Well, I am coming up on 15 years 8/23/2018. My Latest CT/Angio says everything is still stable verified by the U of W team and my buddy at Stanford. But… my valve is still leaking moderately, but…..My left ventricle is getting enlarged somewhat. I am now going to get a second opinion at Swedish Hospital. I am thinking that the suctureless value with the minimally invasive technique where they don’t have to cut your entire sternum would be great. Also, less time on the Heart Lung Machine too and quicker recovery.
Transthoracic Echocardiogram 3/15/2018:
Bicuspid aortic valve (fusion of right and left coronary cusps) with moderate regurgitation and an antegrade velocity of 1.9 m/s.
Severe left ventricular dilation (EDVI 110 ml/m2, ESVI 40 ml/m2) with normal systolic function, EF 64%.
Dilated aortic sinuses, 4.3 cm diameter. Ascending aortic graft not well seen. Diastolic flow reversal seen in the descending thoracic aorta. The aorta would be better imaged by CT or MRI.
Normal estimated pulmonary systolic pressure, 28 mm Hg.
Normal right ventricular size and systolic function.
Compared to 12/10.2015, aortic regurgitant severity is similar with an increase in LV EDVI from 89 to 110 and ESVI from 34 to 40 ml/m2.
ice of Catherine M Otto, MD
04/05/2018 10:00 AM
RE: Latest Echo
Dear Mr. Tinsley,
The echocardiogram shows the degree of aortic valve regurgitation remains the same and is moderate. The size of the aorta is also unchanged. These results are reassuring. We look forward to seeing you in clinic next month.
Predictors of acute aortic dissection diagnosis identified
Ohle R, et al. Acad Emerg Med. 2018;doi:10.1111/acem.13356.
April 11, 2018
Aortic aneurysm and hypotension were among the clinical features identified as putting patients at high risk for acute aortic dissection in a case-control study.
Robert Ohle, MSc, MA, MB, FRCPC, from the department of emergency medicine, the Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada, and colleagues conducted a historical matched case-control study of adults presenting to two tertiary care EDs or one regional cardiac referral center with possible acute aortic dissection between 2002 and 2014.
When to Intervene in Aortic Dissection
TEVAR may be preferable to medical management in…
Aortic valve replacement procedures increased in…
The researchers analyzed 194 patients with nontraumatic acute aortic dissection confirmed by CT or echocardiography and 776 age- and sex-matched controls who had a triage diagnosis of truncal pain but no clear diagnosis upon basic investigation (mean age, 65 years; 67% men).
Ohle and colleagues found that acute aortic dissection could be ruled out by absence of abrupt-onset pain (sensitivity = 95.9%; negative likelihood ratio = 0.07; 95% CI, 0.03-0.14).
They determined the following factors can help rule in a diagnosis of acute aortic dissection:
presence of tearing/ripping pain (specificity = 99.7%; positive likelihood ratio = 42.1; 95% CI, 9.9-177.5);
aortic aneurysm (specificity = 97.8%; positive likelihood ratio = 6.35; 95% CI, 3.54-11.42);
hypotension (specificity = 98.7%; positive likelihood ratio = 17.2; 95% CI, 8.8-33.6);
pulse deficit (specificity = 99.3%; positive likelihood ratio = 31.1; 95% CI, 11.2-86.6);
neurologic deficits (specificity = 96.9%; positive likelihood ratio = 5.26; 95% CI, 2.9-9.3); and
a new murmur (specificity = 97.8%; positive likelihood ratio = 9.4; 95% CI, 5.5-16.2).
“Patients with one or more high-risk feature … should be considered high risk, whereas patients with no high-risk and multiple low-risk features (absence of abrupt-onset pain, history of ischemic heart disease and diabetes) are at low risk for acute aortic dissection,” the researchers wrote.
History of ischemic heart disease decreased the probability of an acute aortic dissection diagnosis, but this was “likely due to it being a risk factor for an alternative diagnosis such as acute coronary dissection,” Ohle and colleagues wrote.
“Ohle [and colleagues] have done a great job at telling us how acute aortic dissection presents to emergency departments,” Lane McNeil Smith, MD, PhD, assistant professor, Lexington Emergency Medicine, Wake Forest Baptist Health, said in a press release. “Are we finally on the verge of a decision rule for this disease that improves our miss rate without ballooning nontherapeutic imaging and costs? This study is a step in the right direction and the authors are in a good position to find the right balance of improved accuracy and increased cost.” – by Erik Swain
Disclosures: The authors and Smith report no relevant financial disclosures.
At ISET 2018, Michael Dake summed up the unmet clinical needs for type A and chronic type B dissection, as well as for cases with arch involvement.
OLLYWOOD, FL—Aortic dissection continues to vex clinicians, but creative approaches to treatment are on the horizon, according to one expert in the field.
Michael Dake, MD (Stanford University, CA), who gave a rundown of what’s coming next at the International Symposium on Endovascular Therapy 2018 here, said that while the US Food and Drug Administration broadly approved thoracic endovascular aortic repair (TEVAR) for use in all type B dissections back in 2013, such “‘blanket approval’ comprises a number of different distinct entities associated with type B dissection—complicated, chronic, uncomplicated—all these things.”
Chronic type B dissection “stands out,” Dake said, as a poor fit for TEVAR. Good results are possible but not guaranteed, he continued. There may be continued perfusion and aneurysm degeneration distal to the treated area. Adjunctive false-lumen techniques, from coils to liquid embolics, abound, Dake acknowledged, “but there’s nothing definitive . . . that really can take care of this,” and branched devices involve “long procedures [with] high radiation and still carry significant frequency of endoleaks and complications.”
Instead, converting the type B dissection to aneurysm seems to be the best solution in the near term, Dake said.
Among the type B dissection subsets, “there’s a lot of not-so-subtle differences” that must be considered when thinking about “new horizons,” he observed. Additionally, there are many unanswered questions and unmet clinical needs, Dake said. For instance, he reported, half of attendees polled at last year’s Houston Aortic Symposium said they’d continue medical therapy in a patient with acute uncomplicated type B aortic dissection who was asymptomatic, while 48% chose TEVAR. “That’s a flip of a coin. We have complete equipoise here,” he stressed.
Over the last decade there’s been an attempt to find ways to predict which patients will have disease progression and late aortic events or mortality, in order to “justify a rationale of treating them early” when needed, Dake said. Numerous factors have been identified: aorta and false lumen size, use of calcium channel blockers, gender, age, ulcer-like projections, and the size, location, and number of tears, among other things.
