Publications by authors named "Pedro A Villablanca"

88 Publications

Pacemaker following transcatheter aortic valve replacement and tricuspid regurgitation: A single-center experience.

J Card Surg 2021 Feb 2. Epub 2021 Feb 2.

Division of Cardiology, Henry Ford Health System, Henry Ford Hospital, Detroit, Michigan, USA.

Background: As transcatheter aortic valve replacement (TAVR) procedures increase, more data is available on the development of conduction abnormalities requiring permanent pacemaker (PPM) implantation post-TAVR. Mechanistically, new pacemaker implantation and incidence of associated tricuspid regurgitation (TR) post-TAVR is not well understood. Studies have evaluated the predictability of patient anatomy towards risk for needing permanent pacemaker (PPM) post-TAVR; however, little has been reported on new PPM and TR in patients post-TAVR.

Methods: This retrospective study identified patients at our health system who underwent PPM following TAVR from January 2014 to June 2018. Data from both TAVR and PPM procedures as well as patient demographics were collected. Echocardiographic data before TAVR, between TAVR and PPM placement, and the most recent echocardiogram at the time of chart review were analyzed.

Results: Of 796 patients who underwent TAVR between January 2014 and June 2018, 89 patients (11%) subsequently required PPM. Out of the 89 patients who required PPM implantation, 82 patients had pre-TAVR and 2-year post-TAVR echocardiographic imaging data. At baseline, 22% (18/82) of patients had at least moderate TR. At 2-year post-TAVR echocardiographic imaging follow-up; 27% (22/82) of patients had at least moderate TR. Subgroup analysis was performed according to the TAVR valve size implanted. In patients who received a TAVR device < 29 mm in diameter in size, 25% (11/44) had worsening TR. In patients who received a TAVR device ≥ 29 mm in diameter, 37% (14/38) had worsening TR.

Conclusion: We have demonstrated a patient population that may be predisposed to developing worsening TR and right heart function after TAVR and Pacemaker implantation.
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http://dx.doi.org/10.1111/jocs.15363DOI Listing
February 2021

Chasing the Cardiogenic Shock Unicorn.

J Cardiothorac Vasc Anesth 2021 Feb 27;35(2):366-367. Epub 2020 Aug 27.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Rochester, MN.

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http://dx.doi.org/10.1053/j.jvca.2020.08.052DOI Listing
February 2021

Impact of Prior Coronary Artery Bypass Grafting in Patients ≥75 Years Old Presenting With Acute Myocardial Infarction (From the National Readmission Database).

Am J Cardiol 2020 11 28;135:9-16. Epub 2020 Aug 28.

Department of Cardiology, Henry Ford Hospital, Detroit, Michigan.

Patients ≥75 years old presenting with acute myocardial infarction (AMI) have complex coronary anatomy in part due to prior coronary artery bypass grafting (CABG), percutaneous coronary interventions (PCI), calcific and valvular disease. Using the National Readmission Database from January 2016 to November 2017, we identified hospital admissions for acute myocardial infarction in patients ≥75 years old and divided them based on a history of CABG. We evaluated in-hospital outcomes, 30-day mortality, 30-day readmission and predictors of PCI in cohorts. Out of a total of 296,062 patients ≥75 years old presenting with an AMI, 42,147 (14%) had history of previous CABG. Most presented with a non-ST segment elevation myocardial infarction, and those with previous CABG had higher burden of co-morbidities and were more commonly man. The in-hospital mortality was significantly lower in those with previous CABG (6.7% vs 8.8%, adjusted odds ratio, 0.88, 95% confidence interval, 0.82 to 0.94). Medical therapy was more common in those with previous CABG and 30-day readmission rates were seen more frequently in those with prior CABG. Predictors of not undergoing PCI included previous PCI, female, older ager groups, heart failure, dementia, malignancy, and higher number of co-morbidities. In conclusion, in patients ≥75 years old with AMI the presence of prior CABG was associated with lower odds of in-hospital and 30-day mortality, as well as lower complications rates, and a decreased use of invasive strategies (PCI, CABG, and MCS). However, 30-day MACE readmission was higher in those with previous CABG.
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http://dx.doi.org/10.1016/j.amjcard.2020.08.036DOI Listing
November 2020

Balloon-Assisted Valve Tracking: Atraumatic Retrieval of a Ventricularized Transcatheter Aortic Valve Prosthesis.

JACC Cardiovasc Interv 2020 Nov 26;13(21):2576-2578. Epub 2020 Aug 26.

Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan.

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http://dx.doi.org/10.1016/j.jcin.2020.06.052DOI Listing
November 2020

Procedural and mid-term outcomes of coronary protection during transcatheter aortic valve replacement in patients at-risk of coronary occlusion: Insight from a single-centre retrospective analysis.

Cardiovasc Revasc Med 2020 Jul 3. Epub 2020 Jul 3.

