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Sharma RK, Laham RJ, Sorajja P, Shah B, Garcia S, Jain R, Fender EA, Philip F, Eisenberg R, Popma JJ, Chetcuti S. Echocardiographic and Clinical Outcomes in Symptomatic Patients With Less Than Severe Aortic Stenosis After Supra-Annular Self-Expanding Transcatheter Aortic Valve Replacement. Am J Cardiol 2023; 208:37-43. [PMID: 37812864 DOI: 10.1016/j.amjcard.2023.08.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023]
Abstract
Optimal timing for aortic valve replacement in symptomatic patients with less than severe aortic stenosis (AS) is not well defined. There is limited information on the benefit of valve replacement in these patients. Symptomatic patients with less than severe AS, defined as a mean aortic gradient ≥20 and <40 mm Hg, peak aortic velocity >3 and <4 m/s, and aortic valve area >1.0 and <1.5 cm2, enrolled in the Society for Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy Registry and who underwent attempted supra-annular, self-expanding transcatheter aortic valve replacement (TAVR) were reviewed. Site-reported valve hemodynamics, clinical events, and quality of life metrics were analyzed at 30 days and 1 year after the procedure. A total of 1,067 patients with attempted TAVR (mean age 78.4 ± 8.4 years; Society for Thoracic Surgery score 4.7 ± 3.4%) were found to have symptoms but less than severe AS. From baseline to postprocedure, mean gradient decreased (29.9 ± 4.9 vs 8.4 ± 4.8 mm Hg, p <0.001), and aortic valve area increased (1.2 ± 0.1 vs 2.2 ± 0.7 cm2, p <0.001). Clinical events included 30-day and 1-year all-cause mortality (1.5% and 9.6%), stroke (2.2% and 3.3%), and new pacemaker implantation (18.1% and 20.9%). There were statistically significant improvements in the New York Heart Association functional class and Kansas City Cardiomyopathy Questionnaire at 30 days and 1 year. In conclusion, patients with symptomatic but less than severe AS who underwent supra-annular, self-expanding TAVR experienced improved valve hemodynamics and quality of life measures 1 year after the procedure. Randomized studies of TAVR versus a control arm in symptomatic patients with less than severe AS are ongoing.
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Affiliation(s)
- Ravi K Sharma
- Division of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Roger J Laham
- Beth Israel Deaconess Medical Center and Harvard School of Medicine, Boston, Massachusetts
| | - Paul Sorajja
- Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Binita Shah
- VA NY Harbor Healthcare System and NYU School of Medicine, New York, New York
| | - Santiago Garcia
- The Christ Hospital Heart and Vascular Institute and the Lindner Research Center, Cincinnati, Ohio
| | - Renuka Jain
- Aurora St. Luke'S Medical Center, Milwaukee, Wisconsin
| | | | - Femi Philip
- Kaiser Permanente Medical Center, Sacramento, California
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2
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Shakir MA, Rambhujun VP, Fender EA, Siric F, Chandra A, Wimmer NJ. Ventricular septal rupture after delayed STEMI: A modern management approach. J Card Surg 2022; 37:5539-5544. [PMID: 36352812 DOI: 10.1111/jocs.17146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Myocardial infarction associated ventricular septal rupture (VSR) is a potentially catastrophic complication. Though surgical repair remains the definitive treatment, outcomes are poor with high mortality rates.Case and Management: We present the case of a 62-year-old male who presented with a delayed STEMI leading to a VSR and cardiogenic shock. His management strategy included early percutaneous VSR closure and use of an intra-aortic balloon pump and inotropes. This served as a bridge to definitive surgical VSR patch repair while allowing hemodynamic stabilization, end-organ recovery, and myocardial tissue stabilization. CONCLUSION Mechanical support devices such as intra-aortic balloon pump and Impella combined with percutaneous closure options can serve as a bridge to definitive surgery for VSR. This requires rapid mobilization of a multi-disciplinary structural heart team including advanced imagers, structural interventionalists, and surgeons.