“So, can we predict who is at high risk of expansion or late complications? Yes, we can, but we’re just not very accurate, and there’s a confusing array of too many predictors,” Dake said. Adding a single high-risk factor, specifically aortic diameter > 45 mm, to the scenario posed in the Houston poll tipped the scales, he reported. With that, fully 94% of those present recommended TAVR.
Importantly, though, it’s a question not just of who we should treat but also who we shouldn’t treat, according to Dake. He suggested that medical therapy is the best route for some patients, such as those with chronic type B dissection, connective tissue disease, or a need for chronic anticoagulation, or in cases where there’s unsuitable or unreconstructable access to the aorta. “There are pathology considerations, there are anatomic considerations,” he emphasized.
Who Can We Treat Better?
For dissection with arch involvement, another area in need, one potential solution may be the TAG thoracic branch endoprosthesis (Gore), which Dake and others are currently studying in a pivotal trial. He reported that 58 patients with type B dissection have been treated so far, with two strokes occurring (3.4%), both late.
Lastly, for type A dissection, Gore is conducting an early feasibility study to test a dedicated device, he said.
“A little more on the horizon is this idea of a combined valve conduit including the ascending aorta married to an endovascular valve,” Dake said. Despite proof-of-concept and first-in-human studies, he added, “it’s something that’s not ready for prime time.”
Until these efforts bear fruit, the “current focus of endovascular dissection management is expanding to include not only who we should treat, but who we should treat better,” he concluded. “[For example, the field is moving to increase our prognostic scope beyond how to assess the individual risk to a patient with uncomplicated type B dissection toward how to best predict the risk of disease progression after TEVAR.”
Our family doctor smiled at me sheepishly as he walked into the exam room.
“You’re the last person I would have expected…,” he said trailing off, as I sat there for a check-up two weeks after emergency open heart surgery that saved my life.
Six months earlier, I had passed my annual physical with flying colors.
Years of aerobics, spinning, distance cycling and wrangling a 90 pound Golden Retriever on treks through the woods had left me in good stead. At 62, my heart was strong. My blood pressure was well within the bounds of normal. Everything looked fine.
Then we got to Labor Day.
Around noon, I went to my plot at the community garden about a mile from home to harvest the final fruits of summer for a cookout that evening. When I bent down I felt a sudden excruciating pain shoot through my sternum, up the side of my neck, around my ear and down my jaw.
It lasted maybe five seconds.
I thought about calling for help, but I didn’t collapse. I wasn’t short of breath and my chest didn’t hurt.
So, I gathered my harvest and headed home.
Later that afternoon, I began to feel nauseous. By the time we put the steaks on the grill, I couldn’t stand the smell of food.
My sister, who has been a nurse for years, called to chat and asked about my day.
When I told her what was going on, she was quick to respond.
“You’ve just described the symptoms of a heart attack in a woman. You need to get to the emergency room now,” she said.
When I balked, protesting that the ER would be too busy on a holiday weekend and said I would gladly go in the morning, she doubled down.
“You’ll be dead in the morning,” she said, growing angry at my reticence.
I’ll be wearing red on Friday for Go Red for Women Day, to raise awareness about women’s heart health, and I’m glad I listened to her.
After sitting in the ER for several hours, physicians baffled at my condition ordered a CT scan.
Shortly after the test, a doctor with a horrified look on his face came in and told me I needed to get to Pittsburgh, now.
It wasn’t a heart attack. My heart was fine. But I had suffered a thoracic aortic aneurysm dissection. A weak spot in the biggest artery in my body — the one in which oxygenated blood flows from the heart to nourish the rest of the body — had given out and I was slowly dying.
Within an hour, I was on a helicopter headed for UPMC Shadyside. A surgical team met me in the operating room in the early hours of the morning. They quickly sawed open my chest, stitched a Dacron patch around my aorta and closed me back up.
I’m told the patch should last a lifetime.
We’ve since learned that this condition tends to run in families. Doctors don’t know exactly what gene or genes hold the key to it, but they’ve seen patterns sufficient to raise red flags. In my case, it has emerged over the past 20 years as first my youngest son was diagnosed with an enlarged aorta and more recently as both my mother and her older sister had to have surgery for thoracic aortic aneurysms in their early 80s.
My surgeon assured me my heart was strong and I would recover quickly.
Four days later, I was back home. Within six weeks, I was able to complete a 5K around the track beside the Aerobic Center in Greensburg.
But as I said earlier, I’ll be wearing red this Friday. I’m aware that no one is invincible.
I had a sister who knew how heart issues manifested in women. We all should be so lucky.
Debra Erdley is a Tribune-Review staff writer. Reach her at 412-320-7996, firstname.lastname@example.org or via Twitter @deberdley_trib.
DALLAS– At the young age of 35 years-old, Mary Worthman is a wife, a mom, and a miracle — because she’s alive.
Click that article source button to watch the video please.
Surgeons saved Mary’s life of last year. Now, the Fort Worth woman is opening her heart, again. But, this time it’s to say thank you.
Mary had an aortic dissection, basically a tear in her heart. Most people who have one of those don’t ever even make it to the hospital. But, Mary did. And doctors saved her life.
Two open heart surgeries later, she’s meeting the doctors and nurses who saved her life.
“How the heck are you, Doc?” asks Mary’s husband as he grabs Dr. Michael Nazarian’s hand for a firm handshake. “Good to see you; you get a hug.” Dr. Narzarian tells Mary. “Aww, thanks.” she responds as she hugs him back.
“I try and not to focus on the things I can’t do, just be grateful that I am here and everything.” Mary tells the doctor and nurses.
“It’s always cool,” Dr. Narzarian says. “For me, that’s the fun. like you get to meet people in some very precarious situations, where they are in life-threatening situations, and you help them through it. And when results are good, which they usually are, it’s great.”
[dropcap]I[/dropcap] am basically drowning in debt. It’s 100% my fault and my lack of financial stupidity. However, I am also aware this was also tied to my depression and my days of buying and selling tennis racket are over. I finally had a come to Jesus meeting and have adopted the Dave Ramsey plan of getting out of debt. My problem is that I can’t quite start, meaning I am not bringing enough in to cover my bills. Again, my problem not your -my own lack of responsibility. But, I am now 1000% committed to getting myself and family out of dept. It’s been all my fault for my careless spending on crap. I have nothing to really show for it. No fancy house, no fancy cars, absolutely really nothing.
