcatheter closure devices are off-label and repurposed from other indications. Further development of percutaneous closure devices is an essential next step in order to improve and optimize outcomes. In patients with surgical and especially transcatheter-replaced heart valves, clinicians need to maintain vigilance for the presence of PVL, particularly in those with new-onset heart failure or hemolysis. Multimodality imaging is essential to detect and quantify PVL. Echocardiography (both transthoracic and transesophageal) is the backbone of diagnosis and quantification, and cardiac computed tomography and cardiac magnetic resonance imaging play an important role in defect characterization and in periprocedural planning. For those patients who are unable to undergo surgery, transcatheter PVL closure is an appropriate next step in management as it has similar outcomes to surgical intervention when performed in a center of expertise.
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Abstract
Functional mitral regurgitation (FMR) in the setting of left ventricular (LV) dysfunction and heart failure portends a poor prognosis. Guideline-directed medical therapy remains the cornerstone of initial treatment, with emphasis placed on treatment of the underlying LV dysfunction, as FMR is a secondary phenomenon and a disease due to LV remodeling. Surgical correction of FMR is controversial because it typically does not address the underlying mechanism and etiology of the condition. However, new, minimally invasive transcatheter therapies, in particular the MitraClip system, have shown promise in the treatment of FMR in selected patients. This review will summarize the pathophysiology underlying FMR, the prognosis of patients with heart failure and FMR, and the various medical and procedural treatment options currently available and under investigation.
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Elbatarny M, Bahji A, Bisleri G, Hamilton A. Management of endocarditis among persons who inject drugs: A narrative review of surgical and psychiatric approaches and controversies. Gen Hosp Psychiatry 2019; 57:44-49. [PMID: 30908961 DOI: 10.1016/j.genhosppsych.2019.01.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND People who inject drugs (PWID) represent a high-risk subgroup of endocarditis patients. This is highlighted by poorer post-operative outcomes in injection drug use-related infective endocarditis (IDU-IE), which is largely attributable to the increased vulnerability of prosthetic valves to re-infection. Consequently, many centres do not perform valve replacement on these patients. A parallel, but often underrecognized, component of care is the role of multidisciplinary management for individuals with IDU-IE, including perioperative addictions and psychiatric care. Consequently, surgical management options in IDU-IE remain a controversial topic. OBJECTIVES To determine the characteristics of optimal surgical and psychiatric care for individuals with IDU-IE. METHODS We conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, organizing the findings into several key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions. RESULTS/CONCLUSIONS Managing IDU-IE involves the treatment of two comorbidities: the intra-cardiac infection and the underlying substance use disorder. Cardiac surgery represents a high-intensity intervention with appreciable risk, and the benefit it is not always clear. As patients often present acutely, it is not feasible to use drug abstinence as a prerequisite to surgery. Involvement of inpatient psychiatry and addictions teams, however, appears to be an evidence-based approach that can bridge IDU-IE patients with opioid agonist therapy in hospital and adequate outpatient treatment options for their underlying addiction upon their discharge from hospital. It is likely that a majority of these patients are not receiving optimal psychiatric management despite increasing recognition of efficacy. Further interdisciplinary studies are needed to elucidate optimal surgical and multidisciplinary protocols. BACKGROUND Infective endocarditis (IE) is an infection of the innermost lining of the heart often affecting the heart valves. Over the last few decades, the epidemiology of IE has shifted in the developed world and while it continues to be a significant cause of morbidity and mortality, there has been a significant increased incidence among persons who inject drugs (PWID). To date, well-conducted epidemiologic studies of IE among PWID have been sparse, which has limited our ability to fully characterize this disease phenomenon. To address this knowledge deficit, we conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, and organized our findings into six key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions.
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Affiliation(s)
- Malak Elbatarny
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Anees Bahji
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Andrew Hamilton
- Division of Cardiac Surgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada
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Thakur K, Nazif TM, Khalique OK, Paradis JM, Harjai KJ. Transcatheter aortic valve replacement: The year in review 2017. J Interv Cardiol 2018; 31:543-552. [PMID: 30225907 DOI: 10.1111/joic.12562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 01/20/2023] Open
Abstract
This article is a continuation of our previously published annual reviews of transcatheter aortic valve replacement (TAVR). In 2017, TAVR further established a foothold in the management of intermediate risk patients with the publication of SURTAVI trial. Randomized trials also addressed the use of cerebral protection during TAVR and single versus dual antiplatelet therapy after TAVR. Newer generation valve systems continued to be studied for their efficacy and safety. This paper summarizes the major studies published in 2017.
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Affiliation(s)
- Kamia Thakur
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania
| | - Tamim M Nazif
- Department of Cardiology, Structural Heart and Valve Center, Columbia University Medical Center, New York, New York
| | - Omar K Khalique
- Department of Cardiology, Structural Heart and Valve Center, Columbia University Medical Center, New York, New York
| | - Jean-Michel Paradis
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Kishore J Harjai
- Department of Cardiology, Geisinger Northeast, Pearsall Heart Hospital, Wilkes Barre, Pennsylvania
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