Center for Structural Heart Diseases, Henry Ford Hospital, Detroit, MI, USA. Electronic address:

Background: Detailed procedural analysis and long-term data is limited for coronary protection (CP) during transcatheter aortic valve replacement (TAVR) for patients with high anatomical risk for coronary occlusion (CO). We aim to assess the procedural and mid-term outcomes of CP during TAVR.

Methods: We retrospectively analyzed patients who underwent TAVR at Henry Ford Hospital, USA from January 2015 to August 2019 and identified those considered at risk of CO and underwent pre-emptive CP with or without subsequent "chimney" stenting (i.e. coronary stenting with intentional protrusion into the aorta). Procedural features, immediate and mid-term clinical outcomes were reviewed.

Results: Twenty-five out of 1166 (2.1%) patients underwent TAVR with CP, including 10 (40%) valve-in-valve procedures. Twenty-eight coronary arteries (Left: n = 11, Right: n = 11; Left + Right: n = 3) were protected. Eleven coronaries (39.3%) were electively "chimney"-stented due to angiographic evidence of coronary impingement (63.6%), tactile resistance while withdrawing stent (27.3%) and electrocardiogram change (9.1%). Twenty-four patients (24/25, 96%) had successful TAVR without CO. Procedure-related complications included stent-balloon entrapment (n = 1), stent entrapment (n = 1) and occlusive distal stent edge dissection (n = 1). After a mean follow-up of 19.1 months, there was 1 cardiac death but no target vessel re-intervention or myocardial infarction.

Conclusions: Our study found that angiographic evidence of coronary impingement (63.6%) was the most common reason for stent deployment during TAVR with CP. The mid-term clinical outcome of CP with TAVR was favorable.
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http://dx.doi.org/10.1016/j.carrev.2020.06.032DOI Listing
July 2020

Impella Versus Extracorporeal Membrane Oxygenation for Acute Myocardial Infarction Cardiogenic Shock.

Cardiovasc Revasc Med 2020 Dec 30;21(12):1465-1471. Epub 2020 May 30.

Department of Cardiology, Henry Ford Hospital, Detroit, MI, United States of America.

Background: Percutaneous ventricular assist devices and extracorporeal membrane oxygenation (ECMO) are increasingly used for mechanical circulatory support (MCS) in patients with acute myocardial infarction with cardiogenic shock (AMI-CS) in hospitals throughout the United States.

Methods: Using the National Inpatient Sample from October 2015 to December 2017, we identified hospital admissions that underwent percutaneous coronary intervention (PCI) and non-elective Impella or ECMO placement for AMI-CS using ICD-10 codes. Propensity-score matching was performed to compare both groups for primary and secondary outcomes.

Results: We identified 6290 admissions for AMI-CS who underwent PCI and were treated with Impella (n = 5730, 91%) or ECMO (n = 560, 9%) from October 2015 to December 2017. After propensity-match analysis, the ECMO cohort had significantly higher in-hospital mortality (43.3% vs 26.7%, OR: 2.10, p = 0.021). The incidence of acute respiratory failure and vascular complications were significantly lower in the Impella cohort. We observed a shorter duration of hospital stay and lower hospital costs in the Impella cohort compared to those who received ECMO.

Conclusions: In AMI-CS, the use of Impella was associated with better clinical outcomes, fewer complications, shorter length of hospital stay and lower hospital cost compared to those undergoing ECMO placement.
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http://dx.doi.org/10.1016/j.carrev.2020.05.042DOI Listing
December 2020

Machine-Learning-Based In-Hospital Mortality Prediction for Transcatheter Mitral Valve Repair in the United States.

Cardiovasc Revasc Med 2021 Jan 15;22:22-28. Epub 2020 Jun 15.

Center for Collaborative Research in Health Disparities, University of Puerto Rico School of Medicine, San Juan, PR, USA.

Background: Transcatheter mitral valve repair (TMVR) utilization has increased significantly in the United States over the last years. Yet, a risk-prediction tool for adverse events has not been developed. We aimed to generate a machine-learning-based algorithm to predict in-hospital mortality after TMVR.

Methods: Patients who underwent TMVR from 2012 through 2015 were identified using the National Inpatient Sample database. The study population was randomly divided into a training set (n = 636) and a testing set (n = 213). Prediction models for in-hospital mortality were obtained using five supervised machine-learning classifiers.

Results: A total of 849 TMVRs were analyzed in our study. The overall in-hospital mortality was 3.1%. A naïve Bayes (NB) model had the best discrimination for fifteen variables, with an area under the receiver-operating curve (AUC) of 0.83 (95% CI, 0.80-0.87), compared to 0.77 for logistic regression (95% CI, 0.58-0.95), 0.73 for an artificial neural network (95% CI, 0.55-0.91), and 0.67 for both a random forest and a support-vector machine (95% CI, 0.47-0.87). History of coronary artery disease, of chronic kidney disease, and smoking were the three most significant predictors of in-hospital mortality.