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Affiliation(s)
| | | | - Erin A Fender
- Department of Cardiology, Christiana Care Health System, Newark, Delaware, USA
| | - Franjo Siric
- Department of Cardiac Surgery, Christiana Care Health System, Newark, Delaware, USA
| | - Avinash Chandra
- Department of Cardiology, Christiana Care Health System, Newark, Delaware, USA
| | - Neil J Wimmer
- Department of Cardiology, Christiana Care Health System, Newark, Delaware, USA
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Affiliation(s)
| | - Chad J Zack
- Cardiology, Penn State College of Medicine, Hershey, Pennsylvania, USA
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4
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Welby JP, Fender EA, Peikert T, Holmes DR, Bjarnason H, Knavel-Koepsel EM. Evaluation of Outcomes Following Pulmonary Artery Stenting in Fibrosing Mediastinitis. Cardiovasc Intervent Radiol 2020; 44:384-391. [PMID: 33205295 DOI: 10.1007/s00270-020-02714-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Fibrosing mediastinitis is a rare disease characterized by fibrosis of mediastinal structures with subsequent constriction of the bronchi and pulmonary vessels leading to potential respiratory compromise and death. Presently, there is no effective curative treatment with available treatments focused on reducing symptomology, including placement of pulmonary artery stents. Limited studies examine the use of stents in fibrosing mediastinitis. Given this knowledge gap, we assessed stent patency, hemodynamics, complications, and secondary outcomes of clinical improvement of pulmonary artery stenting for fibrosing mediastinitis. MATERIALS AND METHODS Nine patients with fibrosing mediastinitis and pulmonary artery stents were retrospectively identified for inclusion (six females, three males; mean age 44.17 years, range 13-68; total 13 primary stents) from 2005 to 2018. Eight patients had history of PH. All patients had dyspnea on presentation. Seven patients had ventilation/perfusion studies demonstrating impairment. Results from computed tomography and echocardiography studies were collected to assess patency and physiologic response. RESULTS All patients received initial angioplasty and stenting of the right pulmonary artery (10 stents). Two patients underwent additional left-sided intervention (3 stents). Stenting significantly increased lesion luminal patency (54-79%; P < 0.005) and reduced systolic pressure gradients across stenoses (mean -9.38 mmHg; P < 0.005). Primary patency at one year was 90%. Two stents received reintervention at 276 and 497 days. 89% reported improvement in dyspnea in the initial post-stenting period. There were no mortalities or major complications. CONCLUSION Pulmonary artery stenting improves vascular patency and provides symptomatic relief in patients with fibrosing mediastinitis.
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Affiliation(s)
- John P Welby
- Mayo Clinic Alix School of Medicine, Mayo Clinic, 200 1st SW, Rochester, MN, 55905, USA.
| | - Erin A Fender
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Tobias Peikert
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - David R Holmes
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Fender EA, Widmer RJ, Mahowald MK, Hodge DO, Packer DL, Holmes DR. Recurrent pulmonary vein stenosis after successful intervention: Prognosis and management of restenosis. Catheter Cardiovasc Interv 2020; 95:954-958. [PMID: 31854110 DOI: 10.1002/ccd.28645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/15/2019] [Accepted: 12/07/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of this study was to describe management of recurrent pulmonary vein stenosis (PVS) and determine if stenting is superior to balloon angioplasty (BA) in preventing subsequent restenosis. BACKGROUND PVS is a serious complication of atrial fibrillation ablation. BA and stenting are effective therapies; however, restenosis frequently occurs. Here we report management of recurrent stenosis. METHODS This was a prospective observational study performed from 2000 to 2014. RESULTS One hundred and thirteen patients with severe PVS underwent intervention in 88 veins treated with BA and 81 treated with stenting. Forty-two patients experienced restenosis. Restenosis was more common in veins treated with BA (RRR 53% [95% CI 32-70%, p = .008]). A second intervention was performed in 41 patients. In the 34 vessels treated with initial BA, 24 were treated for restenosis with a stent and 10 were treated with a second BA. The recurrence rate was 46% in those treated with BA followed by stenting and 50% in those treated with two BA procedures. In the 22 veins treated with initial stenting, 9 were treated with another stent and 13 were treated with BA. The recurrence rate was 44% in those treated with a second stent and 46% for those treated with a stent followed by BA. The risk of a third stenosis was the same among all groups (Analysis of variance [ANOVA] p = .99). Limited sample size precluded analysis of outcome by stent size. CONCLUSIONS Restenosis occurred in 44% of patients overall. Management is challenging; stenting does not appear to be superior to BA.
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Affiliation(s)
- Erin A Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - R Jay Widmer
- Department of Internal Medicine, Division of Cardiovascular Diseases, Baylor Scott and White, Temple, Texas
| | | | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Douglas L Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Mahowald MK, Fender EA, Prasad A, Nishimura RA. Exertional Syncope in an Athlete: The Answer is in the History and Exam. Circ Cardiovasc Imaging 2020; 13:e009992. [PMID: 32208734 DOI: 10.1161/circimaging.119.009992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Madeline K Mahowald
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.K.M., A.P., R.A.N.)
| | - Erin A Fender
- Division of Cardiology, Department of Internal Medicine, Christiana Care Health System, Newark, DE (E.A.F.)
| | - Abhiram Prasad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.K.M., A.P., R.A.N.)
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.K.M., A.P., R.A.N.)