If you are a person that has ever considered about wanting to help out someone who really needs it, then I am that person. I have been running this site for 14 years now and paid for it all by myself. I ONLY would ask if you are that person (s) that feels it in your heart to share some love with a donation, that would be wonderful. Again, don’t feel sorry for me please. I got myself into this, I MUST get myself out of it.
My address for mailing is:
2921 101st Place SE, Everett, WA 98208
Or I have a GO FUND ME button to click as another option to donate to the site. Again, not mandatory and ONLY, and ONLY if your financial situation permits it. Don’t sacrifice your family’s financial obligations to help me please. Only if you are in a situation where you have the ability to offer a donation. 🙂
In summary, I don’t know who you might be, but if you feel it in your heart and you are not sacrificing anything from your own family, it would be wonderful!
May the GOOD LORD richly bless you! And I hope your AD is doing well. I am due for a CT/Angio on 2/14/18. It will be 15 years on 8/22/18 since my AD Ascending dissection date.
I hope I am still remaining stable. I know my heart valve is at a moderate leak and starting to wonder if the reason I am so tired is perhaps the leaking? I will be getting an echo soon too!
Dumfarth J, et al. – Researchers aimed at identifying the predictors for stroke after emergent surgery for acute type A aortic dissection. In addition, they analyzed the impact on morbidity, neurological recovery and mid-term survival. Independent preoperative predictors for postoperative stroke were recognized. Despite an association of postoperative stroke with significant morbidity and postoperative complications, data could not confirm a significant impairment in mid-term survival. Data revealed that postoperative stroke was associated with significant morbidity and postoperative complications, however, its association with significant impairment in mid-term survival could not be confirmed.
Three hundred and three (71.9% men, mean age 58.9 ± 13.6 years) patients with acute type A aortic dissection underwent surgical repair from 2000 and 2017.
Retrospective evaluation of clinical and imaging data was performed.
Depending on the presence of postoperative stroke, patients were divided into 2 groups.
In 15.8% (n = 48) of the patients, researchers detected postoperative stroke.
Among patients with postoperative stroke, higher rates of preoperative cardiopulmonary resuscitation (stroke: 18.8% vs no stroke: 3.5%, P < 0.001) and malperfusion syndrome (stroke: 47.9% vs no stroke: 22.4%, P < 0.001) were evident.
As per multivariable analysis, independent predictors for postoperative stroke included the presence of bovine aortic arch [odds ratio (OR) 2.33, 95% confidence interval (CI) 1.086–4.998; P=0.030], preoperative cardiopulmonary resuscitation (OR 6.483, 95% CI 1.522–27.616; P=0.011) and preoperative malperfusion (OR 2.536, 95% CI 1.238–5.194; P=0.011).
Postoperative stroke was found to have a strong impact on morbidity and was correlated with greater rates of postoperative complications and a markedly longer hospital stay (stroke: 23 ± 16 days vs no stroke: 17 ± 18 days, P=0.021).
No independent association was observed between postoperative stroke and in-hospital mortality (adjusted OR 1.382, 95% CI 0.518–3.687; P=0.518).
Patients with stroke and patients without stroke showed no difference in terms of mid-term survival.
The diagnosis of acute aortic dissection (AD) can be difficult because of its rarity and varied presentation, and this often leads to underdiagnosis. Recent guidelines from both the United States (American Heart Association and American College of Cardiology)1 and Europe (European Society of Cardiology)2 have made recommendations on diagnostic algorithms to improve care.
The American Heart Association/American College of Cardiology guidelines published in 2010 proposed using the Aortic Dissection Detection Risk Score (ADD-RS) as a primary screening tool. The ADD-RS is based on scoring the presence of 3 categorical risks: high-risk conditions (Marfan syndrome, family history of aortic disease, known aortic valve disease, known thoracic aortic aneurysm, or previous aortic manipulation including cardiac surgery), pain features (chest, back, or abdominal pain described as being of abrupt onset, severe intensity, or ripping/tearing), and examination features (evidence of perfusion deficit including pulse deficit, systolic blood pressure difference or focal neurological deficit, or with aortic diastolic murmur and hypotension/shock). The presence of ≥1 markers within each of these categorical features is given a score of 1 with a maximum cumulative score of 3, if all 3 categorical features are present. A score of 0 is considered low risk, a score of 1 is considered intermediate risk, and a score of 2 or 3 is considered to be high risk. The ADD-RS was investigated in the International Registry of Acute Aortic Dissection database in 20113 using the International Registry of Acute Aortic Dissection’s large contemporary repository of AD cases with documentation of clinical presentation and features, management, and outcomes. The study in 2538 cases validated that the ADD-RS has a high sensitivity of 95.7%.
Peiman Nazerian, Christian Mueller, Alexandre de Matos Soeiro, Bernd A. Leidel, Sibilla Anna Teresa Salvadeo, Francesca Giachino, Simone Vanni, Karin Grimm, Múcio Tavares Oliveira, Emanuele Pivetta, Enrico Lupia, Stefano Grifoni, Fulvio Morello, for the ADvISED Investigators
Originally published October 13, 2017
Background: Acute aortic syndromes (AASs) are rare and severe cardiovascular emergencies with unspecific symptoms. For AASs, both misdiagnosis and overtesting are key concerns, and standardized diagnostic strategies may help physicians to balance these risks. D-dimer (DD) is highly sensitive for AAS but is inadequate as a stand-alone test. Integration of pretest probability assessment with DD testing is feasible, but the safety and efficiency of such a diagnostic strategy are currently unknown.
Methods: In a multicenter prospective observational study involving 6 hospitals in 4 countries from 2014 to 2016, consecutive outpatients were eligible if they had ≥1 of the following: chest/abdominal/back pain, syncope, perfusion deficit, and if AAS was in the differential diagnosis. The tool for pretest probability assessment was the aortic dissection detection risk score (ADD-RS, 0–3) per current guidelines. DD was considered negative (DD−) if <500 ng/mL. Final case adjudication was based on conclusive diagnostic imaging, autopsy, surgery, or 14-day follow-up. Outcomes were the failure rate and efficiency of a diagnostic strategy for ruling out AAS in patients with ADD-RS=0/DD− or ADD-RS ≤1/DD−.