Conclusions: We developed a robust machine-learning-derived model to predict in-hospital mortality in patients undergoing TMVR. This model is promising for decision-making and deserves further clinical validation.
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http://dx.doi.org/10.1016/j.carrev.2020.06.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736498PMC
January 2021

Comparison of Outcomes of Alcohol Septal Ablation or Septal Myectomy for Hypertrophic Cardiomyopathy in Patients ≤65 Years Versus >65 Years.

Am J Cardiol 2020 07 22;127:128-134. Epub 2020 Apr 22.

Department of Cardiology, Henry Ford Hospital, Detroit, Michigan.

Alcohol septal ablation (ASA) and septal myectomy (SM) are therapeutic interventions for patients with hypertrophic cardiomyopathy (HC) who remain symptomatic despite medical treatment. Outcomes for both interventions in age groups ≤65 versus >65 years are scarce. We queried the National Readmission Database for adult patients undergoing either SM or ASA between 2010 and 2015 for HC. Patients were divided into 2 age-groups (≤65-years and >65-years). We aimed to compare the in-hospital mortality, complication rates, and resource utilization for each procedure between the 2 age-groups. We identified 4,358 patients with HC who underwent intervention, of which 2,113 were treated with SM and 2,245 with ASA. In-hospital mortality was 6-times higher in patients ≤65 years old who underwent SM compared with ASA (1.5% vs 0.3% odds ratio 6.2; p = 0.04); and 4-times higher in patients >65 years treated with SM compared with ASA (6.7% vs 1.7% odds ratio 4.29; p = 0.04). Blood transfusion rates and stroke were higher in patients undergoing SM, regardless of their age-group. Length of hospital stay was lower in the ASA group (3 days vs 6 days for both age groups, p <0.001) as well as median hospital costs (≤65 years old: $15,474 vs $31.531; and >65 years old: $16,672 vs $36,042, p <0.001). In conclusion, patients with HC treated with ASA had significantly lower in-hospital mortality, complications rates, length of hospital stay, and hospital costs compared with patients undergoing SM at any age.
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http://dx.doi.org/10.1016/j.amjcard.2020.04.018DOI Listing
July 2020

Safety and Effectiveness of MANTA Vascular Closure Device After Large-Bore Mechanical Circulatory Support: Real-World Experience.

Cardiovasc Revasc Med 2020 07 4;21(7):875-878. Epub 2020 Apr 4.

Division of Cardiology, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA; Wayne State University School of Medicine, Detroit, MI, USA. Electronic address:

Background: Real world safety and effectiveness of MANTA vascular closure device (VCD) for large bore arteriotomy closure after decannulation of mechanical circulatory support (MCS) devices is not known.

Methods: All consecutive patients who underwent large bore arteriotomy closure with MANTA VCD following decannulation of MCS between February to October 2019 at a large tertiary care academic medical center were included. Safety and effectiveness of MANTA VCD was assessed on immediate post-closure angiogram for 23 access sites, and immediate post-closure duplex arterial ultrasound or manual vascular examination for 1 access site each. Technical success was defined as achievement of arteriotomy closure in absence of major bleeding or access site endovascular or surgical intervention.

Results: A total of 25 MANTA VCD were placed in 22 unique patients by 7 different operators. A 14 Fr or 18 Fr MANTA VCD was used in 15 (60%) and 10 (40%) of deployments, respectively via transfemoral (n = 23, 92%) or transaxillary (n = 2, 8%) access. Technical success was achieved in 24 of 25 (96%) cases. Minor access site bleeding occurred in 3 patients (12%) and failure of MANTA VCD with major access site bleeding occurred in 1 patient (4%) requiring endovascular balloon tamponade. No cases of retroperitoneal bleeding, collagen plug embolization, covered stent placement, or surgical vascular repair were observed.

Conclusion: In this single center experience, the use of MANTA VCD for large bore arteriotomy closure following percutaneous decannulation of MCS devices appears to be safe and effective. Larger multicenter studies of efficacy, safety, and cost-effectiveness are needed.
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http://dx.doi.org/10.1016/j.carrev.2020.03.032DOI Listing
July 2020

Regional Variation in Procedural and Clinical Outcomes Among Patients With ST Elevation Myocardial Infarction With Cardiogenic Shock.

Am J Cardiol 2020 06 16;125(11):1612-1618. Epub 2020 Mar 16.

Division of Cardiology, Henry Ford Hospital, Detroit, Michigan.