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Al-Hijji M, El Sabbagh A, Fender EA, Thaden J, Rihal CS, Eleid MF. Utility of MitraClip XTR System in Percutaneous Edge-To-Edge Mitral Valve Repair for Severe Flail Leaflet. Heart Views 2020; 21:45-48. [PMID: 32082501 PMCID: PMC7006328 DOI: 10.4103/heartviews.heartviews_106_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/22/2019] [Indexed: 11/04/2022] Open
Abstract
Transcatheter mitral valve (MV) edge-to-edge repair provided alternative solutions to high surgical risk patients with degenerative MV regurgitation (MR) and patients with functional MR leading to symptomatic heart failure. However, the procedure cannot be performed in certain MV anatomy such as excessive mitral annular or leaflet calcification with coexisting stenosis or excessive flail leaflet with wide gap and width. The introduction of MitraClip XTR system with its extended arms provided a wider range of MV anatomies that can be treated with MV edge-to-edge repair. In this report, we present the successful treatment of excessive flail posterior leaflet with MitraClip XTR device.
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Affiliation(s)
- Mohammed Al-Hijji
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Cardiovascular Medicine, The Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdallah El Sabbagh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Erin A Fender
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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8
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Fender EA, Petrescu I, Ionescu F, Zack CJ, Pislaru SV, Nkomo VT, Cochuyt JJ, Hodge DO, Nishimura RA. Prognostic Importance and Predictors of Survival in Isolated Tricuspid Regurgitation: A Growing Problem. Mayo Clin Proc 2019; 94:2032-2039. [PMID: 31279540 DOI: 10.1016/j.mayocp.2019.04.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/22/2019] [Accepted: 04/09/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To define mortality associated with isolated tricuspid regurgitation (TR) and identify risk factors associated with decreased survival. PATIENTS AND METHODS We conducted a retrospective cohort study of residents of southeastern Minnesota with moderate-severe or more severe isolated TR diagnosed between January 1, 2005, and April 15, 2015. Isolated TR was defined as TR in the absence of left-sided heart disease or pulmonary hypertension. Patients with an ejection fraction of less than 50%, right ventricular systolic pressure greater than 45 mm Hg, moderate or more severe left-sided valve disease, congenital cardiac anomalies, previous valve operation, tricuspid stenosis, flail leaflet, carcinoid, and rheumatic disease were excluded. Five-year survival was compared with age- and sex-matched Minnesota census bureau data. Multivariate regression was used to identify variables associated with mortality. RESULTS Over a 10-year period, 289 patients with isolated TR were identified. The mean ± SD age was 79.2±10.6 years, 70.6% (204) were women, atrial fibrillation was present in 74.0% (214), and 24.6% (71) had an intracardiac device. By 5 years after diagnosis, 51.5% had been hospitalized for heart failure. Observed 5-year mortality was 47.8% compared with 36.3% in the census data (P=.005). After adjusting for age and other comorbidities, multivariate regression identified a dilated inferior vena cava (≥2.1 cm) without respiratory variation on echocardiography (hazard ratio, 1.93; 95% CI, 1.13-3.31; P=.02) and creatinine level greater than 1.6 mg/dL (hazard ratio, 1.8; 95% CI, 1.16-2.8; P=.009) as associated with increased mortality. CONCLUSION Patients with isolated TR are frequently hospitalized for heart failure and experience excess mortality. Elevated right atrial pressure and renal dysfunction are associated with mortality. This poor outcome may have implications for timing of intervention.
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Affiliation(s)
- Erin A Fender
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ioana Petrescu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Filip Ionescu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Chad J Zack
- Division of Cardiology, Pennsylvania State University, Hershey
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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El Sabbagh A, Goel K, Reddy G, Al-Hijji M, Fender EA, Eleid MF, Rihal CS, Reeder GS. Novel Antegrade Approach to Transcatheter Aortic Valve Paravalvular Leak Closure. J Invasive Cardiol 2019; 31:E306-E307. [PMID: 31567123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Aortic paravalvular leak (PVL) is a known complication of TAVR. PVL closure using vascular occluder devices can be used, particularly in cases with annular calcification preventing adequate seal; however, delivery of equipment can be challenging in TAVR patients due to interaction with the valve stent. We describe a novel antegrade closure approach to treat transcatheter aortic PVL.
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Affiliation(s)
| | | | | | | | | | | | | | - Guy S Reeder
- Mayo Clinic, 200 First St. SW, Rochester, MN 55905 USA.
