Pacemaker Following TAVR Associated With Increased Tricuspid Reguritation

Background: Transcatheter Aortic Valve Replacement (TAVR) therapies have increased in the treatment of aortic disease. As TAVR procedures increase, more data is available on complications, such as the development of conduction abnormalities, often requiring pacemaker placement (PMP). A common complication of pacemaker lead placement is the development of tricuspid regurgitation which develops due to pacemaker wire impingement of leaflet function and coaptation. Methods: Retrospective data was obtained from a major urban Midwestern health center. 796 patients were isolated who underwent TAVR from January 2014 through June 2018. From that sample, 89 patients (11%) underwent PMP following TAVR procedure. From those 89 patients, a sample of 34 patients was isolated that received their pacemaker at 2 years or more prior from the date of data collection. In addition to data from both procedures and patient demographics, echographic data was obtained [1] prior to TAVR procedure [2] between TAVR procedure and PMP and [3] the most recent echocardiogram. Data obtained from the echocardiogram included ejection fraction, degree of tricuspid regurgitation, pulmonary artery pressure, Tricuspid Annular Plane Systolic Excursion (TAPSE), degree of inferior vena cava (IVC) dilation, right ventricular diameter (RVD), right ventricle systolic pressure, right atrium (RA) area and degree of hepatic flow reversal. Results: Overall there was an increase in the incidence of significant tricuspid regurgitation (defined as above mild) from 29% to 38% following TAVR and PMP. The various changes between echographic parameters were analyzed using the paired t-test and the Wilcoxon signed rank test. The results indicate that a statistically significant change for the RVD from prior to TAVR to after PMP, where the mean RVD increased from 2.9 cm to 3.5 cm (p-value = 0.039). While not statistically significant, it should also be noted that there was an increase in the degree of tricuspid regurgitation and RA area. Conclusion: There is increasing awareness of the prevalence of tricuspid valve disease. This project serves as a basis to understand the risk of developing tricuspid regurgitation after TAVR procedure. This research can help guide clinicians in future in TAVR patients who have preexisting tricuspid regurgitation and may be evaluated for pacemaker placement. Given recent advances in transcatheter tricuspid valve therapies, more research is required to understand the risk of TAVR procedure and to push therapy and development that may help correct such complications.https://scholarlycommons.henryford.com/merf2019clinres/1045/thumbnail.jp

Quadricuspid aortic valve with aortic insufficiency: a rare echocardiographic finding

Introduction: Quadriscupidaortic valve (QAV) is a rare congenital heart defect typically found incidentally without any associated cardiac defects. The functional status of QAV is pure aortic insufficiency (AI), however, clinical manifestations are dependent on the functional status of the valve, presenting in the fifth or sixth decade of life due to progressive degeneration of the leaflets. In our case, we present a 37-year-old female who developed post-partum dyspnea with elevated brain natriuretic peptide (BNP) levels concerning for heart failure. Transesophageal echocardiography (TEE) revealed a preserved ejection fraction with aortic regurgitation consistent with valvular heart failure, however, incidentally showed a QAV. Case Presentation: A 37-year-old female 5 days post cesarean section presented with dyspnea on exertion. Her physical examination was significant for a decrescendo diastolic murmur at the aortic area and bibasilar rales. Pertinent labs revealed a BNP level elevation of 345 pg/mL with normal troponin levels. Given her symptoms and elevated biomarkers, a transthoracic echocardiogram was obtained and was suggestive of AI. She was referred for transesophageal echocardiogram for better visualization of the aortic valve. TEE revealed a QAV with all four leaflets equal in size with normal thickness and mobility. Moderate malcoaptation of all valves was present and severe AI was visualized. Planimetry of aortic regurgitant orifice was measured at 0.29 cm2, the AI jet was greater than 65% of left ventricular outflow tract, pressure half time calculated at 252 ms, and venacontracta measured 0.6 cm. Her systolic (ejection fraction 60%) and diastolic function were both preserved. After diuresis, she was discharged home and followed up with structural heart and cardiac surgery. She was to have a CT coronary angiography performed part of her pre-operative evaluation, but was lost to follow up. Discussion: QAV is a rare congenital cardiac anomaly that is typically found incidentally. The most prevalent complication of QAV is AI, however, these patients are also at increased risk for infective endocarditis. This is due to the progressive degeneration of the leaflets from the asymmetric mechanical stress around the four cusps. Echocardiography allowed for visualization of the aortic valve and for quantification of the degree of AI. Given her clinical presentation and cardiac risk factors, it was unclear what was causing her symptoms on admission. Through echocardiography, a diagnosis was made and the patient was able to receive appropriate care. The advancement in imaging techniques has increased the capability to diagnose QAV and its complications. The definitive treatment of QAV with AI is valve replacement, which was recommended to our patient. Conclusion: QAV is a rare congenital disease that most commonly manifests with AI. QAV is typically found incidentally in the fifth and sixth decade of life and best visualized by TEE. Definitive management of QAV is valve replacement.https://scholarlycommons.henryford.com/merf2020caserpt/1034/thumbnail.jp