There is limited data on regional differences in patient characteristics, practice patterns, and clinical outcomes in patients with ST elevation myocardial infarction (STEMI) with cardiogenic shock (CS) in the United States (US). We aimed to identify variations in treatment methods and clinical outcomes in patients with STEMI CS between the 4 US regions. Using the National Inpatient Sample database, we identified adult patients admitted with STEMI associated with CS between 2006 and 2015 using ICD-9-DM codes. Based on the US regions (Northeast, Midwest, South, and West), we divided patients in 4 cohorts and compared baseline patient characteristics, clinical outcomes and procedural outcomes. A total of 186,316 patients with STEMI CS were included; 32,303 (17.3%) were hospitalized in the Northeast, 43,634 (23.4%) in the Midwest, 70,036 (37.8%) in the South, and 40,043 (21.5%) in the West. Although nonstatistically significant, the in-hospital mortality was higher in Northeast region (37.7%), followed by the South (36.6%), West (35.7%), and Midwest (35.2%). Rates of percutaneous coronary intervention were higher in the Midwest (68.5%) and lower in the Northeast (56%). The use of percutaneous ventricular assist device and ECMO was higher in the Northeast (3.3% and 2.2%) and lower in the West (2.1% and 0.4%). The median length of stay was similar among all 4 cohorts (6 days) but median hospital costs were higher in the West ($36, 614) and lower in the South ($28,795). In conclusion, there are significant geographic variations in practice patterns, healthcare cost, and in-hospital outcomes in patients with STEMI complicated by CS between 4 US regions.
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http://dx.doi.org/10.1016/j.amjcard.2020.02.033DOI Listing
June 2020

Functional Tricuspid Regurgitation: Analysis of Percutaneous Transcatheter Techniques and Current Outcomes.

J Cardiothorac Vasc Anesth 2021 Mar 28;35(3):921-931. Epub 2020 Feb 28.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN. Electronic address:

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http://dx.doi.org/10.1053/j.jvca.2020.02.036DOI Listing
March 2021

Transseptal Puncture Through an Amplatzer Atrial Septal Occluder for Edge-to-Edge Repair With MitraClip NTr System.

Cardiovasc Revasc Med 2020 Nov 28;21(11S):63-64. Epub 2020 Feb 28.

Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI, USA.

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http://dx.doi.org/10.1016/j.carrev.2020.02.021DOI Listing
November 2020

Transcatheter Mitral Valve Repair and Replacement: Analysis of Recent Data and Outcomes.

J Cardiothorac Vasc Anesth 2020 Oct 15;34(10):2793-2806. Epub 2020 Jan 15.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN. Electronic address:

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http://dx.doi.org/10.1053/j.jvca.2020.01.009DOI Listing
October 2020

The Low Risk Transcatheter Aortic Valve Replacement Trials-An Analysis.

J Cardiothorac Vasc Anesth 2020 Nov 25;34(11):3133-3138. Epub 2020 Jan 25.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MI. Electronic address:

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http://dx.doi.org/10.1053/j.jvca.2020.01.039DOI Listing
November 2020

Increased Risk of Perioperative Ischemic Stroke in Patients Who Undergo Noncardiac Surgery with Preexisting Atrial Septal Defect or Patent Foramen Ovale.

J Cardiothorac Vasc Anesth 2020 Aug 16;34(8):2060-2068. Epub 2020 Jan 16.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ. Electronic address:

Objectives: To evaluate whether a preoperative diagnosis of atrial septal defect (ASD) or patent foramen ovale (PFO) is associated with perioperative stroke in noncardiac surgery and their outcomes.

Design: Retrospective cohort analysis.

Setting: United States hospitals.

Participants: Adults patients (≥18 years old) who underwent major noncardiac surgery from 2010 to 2015 were identified using the Healthcare Cost and Utilization Project's National Readmission Database.

Interventions: Preoperative diagnosis of ASD or patent foramen ovale.

Measurements And Main Results: Among the 19,659,161 hospitalizations for major noncardiac surgery analyzed, 12,248 (0.06%) had a preoperative diagnosis of ASD/PFO. Perioperative ischemic stroke occurred in 723 (5.9%) of patients with ASD/PFO and 373,291 (0.02%) of those without ASD/PFO (adjusted odds ratio [aOR], 16.7; 95% confidence interval [CI]: 13.9-20.0). Amongst the different types of noncardiac surgeries, obstetric, endocrine, and skin and burn surgery were associated with higher risk of stroke in patients with pre-existing ASD/PFO. Moreover, patients with ASD/PFO also had an increased in-hospital mortality (aOR, 4.6, 95% CI: 3.6-6.0), 30-day readmission (aOR, 1.2, 95% CI: 1.04-1.38), and 30-day stroke (aOR, 7.2, 95% CI: 3.1-16.6). After adjusting for atrial fibrillation, ischemic stroke remained significantly high in the ASD/PFO group (aOR: 23.7, 95%CI 19.4-28.9), as well as in-hospital mortality (aOR: 5.6, 95% CI 4.1-7.7), 30-day readmission (aOR: 1.19, 95%CI 1.0-1.4), and 30-day stroke (aOR: 9.3, 95% CI 3.7-23.6).

Conclusions: Among adult patients undergoing major noncardiac surgery, pre-existing ASD/PFO is associated with increased risk of perioperative ischemic stroke, in-hospital mortality, 30-day stroke, and 30-day readmission after surgery.
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http://dx.doi.org/10.1053/j.jvca.2020.01.016DOI Listing
August 2020

Meta-Analysis of Hospital-Volume Relationship in Transcatheter Aortic Valve Implantation.

Heart Lung Circ 2020 Jul 9;29(7):e147-e156. Epub 2019 Dec 9.