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10
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Fender EA, El Sabbagh A, Al-Hijji M, Holmes DR. Left Atrial Appendage Peridevice Leak Presenting With Stroke. JACC Cardiovasc Interv 2019; 12:e123-e125. [DOI: 10.1016/j.jcin.2019.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 11/16/2022]
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Lemond LM, Fender EA, Kalra A. Finding Your First Job After Fellowship. Eur Heart J 2019; 40:1581-1583. [DOI: 10.1093/eurheartj/ehz277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lisa M Lemond
- Advanced Heart Failure & Transplant Cardiology Mayo Clinic Phoenix, AZ. USA
| | - Erin A Fender
- Interventional Cardiology Section Division of Cardiovascular Disease Department of Medicine Mayo Clinic Rochester, MN. USA
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12
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Fender EA, Widmer RJ, Knavel Koepsel EM, Welby JP, Kern R, Peikert T, Bjarnason H, Holmes DR. Catheter based treatments for fibrosing mediastinitis. Catheter Cardiovasc Interv 2019; 94:878-885. [PMID: 30790443 DOI: 10.1002/ccd.28152] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/01/2019] [Accepted: 02/02/2019] [Indexed: 11/07/2022]
Abstract
Fibrosing mediastinitis is a rare, often debilitating and potentially lethal disease characterized by an exuberant fibroinflammatory response within the mediastinum. Patients typically present with insidious symptoms related to compression of adjacent structures including the esophagus, heart, airways, and cardiac vessels. Fibrosing mediastinitis is most often triggered by Histoplasmosis infection; however, antifungal and anti-inflammatory therapies are largely ineffective. While structural interventions aimed at alleviating obstruction can provide significant palliation, surgical interventions are challenging with high mortality and clinical experience with percutaneous interventions is limited. Here, we will review the presentation, natural history, and treatment of fibrosing mediastinitis, placing particular emphasis on catheter-based therapies.
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Affiliation(s)
- Erin A Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - R Jay Widmer
- Department of Cardiovascular Diseases, Baylor Scott and White, Temple, Texas
| | | | - John P Welby
- Mayo Clinic School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan Kern
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Tobias Peikert
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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13
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Joseph TA, Lane CE, Fender EA, Zack CJ, Rihal CS. Catheter-based closure of aortic and mitral paravalvular leaks: existing techniques and new frontiers. Expert Rev Med Devices 2018; 15:653-663. [DOI: 10.1080/17434440.2018.1514257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Timothy A. Joseph
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Colleen E. Lane
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Erin A. Fender
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Chad J. Zack
- Department of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Charanjit S. Rihal
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
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14
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Widmer RJ, Fender EA, Hodge DO, Monahan KH, Peterson LA, Holmes DR, Packer DL. Contributors Toward Pulmonary Vein Restenosis Following Successful Intervention. JACC Clin Electrophysiol 2018; 4:547-552. [PMID: 30067496 DOI: 10.1016/j.jacep.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/01/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study sought to identify clinical and procedural risk factors associated with pulmonary vein (PV) restenosis. BACKGROUND Pulmonary vein stenosis (PVS) is a rare but morbid complication of PV isolation for atrial fibrillation (AF) ablation. Interventions such as PV balloon angioplasty (BA) or stenting achieve excellent acute success; however, subsequent restenosis is common. METHODS A total of 113 patients underwent invasive treatment for severe PVS between 2000 and 2014 and were followed prospectively. Baseline patient and lesion characteristics were abstracted from chart review and analyzed. Univariate and multivariate analyses were performed using patient and procedural characteristics to determine which factors were associated with an increased risk for subsequent PV restenosis. RESULTS Over a median follow-up of 4.6 years there was PVS recurrence in 75 veins; 52 veins (57%) were treated with index BA and 23 veins were treated with stenting. After multivariate analysis, the only patient factor that was significantly associated with restenosis was a history of more than 1 AF ablation (hazard ratio [HR]: 1.91; 95% confidence interval [CI]: 1.07 to 3.41; p = 0.03). Multivariate analysis on a per-vein level demonstrated a significantly lower risk of restenosis in veins treated with a stent (HR: 2.84; 95% CI: 1.75 to 4.61; p < 0.0001). In veins treated with BA alone, inflation of the balloon to higher atmospheres significantly reduced the risk of recurrence (HR: 0.87; 95% CI: 0.78 to 0.98; p = 0.02). CONCLUSIONS Restenosis is common after a successful PV intervention and the risk of restenosis is highest in those with a history of multiple AF ablations and in those treated with BA. Proceduralists should take into account the number of AF ablations a patient has undergone and should strongly consider stent deployment when intervening on PVS to reduce risk of restenosis.
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Affiliation(s)
- R Jay Widmer
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and College of Medicine, Rochester, Minnesota
| | - Erin A Fender
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and College of Medicine, Rochester, Minnesota
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic and College of Medicine, Rochester, Minnesota
| | - Kristi H Monahan
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and College of Medicine, Rochester, Minnesota
| | - Lauri A Peterson
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and College of Medicine, Rochester, Minnesota
| | - David R Holmes
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and College of Medicine, Rochester, Minnesota
| | - Douglas L Packer
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and College of Medicine, Rochester, Minnesota.