Results: A total of 1850 patients were analyzed. Of these, 438 patients (24%) had ADD-RS=0, 1071 patients (58%) had ADD-RS=1, and 341 patients (18%) had ADD-RS >1. Two hundred forty-one patients (13%) had AAS: 125 had type A aortic dissection, 53 had type B aortic dissection, 35 had intramural aortic hematoma, 18 had aortic rupture, and 10 had penetrating aortic ulcer. A positive DD test result had an overall sensitivity of 96.7% (95% confidence interval [CI], 93.6–98.6) and a specificity of 64% (95% CI, 61.6–66.4) for the diagnosis of AAS; 8 patients with AAS had DD−. In 294 patients with ADD-RS=0/DD−, 1 case of AAS was observed. This yielded a failure rate of 0.3% (95% CI, 0.1–1.9) and an efficiency of 15.9% (95% CI, 14.3–17.6) for the ADD-RS=0/DD− strategy. In 924 patients with ADD-RS ≤1/DD−, 3 cases of AAS were observed. This yielded a failure rate of 0.3% (95% CI, 0.1–1) and an efficiency of 49.9% (95% CI, 47.7–52.2) for the ADD-RS ≤1/DD− strategy.
Conclusions: Integration of ADD-RS (either ADD-RS=0 or ADD-RS ≤1) with DD may be considered to standardize diagnostic rule out of AAS.
Cite this article as: Mohamed M A, Abraham R, Maraqa T I, et al. (January 12, 2018) Cocaine-induced Type-A Aortic Dissection Extending to the Common Iliac Arteries. Cureus 10(1): e2059. doi:10.7759/cureus.2059
Aortic dissection is a rare and fatal complication of cocaine-induced hypertension. The injury mechanism is through shear stress that penetrates the intimal vessel layer, allowing blood flow to separate intimal and medial layers. Due to its scarcity and the paucity of related literature, our knowledge of this condition is limited. We present a rare case of a cocaine-induced aortic dissection, which extended continuously from the aortic root to the common iliacs, along with a literature review of similar cases.
A 48-year-old male with recent cocaine use presented with left-sided chest-pain, which radiated to the back with nausea, diaphoresis, and shortness of breath. The patient was hypotensive. The initial radiographs and computed tomography were negative. The cardiac enzymes were elevated and the patient was admitted to rule out acute coronary syndrome. Next day echocardiogram and computed tomography revealed a Type-A aortic dissection continuously extending from the aortic root to the left common iliac artery. The patient was immediately transferred for surgery. Postoperatively, he developed acute kidney injury and shock liver. The patient status continued to deteriorate and he expired on postoperative day four.
This case demonstrates the importance of prompt and thorough diagnostic evaluation, despite subjective history and initially negative imaging that might point towards other conditions. Unlike the previous cases, our case failed to identify the positive history of cocaine until nearly 24 hours into the patient’s hospital course, suggesting a need for close monitoring in these patients and a possible need for repeat imaging.
Recently, in Japan, the J Graft Open Stent Graft (JOSG) was commercialized for surgical repair of an aortic aneurysm and aortic dissection and the frozen elephant trunk technique was applied. Kinking of the JOSG is a rare adverse event that requires additional intervention. We experienced 2 patients who developed kinking of a JOSG after translocated total arch replacement with the frozen elephant trunk technique for acute Type A aortic dissection. Both patients had intermittent claudication with a decreased ankle–brachial pressure index after the operation. Computed tomography angiography showed kinking between the non-stent and stent parts of the JOSG. Therefore, we performed endovascular repair. A severely angulated arch preserved by a translocated technique may lead to kinking of a JOSG. This suggests that the removed non-stent part should be as short as possible to prevent kinking of the JOSG.
The J Graft Open Stent Graft (JOSG) (Japan Lifeline Inc., Tokyo, Japan) (Fig. 1) was commercialized in 2014 in Japan  and is applied using the frozen elephant trunk (FET) technique for extensive aortic arch aneurysm and aortic dissection. In aortic dissection, the FET is used for closing the entry of the descending aorta, securing flow of the true lumen and decreasing the pressure of the false lumen, which may promote thrombosis of the false lumen. The E-vita OPEN PLUS (Jotec Inc., Hechingen, Germany) and Thoraflex Hybrid (VASCUTEK Ltd., Scotland, UK) have been used in Western countries with good results [2, 3]. Similarly, although the JOSG has different characteristics compared with other open stent grafts, good early outcomes after total arch replacement (TAR) with the FET using the JOSG for acute Type A aortic dissection have been reported . However, some adverse events are associated with this procedure, requiring additional interventions [1–4]. Kinking of the JOSG is rare . We describe 2 patients who developed kinking of JOSGs after TAR with the FET for acute Type A aortic dissection.
The J Graft Open Stent Graft. (A) Stent part. (B) Non-stent part.
Case 1 was a 44-year-old man, who was transferred to our hospital because of chest pain. Computed tomography (CT) angiography showed acute Type A aortic dissection that consisted of entry of the ascending aorta and large re-entry of the descending aorta with compression of the true lumen by a patent false lumen. Therefore, he underwent translocated TAR with the FET emergently. After TAR, transoesophageal echocardiography detected kinking of the JOSG. We then performed a remodelling root procedure because of aortic root rupture near the left coronary artery ostia and aorto-left femoral artery bypass to maintain blood flow of the lower body. After the operation, our patient developed intermittent claudication. CT angiography showed kinking between the non-stent and stent parts of the JOSG due to a severely angulated arch (Fig. 2A). This required additional endovascular repair. After endovascular repair, CT angiography showed an expanded lumen of the JOSG (Fig. 2B).
(A and C) Computed tomography angiography after the operation in Cases 1 and 2, respectively. The black arrow shows kinking of the J Graft Open Stent Graft. (B and D) Computed tomography angiography after endovascular repair in Cases 1 and 2, respectively.
Case 2 was a 30-year-old man, who had annuloaortic ectasia and moderate aortic valve regurgitation with Marfan syndrome. CT angiography showed acute Type A aortic dissection from the aortic root to the thoraco-abdominal aorta with entry of the ascending aorta and a patent false lumen. Therefore, we performed a reimplantation root procedure and translocated TAR with the FET emergently. After the operation, he had decreased blood pressure in the lower body and intermittent claudication. CT angiography showed kinking between the non-stent and stent parts of the JOSG caused by a severely angulated arch (Fig. 2C). We then performed additional endovascular repair, which improved kinking of the JOSG (Fig. 2D).