Department of Medicine, Division of Cardiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

Background: Whether a volume-outcome relationship, that is, higher volume centres have better outcomes compared with lower volume hospitals, exists in transcatheter aortic valve implantation (TAVI) has not yet been systematically explored.

Methods: We performed a systematic review and meta-analysis to evaluate whether highest or intermediate annual TAVI volume hospitals has better short-term (in-hospital or 30-days) mortality compared with the lowest volume hospitals. Odds ratio (OR) and 95% confidence interval (CI) was calculated with the Mantel-Haenszel method.

Results: We identified 10 publications from nine different countries including TAVI performed between 2005-2017. Included patients were mainly high-risk cohorts. We included five and six studies to assess volume-outcome relationship in the highest and intermediate volume hospitals compared with the lowest volume hospitals, respectively. Our results showed that in both the highest (OR 0.66, 95%CI 0.53-0.83, p=0.0003, I=78%) and intermediate (OR 0.85, 95%CI 0.79-0.92, p<0.0001, I=0%) volume hospitals, there was a statistically significant volume-outcome relationship for short-term mortality compared with the lowest volume hospitals.

Conclusions: Our review suggests a significant volume-outcome relationship post-TAVI in both the highest and intermediate volume hospitals compared with the lowest volume hospitals mainly in high surgical risk patients. The high heterogeneity in this relationship between the highest and the lowest volume hospitals warrant cautious interpretation. Whether this relationship remains significant in low-risk cohort requires further study.
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http://dx.doi.org/10.1016/j.hlc.2019.10.016DOI Listing
July 2020

The "Snare-and-Anchor" Technique to Rescue Frozen Mechanical Mitral Valve Leaflet After Transcatheter Aortic Valve Replacement.

JACC Cardiovasc Interv 2020 05 12;13(9):e77-e78. Epub 2020 Feb 12.

Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2019.12.009DOI Listing
May 2020

Comparison of Incidence and Outcomes of Cardiogenic Shock Complicating Posterior (Inferior) Versus Anterior ST-Elevation Myocardial Infarction.

Am J Cardiol 2020 04 7;125(7):1013-1019. Epub 2020 Jan 7.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Cardiovascular Research Foundation, New York, New York. Electronic address:

Cardiogenic shock (CS) is a catastrophic consequence of ST-elevation myocardial infarction (STEMI). CS has been reported to be associated less often with inferior wall (IWMI) than anterior wall STEMI (AWMI). We queried the National Inpatient Sample databases from January 2010 to September 2015 to identify all patients aged ≥18 years admitted with AWMI or IWMI. Patients with a concomitant diagnosis of CS were then identified. Complex samples multivariable logistic regression models were used to compare the incidence, management, and in-hospital mortality of CS complicating IWMI versus AWMI. The incidence of CS was lower in IWMI (9.5%) versus AWMI (14.1%), adjusted OR (aOR) 0.84 (95% confidence interval [CI] 0.81 to 0.87). Revascularization rates with either percutaneous coronary intervention or coronary artery bypass grafting were similar in CS complicating IWMI versus AWMI (80.9% vs 80.3%; aOR 1.05; 95% CI 0.97 to 1.14). The reported use of percutaneous mechanical circulatory support devices was lower in patients with CS-IWMI versus CS-AWMI (44.7% vs 61.0%; aOR 0.55; 95% CI 0.52 to 0.59). In-hospital mortality was modestly lower in patients with CS complicating IWMI versus AWMI (30.3% vs 31.9%; aOR, 0.80; 95% CI 0.75 to 0.86). Use of percutaneous mechanical circulatory support was not associated with lower in-hospital mortality in either CS-AWMI (30.0% vs 34.7; aOR 1.04; 95% CI 0.94 to 1.14) or CS-IWMI (31.0% vs 29.8%; aOR 1.20; 95% CI 1.08 to 1.33). In conclusion, the incidence of CS in the contemporary era is lower in patients with IWMI compared with those with AWMI. CS complicating STEMI is associated with higher in-hospital mortality in AWMI versus IWMI, and outcomes were not different with or without percutaneous circulatory support.
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http://dx.doi.org/10.1016/j.amjcard.2019.12.052DOI Listing
April 2020

Using the Arm for Structural Interventions: Case Selection or Wave of the Future.

Interv Cardiol Clin 2020 01 21;9(1):63-74. Epub 2019 Oct 21.

Center for Structural Heart Disease, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA.

The transradial approach has emerged as the preferred alternative to the traditional transfemoral approach owing to the increased evidence of its safety and efficacy. The field of structural heart disease is rapidly evolving; however, periprocedural complications related to access site remain a major determinant of morbidity and mortality. The transradial approach as primary or secondary access site in structural heart interventions like transcatheter aortic valve replacement, balloon aortic valvuloplasty, alternative access, alcohol septal ablations, paravalvular leak, valve snaring, coronary protection, and ventricular septal defect is feasible, safe, with lower vascular complications and high procedural success.
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http://dx.doi.org/10.1016/j.iccl.2019.08.007DOI Listing
January 2020

The changing landscape of aortic valve replacement in the USA.

