Faculty Bibliography

Background: Many uremic solutes are protein bound and removed by proximal tubular organic anion transporters (OATs) rather than filtration.
Method(s): In 4 subjects undergoing right heart catheterization, samples were obtained from the right renal vein and the inferior vena cava below the renal veins.Total and ultrafiltrate concentrations of uremic solutes were measured utilizing MS-HPLC.
Result(s): Renal extraction ratio (removal across the renal vascular bed) and renal excretion fraction (renal clearance of solute relative to creatinine) varied greatly. HA and PAG exhibited the highest renal extraction ratios and excretion fractions approximating values reported for para-amino-hippurate (PAH). The dialytic clearance of these solutes exhibited the same pattern but never exceeded estimated creatinine clearance. Highly bound solutes (IS, PCS) exhibited low renal extraction and low renal excretion fractions. KA was an anomaly. Though highly bound, renal extraction and excretion were higher than expected, possibly related to pKa or other unique properties of this solute.
Conclusion(s): The findings suggest that endogenous hippurate clearance might provide a measure of effective renal plasma flow. The finding that uremic retention solutes such as IS, PCS, and KA, known to bind to OAT receptors on vascular endothelium where they act as transcription factors, are also tightly bound to albumin suggests that protein binding serves to deliver solutes to receptors in a manner analogous to the delivery of hormones, bound to carrier proteins, from an endocrine source to distant receptors

Background/UNASSIGNED:Multiple studies demonstrate the benefit of a vegan diet on cardiovascular risk factors when compared to no intervention or usual dietary patterns. The aim of this study is to evaluate the effect of a vegan diet versus the American Heart Association (AHA)-recommended diet on inflammatory and glucometabolic profiles in patients with angiographically defined coronary artery disease (CAD). Study Design/UNASSIGNED:This study is a randomized, open label, blinded end-point trial of 100 patients with CAD as defined by ≥50% diameter stenosis in a coronary artery ≥2 mm in diameter on invasive angiography. Participants are randomized to 8 weeks of either a vegan or AHA-recommended diet (March 2014 and February 2017). Participants are provided weekly groceries that adhere to the guidelines of their diet. The primary endpoint is high sensitivity C-reactive concentrations. Secondary endpoints include anthropometric data, other markers of inflammation, lipid parameters, glycemic markers, endothelial function, quality of life data, and assessment of physical activity. Endpoints are measured at each visit (baseline, 4 weeks, and 8 weeks). Dietary adherence is measured by two weekly 24-hour dietary recalls, a 4-day food record during the week prior to each visit, and both plasma and urine levels of trimethylamine-N-oxide at each visit. Conclusion/UNASSIGNED:This study is the first to comprehensively assess multiple indices of inflammation and glucometabolic profile in a rigorously conducted randomized trial of patients with CAD on a vegan versus AHA-recommended diet.

This paper provides a comprehensive overview of 3D transesophageal echocardiography still images and movies of mechanical mitral valves, mitral bioprostheses, and mitral valve repairs. Alongside these visual descriptions, the historical overview of surgical and percutaneous mitral valve intervention is described with the special emphasis on the incremental value of 3D transesophageal echocardiography (3DTEE). For each mitral valve intervention, 2D echocardiography, chest x-ray, and fluoroscopy images corresponding to 3DTEE are given. In addition, key references on echocardiographic imaging of individual valves and procedures are enumerated in accompanying figures and tables.

Background/Introduction: The EVEREST II REALISM Continued Access study (REALISM) is a prospective, multi-center, continued access study to collect data on the "real world" use of the MitraClip device in both high and non-high surgical risk patients. Enrollment in REALISM was initiated in January 2009 at the conclusion of the EVEREST II Randomized Controlled Trial (RCT) to allow patients continued access to the therapy. Enrollment in the non-high risk arm was completed in April 2011, and subjects have reached 5-year follow-up. Purpose: Mid- and long-term outcomes through 5 years will be presented to evaluate durability of transcatheter mitral valve (MV) repair with the MitraClip device and long-term safety in standard risk patients. Methods: Patients with 3+/4+ mitral regurgitation (MR) were enrolled. Pre- and post-procedure and follow-up echocardiograms for all patients were evaluated by an independent core lab. Safety outcomes include acute procedural results at 30 days and survival. Clinical outcomes at 5 years include MR severity, change in left ventricular (LV) volumes and dimensions and NYHA Functional Class. Results: A total of 271 non-high risk patients were enrolled. The mean age was 74+/-11 years. MR etiology was degenerative in 68% and functional in 32%. At baseline, 54% of patients were in NYHA Class III/IV and mean ejection fraction was 56+/-11% (61+/-7% degenerative MR; 45+/-12% functional MR). Kaplan-Meier estimated survival rates were 91%, 78%, and 61% at 1, 3, and 5 years, respectively. Similarly, freedom from MV surgery was 90%, 87%, and 84% at 1, 3, and 5 years, respectively. In surviving patients with paired data available at baseline and 3 years (n=140), MR severity was <=2+ in 87% and <=1+ in 43%. This was accompanied by a significant reduction in LV end diastolic volumes from 134+/-42 ml at baseline to 124+/-53 ml (p=0.03, n=127 with paired data; 128+/-39 ml to 118+/-53 ml degenerative MR, p=0.077 (n=95); 149+/-46 ml to 140+/-52 ml functional MR, p=0.12 (n=32)) and improvement in NYHA Functional Class I/II from 56% at baseline to 92% at 3 years (p<0.0001, n=154 with paired data). Conclusions: The mid-term data from the EVEREST II REALISM non-high risk arm confirmed the efficacy and stability of repair over 3 and 5 years. The low rates of MV surgery beyond the first year was consistent with the results of the EVEREST II RCT, reconfirming the stability of repair using the MitraClip device. In the EVEREST II RCT freedom from MV surgery was 79%, 78%, and 74% at 1, 3 and, 5 years respectively. The lower rates of MV surgery observed in the REALISM non-high risk study reflect the learning curve associated with the MitraClip procedure and are a result of improved case selection and better procedural outcomes. Final 5-year results of the EVEREST II REALISM non-high risk arm will be presented to evaluate long-term durability of outcomes post-treatment with the MitraClip device

