Faculty Bibliography

Background: Following a period of stability, the coronavirus disease 2019 (COVID-19) pandemic appears to be re-intensifying globally. As the pandemic continues to evolve, so does our understanding of its implications on ST-segment elevation myocardial infarction (STEMI). We sought to describe a single center STEMI experience at one of the epicenters of the COVID-19 pandemic.
Method(s): This was a retrospective observational study which included consecutive suspected STEMI patients from March 1 through August 31, 2019, (Cohort 1) compared to the same time period in 2020 (Cohort 2), at a tertiary referral center in Nassau County, New York.
Result(s): Cohort 2 (n=93) saw a similar number of acute myocardial infarction (AMI) team activations compared to cohort 1 (n=90) (Figure 1). Infection control measures and additional investigation were required to clarify the diagnosis in cohort 2, resulting in longer door-to-balloon times (95.9 minutes vs. 74.4 minutes, p=0.0587). We observed similar inpatient length of stay (LOS) (3.6 days vs. 5.0 days, p=0.0901) and mortality (13.2% vs. 9.2%, p=0.5876).
Conclusion(s): Our single-center study, located at one of the epicenters of the pandemic, demonstrated a similar number of AMI team activations, mimicking the seasonal variability seen in 2019, but with longer door-to-balloon times. Despite this, inpatient LOS and mortality remained unchanged. [Formula presented]
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Background: The advent of transcatheter aortic valve replacement (TAVR) has ignited the search for a mitral equivalent. Ongoing trials will attempt to design a safe and effective transcatheter mitral valve replacement (TMVR) device. In the interim, the US Food and Drug Administration has approved the balloon-expandable transcatheter heart valve system for the treatment of degenerated mitral bioprostheses. The purpose of this study was to detail the short- and long-term outcomes of high-risk patients undergoing TMVR at our institution.
Method(s): In this retrospective observational study, we reviewed data on the first 26 patients with previous surgical mitral valve replacement (MVR, 76.9%) or repair with ring (23.1%) who underwent TMVR using the third-generation transcatheter balloon-expandable valve at NYU Langone Hospital - Long Island from 2015 through 2019. We reviewed pre-/post-TMVR echocardiographic data, inpatient, 30-day, and 1-year data. Statistical analysis was performed using Student's t-test and Wilcoxon signed rank test.
Result(s): Of the 26 patients, the primary indication for TMVR was bioprosthetic valve regurgitation in 9 patients, bioprosthetic transvalvular stenosis in 9 patients, and mixed mitral disease in 8 patients. The average Society of Thoracic Surgeons score for MVR was 13.0%. Of the 26 TMVRs, 19 were transseptal and 7 were transapical. There was a 100% device implantation success rate and a 96.2% inpatient survival rate. At 30 days, there was a 96% survival rate. Mitral valve mean gradient (13.3 mmHg to 6.8 mmHg, p < 0.0001) and mitral regurgitation (3+ to 1+, p < 0.0001) showed significant improvement after TMVR. There were significant 30-day and 1-year improvements in patients' Kansas City Cardiomyopathy Questionnaire score following TMVR (47.8 to 75.7 to 84.0, p <0.0001).
Conclusion(s): We found that treatment of degenerated mitral bioprostheses using TMVR with the third-generation balloon-expandable transcatheter heart valve in high-risk patients resulted in significant improvements in short-term and long-term heart failure symptoms, which translated to robust short- and long-term survival.
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BACKGROUND:Previous studies from the Low Risk TAVR (LRT) trial demonstrated that transcatheter aortic valve replacement (TAVR) is safe and feasible in low-risk patients, with excellent 30-day and 1-year outcomes. The objective of this study was to report clinical outcomes and the impact of 30-day hypoattenuated leaflet thickening (HALT) on structural valve deterioration (SVD) 2 years after TAVR. METHODS:The LRT trial was the first Food and Drug Administration-approved Investigational Device Exemption trial in the United States to evaluate the safety and feasibility of TAVR in low-risk patients with symptomatic severe tricuspid aortic stenosis (AS). Valve hemodynamics and SVD by echo were recorded 30 days, 1 year, and 2 years post-TAVR. RESULTS:The LRT trial enrolled 200 low-risk patients to receive TAVR. Their mean age was 73.6 years and 61.5% were men. At 2-year follow-up, the mortality rate was 4.2%; the cardiovascular death rate was 1.6%. The disabling stroke rate was 1.1%, permanent pacemaker implantation rate was 8.6%, and 4 patients (2.2%) presented with endocarditis (2 between years 1 and 2). Of the 14% of TAVR subjects who had evidence of HALT at 30 days, there was no impact on valve hemodynamics, endocarditis or stroke at 2 years. CONCLUSIONS:TAVR for low-risk patients with symptomatic severe tricuspid AS is safe at 2 years. The presence of HALT at 30 days did not impact the early hemodynamic improvements nor the durability of the valve structure.