EuroIntervention 2019 12 6;15(11):e968-e974. Epub 2019 Dec 6.

Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Aims: The aim of this study was to analyse the real-world national data on parallel utilisation of transcatheter (TAVR) and surgical (SAVR) aortic valve replacement.

Methods And Results: We queried an all-payer, administrative United States in-patient database to identify all AVR hospitalisations in patients aged ≥18 years from January 2012 to December 2016 and examined the temporal changes in the number of AVR procedures and in-hospital mortality. A total of 463,675 AVRs were performed - 363,275 (78.4%) SAVR and 100,400 (21.6%) TAVR. AVR linearly increased (from 78,985 in 2012 to 103,415 in 2016; +30.9%; ptrend<0.001) largely due to a marked increase in TAVR (from 7,655 to 33,545; +338%; ptrend<0.001), whereas the absolute number of SAVRs remained relatively stable (from 71,330 to 69,870; -1%; ptrend<0.001). The number of TAVRs increased in all pre-specified age groups (<75, 75-79, 80-85, and ≥85 years; ptrend<0.001 for all). In contrast, the number of SAVRs increased modestly in patients aged <75 years (ptrend<0.001) and declined in those aged 75-79 years, 80-84 years, or ≥85 years (ptrend<0.001 for all). Age- and sex-adjusted in-hospital mortality after isolated (aOR 1.00 [0.95-1.05]; ptrend=0.96) or combined SAVR (aOR 1.01 [0.97-1.05]; ptrend=0.66) remained unchanged during the study period, whereas in-hospital mortality after TAVR declined (aOR 0.75 [0.70-0.79]; ptrend<0.001). Similar trends in in-hospital mortality were seen in the age subgroups.

Conclusions: The number of AVRs markedly increased in the USA from 2012 to 2016, mainly due to the widespread adoption of TAVR, whereas the number of SAVRs remained relatively stable. In-hospital mortality after TAVR declined, whereas that after SAVR has remained unchanged.
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http://dx.doi.org/10.4244/EIJ-D-19-00381DOI Listing
December 2019

Coronary artery aneurysms, insights from the international coronary artery aneurysm registry (CAAR).

Int J Cardiol 2020 01 19;299:49-55. Epub 2019 Jul 19.

Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.

Background: Coronary Aneurysms are a focal dilatation of an artery segment >1.5-fold the normal size of adjacent segments. Although some series have suggested a prevalence of 0.3-12%, data are lacking. In addition, they are not mentioned in practice guidelines. Our aim was investigate its prevalence, management and long-term outcomes.

Methods And Results: The coronary artery aneurysm registry (CAAR) involved 32 hospitals across 9 countries in America and Europe. We reviewed 436,467 consecutive angiograms performed over the period 2004-2016. Finally, 1565 patients were recruited. Aneurysm global prevalence was 0.35%. Most patients were male (78.5%) with a mean age of 65 years and frequent cardiovascular risk factors. The main indication for angiogram was an acute coronary syndrome, 966 cases. The number of aneurisms was ≤2 per patient in 95.8% of the cases, mostly saccular, most frequently found in the left anterior descending and with numbers proportional with coronary stenosis. Aortopathies were related with more aneurysms too. Most patients received any revascularization procedure (69%), commonly percutaneous (53%). After a median follow-up of 37.2 months, 485 suffered a combined event (MACE) and 240 died. Without major differences comparing CABG vs PCI, MACE and death were more frequent in patients who received bare metal stents.

Conclusions: Coronary artery aneurysms are not uncommon. Usually, they are associated with coronary stenosis and high cardiovascular risk. Antiplatelet therapy seems reasonable and a percutaneous approach is safe and effective.
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http://dx.doi.org/10.1016/j.ijcard.2019.05.067DOI Listing
January 2020

Percutaneous Mitral Valve Repair Vs. Stand-Alone Medical Therapy in Patients with Functional Mitral Regurgitation and Heart Failure.

Cardiovasc Revasc Med 2020 01 25;21(1):52-60. Epub 2019 Jun 25.

Department of Cardiology, University Hospital of León, León, Spain.

Background: Functional mitral regurgitation (FMR) is a common finding among patients with heart failure (HF) and it is related to adverse events. Outcomes in patients undergoing transcatheter mitral valve repair (TMVR) are still a matter of debate. We performed a meta-analysis to assess mid- and long-term outcomes of patients with FMR treated with MitraClip® compared to medical management.

Methods: We conducted an electronic database search of all published data PubMed Central, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases. The primary end-point was all-cause mortality. The secondary end-points were hospitalizations for HF, need for heart transplantation or left ventricular assist device, unplanned mitral valve surgery, myocardial infarction and stroke.

