Iatrogenic Circumflex Artery Stenosis Following Mitral Valve Repair

Injury of the left circumflex coronary artery is a potentially serious complication of mitral valve surgery due to the proximity of the vessel to the posterior segment of the mitral annulus. Suture-related distortion of the artery with partial or subtotal occlusion is the most commonly implicated mechanism. Herein, we present a case of symptomatic iatrogenic circumflex coronary artery stenosis following mitral valve annuloplasty for degenerative mitral valve regurgitation

Racial Disparities in the Utilization and Outcomes of Structural Heart Disease Interventions in the United States

Background-—Data on race- and ethnicity-based disparities in the utilization and outcomes of structural heart disease interventions in the United States are scarce. Methods and Results-—We used the National Inpatient Sample (2011-2016) to examine racial and ethnic differences in the utilization, in-hospital outcomes, and cost of structural heart disease interventions among patients ≥65 years of age. A total of 106 119 weighted hospitalizations for transcatheter aortic valve replacement, transcatheter mitral valve repair, and left atrial appendage occlusion were included. The utilization rates (defined as the number of procedures performed per 100 000 US people \u3e65 years of age) were higher in whites compared with blacks and Hispanics for transcatheter aortic valve replacement (43.1 versus 18.0 versus 21.1), transcatheter mitral valve repair (5.0 versus 3.2 versus 3.2), and left atrial appendage occlusion (6.6 versus 2.1 versus 3.5), respectively (P\u3c0.001). Black and Hispanic patients had distinctive socioeconomic and clinical risk profiles compared with white patients. There were no significant differences in the adjusted in-hospital mortality or key complications between patients of white race, black race, and Hispanic ethnicity following transcatheter aortic valve replacement, transcatheter mitral valve repair, or left atrial appendage occlusion. No difference in cost was observed between white and black patients following any of the 3 procedures. However, Hispanic patients incurred modestly higher cost with transcatheter mitral valve repair and left atrial appendage occlusion compared with white patients. Conclusions-—Racial and ethnic disparities exist in the utilization of structural heart disease interventions in the United States. Nonetheless, adjusted in-hospital outcomes were comparable among white, black, and Hispanic patients. Further studies are needed to understand the reasons for these utilization disparities. (J Am Heart Assoc. 2019;8:e012125. DOI: 10.1161/JAHA. 119.012125.

Contemporary Trends in the Use and Outcomes of Surgical Treatment of Tricuspid Regurgitation

Background Tricuspid regurgitation (TR), if untreated, is associated with an adverse impact on long‐term outcomes. In recent years, there has been an increasing enthusiasm about surgical and transcatheter treatment of patients with severe TR. We aim to evaluate the contemporary trends in the use and outcomes of tricuspid valve (TV) surgery for TR using the National Inpatient Sample. Methods and Results Between January 1, 2003 and December 31, 2014, an estimated 45 477 patients underwent TVsurgery for TR in the United States, of whom 15% had isolated TV surgery and 85% had TVsurgery concomitant with other cardiac surgery. There was a temporal upward trend to treat sicker patients during the study period. Patients who underwent isolated TV repair or replacement had a distinctly different clinical risk profile than those patients who underwent TVsurgery simultaneous with other surgery. Isolated TV replacement was associated with high in‐hospital mortality (10.9%) and high rates of permanent pacemaker implantation (34.1%) and acute kidney injury requiring dialysis (5.5%). Similarly, isolated TV repair was also associated with high in‐hospital mortality (8.1%) and significant rates of permanent pacemaker implantation (10.9%) and new dialysis (4.4%). Isolated TV repair and TV replacement were both associated with protracted hospitalizations and substantial cost. Conclusions In contemporary practice, surgical treatment of TR remains underused and is associated with high operative morbidity and mortality, prolonged hospitalizations, and considerable cost

A Case of Transient ST Elevation and Polymorphic Tachycardia without Angina Diagnosed by Holter Monitoring

We report the case of 52-year-old female with recurrent episodes of palpitations and dizziness. Holter monitoring revealed transient ST elevations followed by episodes of polymorphic ventricular tachycardia associated with episodes of palpitations and dizziness. Coronary angiography revealed mildly irregular right coronary artery with 90% stenosis. The patient underwent percutaneous coronary intervention with successful placement of a stent to the mid-right coronary artery. The patient has been followed closely over a period of 12 months. There haven\u27t been any recorded episodes of tachycardia, and the patient has remained symptom-free

A Case of Transient ST Elevation and Polymorphic Tachycardia without Angina Diagnosed by Holter Monitoring