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15
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Fu H, Ho G, Yang M, Huang X, Fender EA, Mulpuru S, Asirvatham R, Pretorius VG, Friedman PA, Birgersdotter-Green U, Cha YM. Outcomes of repeated transvenous lead extraction. Pacing Clin Electrophysiol 2018; 41:1321-1328. [PMID: 30058073 DOI: 10.1111/pace.13464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 05/29/2018] [Accepted: 06/24/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The outcomes of repeated cardiovascular implantable electronic device (CIED) lead extraction have not been well studied. We sought to determine the indications, outcomes, and safety of repeated lead extraction procedures. METHODS This retrospective study was conducted using data from two medical centers, including 38 patients who had undergone two or more lead extraction procedures compared to 439 patients who had a single procedure. The electronic medical records and procedural databases were reviewed to determine the indications, procedural characteristics, and outcomes. The outcomes of the first procedure were compared to the outcomes of subsequent procedures. RESULTS The 5-year cumulative probability of a repeated extraction procedure was 11% (95% confidence interval, 7%-15%). In 439 patients who underwent single lead extractions, 72% had device and lead related infections as the procedure indication compared to 39% for 38 patients who underwent repeated extraction (P < 0.001). The mean duration from device reimplant to repeated extraction procedures was 63 ± 48 months. Ninety-eight percent of the leads were removed completely in repeated procedures, similar to the 95% success rate of the first procedure (P = 0.51). There was no significant difference in major complication rate in the first or repeated extractions (2.6% vs 5.2%, P = 0.79). CONCLUSIONS Repeated transvenous lead extraction is not uncommon. It had a high success rate comparable to that of the initial procedure and was not associated with an increased incidence of adverse events.
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Affiliation(s)
- Haixia Fu
- Department of Cardiovascular Diseases, Henan Provincial People's Hospital, Zhengzhou University, Henan, China.,Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Gordon Ho
- Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Mei Yang
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinmiao Huang
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Diseases, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Erin A Fender
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Siva Mulpuru
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Victor G Pretorius
- Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Abstract
Isolated tricuspid regurgitation (TR) can be caused by primary valvular abnormalities such as flail leaflet or secondary annular dilation as is seen in atrial fibrillation, pulmonary hypertension and left heart disease. There is an increasing recognition of a subgroup of patients with isolated TR in the absence of other associated cardiac abnormalities. Left untreated isolated TR significantly worsens survival. Stand-alone surgery for isolated TR is rarely performed due to an average operative mortality of 8%–10% and a paucity of data demonstrating improved survival. When surgery is performed, valve repair may be preferred over replacement; however, there is a risk of significant recurrent regurgitation after repair. Existing society guidelines do not fully address the management of isolated TR. We propose that patients at low operative risk with symptomatic severe isolated TR and no reversible cause undergo surgery prior to the onset of right ventricular dysfunction and end-organ damage. For patients at increased surgical risk novel percutaneous interventions may offer an alternative treatment but further research is needed. Significant knowledge gaps remain and future research is needed to define operative outcomes and provide comparative data for medical and surgical therapy.
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Affiliation(s)
- Erin A Fender
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | - Chad J Zack
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA.,Division of Cardiology, Duke University, Durham, NC, USA
| | - Rick A Nishimura
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
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17
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Fender EA, Killu AM, Cannon BC, Friedman PA, Mcleod CJ, Hodge DO, Broberg CS, Henrikson CA, Cha YM. Lead extraction outcomes in patients with congenital heart disease. Europace 2017; 19:441-446. [PMID: 27738059 DOI: 10.1093/europace/euw049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/06/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Patients with congenital heart disease (CHD) are at increased risk for intracardiac device malfunction and infection that may necessitate extraction; however, the risk of extraction is poorly understood. This study addresses the safety of extraction in patients with structural heart disease and previous cardiac surgery. Methods and results This retrospective study included 40 CHD and 80 matched control patients, who underwent transvenous lead extractions between 2001 and 2014. Only leads >12 months were included. There were 77 leads in CHD patients and 146 in controls. The mean age was 38 ± 16 years in CHD patients. Ninety per cent of CHD patients had ≥1 cardiac surgeries when compared with 21% of controls (P < 0.001). The number of abandoned leads was significantly different (17 vs. 3, P < 0.001). Lead age was similar with an average duration of 83 ± 87 months in CHD patients and 62 ± 65 months in controls (P = 0.24). There was no significant difference in extraction techniques. Manual traction was successful in 40% of CHD patients and 47% of controls, and advanced techniques were used in 60 and 53% of CHD patients and controls, respectively. Complete extraction was achieved in 94% of the patients in both groups. There was no significant difference in complications. Conclusion Lead extraction can be safely performed in patients with CHD. Despite anatomic abnormalities and longer implantation times, the difficulty of lead extraction in patients with CHD is comparable with controls.