OBJECTIVES:The aim of this study was to investigate whether the degree of aortic angulation (AA) affects outcomes after transcatheter aortic valve replacement (TAVR) using newer-generation transcatheter heart valves (THVs). BACKGROUND:AA ≥48° has been reported to adversely influence accurate THV deployment, procedural success, fluoroscopy time, and paravalvular leak (PVL) in patients undergoing TAVR with early generation self-expanding (SE) THVs. METHODS:A retrospective observational study was conducted among 841 patients across all risk strata who underwent transfemoral TAVR using the balloon-expandable (BE) SAPIEN 3 or the SE CoreValve Evolut PRO from 2015 to 2020. The previously published cutoff of 48° was used to analyze procedural success and in-hospital outcomes according to THV type. Receiver-operating characteristic analysis was performed to investigate the impact of AA on an in-hospital composite outcome (need for >1 THV, more than mild PVL, new permanent pacemaker implantation, stroke, and death). RESULTS:AA ≥48° did not influence outcomes in patients with BE THVs. Additionally, AA ≥48° did not influence procedural success (99.1% vs. 99.1%; p = 0.980), number of THVs used (1.02 vs. 1.04; p = 0.484), rates of more than mild PVL (0.4% vs. 0%; p = 0.486), new permanent pacemaker implantation (11.8% vs. 17.1%; p = 0.178), in-hospital stroke (3.9% vs. 1.8%; p = 0.298), or in-hospital death (0.4% vs. 0.9%; p = 0.980) in patients with SE THVs. Receiver-operating characteristic analysis demonstrated similar outcomes irrespective of AA, with areas under the curve of 0.5525 for SE THVs and 0.5115 for BE THVs. CONCLUSIONS:AA no longer plays a role with new-generation BE or SE THVs in contemporary TAVR practice. AA ≥48° did not affect procedural success or in-hospital outcomes and should no longer be a consideration when determining THV selection.

BACKGROUND/PURPOSE:We present three recent cases at our institution that demonstrate early, aggressive in-stent restenosis (ISR) of double-kissing (DK) crush technique despite careful adherence to the technique and compliance of the patient. There are multiple percutaneous coronary intervention strategies for left main (LM) coronary artery bifurcation disease. The DK crush technique has gained popularity for the treatment of complex bifurcation lesions, including distal LM bifurcations. METHODS/MATERIALS:We reviewed clinical and procedural characteristics of three recent patients who presented at our tertiary center with non-ST-elevation myocardial infarction (NSTEMI) in the setting of early, aggressive ISR of DK crush. All patients underwent imaging-guided DK crush stenting with full adherence to all steps of the technique. RESULTS:The median age was 65 years, median follow-up was 8 months from initial DK crush, and all three patients presented with NSTEMI. Patients had significant ISR in both limbs of the bifurcation involving aggressive tissue proliferation. These patients were treated differently: intracoronary brachytherapy, direct stenting, and coronary artery bypass grafting. CONCLUSIONS:DK crush for unprotected LM distal bifurcation can result in aggressive ISR with tissue proliferation and target vessel failure despite adhering to all steps of the technique. More research is warranted before DK crush is adopted as the default technique for bifurcation lesions.