Coarctation or kinking of an open stent graft after TAR with the FET is a rare adverse event. Uchida et al.  reported kinking between the non-stent and stent parts of the JOSG for a sharply bending aorta. We also experienced 2 patients who developed kinking of the JOSG between the non-stent and stent parts after TAR with the FET for acute Type A aortic dissection. A risk of kinking may be a severely angulated arch in acute aortic dissection, which is associated with a relatively young age. Moreover, translocated TAR may aggravate this adverse event due to preservation of the curve of the aortic arch, instead of achieving haemostasis. Uchida et al.  recommended that the stent part should sufficiently cover the aortic arch, and the non-stent part should be kept as short as possible to protect the stent graft from kinking. E-vita OPEN PLUS and Thoraflex may prevent kinking of open stent grafts in severely angulated arches because these open stent grafts have no non-stent parts between the distal anastomosis site and the stent [2, 3]. However, the JOSG has an inner stent made of nitinol wire with a soft woven graft, which reduces injury to the intima. This is different from other commercialized open stent grafts, such as E-vita OPEN PLUS, which consists of an outer stent. The inner stent end boundary between the non-stent soft woven graft and the stent may easily lead to kinking by an angulated arch compared with other open stent grafts. Therefore, in translocated TAR with the FET for acute aortic dissection, the removed non-stent part of the JOSG should be as short as possible to prevent kinking of the JOSG.
The need for emergent cardiac surgery resulting from complications during transcatheter aortic valve replacement is a “rare event” but “highly consequential” when it is required, according to a large analysis of patients treated at European centers.
Emergent surgery for complications such as left ventricle guidewire perforation, annular rupture, valve embolization/migration, and aortic dissection was required in just 0.76% of TAVR-treated patients. Of these, more than one-third died within 72 hours and 46% died in-hospital.
“Although half of the patients with such complications proceeding to [emergent cardiac surgery] were salvaged acutely, mid-term outcomes were bleak,” Holger Eggebrecht, MD (Cardiovascular Center Bethanien, Frankfurt, Germany), and colleagues report in their study published online recently in the European Heart Journal. Prevention of complications needing emergent surgery remains the most important strategy for improving clinical outcomes of TAVR patients, they add.
Speaking with TCTMD, Tamim Nazif, MD (Columbia University Medical Center, New York, NY), said the study is a reminder that while TAVR is a less invasive procedure than surgery and is increasingly performed via a minimalist approach to expedite recovery and discharge, it does carry risk. “People tend to lose sight of that with the evolution in the field, but this is a sobering reminder that it’s a major cardiac procedure that comes with some degree of risk,” he commented.
That said, Nazif also found the results reassuring, particularly since they are in line with what has been observed in randomized clinical trials, such as PARTNER 2Aand the SAPIEN 3 registry. “It’s comforting that the real-world experience seems to be mimicking the trial experience,” he said.
Rodrigo Bagur, MD, PhD (Western University, London, Canada), who also was not involved in the study, pointed out that while the overall rate of emergency cardiac surgery is “quite low,” an additional 60 patients were considered for emergency surgery but did not undergo any procedure. The outcome of these patients is unknown, but “likely may have been fatal,” said Bagur.
“The bottom line is that even though TAVI teams and operators became more and more proficient in different aspects of the procedure, there are still procedural-related complications that can occur and perhaps might not be absolutely predictable and/or avoidable,” he said.
Large Registry of European Centers
The new analysis from the European Registry on Emergent Cardiac Surgery During TAVI (EuRECS-TAVI) is based on 27,760 patients undergoing transfemoral interventions at 79 centers between 2013 and 2016. The mean age of TAVR patients was 82.4 years, and the mean logistic EuroSCORE was 17.1% (mean STS risk score was 5.8%). Less than one-quarter of patients were considered to be at high risk for surgery.
In total, 212 patients required emergency surgery for complications, the most frequent being left ventricular guidewire perforation (28.3%) and annular rupture (21.2%). More than 90% of the complications manifested acutely during the TAVR procedure, report investigators. Cardiac surgery was performed most frequently on the TAVR table in a hybrid catheterization lab (61.1%), while the remainder were transferred to the operating room.
Overall, 24.2% of those requiring emergency surgery died the day of the operation and 34.6% died within 72 hours. The in-hospital and 1-year mortality rate was 46.0% and 78.2%, respectively. In-hospital mortality was highest for patients needing surgery for annular rupture (62.2%), coronary obstruction (54.5%), aortic dissection (52.0%), and left ventricle guidewire perforation (50.8%).
Bagur pointed out that the rate of emergency surgery declined over time, which might be related to more systematic use of preprocedural CT planning. This allows physicians to select an appropriate valve type and choose how aggressive to be with pre- and postdilatation. He said the rate of left ventricle perforations seems high and deserves attention to reduce the risk, such as being more careful in shaping the wire or using preshaped guidewires.
The EuRECS data showed no significant difference between low- and high-volume hospitals with respect to the incidence of emergency surgery during TAVR and in-hospital mortality following the operation. Nazif said he was surprised by those findings, noting that a previous analysis of the Society of Thoracic Surgeons/American College of Cardiology TVT Registry did show that higher-volume centers had better clinical outcomes than low-volume institutions, including lower in-hospital mortality.
Is Surgical Backup Necessary? Yes, Say Experts
In an editorial, Craig Smith, MD (Columbia University Medical Center), writes that these latest results raise the question of whether TAVR should be restricted to centers that have on-site cardiac surgery. For Smith, a cardiac surgeon, it is “grossly obvious” that only centers with surgical backup perform TAVR, but he acknowledges that restricting the procedure to such centers is subject to intense debate.
“Opponents of restriction rely on two primary arguments—access and an analogy to PCI. The problem with ‘access’ is that it can have many different meanings,” writes Smith. “It becomes synonymous with ‘convenience’ when argued to be a patient’s ‘right’ to a TAVI program in every local hospital. The results from EuRECS suggest that patients under that scenario would be acquiring, along with convenience, access to unjustifiable risk.”
In the United States, the Centers for Medicare & Medicaid Services (CMS) has placed conditions on reimbursement, stating TAVR should take place in a facility using a heart team approach, which includes interventionalists and surgeons experienced in both procedures. CMS also requires that TAVR be performed at a hospital with on-site surgical backup. In Europe, there are centers where TAVR is performed without the surgical safety net.
For Nazif, the EuRECS analysis reinforces the need for a surgical presence at TAVR centers, particularly as physicians move into treating intermediate- and low-risk patients where a preventable mortality risk is not acceptable.
