TAVR Valves in the Mitral Position: Forever Between a Ring and a Hard Place [Editorial]
The PARTNER 3 Trial at Two Years: What We Have Learned and What Time Will Tell [Editorial]
Functional Tricuspid Regurgitation in Patients With Chronic Mitral Regurgitation: An Evidence-Based Narrative Review
Chronic mitral regurgitation leads to a series of downstream pathologic changes, including pulmonary hypertension, right ventricular dilation, tricuspid leaflet tethering, and tricuspid annular dilation, which can result in functional tricuspid regurgitation (FTR). The five-year survival rate for patients with severe FTR is reported to be as low as 34%. While FTR was often left uncorrected during left-heart valvular surgery, under the assumption that correction of the left-sided lesion would reverse the right-heart changes that cause FTR, recent data largely have supported concomitant tricuspid valve repair at the time of mitral surgery. In this review, the authors discuss the potentially irreversible nature of the changes leading to FTR, the likelihood of progression of FTR after mitral surgery, and the evidence for and against concomitant tricuspid valve repair at the time of mitral valve intervention. Lastly, this narrative review also examines advances in transcatheter therapies for the tricuspid valve and the evidence behind concomitant transcatheter tricuspid repair at the time of transcatheter mitral repair.
Vasoplegia in cardiac surgery: Know your enemy and attack early [Editorial]
Anesthetic Management of Conduction Disturbances Following Transcatheter Aortic Valve Replacement: A Review of the 2020 ACC Expert Consensus Decision Pathway [Editorial]
Impact of operator characteristics on outcomes in transcatheter aortic valve replacement
BACKGROUND:Operator characteristics and outcome relationships have not been evaluated at the individual operator level. METHODS:New York State Department of Health Statewide Planning and Research Cooperative System from 5,896 elective transfemoral TAVR procedures performed by 161 operators between 2012 and 2016 were analyzed. We examined the following characteristics of the primary operator: specialty (surgery vs. cardiology), gender, medical school location, experience of cardiology practice, interventional cardiology credentialing, past-year TAVR volume, and first year performing TAVR in New York State. The primary outcome was a composite of in-hospital mortality, stroke, and/or acute myocardial infarction. RESULTS:After adjusting for patient and other provider characteristics, there was no significant difference in the risk of major events between surgeons and cardiologists in performing TAVR (3.4% vs. 3.6%, p-value = 0.60), between male operators and female operators (p-value = 0.80), and between operators who graduated from a US medical school and operators educated outside the US (3.4% vs. 3.6% p-value = 0.73). In the subgroup analysis, interventional cardiology credentialing was not significantly associated with the in-hospital major events (OR=1.03, 95%CI (0.56-1.88), p-value = 0.80). CONCLUSIONS:Primary operator specialty and other characteristics for TAVR were not associated with a difference in risk-adjusted in-hospital outcomes. This may be due to the heart team model that allows proceduralists of different backgrounds to lend their expertise to the procedure.
Anesthesiology Research Using Surgical Registries: Consider the Source [Editorial]
The Economics of Transcatheter Aortic Valve Replacement and the Anesthesiologist [Editorial]
Long-term outcomes after transcatheter aortic valve replacement with minimal contrast in chronic kidney disease
BACKGROUND:Patients with renal insufficiency have poor short-term outcomes after transcatheter aortic valve replacement (TAVR). METHODS:Retrospective chart review identified 575 consecutive patients not on hemodialysis who underwent TAVR between September 2014 and January 2017. Outcomes were defined by VARC-2 criteria. Primary outcome of all-cause mortality was evaluated at a median follow-up of 811â€‰days (interquartile range 125-1,151). RESULTS:Preprocedural glomerular filtration rate (GFR) was â‰¥60â€‰ml/min in 51.7%, 30-60â€‰ml/min in 42.1%, andâ€‰<â€‰30â€‰ml/min in 6.3%. Use of transfemoral access (98.8%) and achieved device success (91.0%) did not differ among groups, but less contrast was used with lower GFR (23â€‰ml [15-33], 24â€‰ml [14-33], 13â€‰ml [8-20]; pâ€‰<â€‰.001). Peri-procedural stroke (0.7%, 2.1%, 11.1%; pâ€‰<â€‰.001) was higher with lower GFR. Core lab analysis of preprocedural computed tomography scans of patients who developed a peri-procedural stroke identified potential anatomic substrate for stroke in three out of four patients with GFR 30-60â€‰ml/min and all three with GFR <30â€‰ml/min (severe atheroma was the most common subtype of anatomical substrate present). Compared to GFR â‰¥60â€‰ml/min, all-cause mortality was higher with GFR 30-60â€‰ml/min (HR 1.61 [1.00-2.59]; aHR 1.61 [0.91-2.83]) and GFR <30â€‰ml/min (HR 2.41 [1.06-5.48]; aHR 2.34 [0.90-6.09]) but not significant after multivariable adjustment. Follow-up echocardiographic data, available in 63%, demonstrated no difference in structural heart valve deterioration over time among groups. CONCLUSIONS:Patients with baseline renal insufficiency remain a challenging population with poor long-term outcomes despite procedural optimization with a transfemoral-first and an extremely low-contrast approach.
Left ventricular global longitudinal strain and cardiac surgical outcomes
Global longitudinal strain (GLS) has emerged as a valuable diagnostic and prognostic tool for evaluating left ventricular (LV) function. GLS has been shown to be a more sensitive marker of LV dysfunction than LV ejection fraction alone and have prognostic impact in non-surgical cardiac populations. GLS, is validated, reproducible, and easily obtained from 2-dimensional speckle- tracking echocardiography. While there is strong evidence for using GLS in clinical decision- making in non-surgical populations, there is less summarized evidence on using GLS in the cardiac surgical population. This review combines the evidence on the implications of using baseline transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) GLS in cardiac surgical populations including ischemic and structural heart disease to determine surgical outcomes. We found that results seem promising on the prognostic utility of LV strain in cardiac surgical populations. However due to the variability of study populations and outcomes, and modalities (TTE versus TEE), further research on normal versus abnormal values for different surgical populations, as well potential treatment options that may modify and potentially decrease surgical risk for those with abnormal GLS are needed.