Results: Five studies (n = 1513 patients) were included in the analysis. The summary estimate including all the available studies showed a statistically significant reduction in all-cause mortality favoring MitraClip® (HR 0.56, CI 95% [0.38-0.84]) and HF hospitalizations (HR 0.65; CI 95% [0.46-0.92]). A significant reduction in the indication for advanced HF therapies (OR 0.48; CI 95% [0.25-0.90]) or the need for unplanned mitral valve surgery (OR 0.20; CI 95% [0.07-0.57]) was also found in the group of patients that underwent TMVR. No differences in the incidence of myocardial infarction or stroke were found between both groups of treatment. No publication bias was detected.

Conclusion: TMVR with MitraClip® system was related to a significant reduction in all-cause mortality, hospitalizations for HF and the need for HF transplant, left ventricular assist device or unplanned surgery beyond 1-year follow up.
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http://dx.doi.org/10.1016/j.carrev.2019.06.008DOI Listing
January 2020

Patent Foramen Ovale and Risk of Cryptogenic Stroke - Analysis of Outcomes and Perioperative Implications.

J Cardiothorac Vasc Anesth 2020 Mar 22;34(3):819-826. Epub 2019 Apr 22.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ. Electronic address:

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http://dx.doi.org/10.1053/j.jvca.2019.04.017DOI Listing
March 2020

Corrigendum to `Trends in Utilization of Surgical and Transcatheter Mitral Valve Repair in the United States☆' [The American Journal of Cardiology 123/7 (2019) 1187-1189].

Am J Cardiol 2019 Jul 26;124(1):168. Epub 2019 Apr 26.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Cardiovascular Research Foundation, New York, New York.

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http://dx.doi.org/10.1016/j.amjcard.2019.04.001DOI Listing
July 2019

Outcomes After Transcatheter Mitral Valve Repair in Patients With Renal Disease.

Circ Cardiovasc Interv 2019 02;12(2):e007552

Department of Cardiothoracic Surgery (Adult Cardiac Surgery) (M.R.W.), New York University School of Medicine.

Background: Renal disease is associated with poor prognosis despite guideline-directed cardiovascular therapy, and outcomes by sex in this population remain uncertain.

Methods And Results: Patients (n=5213) who underwent a MitraClip procedure in the National Cardiovascular Data Registry Transcatheter Valve Therapy registry were evaluated for the primary composite outcome of all-cause mortality, stroke, and new requirement for dialysis by creatinine clearance (CrCl). Centers for Medicare and Medicaid Services-linked data were available in 63% of patients (n=3300). CrCl was <60 mL/min in 77% (n=4010) and <30 mL/min in 23% (n=1183) of the cohort. Rates of primary outcome were higher with lower CrCl (>60 mL/min, 1.4%; 30-<60 mL/min, 2.7%; <30 mL/min, 5.2%; dialysis, 7.8%; P<0.001), and all low CrCl groups were independently associated with the primary outcome (30-<60 mL/min: adjusted odds ratio, 2.32; 95% CI, 1.38-3.91; <30 mL/min: adjusted odds ratio, 4.44; 95% CI, 2.63-7.49; dialysis: adjusted hazards ratio, 4.52; 95% CI, 2.08-9.82) when compared with CrCl >60 mL/min. Rates of 1-year mortality were higher with lower CrCl (>60 mL/min, 13.2%; 30-<60 mL/min, 18.8%; <30 mL/min, 29.9%; dialysis, 32.3%; P<0.001), and all low CrCl groups were independently associated with 1-year mortality (30-<60 mL/min: adjusted hazards ratio, 1.50; 95% CI, 1.13-1.99; <30 mL/min: adjusted hazards ratio, 2.38; 95% CI, 1.78-3.20; adjusted hazards ratio: dialysis, 2.44; 95% CI, 1.66-3.57) when compared with CrCl >60 mL/min.

Conclusions: The majority of patients who undergo MitraClip have renal disease. Preprocedural renal disease is associated with poor outcomes, particularly in stage 4 or 5 renal disease where 1-year mortality is observed in nearly one-third. Studies to determine how to further optimize outcomes in this population are warranted.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.118.007552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6839891PMC
February 2019

Trends in Utilization of Surgical and Transcatheter Mitral Valve Repair in the United States.

Am J Cardiol 2019 04 16;123(7):1187-1189. Epub 2019 Jan 16.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Cardiovascular Research Foundation, New York, New York.

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http://dx.doi.org/10.1016/j.amjcard.2019.01.005DOI Listing
April 2019

Predictors of Hospital Cost After Transcatheter Aortic Valve Implantation in the United States: From the Nationwide Inpatient Sample Database.

Am J Cardiol 2019 04 8;123(7):1142-1148. Epub 2019 Jan 8.