To TCTMD, Bagur pointed out that TAVR requires a team approach. Even if transfemoral TAVR is performed by interventional cardiologists, “it is important to rely on the rapid availability of our cardiac surgeons that were part of the clinical decision-making process.” He noted that performing TAVR in centers without surgical backup seems quite courageous but may result in some centers, including low-volume centers and/or those with insufficient training, “being unable to properly handle critical complications, such as saving 40% to 50% of lives as shown in the paper.”
In his editorial, Smith stresses that TAVR is not PCI, a procedure that has been shown to be acceptably safe in centers without surgical backup. Although the frequency of emergent surgery during PCI is in the range of 0.2% to 0.6%, complications are less lethal than in TAVR, where structural heart device complications are so challenging, writes Smith.
Nazif agreed. “These are very severe complications that carry very severe mortality rates,” he said. “We need to take TAVI seriously—it’s not the same as PCI. It should be done at experienced centers with surgical backup.”
Eggebrecht H, Vaquerizo B, Moris C, et al. Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI). Eur Heart J. 2017;Epub ahead of print.
Smith CR. Emergent cardiac surgery following TAVI: implications for the future. Eur Heart J. 2018;Epub ahead of print.
Eggebrecht, Smith, Nazif, and Bagur report having no relevant conflicts of interest.
[dropcap]A[/dropcap]bout 90 percent of people with Marfan syndrome will develop changes in their heart and blood vessels.
If you have Marfan syndrome, you have abnormal connective tissue that can cause your blood vessel walls to weaken and stretch. This damage often affects the aorta, the main artery that carries blood from your heart to the rest of your body.
When the walls of your aorta stretch, you have a higher risk of:
Aortic aneurysm (bulging)
These can lead to a life-threatening medical emergency.
In this Q&A, Lars Svensson, MD, PhD, Chairman of Cleveland Clinic’s Sydell and Arnold Miller Family Heart & Vascular Institute, answers five of the most common questions he hears from patients with Marfan syndrome.
Q.: When does an aortic aneurysm require surgery?
A.: The larger the aneurysm, the higher the risk of dissection or rupture — and need for emergency surgery. Preventive, repair surgery is an elective, non-emergency procedure that has much better outcomes. Futhermore, long term survival is then similar to age and gender matched survival for the United States.
For the way Cleveland Clinic performs the modified reimplantation operation, now exceeding 700 patients, for elective surgery a mortality risk of less than 0.5 percent can be expected and a 95 percent or better likelihood of the repair working beyond 10 years after surgery.
Typically, we recommend repair surgery when aneurysms become 5.5 cm or larger. However, we may recommend it sooner if you have:
Shorter, smaller stature
Family history of aortic dissection
An aneurysm that is growing quickly (5 mm or more per year)
Q.: Can I stop my aortic aneurysm from growing?
A.: Aneurysms can grow quickly or not at all, depending on the underlying disease. That’s why we monitor them with regular echocardiograms, or cardiac MRI or CT scans, if needed. Blood pressure control is important.
For patients with Marfan syndrome, the best ways to try to limit the growth of an aortic aneurysm is to:
Keep blood pressure below 130/80 mm Hg. Often, we will prescribe beta blockers, ACE inhibitors or other medications to help
Maintain healthy cholesterol levels
Keep resting heart rate below 70 beats per minute
Eat a plant-based diet
Q.: What does an aortic aneurysm feel like? How do I know if I have one or if it’s getting worse?
A.: Most of the time, you can’t feel an aneurysm. The only way to detect one or see if it’s changing is through imaging scans.
However, if an aneurysm is quite large, you may have:
Pain in the jaw, neck, upper back or chest
Coughing, hoarseness or difficulty breathing
Pain in the lower back, abdomen or groin not relieved by body movement or taking pain medication
If your aorta has started to tear, you may feel severe pain in your chest or back or both. Some people also report pain in the abdomen or stroke symptoms, including sudden weakness, numbness or loss of balance.
Call 911 if you have any of these symptoms.
Q.: Should I be careful about exercising if I have an aortic aneurysm?
A.: In general, people with aortic aneurysms can still do aerobic exercise, while carefully monitoring their heart rate. Sometimes a stress test will help us assess the heart and determine appropriate heart rate limits.
We typically advise patients to avoid heavy isometric exercise and to not lift more than half of their body weight. Doing multiple repetitions with lighter weights is OK.
There are no limits on physical exercise or exertion after you’ve had (and recovered from) surgery to repair an aortic aneurysm. Cleveland Clinic has cared for professional athletes who’ve returned to active competition.
Q.: Should I be careful about doing other recreational activities if I have an aortic aneurysm?
A.: Flying in an airplane, sitting in a hot tub and jumping on a trampoline are typically safe for people who have an aortic aneurysm. There is no scientific evidence indicating otherwise.
Riding roller coasters or other thrill rides may be best to avoid, however. They can cause blood pressure to swing rapidly.
Name: James Brown
Age at time of Dissection: 62
Type of Dissection: Ascending
Date of Aortic Dissection: 7 September 2016
Tell Us Your Story:
[dropcap]T[/dropcap]he day started out as any other day I was feeling good and about 3:00 PM I started making dinner I needed to make a run to the store my wife and I went and on the way back we stopped at the mailbox’s to check for mail, I got out of the truck and all of a sudden felt this pressure in my chest and back, it was as if I was being pushed to the ground.
We went straight back to the house where I tried to lay down but the pain was excruciating, so I laid down on the floor the wife called 911 and paramedics came. I don’t remember a whole lot after that. I was rushed to the er where they treated me for heart attack and sent me to St. Peter’s later that night.
The admitting doctor Jimmy Swan did not believe I had heart attack so he ran a catheter up my arm and discovered the tear. I was immediately prepped for surgery. Doctor Santemerino performed the surgery which took 11 hours, He nearly lost me on the table.
I spent 17 days in I.C.U and a total of 30 days in the hospital with one week spent in a nursing home. My recovery has been slow, I haven’t felt good since the dissection. I found out just a few weeks ago that my aorta has increased from 4,4 to 6 cm with the dissection continuing into the abdomen.
I was told by a cardiologist that there was no need to see a vascular surgeon because there was nothing that could be be done for me and if I did see the surgeon he just tell me the same thing. Now I am scheduled to see the vascular surgeon this week and discuss my next steps.
It may well be that they can’t repair the dissection because of where it is and the risk involved the cardiologist said if they did operate it could leave me brain dead or paralyzed. I will leave my fate in the Hands of God and the vascular surgeon.
