Faculty Bibliography

Transcatheter mitral valve implantation (TMVI) is at various levels of preclinical investigation and has proven to be more challenging than transcatheter aortic valve implantation due to more complex anatomy. The purpose of this study is to evaluate the short-term and long-term outcomes of high-risk patients who underwent TMVI for degenerated mitral bioprostheses. In this retrospective, observational study, we reviewed data on the first 26 patients with previous surgical mitral valve replacement or repair with annular ring that underwent TMVI using the balloon-expandable heart-valve system at our institution from 2014 to 2019. We reviewed pre/postprocedure echocardiographic data, in-hospital, 30-day data and 1-year outcomes. The indication for TMVI was mitral regurgitation (MR) in 9 patients, mitral stenosis in 9 patients and mixed mitral disease in 8 patients. There was a 100% device implantation success rate and a 96% in-hospital survival rate. Survival was 96% at 30 days and 85% at 1 year. Mean mitral gradient (MMG) improved postprocedure (13.3 mm Hg to 6.8 mm Hg, p <0.0001) and was sustained at 1 year (13.3 mm Hg to 7.2 mm Hg, p <0.0001). MR grade improved postprocedure (3+ to 1+, p <0.0001) and was sustained at 1 year (3+ to 0, p <0.0001). Additionally there was significant 30-day and 1-year improvements in patients' Kansas City Cardiomyopathy Questionnaire score after TMVI (47.8 to 75.7 to 84.0, p = <0.0001). In conclusion, our early experience with treatment of degenerated mitral bioprostheses using TMVI in high-risk patients resulted in significant short-term and sustained long-term improvements in mean mitral gradient, MR and heart failure symptoms.

B-type natriuretic peptide (BNP) levels have been shown to predict outcomes in surgical aortic valve replacement patients. BNP levels have not been well studied in patients undergoing transcatheter aortic valve implantation (TAVI). The purpose of this study is to define the utility of baseline BNP levels in predicting short-term outcomes after TAVI. In this retrospective, observational, study from 2012 to 2019, we reviewed data on 1297 low-risk, intermediate-risk and high-risk patients who underwent TAVI. Patients were dichotomized into those with baseline BNP levels above or below 500 pg/ml. Our primary outcome was a composite of inpatient stroke and death. Our secondary outcome was a composite of 30-day stroke, death and readmission. There were 975 patients with a baseline BNP level of <500 pg/ml and of those, 2% had our primary composite outcome and 13% of patients had our secondary composite outcome. There were 322 patients with a baseline BNP level of ≥500 pg/ml and of those, 6% had our primary composite outcome and 19% of patients had our secondary composite outcome. Those with a baseline BNP level ≥500 pg/ml were 3.47 times more likely (confidence of interval [CI] 1.727, 6.993, p = 0.0005) to have our primary composite outcome and were 1.72 times more likely (CI 1.186, 2.506, p = 0.0043) to have our secondary composite outcome. In conclusion, after adjustments for discrepant baseline characteristics, baseline BNP levels were independently predictive of a composite of inpatient stroke or death and a composite of 30-day stroke, death or readmission after TAVI. Those low, intermediate and high-risk patients whose baseline BNP is ≥500 pg/ml may ultimately require closer post-TAVI monitoring.

Currently, there is no approved guideline regarding management of patients with polycythemia vera (PCV) undergoing percutaneous coronary intervention (PCI) given the low prevalence. Standard maintenance therapy may be inadequate in cases where patients' response to standard treatment show heterogeneity. Approximately 5-10% of patients undergoing PCI are reported to have an additional indication for triple antiplatelet therapy consisting of aspirin, an adenosine diphosphate (ADP)-receptor antagonist and oral anticoagulant. However, considering the higher bleeding risk that arises with triple antiplatelet therapy, physicians act reluctantly in prescribing the regimen. Here, we present a case of subacute stent thrombosis in a patient with PCV prompting the consideration of triple antiplatelet therapy given increased thrombotic risk.