Wayne State University/Detroit Medical Center, Detroit, Michigan. Electronic address:

We aimed to identify risk factors of high hospitalization cost after transcatheter aortic valve implantation (TAVI). TAVI expenditure is generally higher compared with surgical aortic valve replacement. We queried the Nationwide Inpatient Sample database from January 2011 to September 2015 to identify those who underwent endovascular TAVI. Estimated cost of hospitalization was calculated by merging the Nationwide Inpatient Sample database with cost-to-charge ratios available from the Healthcare Cost and Utilization Project. Patients were divided into quartiles (lowest, medium, high, and highest) according to the hospitalization cost, and multivariable regression analysis was performed to identify patient characteristics and periprocedural complications associated with the highest cost group. A total of 9,601 TAVI hospitalizations were identified. Median in-hospital costs of the highest and lowest groups were $82,068 and $33,966, respectively. Patients in the highest cost group were older and more likely women compared with the lowest cost group. Complication rates (68.4% vs 22.5%) and length of stay (median 10 days vs 3 days) were both approximately 3 times higher and longer, respectively, in the highest cost group. Co-morbidities such as heart failure, peripheral vascular disease, atrial fibrillation, anemia, and chronic dialysis as well as almost all complications were associated with the highest cost group. The complications with the highest incremental cost were acute respiratory failure requiring intubation ($28,209), cardiogenic shock ($22,401), and acute kidney injury ($16,974). Higher co-morbidity burden and major complications post-TAVI were associated with higher hospitalization costs. Prevention of these complications may reduce TAVI-related costs.
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http://dx.doi.org/10.1016/j.amjcard.2018.12.044DOI Listing
April 2019

Meta-Analysis Comparing the Incidence of Infective Endocarditis Following Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement.

Am J Cardiol 2019 03 3;123(5):827-832. Epub 2018 Dec 3.

Department of Medicine Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa, Iowa.

Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) is a rare but life-threatening complication. Paravalvular regurgitation, compression of native leaflets, and space between transcatheter valve prosthesis and native valves could dispose TAVI recipients at increased risk of IE compared with SAVR. To assess the comparative risk of IE between TAVI and SAVR, we performed a systematic review and meta-analysis. A literature search of PUBMED and EMBASE was performed to identify randomized controlled trials that reported the event rate of IE in both TAVI and SAVR. A Mantel-Haenszel method and a random-effects model was used to calculate the odds ratio (OR) and 95% confidence interval (CI). The studied outcomes were early (at 1-year), late (>1-year), and overall IE (postprocedure to longest follow-up) in TAVI versus SAVR. We performed subgroup analysis based on valve-type (self or balloon-expandable) and surgical risk (high or intermediate). A total of 4 studies with 3,761 (1,895 TAVI and 1,866 SAVR) patients were included. The incidence of early IE, (3 studies, 0.86% vs 0.73%, OR 1.17, 95% CI 0.51 to 2.65, p = 0.71, I = 0%), late IE (mean follow-up 2.0 years) (3 studies, 1.3% vs 0.6%, OR 1.85, 95% CI 0.81 to 4.20, p = 0.42, I = 0%), and overall IE (mean follow-up 3.4 years) (4 studies, 2.0% vs 1.3%, OR 1.44, 95% CI 0.85 to 2.43, p = 0.18, I = 0%) was similar between TAVI and SAVR. Subgroup analysis suggested that in intermediate surgical risk cohort, there was a trend toward increased risk of overall IE in TAVI (2.3% in TAVI and 1.2% in SAVR, OR 1.92, 95% CI 0.99 to 3.72, p = 0.05 I = 0%). In this meta-analysis, we did not find an increased risk of IE in TAVI compared with SAVR. Appropriate preventative measure and early recognition of IE in these cohorts are important.
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http://dx.doi.org/10.1016/j.amjcard.2018.11.031DOI Listing
March 2019

Transradial versus transfemoral percutaneous coronary intervention of left main disease: A systematic review and meta-analysis of observational studies.

Catheter Cardiovasc Interv 2019 08 10;94(2):264-273. Epub 2018 Dec 10.

Department of Medicine Division of Cardiology, North Shore University Hospital, Hofstra Northwell School of Medicine, New York.

Objectives: To assess the efficacy and safety of transradial (TR) versus transfemoral (TF) percutaneous coronary intervention (PCI) in left main (LM) lesion.

Background: TR-PCI is the preferred approach compared with TF approach because of less bleeding risk. LM-PCI is often challenging because of the anatomical complexity and uniqueness of supplying a large myocardium territory. We performed a systematic review and meta-analysis to assess the safety and efficacy of TR-PCI compared with TF-PCI of the LM lesions.

Methods: A comprehensive literature search of PUBMED, EMBASE, and Cochrane database was conducted to identify studies that reported the comparable outcomes between both approaches. Odds ratio (OR) and 95% confidence interval (CI) was calculated using the Mantel-Haenszel method.

Results: A total of eight studies were included in the quantitative meta-analysis. TR-PCI resulted in lower bleeding risk (OR 0.31, 95%CI 0.18-0.52, P < 0.01, I = 0%) while maintaining similar procedural success rate, target lesion revascularization, myocardial infarction, stent thrombosis, and all-cause mortality during the study follow-up period.

Conclusions: TR-PCI may achieve similar efficacy with decreased bleeding risk compared to TF-PCI in LM lesions. When operator experience and anatomical complexity are favorable, TR approach is an attractive alternative access over TF approach in LM-PCI.
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http://dx.doi.org/10.1002/ccd.28025DOI Listing
August 2019