I survived this life threatening ordeal once hopefully I will survive this also and be around to complete my story and this journey.
[dropcap]T[/dropcap]here’s a vine that needs trimming on Tom Tolbert’s roof. It’s an assignment he savors, tricky and satisfying as he saves himself a few bucks, but Tolbert’s roof-climbing days are over.
[dropcap]Y[/dropcap]our next patient is a 32-year-old woman complaining of a headache. You check her vitals: a heart rate of 101 bpm, blood pressure of 150/90 mm Hg, sat of 100%, respirations of 22 bpm, and a 10/10 on the pain scale. You talk to her about her complaint of headache. She says she is allergic to Tylenol.
The patient is calm, healthy-looking, and in no distress. You do your usual head-to-toe review, and ask your typical history and physical questions. Her neurological exam is negative. She is positive for a wide range of complaints—body aches, crampy back pain, runny nose, slight abdominal pain, maybe some diarrhea, and of course, the headache. You spend minimal time on the other systems, and inquire about her main complaint. Because this patient has a plethora of issues and is of child-bearing age, you check her CBC, BMP, ECG, flu, UA, and hCG. You know they are going to come back negative. You consider a D-dimer because she is on birth control and might be PERC-positive, but you’re not convinced this is PE-related.
What if we start the conversation differently? What if we did an HPI with specific questions? She has been to the ED before, and doesn’t have a primary care physician. Nothing stands out as an emergency. You wonder if a workup is necessary, but don’t want to miss any zebras. A few clues suggest this could be something nefarious, but the opioid epidemic should tell us otherwise.
The bottom line is patients want pain medications. We have to figure out if a patient is drug-seeking or has a valid complaint. The problem is we cannot predict what she has based on a limited history and physical. The answer to this case lies in our bedside manner, approach, and honesty. Opioid abuse, misuse, withdrawal, and addiction are not diagnoses of exclusion; none of us wants all those tests done.
ED visits and overdose deaths involving opioid analgesics and benzodiazepines increased from 0.6 to 1.7 per 100,000 between 2004 and 2011. (Am J Prev Med 2015;49:493.) The number of deaths per year attributed to prescription opioid medications reached 16,651 in 2010. (MMWR 2013;62:234; http://bit.ly/2yM9QfS.)
We don’t ignore the one or two percent risk of certain diagnoses like PE, MI, and aortic dissection, so why ignore the signs of drug-seeking? The abuse of and addiction to opioids is a serious global problem that affects the health, social, and economic welfare of all societies. (National Institutes of Health, 2014; http://bit.ly/2yPhFUg.) Just like we would not forget to ask about smoking or cholesterol levels in a patient with chest pain, we cannot forget to ask about pain medication use.
It is estimated that between 26.4 and 36 million people abuse opioids worldwide. (United Nations Office on Drugs and Crime, 2012; http://bit.ly/2yQcYJU.) An estimated 2.1 million Americans suffered from substance abuse disorders related to prescription opioid pain relievers in 2012, and 467,000 people are addicted to heroin. (Substance Abuse and Mental Health Services Administration, 2013; http://bit.ly/2yRKaAw.) Surely, the smaller percentage of those with PE, MI, or dissection is outweighed by a diagnosis of opioid abuse or withdrawal.
A study in the Western Journal of Emergency Medicine looked at 178 patients from the case management program who made 2,486 visits in one year. (2012;13:416.) Headache accounted for 21.7 percent and back pain 20.8 percent, while requesting a refill took up seven percent, lost or stolen medication 0.6 percent, 10/10 pain 29.1 percent, greater than 10/10 pain 1.8 percent, and out of medication 9.5 percent. Not every headache is going to be a stroke.
Just as we take measures to rule out PE, dissection, and MI by risk-stratifying patients, we should consider an individual’s risk for abuse before prescribing opioids. (Ann Emerg Med 2016;68:S81.) We are behind the times if we do not risk-stratify patients for potential abuse or misuse. Narcotics-seeking is often hidden among the initial investigation. It may even get lost in a triage provider’s initial questions and three to four hours of unnecessary tests. Neither the provider nor the patient really wants to talk about narcotic abuse, but we should be asking our patients flat-out: Do you have a problem with narcotic pain medication use?
Addiction has a strong, visceral hold on our patients, and we are ignoring the easy stuff. Questioning our patients directly about it should not be a game. When all the information is gathered in the initial interview without bias or judgment, patients are more likely to get the treatment they need. This may stop us all from doing unnecessary workups and costly imaging.
Next time we interview a patient, we should ask if he has tried anything for pain and list multiple medications: acetaminophen, ibuprofen, tramadol, morphine, or methadone. Patients may not be upfront about these medications if they have true addiction issues. They are fearful we will not prescribe pain medications or treat their acute pain. When we set the standard of care in the beginning, however, we can avoid drama and overtesting.
We should ask every patient of every age and walk of life about his personal experience with pain and then consider how to address it. This starts with being upfront in a nonjudgmental way and using a team approach to their care. It may prevent thousands of deaths and save hospitals millions of dollars. It will also get patients the help they actually need. The nature of their complaint doesn’t even matter, but our practices can change because of it.
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[dropcap]H[/dropcap]ello – I had a Type A aortic dissection repair August 31, 2017 at Baylor in Dallas. My surgeon, Juan MacHannaford, told me the dissection was from top to bottom. I was flown there from Pampa, TX due to the wonderful diagnostic abilities of my cardiologist in our local emergency room.
His quick action saved my life. I had a history of untreated high blood pressure for approximately 3-5 years before beginning treatment in October, 2013. When he saw me in the ER, I had experiences sever stabbing pain from my throat down to my stomach and almost immediately lost feeling in my legs. I also eventually had vomiting and lost consciousness.
My surgeon almost immediately from visual examination and I am not sure what other indicators, told me when I saw him a week after being released from the hospital, he felt 99% sure I have Marfans Syndrome. I am female, 6′ tall with a long torso, arms and legs.
I had a great uncle who had a aortic aneurysm in the 1960’s. That is the only family history I am aware of. Both of my parents are deceased and there are no other living relatives to talk to about this. I have had retina detachments in both eyes and a vitriol hemorrhage in one eye, all happening within 8 to 10 years intervals, starting when I was in my mid 30’s. I have two sons who are 6’2″ and 6’5″.
The surgeon has recommended genetic testing for them. I have changed my eating habits more than what they were, increased my exercise and made other life style changes, all thanks to a wonderful cardiac rehab program I have been attending since the surgery.