OBJECTIVES: This study sought to evaluate this transcatheter aortic valve (TAV) bioprosthesis in patients who are poorly suitable for surgical aortic valve (AV) replacement. BACKGROUND: A novel self-expandable TAV bioprosthesis was designed to provide a low-profile delivery system, conformable annular sealing, and the ability to resheath and reposition during deployment. METHODS: The Evolut R U.S. study included 241 patients with severe aortic stenosis who were deemed to be at least high risk for surgery treated at 23 clinical sites in the United States. Clinical outcomes at 30 days were evaluated using Valve Academic Research Consortium-2 criteria. An independent echocardiography laboratory was used to evaluate hemodynamic outcomes. RESULTS: Patients were elderly (83.3 +/- 7.2 years of age) and had high surgical risk (Society of Thoracic Surgeons predicted risk of mortality of 7.4 +/- 3.4%). The majority of patients (89.5%) were treated by iliofemoral access. Resheathing or recapturing was performed in 22.6% of patients; more than 1 valve was required in 3 patients (1.3%). The 30-day outcomes included all-cause mortality (2.5%), disabling stroke (3.3%), major vascular complications (7.5%), life-threatening or disabling bleeding (7.1%), and new permanent pacemaker (16.4%). AV hemodynamics were markedly improved at 30 days: the mean AV gradient was reduced from 48.2 +/- 13.0 mm Hg to 7.8 +/- 3.1 mm Hg (p < 0.001) and AV area increased from 0.6 +/- 0.2 cm2 to 1.9 +/- 0.5 cm2 (p < 0.001). Moderate residual paravalvular leak was identified in 5.3% of patients. CONCLUSIONS: We conclude that this novel self-expanding TAV bioprosthesis is safe and effective for the treatment of patients with severe aortic stenosis who are suboptimal for surgery. (Medtronic CoreValve Evolut R U.S. Clinical Study; NCT02207569).

A 48-year-old man with hypertension presented with heart failure and reduced left ventricular systolic function. Coronary angiography revealed a non-dominant right coronary artery and a long anomalous branch of the proximal left anterior descending coronary artery that coursed inferiorly to give rise to the posterior descending artery. No epicardial coronary artery disease was visualized. The highly unusual anomalous branch was considered to be an incidental finding, with no pathological contribution to the clinical presentation.

OBJECTIVE: To determine how two different types of iodinated contrast media (CM), low-osmolar ionic dimer ioxaglate (Hexabrix) and iso-osmolar non-ionic dimer iodixanol (Visipaque), affect multiple indices of hemostasis. BACKGROUND: In vitro models demonstrate differential effects of ionic and non-ionic CM on markers of hemostasis. METHODS: This blinded endpoint trial randomized 100 patients to ioxaglate or iodixanol. The primary endpoint was change in endogenous thrombin potential (ETP) following diagnostic angiography. Secondary endpoints included change in markers of fibrinolysis [tissue plasminogen activator (tPA) and plasminogen activator inhibitor 1 (PAI-1)] and platelet aggregation following diagnostic angiography and percutaneous coronary intervention (PCI) with bivalirudin. Data are presented as median [interquartile range]. RESULTS: ETP significantly decreased after diagnostic angiography in both ioxaglate (baseline 1810 nM*minute [1540-2089] to post-angiography 649 nM*minute [314-1347], p < 0.001) and iodixanol groups (baseline 1682 nM*minute [1534-2147] to post-angiography 681 nM*minute [229-1237], p < 0.001), but the decrease was not different between CM (p = 0.70). There was a significant increase in ETP during PCI (n = 45), despite the use of bivalirudin, suggesting a prothrombotic effect of PCI (post-angiography 764 nM*minute [286-1283] to post-PCI 1081 nM*minute [668-1552], p = 0.02). There were no significant differential effects on tPA, PAI-1, and markers of platelet activity. CONCLUSION: There were no significant differential effects between ioxaglate and iodixanol. Both CM led to significant reductions in thrombin generation and no significant effects on fibrinolytic activity or platelet activity, thereby contributing to a favorable antithrombotic milieu. (c) 2015 Wiley Periodicals, Inc.

Left transradial approach (TRA) for coronary angiography is associated with lower radiation parameters than right TRA in an all-comers population. The aim of this study was to determine the effects of left versus right TRA on radiation parameters in patients with predictors of TRA failure. Patients with predictors of TRA failure (>/=3 of 4 following criteria: age >/=70 years, female gender, height