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Affiliation(s)
- Erin A Fender
- Mayo Clinic, St. Mary's Campus, Mail Code RO MB 04 506CAR, 1216 2nd St SW, Rochester, MN 55902, USA
| | - Ammar M Killu
- Mayo Clinic, St. Mary's Campus, Mail Code RO MB 04 506CAR, 1216 2nd St SW, Rochester, MN 55902, USA
| | - Bryan C Cannon
- Mayo Clinic, St. Mary's Campus, Mail Code RO MB 04 506CAR, 1216 2nd St SW, Rochester, MN 55902, USA
| | - Paul A Friedman
- Mayo Clinic, St. Mary's Campus, Mail Code RO MB 04 506CAR, 1216 2nd St SW, Rochester, MN 55902, USA
| | - Christopher J Mcleod
- Mayo Clinic, St. Mary's Campus, Mail Code RO MB 04 506CAR, 1216 2nd St SW, Rochester, MN 55902, USA
| | - David O Hodge
- Mayo Clinic, St. Mary's Campus, Mail Code RO MB 04 506CAR, 1216 2nd St SW, Rochester, MN 55902, USA
| | - Craig S Broberg
- Oregon Health and Science University, Knight Cardiovascular Institute, Mail Code UHN-62 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Charles A Henrikson
- Oregon Health and Science University, Knight Cardiovascular Institute, Mail Code UHN-62 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Yong-Mei Cha
- Mayo Clinic, St. Mary's Campus, Mail Code RO MB 04 506CAR, 1216 2nd St SW, Rochester, MN 55902, USA
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18
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Fender EA, Widmer RJ, Packer DL, Holmes DR. A History Lesson: Pulmonary Vein Stenosis. Am J Med 2017; 130:922-924. [PMID: 28522385 DOI: 10.1016/j.amjmed.2017.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/03/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Erin A Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - R Jay Widmer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Douglas L Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.
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19
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Fender EA, Widmer RJ, Holmes DR, Packer DL. Response by Fender et al to Letter Regarding Article, "Severe Pulmonary Vein Stenosis Resulting From Ablation for Atrial Fibrillation: Presentation, Management, and Clinical Outcomes". Circulation 2017; 135:e1014-e1015. [PMID: 28461424 DOI: 10.1161/circulationaha.117.027480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Erin A Fender
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - R Jay Widmer
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - David R Holmes
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Douglas L Packer
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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20
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Fender EA, Liang JJ, Sio TT, Stulak JM, Lennon RJ, Slusser JP, Ashman JB, Miller RC, Herrmann J, Prasad A, Sandhu GS. Percutaneous revascularization in patients treated with thoracic radiation for cancer. Am Heart J 2017; 187:98-103. [PMID: 28454813 DOI: 10.1016/j.ahj.2017.02.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 02/11/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess coronary revascularization outcomes in patients with previous thoracic radiation therapy (XRT). BACKGROUND Previous chest radiation has been reported to adversely affect long term survival in patients with coronary disease treated with percutaneous coronary interventions (PCI). METHODS Retrospective, single center cohort study of patients previously treated with thoracic radiation and PCI. Patients were propensity matched against control patients without radiation undergoing revascularization during the same time period. RESULTS We identified 116 patients with radiation followed by PCI (XRT-PCI group) and 408 controls. Acute procedural complications were similar between groups. There were no differences in all-cause and cardiac mortality between groups (all-cause mortality HR 1.31, P=.078; cardiac mortality 0.78, P=.49). CONCLUSION Patients with prior thoracic radiation and coronary disease treated with PCI have similar procedural complications and long term mortality when compared to control subjects.
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Affiliation(s)
- Erin A Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jackson J Liang
- Division of Cardiovascular Disease, University of Pennsylvania, Philadelphia, PA, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Joshua P Slusser
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Robert C Miller
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Abhiram Prasad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Gurpreet S Sandhu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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21
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Chandrashekar P, Fender EA, Al-Hijji MA, Chandrasekaran K, Rihal CS, Eleid MF, Anavekar NS. Novel Use of MitraClip for Severe Mitral Regurgitation Due to Infective Endocarditis. J Invasive Cardiol 2017; 29:E21-E22. [PMID: 28145876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A 75-year-old man presented with infective endocarditis. Transesophageal echocardiogram (TEE) revealed mild-moderate mitral regurgitation (MR). After 4 weeks of antibiotics, he presented with New York Heart Association class III dyspnea. Repeat TEE demonstrated severe MR. After consultation with Infectious Diseases, it was determined the infection risk was low and transcatheter mitral valve repair (TMVR) was offered. Deployment of two MitraClip devices (Abbott Vascular) resulted in symptom relief. This case demonstrates a potential role of TMVR in treating acute severe MR due to endocarditis.
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22
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Zack CJ, Fender EA, Holmes DR. Stroke prevention in atrial fibrillation with left atrial appendage closure. Minerva Med 2016; 108:199-211. [PMID: 28001014 DOI: 10.23736/s0026-4806.16.04981-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Patients with atrial fibrillation (AF) are at risk for stroke and thromboembolism. Oral anticoagulants (OAC) are effective therapies to reduce the risk of stroke; however, these agents also increase the risk of bleeding complications. Concerns over bleeding contribute to significant under treatment and leave a substantial proportion of patients at risk for a serious or life-threatening stroke. Identification of the left atrial appendage (LAA) as the major site of pathogenic thrombus formation in AF patients has led to the development of devices which exclude the appendage from the systemic circulation. These devices offer a potential alternative treatment for some AF patients who cannot tolerate long term OAC. This article will review the pathogenesis of LAA thrombus formation and identify the patient population most likely to benefit from LAA closure devices. Finally, we will review LAA closure techniques (both surgical and percutaneous), evaluate published outcomes data, and discuss the indications and risk/benefit considerations of each approach.