Conservative Management of Spontaneous Coronary Artery Dissection: A Case Report

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare but fatal cause of acute coronary syndrome (ACS), often seen in young healthy women without any significant cardiovascular disease. If not treated early, it can lead to sudden cardiac death. We report an interesting case of ACS due to SCAD. Case Presentation: A 40-year-old woman presented to the emergency department with retrosternal chest pain at rest, associated with diaphoresis, palpitations, and nausea. Her past medical history was significant for hypertension and type 2 diabetes. On presentation, blood pressure was elevated to 150/81 mmHg, remaining vitals were normal. Initial electrocardiogram (ECG) showed normal sinus rhythm with no ischemic changes. Laboratory tests revealed an elevated high sensitivity troponin level to 104 ng/L (ref:/L). Given her clinical picture and biomarker elevation, there was concern for acute coronary syndrome. Echocardiography displayed an ejection fraction of 60% and no regional wall motion abnormalities. Coronary angiography was performed, which revealed non-obstructive coronary artery disease (CAD) with dissection of the mid-to-distal right posterolateral branch of the right coronary artery (RCA). No intervention was performed given mild extension of dissection and location. Of note, she did have recurrent chest pain with subsequent resolution. Given her overall symptomatic improvement, she was eventually discharged on metoprolol succinate, aspirin, and a moderate dose statin. Discussion: SCAD involves dissection of an epicardial coronary artery that is not secondary to atherosclerosis, trauma, or iatrogenic causes. It is the cause of up to 1-4% of ACS cases, occurs mostly in women, and is the most common cause of pregnancy-associated myocardial infarction (MI). The left anterior descending (LAD) artery is the most common artery affected, although it can affect any artery. The pathogenesis of SCAD involves the sudden disruption of the intimal layer, leading to dissection of the tunica media and subsequent formation of an intramural hematoma within a false lumen, and eventual compression of the true lumen. This leads to reduced coronary blood flow and MI. Acute coronary syndrome is the most common presentation, though clinical manifestations of SCAD can range from stable angina, to cardiogenic shock and life-threatening arrhythmias. When diagnosing SCAD, coronary angiography should be the first-line diagnostic imaging study. Other modalities including intravascular ultrasonography and optical coherence tomography allow for more detailed visualization of the artery wall and can be used to aid diagnosis. Management of SCAD varies depending on the case presentation and the severity of the condition. Patients with extensive dissections resulting in recurring symptoms and myocardial ischemia usually require percutaneous coronary intervention (PCI), while surgery is preferred for multi-vessel disease. Medical therapy is indicated for cases with mild involvement, and may include aspirin, P2Y12 inhibitors, beta blockers, and nitrates. Generally, patients with SCAD have a good prognosis especially with early detection and treatment. Recurrence of SCAD occurs in a minority of cases.https://scholarlycommons.henryford.com/merf2020caserpt/1052/thumbnail.jp

Inflammatory Markers in Bicuspid Transcatheter Aortic Valve Replacement

Background Aortic stenosis (AS) has a prevalence of 2%. Valve replacement is the definitive treatment for AS, with transcatheter aortic valve replacement (TAVR) offering a minimally invasive alternative to surgery. Bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality. BAV patients are predisposed to AS, and comprise a distinct, younger TAVR patient population. Given limited prior work on inflammatory markers for TAVR risk assessment, this study sought to investigate if white blood cell count (WBC) correlates with BAV TAVR patient severity and post-TAVR outcomes. Methods A single-center retrospective analysis was performed on patients with BAV who underwent TAVR from 2014 to 2018 (N=37). Patient demographics, symptomatic severity (NYHA class) and anatomic severity: aortic valve area (AVA) and indexed aortic valve area (AVAI) were collected. WBC prior to TAVR and post-TAVR complications/readmissions were also collected. Correlations between WBC, patient severity, and adverse outcomes were assessed using the Pearson and Spearman correlation tests, two-sample t-tests, and the Wilcoxon rank sum test. Results A statistically significant correlation (p = .041) was found between elevated pre-procedure WBC and patient NYHA class. No association was found between pre-procedure WBC and AVA (p = .723), AVAI (p = .961), or adverse outcomes/readmission post-procedure (p = .116). Conclusions A statistically significant correlation between pre-procedure WBC and NYHA class demonstrates that WBC is an accurate predictor of BAV patient’s functional symptom severity and could thus serve as a readily-accessible metric to stratify BAV TAVR patients in pre-procedure planning. No correlation existed between WBC and anatomic valve severity

