Will Transcatheter Aortic Valve Replacement (TAVR) be the Primary Therapy for Aortic Stenosis?

Transcatheter aortic valve replacement (TAVR) is increasingly used for the treatment of high or very high surgical risk patients with severe aortic stenosis (AS) or failing surgical bioprosthesis (valve-in-valve, VIV-TAVR). In TAVR, the collapsed transcatheter heart valve (THV) is introduced using the delivery system inserted from the femoral artery (preferred) or other alternative accesses (transapical, transaortic, transcarotid, subclavian/transinnominate or transcaval). The delivery system is then advanced until coaxially aligned with the aortic annulus, where the THV is deployed. This procedure can be associated with complications such as access site injury (vascular complication), paravalvar leak, cerebrovascular events and conduction disturbances. However, the rapid acceptance and successes observed with TAVR have been made possible through careful patient selection, preprocedural planning (i.e. MDCT annular sizing), THV technology (i.e. new generation valves), and procedural techniques (i.e. minimalist TF-TAVR and alternative percutaneous access options), as well as a decrease in complications as TAVR experience grows. Though the results or ongoing clinical trials evaluating TAVR in intermediate surgical risk patients are pending, it is likely that TAVR will soon be approved for lower risk patients as well

The Search for Anticarcinogenic Organoselenium Compounds from Natural Sources

Consumption of Se-enriched plants or yeast-based nutritional supplements is reported to reduce the risk of cancer. Separation and identification of natural organoselenium compounds in these plants is essential to understand the basis for their biological activity. Earlier work suggests that plants convert inorganic selenium in the soil or growth medium into organoselenium compounds, such as selenoamino acids, following a route similar to the sulfur assimilatory pathway. To separate and detect selenoamino acids in plant extracts, we employ ion pair LC with an inductively coupled plasma mass spectrometer (ICP-MS) detector and capillary GC with an atomic emission detector (AED), for underivatized and derivatized compounds, respectively. Volatile selenium compounds, such as those found in human garlic breath, have been analyzed using GC­AED. Results involving Se-enriched garlic and yeast-based nutritional supplements are presented

Curvature Dependence of Surface Free Energy of Liquid Drops and Bubbles: A Simulation Study

We study the excess free energy due to phase coexistence of fluids by Monte Carlo simulations using successive umbrella sampling in finite LxLxL boxes with periodic boundary conditions. Both the vapor-liquid phase coexistence of a simple Lennard-Jones fluid and the coexistence between A-rich and B-rich phases of a symmetric binary (AB) Lennard-Jones mixture are studied, varying the density rho in the simple fluid or the relative concentration x_A of A in the binary mixture, respectively. The character of phase coexistence changes from a spherical droplet (or bubble) of the minority phase (near the coexistence curve) to a cylindrical droplet (or bubble) and finally (in the center of the miscibility gap) to a slab-like configuration of two parallel flat interfaces. Extending the analysis of M. Schrader, P. Virnau, and K. Binder [Phys. Rev. E 79, 061104 (2009)], we extract the surface free energy gamma (R) of both spherical and cylindrical droplets and bubbles in the vapor-liquid case, and present evidence that for R -> Infinity the leading order (Tolman) correction for droplets has sign opposite to the case of bubbles, consistent with the Tolman length being independent on the sign of curvature. For the symmetric binary mixture the expected non-existence of the Tolman length is confirmed. In all cases {and for a range of radii} R relevant for nucleation theory, gamma(R) deviates strongly from gamma (Infinity) which can be accounted for by a term of order gamma(Infinity)/gamma(R)-1 ~ 1/R^2. Our results for the simple Lennard-Jones fluid are also compared to results from density functional theory and we find qualitative agreement in the behavior of gamma(R) as well as in the sign and magnitude of the Tolman length.Comment: 25 pages, submitted to J. Chem. Phy

Impact of varying degrees of renal dysfunction on transcatheter and surgical aortic valve replacement

BackgroundRenal impairment portends adverse outcomes in patients undergoing valvular heart surgery. The relationship between renal dysfunction in patients undergoing transcatheter aortic valve replacement (TAVR) is incompletely understood.MethodsA retrospective review of 1336 patients undergoing surgical aortic valve replacement (SAVR; 2002-2012) and 321 patients undergoing TAVR (2007-2012) was performed. Patients were divided into 3 glomerular filtration rate (GFR) groups: GFR greater than 60 mL/min, GFR 31 to 60 mL/min, and GFR 30 mL/min or less. Logistic and linear regression analysis was performed to estimate the TAVR effect on outcomes. Risk adjustments were made using the Society for Thoracic Surgeons (STS) predicted risk of mortality (PROM).ResultsTAVR patients were older (82 vs 65 years; P < .001), had a poorer ejection fraction (48% vs 53%; P < .001), were more likely female (45% vs 41%; P = .23), and had a higher STS PROM (11.9% vs 4.6%; P < .001). In-hospital mortality rates for TAVR and SAVR were 3.5% and 4.1%, respectively (P = .60), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio = .52, P = .06). In SAVR patients, worsening preoperative renal failure was associated with increased in-hospital mortality (P = .004) and hospital (P < .001) and intensive care unit (ICU) (P < .001) lengths of stay. In contrast, worsening renal function did not influence in-hospital mortality (P = .78) and hospital (P < .23) and ICU (P = .88) lengths of stay in TAVR patients.ConclusionsWorsening renal function was associated with increased in-hospital mortality, hospital length of stay, and ICU length of stay in SAVR patients, but not in TAVR patients. This unexpected finding may have important clinical implications in patients with aortic stenosis and preoperative renal dysfunction

Unusual sequelae after percutaneous mitral valvuloplasty: A Doppler echocardiographic study