We report the case of 52-year-old female with recurrent episodes of palpitations and dizziness. Holter monitoring revealed transient ST elevations followed by episodes of polymorphic ventricular tachycardia associated with episodes of palpitations and dizziness. Coronary angiography revealed mildly irregular right coronary artery with 90% stenosis. The patient underwent percutaneous coronary intervention with successful placement of a stent to the mid-right coronary artery. The patient has been followed closely over a period of 12 months. There haven\u27t been any recorded episodes of tachycardia, and the patient has remained symptom-free

Contemporary outcomes of isolated bioprothestic mitral valve replacement for mitral regurgitation

Background Early experience with transcatheter mitral valve replacement (TMVR) highlighted several investigational challenges related to this novel therapy. Conclusive randomised clinical trials in the field may, therefore, be years ahead. In the interim, contemporary outcomes of isolated surgical bioprosthetic mitral valve replacement (MVR) can be used as a benchmark for the emerging TMVR therapies. Methods We used the nationwide inpatient sample to examine recent trends and outcomes of surgical bioprosthetic MVR for mitral regurgitation (isolated and combined). Results 21 007 patients who had bioprosthetic MVR between 2003 and 2014 were included. Of those, 30% had isolated MVR and 70% had concomitant cardiac surgical procedure(s). In patients who underwent isolated bioprothestic MVR, mean age was 68±13, and females were the majority (58.4%). Most of these procedures were performed at teaching institutions (71.3%) and during an elective admission (64%). In-hospital mortality improved during the study period (7.8% in 2003 to 4.7% in 2014, p trend=0.016). Postoperative morbidities were common; permanent pacemaker 11.7%, stroke 2.4%, new dialysis 4.9% and blood transfusion 41.6%. Mean length of stay was 13±12 days, and 27.2% of patients were discharged to an intermediate care of rehabilitation facility. Cost of hospitalisation was $62 443±50 997. Conclusions Isolated bioprosthetic MVR for mitral regurgitation is performed infrequently but is associated with significant in-hospital morbidity and mortality and cost in contemporary practice. These data are useful as benchmarks for the evolving TMVR therapies

Impact of acute diabetes decompensation on outcomes of diabetic patients admitted with ST-elevation myocardial infarction

Background: Acute hyperglycemia is associated with worse outcomes in diabetic patients admitted with ST‐eleva‐ tion myocardial infarction (STEMI). However, the impact of full‐scale decompensated diabetes on STEMI outcomes has not been investigated. Methods: We utilized the national inpatient sample (2003–2014) to identify adult diabetic patients admitted with STEMI. We defined decompensated diabetes as the presence of diabetic ketoacidosis (DKA) or hyperglycemic hyper‐ osmolar state (HHS). We compared in‐hospital morbidity and mortality and cost between patients with and without diabetes decompensation before and after propensity‐score matching. Results: A total of 73,722 diabetic patients admitted with STEMI were included in the study. Of those, 1131 (1.5%) suf‐ fered DKA or HSS during the hospitalization. After propensity‐score matching, DKA/HHS remained associated with a significant 32% increase in in‐hospital mortality (25.6% vs. 19.4%, p = 0.001). The DKA/HHS group also had higher inci‐ dences of acute kidney injury (39.4% vs. 18.9%, p \u3c 0.001), sepsis (7.3% vs. 4.9%, p = 0.022), blood transfusion (11.3% vs. 8.2%) and a non‐significant trend towards higher incidence of stroke (3.8% vs. 2.4%, p = 0.087). Also, DKA/HHS diagnosis was associated with lower rates of referral to coronary angiography (51.5% vs. 55.5%, p = 0.023), coronary stenting (26.1% vs. 34.8%, p \u3c 0.001), or bypass grafting (6.2% vs. 8.7%, p = 0.033). Referral for invasive angiography was associated with lower odds of death during the hospitalization (adjusted OR 0.66, 95%CI 0.44‐0.98, p = 0.039). Conclusions: Decompensated diabetes complicates ~ 1.5% of STEMI admissions in diabetic patients. It is associated with lower rates of referral for angiography and revascularization, and a negative differential impact on in‐hospital morbidity and mortality and cost

Mechanical circulatory support in patients with severe aortic stenosis and left ventricular dysfunction undergoing percutaneous coronary intervention

Management of obstructive coronary artery disease in patients with aortic stenosis and severe left ventricular dysfunction is challenging. Mechanical circulatory support at the time of percutaneous coronary interventions may be necessary in these extreme-risk patients. We present a case in which the TandemHeart was used to support a patient with severe aortic stenosis, severe protected left main and circumflex disease, and severe cardiomyopathy and review the literature on this subject