Valvuloarterial Impedence, Strain, Exercise, and AS

Background - In asymptomatic patients with severe aortic stenosis and preserved left ventricular ejection fraction, we sought to assess the incremental prognostic value of resting valvuloarterial impedence (Zva) and left ventricular global longitudinal strain (LV-GLS) to treadmill stress echocardiography. Methods and Results - We studied 504 such patients (66±12 years, 78% men, 32% with coronary artery disease who underwent treadmill stress echocardiography between 2001 and 2012. Clinical and exercise variables (% of age-sex predicted metabolic equivalents [%AGP-METs]) were recorded. Resting Zva ([systolic arterial pressure+mean aortic valve gradient]/[LV-stroke volume index]) and LV-GLS(measured offline using Velocity Vector Imaging, Siemens) were obtained from the baseline resting echocardiogram. Death was the primary outcome. There were no major adverse cardiac events during treadmill stress echocardiography. Indexed aortic valve area, Zva, and LV-GLS were 0.46±0.1 cm2/m2, 4.5±0.9 mm Hg/mL per m2 and -16±4%, respectively; only 50% achieved >100% AGP-METs. Sixty-four percent underwent aortic valve replacement. Death occurred in 164 (33%) patients over 8.9±3.6 years (2 within 30 days of aortic valve replacement). On multivariable Cox survival analysis, higher Society of Thoracic Surgeons score (hazard ratio or HR 1.06), lower % AGP-METS (HR 1.16), higher Zva (HR 1.25) and lower LV-GLS (HR 1.12) were associated with higher longer-term mortality, while aortic valve replacement (HR 0.45) was associated with improved survival (all P<0.01). Sequential addition of ZVa and LV-GLS to clinical model (Society of Thoracic Surgeons score and %AGP-METs) increased the c-statistic from 0.65 to 0.69 and 0.75, respectively, both P<0.001); findings were similar in the subgroup of patients who underwent aortic valve replacement. Conclusions - In asymptomatic patients with severe aortic stenosis undergoing treadmill stress echocardiography, LV-GLS and ZVa offer incremental prognostic value

Heart Failure after Aortic Valve Replacement: Incidence, Risk Factors, and Implications

Severe aortic stenosis (AS) carries a poor prognosis with the onset of heart failure (HF) symptoms, and surgical or transcatheter aortic valve replacement (AVR) is its only definitive treatment. The management of AS has seen a paradigm shift with the adoption of transcatheter aortic valve replacement (TAVR), allowing for the treatment of AS in patients who would not otherwise be candidates for surgical AVR. Despite improving long-term survival after TAVR in recent years, residual HF symptoms and HF hospitalization are common and are associated with an increased mortality and a poor health status. This review article summarizes the incidence and risk factors for HF after AVR. Strategies for preventing and better managing HF after AVR are necessary to improve outcomes in this patient population. Extensive research is underway to assess whether earlier timing for AVR, prior to the development of severe symptomatic AS and associated extra-valvular cardiac damage, can improve post-AVR patient outcomes

Prevalence and clinical significance of stent fracture and deformation following carotid artery stenting

ObjectiveCarotid artery stenting (CAS) is a developing intervention for carotid artery stenosis, and long-term outcomes remain unclear. We examined the prevalence and clinical significance of carotid stent fractures or deformations following CAS.MethodsTwo hundred thirty-one CAS performed in 219 patients at one academic institution between August 2000 and March 2009 were reviewed. One hundred sixteen stents (57 closed cell, 59 open cell) were evaluated with multiplanar plain films of the neck to assess for stent fracture or deformation. Stent fracture was identified by wire strut disruption. Deformation was defined as an increase in stent-cell area from stent strut distortion. Study endpoints included rate of stent fracture or deformation determined using Kaplan–Meier and life table analysis. Factors associated with stent fracture or deformation were identified by Cox regression. Effect of stent fracture or deformation on recurrent carotid artery stenosis >70% requiring reintervention and postoperative stroke was studied.ResultsThere were five stent fractures (4%) and 27 deformed stents (23%). Rate of stent fracture or deformation was 15% at 2 years and 50% at 4 years. Deformations were significantly more common in open cell stents than in closed cell stents (58% vs 5% at 4 years, P < .00005). Presence of calcified plaque on plain film was significantly associated with increased rate of stent fracture or deformation (P = .0006). At median follow-up of 25 months, restenosis requiring treatment occurred in four (5%) and late stroke in one (1%). Neither stent fracture nor deformation was associated with late stroke or reintervention.ConclusionsStent fracture and deformation is not uncommon following CAS and is associated with the presence of heavy calcification. Whether a carotid stent fractures or deforms correlates with stent design. Larger studies are necessary to determine the possible clinical significance of carotid stent fracture and deformation

Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST‐Segment–Elevation Myocardial Infarction Protocol

Background We evaluated whether a comprehensive ST‐segment–elevation myocardial infarction protocol (CSP) focusing on guideline‐directed medical therapy, transradial percutaneous coronary intervention, and rapid door‐to‐balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011–July 14, 2014) and after (July 15, 2014– July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st –90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door‐to‐balloon time. Achievement of guideline‐recommend door‐to‐balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all P<0.001). Median door‐to‐balloon time among emergency department/in‐hospital patients was significantly noninferior in higher versus lower deprivation groups after CSP (noninferiority limit=5 minutes; Pnoninferiority high versus moderate = 0.002, high versus low <0.001, moderate versus low = 0.02). In‐hospital mortality, the primary clinical outcome, was significantly lower after CSP in patients with moderate/high deprivation in unadjusted (before CSP 7.0% versus after CSP 3.1%; odds ratio [OR], 0.42 [95% CI, 0.25–0.72]; P=0.002) and risk‐adjusted (OR, 0.42 [95% CI, 0.23–0.77]; P=0.005) models. Conclusions A CSP was associated with improved ST‐segment–elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time‐sensitive conditions such as ST‐segment–elevation myocardial infarction