AbstractPercutaneous mitral valvuloplasty is a promising new technique for the treatment of mitral stenosis, with a relatively low complication rate reported to date. To assess the sequelae of this procedure, Doppler echocardiographic studies were prospectively performed before and after percutaneous mitral valvuloplasty in a series of 172 patients (mean age 53 ± 17 years). After balloon dilation, mitral valve area increased from 0.9 ± 0.3 to 2 ± 0.8 cm2(p < 0.0001), mean gradient decreased from 16 ± 6 to 6 ± 3 mm Hg (p < 0.0001) and mean left atrial pressure decreased from 24 ± 7 to 14 ± 6 mm Hg (p < 0.0001).Although most patients were symptomatically improved, six (4%) were identified who had unusual sequelae evident on Doppler echocardiographic examination immediately after percutaneous mitral valvuloplasty. These included rupture of a posterior mitral valve leaflet, producing a flail distal leaflet portion with severe mitral regurgitation detected on Doppler color flow mapping (n = 1); asymptomatic rupture of the chordae tendineae attached to the anterior mitral valve leaflet with systolic anterior motion of the ruptured chordae into the left ventricular outflow tract (n = 1); a double-orifice mitral valve (n = 1); and evidence of a tear in the anterior mitral valve leaflet (n = 3), producing on both pulsed Doppler ultrasound and color flow mapping a second discrete jet of mitral regurgitation in addition to regurgitation through the main mitral valve orifice. All six patients made a satisfactory recovery and none has required mitral valve replacement.In a small percent of cases, percutaneous mitral valvuloplasty may produce unusual disruption of the mitral valve and supporting apparatus that may be readily detected by Doppler echocardiographic studies

A contemporary overview of percutaneous coronary interventions The American College of Cardiology–National Cardiovascular Data Registry (ACC–NCDR)

AbstractObjectivesThe American College of Cardiology (ACC) established the National Cardiovascular Data Registry (ACC–NCDR) to provide a uniform and comprehensive database for analysis of cardiovascular procedures across the country. The initial focus has been the high-volume, high-profile procedures of diagnostic cardiac catheterization and percutaneous coronary intervention (PCI).BackgroundSeveral large-scale multicenter efforts have evaluated diagnostic catheterization and PCI, but these have been limited by lack of standard definitions and relatively nonuniform data collection and reporting methods.MethodsBoth clinical and procedural data, and adverse events occurring up to hospital discharge, were collected and reported according to uniform guidelines using a standard set of 143 data elements. Datasets were transmitted quarterly to a central facility for quality-control screening, storage and analysis. This report is based on PCI data collected from January 1, 1998, through September 30, 2000.ResultsA total of 139 hospitals submitted data on 146,907 PCI procedures. Of these, 32% (46,615 procedures) were excluded because data did not pass quality-control screening. The remaining 100,292 procedures (68%) were included in the analysis set. Average age was 64 ± 12 years; 34% were women, 26% had diabetes mellitus, 29% had histories of prior myocardial infarction (MI), 32% had prior PCI and 19% had prior coronary bypass surgery. In 10% the indication for PCI was acute MI ≤6 h from onset, while in 52% it was class II to IV or unstable angina. Only 5% of procedures did not have a class I indication by ACC criteria, but this varied by hospital from a low of 0 to a high of 38%. A coronary stent was placed in 77% of procedures, but this varied by hospital from a low of 0 to a high of 97%. The frequencies of in-hospital Q-wave MI, coronary artery bypass graft surgery and death were 0.4%, 1.9% and 1.4%, respectively. Mortality varied by hospital from a low of 0 to a high of 4.2%.ConclusionsThis report presents the first data collected and analyzed by the ACC–NCDR. It portrays a contemporary overview of coronary interventional practices and outcomes, using uniform data collection and reporting standards. These data reconfirm overall acceptable results that are consistent with other reported data, but also confirm large variations between individual institutions

Development of a risk adjustment mortality model using the American College of Cardiology–National Cardiovascular Data Registry (ACC–NCDR) experience: 1998–2000

AbstractObjectivesWe sought to develop and evaluate a risk adjustment model for in-hospital mortality following percutaneous coronary intervention (PCI) procedures using data from a large, multi-center registry.BackgroundThe 1998–2000 American College of Cardiology–National Cardiovascular Data Registry (ACC–NCDR) dataset was used to overcome limitations of prior risk-adjustment analyses.MethodsData on 100,253 PCI procedures collected at the ACC–NCDR between January 1, 1998, and September 30, 2000, were analyzed. A training set/test set approach was used. Separate models were developed for presentation with and without acute myocardial infarction (MI) within 24 h.ResultsFactors associated with increased risk of PCI mortality (with odds ratios in parentheses) included cardiogenic shock (8.49), increasing age (2.61 to 11.25), salvage (13.38) urgent (1.78) or emergent PCI (5.75), pre-procedure intra-aortic balloon pump insertion (1.68), decreasing left ventricular ejection fraction (0.87 to 3.93), presentation with acute MI (1.31), diabetes (1.41), renal failure (3.04), chronic lung disease (1.33); treatment approaches including thrombolytic therapy (1.39) and non-stent devices (1.64); and lesion characteristics including left main (2.04), proximal left anterior descending disease (1.97) and Society for Cardiac Angiography and Interventions lesion classification (1.64 to 2.11). Overall, excellent discrimination was achieved (C-index = 0.89) and application of the model to high-risk patient groups demonstrated C-indexes exceeding 0.80. Patient factors were more predictive in the MI model, while lesion and procedural factors were more predictive in the analysis of non-MI patients.ConclusionsA risk adjustment model for in-hospital mortality after PCI was successfully developed using a contemporary multi-center registry. This model is an important tool for valid comparison of in-hospital mortality after PCI