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Affiliation(s)
- Chad J Zack
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Erin A Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA -
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23
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Affiliation(s)
- Erin A. Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Rick A. Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - David R. Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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24
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Fender EA, Widmer RJ, Hodge DO, Cooper GM, Monahan KH, Peterson LA, Holmes DR, Packer DL. Severe Pulmonary Vein Stenosis Resulting From Ablation for Atrial Fibrillation. Circulation 2016; 134:1812-1821. [DOI: 10.1161/circulationaha.116.021949] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 10/05/2016] [Indexed: 02/02/2023]
Abstract
Background:
The frequency of pulmonary vein stenosis (PVS) after ablation for atrial fibrillation has decreased, but it remains a highly morbid condition. Although treatment strategies including pulmonary vein dilation and stenting have been described, the long-term impacts of these interventions are unknown. We evaluated the presentation of severe PVS, and examined the risk for restenosis after intervention using either balloon angioplasty (BA) alone or BA with stenting.
Methods:
This was a prospective, observational study of 124 patients with severe PVS evaluated between 2000 and 2014.
Results:
All 124 patients were identified as having severe PVS by computed tomography in 219 veins. One hundred two patients (82%) were symptomatic at diagnosis. The most common symptoms were dyspnea (67%), cough (45%), fatigue (45%), and decreased exercise tolerance (45%). Twenty-seven percent of patients experienced hemoptysis. Ninety-two veins were treated with BA, 86 were treated with stenting, and 41 veins were not treated. A 94% acute procedural success rate was observed and did not differ by initial management. Major procedural complications occurred in 4 of the 113 patients (3.5%) who underwent invasive assessment, and minor complications occurred in 15 patients (13.3%). Overall, 42% of veins developed restenosis including 27% of veins (n=23) treated with stenting and 57% of veins (n=52) treated with BA. The 3-year overall rate of restenosis was 37%, with 49% of BA-treated veins and 25% of stented veins developing restenosis (hazard ratio, 2.77; 95% confidence interval, 1.72–4.45;
P
<0.001). After adjustment for age, CHA2DS2-VASc score, hypertension, and the time period of the study, there was still a significant difference in the risk of restenosis for BA versus stenting (hazard ratio, 2.46; 95% confidence interval, 1.47–4.12;
P
<0.001).
Conclusions:
The diagnosis of PVS is challenging because of nonspecific symptoms and the need for dedicated pulmonary vein imaging. There is no difference in acute success by type of initial intervention; however, stenting significantly reduces the risk of subsequent pulmonary vein restenosis in comparison with BA.
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Affiliation(s)
- Erin A. Fender
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - R. Jay Widmer
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - David O. Hodge
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - George M. Cooper
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - Kristi H. Monahan
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - Laurie A. Peterson
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - David R. Holmes
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - Douglas L. Packer
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
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25
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Killu AM, Fender EA, Deshmukh AJ, Munger TM, Araoz P, Brady PA, Cha YM, Packer DL, Friedman PA, Asirvatham SJ, Noseworthy PA, Mulpuru SK. Acute Sinus Node Dysfunction after Atrial Ablation: Incidence, Risk Factors, and Management. Pacing Clin Electrophysiol 2016; 39:1116-1125. [PMID: 27530090 DOI: 10.1111/pace.12934] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 06/24/2016] [Accepted: 07/17/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many patients with atrial fibrillation (AF) or atrial flutter (Aflutter) have concomitant sinus node dysfunction (SND). Ablation may result in injury to the sinus node complex or its blood supply resulting in sinus arrest and need for temporary pacing. We sought to characterize patients who develop acute SND (ASND) during/immediately after AF/Aflutter ablation. METHODS We performed a retrospective analysis of AF/Aflutter ablation patients between January 1, 2010 and February 28, 2015 to characterize those who required temporary pacemaker (TPM) implantation due to ASND (sinus arrest, sinus bradycardia <40 beats/min, or junctional rhythm with hemodynamic compromise) following atrial ablation. RESULTS Of 2,151 patients, eight patients (<0.5%) with ASND manifesting as sinus arrest (n = 2), severe sinus bradycardia (n = 2), and junctional rhythm with hemodynamic compromise (n = 4) were identified (all male, age 66 ± 9.9 years, 4/8 [50%] persistent AF). AF ablation was performed in four, atypical Aflutter in one, and AF/Aflutter in three patients. The ablation set consisted of: pulmonary vein (PV) isolation (n = 6), roof line ablation (n = 6), mitral annulus-left inferior PV line ablation (n = 5), left atrial appendage-mitral annulus ablation (n = 1), cavotricuspid isthmus ablation (n = 5), and isolation or ablation near the superior vena cava (SVC, n = 4). Patients with peri-SVC ablation were more likely to develop ASND (P = 0.03). All patients received TPM; six received permanent pacemaker before discharge, performed 3.5 days postablation (range 2-6 days). At 3-month device interrogation, all patients were atrially paced >50%. CONCLUSION ASND is a rare complication of atrial ablation. It may be more common when peri-SVC ablation is performed and may necessitate permanent pacemaker implantation.