NEUROLOGIC COMPLICATIONS OF TRANSAXILLARY ACCESS IN TAVR - A CASE OF POSTPROCEDURAL ULNAR AND MEDIAN NERVE INJURY

Background: Peripheral nerve injuries secondary to endovascular procedures are relatively rare but cause significant functional impairment. With transaortic valve replacement (TAVR), these injuries more commonly occur during axillary access compared to femoral and radial access (due to its proximity to brachial plexus). While hematoma and pseudoaneurysm formation are the more common complications, nerve injury may occur secondary to compression or direct needle puncture. Case: A 76-year-old male with severe aortic stenosis underwent two failed TAVR attempts due to poor access. Initial attempts at femoral access and transcaval access were aborted due to existing abdominal aortic endograft. Further attempts via carotid access were aborted due to stenosis. An attempt at left axillary access was then performed and TAVR was successful. Postoperatively (day 0), the patient developed left upper extremity (LUE) numbness over the 4th and 5th digits, medial palm, and dorsum of the hand with weakness when holding objects. Our neurological evaluation identified a total ulnar nerve (UN) and partial median nerve (MN) injury. Decision-making: Transaxillary access for TAVR is a disfavored approach due to the better outcomes when performed with other access sites. After out identification of a postprocedural nerve injury, we ordered a LUE arterial duplex ultrasound (US) and CT angiogram which excluded hematoma or pseudoaneurysm formation. US of the left brachial plexus revealed questionable edematous change at the take-off of the left UN and MN. Patient’s symptoms did not improve postoperatively until his discharge from the hospital (day 3) and an outpatient nerve conduction study was scheduled. Conclusion: We report a rare case of proximal UN and MN injury in a patient who underwent transaxillary TAVR due to the lack of alternative access. Prompt evaluation to rule-out vascular mechanism of injury in this patient was critical as early intervention results reduce further morbidity. With symptoms of motor and sensory brachial plexopathy and concerning imaging findings, the patient was scheduled for outpatient follow-up

"The great unspoken shame of UK Higher Education" : addressing inequalities of attainment

UK universities are achieving some success in attracting increasingly diverse undergraduate cohorts, although distributed unevenly across different types of institutions. It is therefore a concern that once at university, students from black and minority ethnic (BME) backgrounds perform less well in their final degree classifications, even when entry qualifications, subject of study and student characteristics are taken into account. This paper firstly, reviews the research on what is understood about the BME attainment gap, described by an independent university governor as “the great unspoken shame of higher education” and secondly tells the story of institutional change initiated by Kingston University, which is a large, “modern” and widening participation institution in South West London. The multifaceted change involved: defining the problem; establishing an institutional key performance indicator; engaging the university leadership and academy; using a value added metric; and measuring attainment outcomes over a four year period. Results show significant improvement in attainment and qualitative evidence of improved staff awareness. The paper discusses the ethical challenges of complex and institutional change, including, the importance of committed leadership, the value of data as a vehicle for initiating engagement when staff are reluctant to discuss race, equality and social justice, and the implications for moving away from a student deficit to an institutional deficit model through developing inclusive cultures and an inclusive curriculum. It reflects on the parallels with higher education chances and success for young black South Africans and concludes with describing Kingston University’s role in influencing change across the sector

Mapping genomic and transcriptomic alterations spatially in epithelial cells adjacent to human breast carcinoma.

Almost all genomic studies of breast cancer have focused on well-established tumours because it is technically challenging to study the earliest mutational events occurring in human breast epithelial cells. To address this we created a unique dataset of epithelial samples ductoscopically obtained from ducts leading to breast carcinomas and matched samples from ducts on the opposite side of the nipple. Here, we demonstrate that perturbations in mRNA abundance, with increasing proximity to tumour, cannot be explained by copy number aberrations. Rather, we find a possibility of field cancerization surrounding the primary tumour by constructing a classifier that evaluates where epithelial samples were obtained relative to a tumour (cross-validated micro-averaged AUC = 0.74). We implement a spectral co-clustering algorithm to define biclusters. Relating to over-represented bicluster pathways, we further validate two genes with tissue microarrays and in vitro experiments. We highlight evidence suggesting that bicluster perturbation occurs early in tumour development

Mechanical Circulatory Support in Cardiogenic Shock due to Structural Heart Disease

Despite advances in cardiovascular care, managing cardiogenic shock caused by structural heart disease is challenging. Patients with cardiogenic shock are critically ill upon presentation and require early disease recognition and rapid escalation of care. Temporary mechanical circulatory support provides a higher level of care than current medical therapies such as vasopressors and inotropes. This review article focuses on the role of hemodynamic monitoring, mechanical circulatory support, and device selection in patients who present with cardiogenic shock due to structural heart disease. Early initiation of appropriate mechanical circulatory support may reduce morbidity and mortality

Single-cell transcriptomics reveals involution mimicry during the specification of the basal breast cancer subtype

Basal breast cancer is associated with younger age, early relapse, and a high mortality rate. Here, we use unbiased droplet-based single-cell RNA sequencing (RNA-seq) to elucidate the cellular basis of tumor progression during the specification of the basal breast cancer subtype from the luminal progenitor population in the MMTV-PyMT (mouse mammary tumor virus-polyoma middle tumor-antigen) mammary tumor model. We find that basal-like cancer cells resemble the alveolar lineage that is specified upon pregnancy and encompass the acquisition of an aberrant post-lactation developmental program of involution that triggers remodeling of the tumor microenvironment and metastatic dissemination. This involution mimicry is characterized by a highly interactive multicellular network, with involution cancer-associated fibroblasts playing a pivotal role in extracellular matrix remodeling and immunosuppression. Our results may partially explain the increased risk and poor prognosis of breast cancer associated with childbirth.</p