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Affiliation(s)
- Ammar M Killu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Erin A Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Thomas M Munger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Philip Araoz
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Peter A Brady
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Yong-Mei Cha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Douglas L Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.,Department of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Siva K Mulpuru
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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26
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27
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Liang JJ, Fender EA, Cha YM, Lennon RJ, Prasad A, Barsness GW. Long-Term Outcomes in Survivors of Early Ventricular Arrhythmias After Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction Treated With Percutaneous Coronary Intervention. Am J Cardiol 2016; 117:709-13. [PMID: 26796195 DOI: 10.1016/j.amjcard.2015.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 12/01/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
Abstract
Guidelines do not recommend an implantable cardioverter defibrillator (ICD) for prevention of sudden death in patients who develop ventricular arrhythmia (VA) within 48 hours of acute myocardial infarction (AMI) if they are successfully revascularized. We aimed to determine long-term survival in a cohort of early VA survivors treated with percutaneous coronary intervention (PCI) and to determine whether certain high-risk characteristics predicted worse outcomes. This retrospective study included all patients with early VA after AMI treated with PCI at our institution from 2002 to 2012 who survived to hospital discharge. Patients who had an ICD before their index AMI and those who received ICD before hospital discharge were excluded. Overall survival in the early VA survivors was analyzed based on post-MI left ventricular ejection fraction (LVEF) (≥50% vs <50%), MI type (ST-segment elevation myocardial infarction [STEMI] vs non-ST-segment elevation myocardial infarction [NSTEMI]), and single-vessel versus multivessel disease. Baseline presenting clinical and PCI characteristics plus outcomes were compared with matched controls with PCI-treated AMI but no early VA. Of the 79 early VA survivors treated with PCI, there were no significant differences in long-term overall survival between AMI type (STEMI vs NSTEMI), single-vessel versus multivessel disease, and LVEF at time of MI (>50% vs <50%). Despite having lower presenting LVEF (46% vs 55%, p <0.001) and higher rates of cardiogenic shock (28% vs 4%; p <0.001), survivors of early VA had similar overall survival compared with PCI-treated controls whose post-AMI hospital course was not complicated by early VA (p = 0.61). In conclusion, patients with early VA treated with PCI who survive to discharge were more likely to have STEMI, lower LVEF, and cardiogenic shock. Type of AMI or the presence of systolic dysfunction or multivessel disease did not predict long-term mortality. With early PCI, early VA survivors have similar long-term prognosis compared with those without early VA.
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28
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Widmer RJ, Fender EA, Monahan KH, Peterson L, Holmes DR, Packer DL. TCT-27 Impact of Primary Stenting Compared to Balloon Dilatation Alone on Pulmonary Vein Restenosis. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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29
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Fender EA, Sibley CT, Nazarian S, Cheng A, Spragg DD, Marine JE, Berger RD, Calkins H, Lima JAC, Brinker JA, Henrikson CA. Atrial septal angulation varies widely in patients undergoing pulmonary vein isolation. J Invasive Cardiol 2014; 26:128-131. [PMID: 24610507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE Transseptal puncture (TSP) allows left atrial access for curative procedures. Intracardiac echocardiography (ICE) provides direct visualization of the interatrial septum (IAS), but adds time and expense. We reviewed 100 cardiac multidetector computed tomography (MDCT) scans of patients undergoing AF ablation to determine if the angulation and orientation of the IAS are conserved or variable. Significant variability may suggest a potential role for direct visualization of the IAS during TSP. METHODS We reviewed 100 MDCT scans obtained prior to AF ablation. The IAS plane at the fossa ovalis was identified in axial and coronal images. We measured the angle of the septum relative to an orthogonal plane. Optimal needle orientation was defined as perpendicular to the fossa ovalis. RESULTS The mean axial plane angle was -60.6 ± 10.6°; range, -29.5° to -88.7°). The mean coronal plane angle was 142.6 ± 9.1°; range, 115° to 162°). The axial angle corresponded to variation in the "clock-face" orientation of the needle during puncture, and was calculated between 4 and 6 o'clock. Coronal plane angulation corresponds to the curvature of the needle tip, which varied by 47°. We found no association between patient characteristics and IAS angle. CONCLUSION The septal orientation in the axial plane varied widely and was not predicted by clinical variables such as atrial size or prior valve surgery. The high degree of interpatient variability observed suggests that direct visualization of the septum may be helpful in the performance of TSP.
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Affiliation(s)
- Erin A Fender
- Knight Cardiovascular Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland OR 97239 USA.
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