I will have a CT scan in 6 months and then once a year for the rest of my life. My scan October 26th, showed 3.2 in my abdomen and 3.4 in my chest. I know this is not something I should think about a lot, but I feel good about my future as long as I keep my scans up.
Are aneurysms common for someone in my situation? Thank you for any input you can give.
Answer from Dr. Liang:
I would certainly agree with your surgeons concerns about Marfan syndrome as a cause cause of the dissection. After the dissection the part of the aorta that is dissected beyond the repair is at increased risk for aneurysm formation so the regular CT’s recommended by your surgeon make sense. We also recommend very rigorous blood pressure control at this point to reduce the stress on the aorta.
Getting evaluated for a genetic cause of the dissection such as Marfan syndrome is very important, especially since you have children. If you can I would recommend seeing Dianna Milewicz at UT Houston.
TCTMD journalists asked a range of experts about what developments rocked the field this year—or at least made it tremble. Here’s what they had to say.
[dropcap]I[/dropcap]n the last few weeks of 2017, the entire TCTMD news team reached out to a range of cardiologists around the world to ask what they see as the biggest studies, the most auspicious advances, or the most conspicuous flops of the year gone by. Here’s what they had to say.
Coronary Artery Disease
No surprise: several of the physicians we spoke with mentioned the ORBITA trial. “Interesting and provocative,” Allen Jeremias, MD (St. Francis Hospital, Roslyn, NY), called the trial results, which have met with robust debate since they were reported at TCT 2017. Jeremias said he would be interested in seeing an analysis of the roughly three-quarters of patients who had abnormal physiology at baseline and who might derive a benefit from PCI.
ORBITA was on the list for Andrew Foy, MD (Penn State Hershey Medical Center, PA), as well. “I would have been one of those people that would have hypothesized that a lot of the subjective benefit of PCI would not be present in a sham-controlled trial, but it was great that this trial was able to be done. It really shows that interventions aimed at improving subjective endpoints need to be subject to rigorous study. It would be nice if we would do these studies before the widespread adoption of the service as opposed to after the fact.”
Foy said ORBITA should be a game-changer, but doesn’t think it will be, unfortunately. “At least it gets people thinking though, that when it comes to these things, maybe we should be doing more sham-controlled trials and that it’s not unethical,” he said. “In fact, it’s really helpful.”
While ORBITA seemed to steal the show in the last 2 months of the year, Jeremias argued that the DEFINE-FLAIR and iFR-SWEDEHEART trials, showing that instantaneous wave-free ratio (iFR) was noninferior to fractional flow reserve (FFR) for guiding revascularization decisions in intermediate lesions, were arguably the bigger story in CAD this year. Jeremias said he expects to see a lot of interesting subanalyses in the coming year, but believes the trials have already had an impact.
“I’ve been using both for quite some time, but I’ve spoken to many people and they basically completely abandoned FFR and now switched over to iFR, which I think might be a little bit of a strong statement,” he said. “There’s a role for both but in terms of usability, iFR certainly is more user-friendly. It’s quicker, with less side effects because you don’t have to give adenosine. So it’s a more appealing concept for sure.”
The two iFR/FFR trials also got the nod from Ik-Kyung Jang, MD, PhD (Massachusetts General Hospital, Boston, MA), who told TCTMD that at his center, FFR has been almost completely replaced by iFR. “When those two large trials were done independently and showed almost superimposable data, it was very convincing,” Jang said.
Jeremias said important developments also occurred in the areas of complete revascularization for patients with acute MI complicated by cardiogenic shock (CULPRIT-SHOCK), left main PCI, and bioresorbable scaffolds. The latter weathered its share of alarmist headlines in 2017 and was ultimately taken off the market.
“It’s a disappointment,” Jang said, “but I don’t think it’s dead. I think the better second-generation versions will come shortly.”
Joanna Wykrzykowska, MD (Academic Medical Center, Amsterdam, the Netherlands), said the disappointing results of bioresorbable scaffolds shifted focus back to metallic DES. “When everybody realized . . . that the bioresorbable scaffolds were not ready for prime time and were not going to bring down the risk of stent thrombosis to zero as promised, I think we all started rethinking metallic drug-eluting stents.
“The question in everybody’s mind,” she said, “is whether or not there are DES platforms where you can afford to reduce DAPT—to decrease the bleeding risk when somebody has to operate or because the patient has a high risk of bleeding—without the additional risk of stent thrombosis. This is the thinking behind a lot of the ongoing trials.”
Wykrzykowska cited several DAPT de-escalation trials as the “big news” of 2017, including CHANGE DAPT and PRAGUE-18.
“We see in clinical practice that people who take ticagrelor have a lot of little nuisance bleeds,” said Wykrzykowska. “Even if they have STEMI or NSTEMI and indications for 1-year of treatment with aspirin and ticagrelor, these studies have shown that it’s okay after a month to switch down to aspirin and Plavix.”
In addition, several ongoing trials will provide important answers with regard to DAPT duration and stent technology, said Wykrzykowska.
Clinical Cardiology and Prevention
Secondary prevention of CVD saw some of the biggest trials in 2017, including FOURIER and CANTOS. “These results were more robust compared with 2015’s IMPROVE-IT trial that used the cholesterol absorption inhibitor ezetimibe (Zetia, Merck/Schering-Plough),” Michael Miller, MD (University of Maryland Medical School, Baltimore, MD), told TCTMD.
With regard to FOURIER, Miller said one aspect of the study that particularly impressed him was the continued benefit of evolocumab (Repatha; Amgen) when on-treatment LDL cholesterol levels were reduced to as low as 10 mg/dL. At these extremely low levels, there was no signal of risk observed, he noted. Alternatively, CANTOS demonstrated support for the inflammatory hypothesis and represented a new means of treatment outside of lowering LDL cholesterol.
Foy, on the other hand, wasn’t as impressed with FOURIER. In fact, what struck him the most was the hubristic thought that adding evolocumab to optimized high-dose statin therapy could abolish the residual risk of cardiovascular events in a secondary-prevention population.
“Sometimes people joke with me that I’m a medical Luddite,” said Foy. “It’s not that I’m against progress, because I’m not, but this study is interesting because evolocumab, more or less, wipes out LDL cholesterol, or at least to very low levels in patients with atherosclerotic cardiovascular disease. Even though the trial was positive, what this shows is that we didn’t do very much.”
Foy said that even though LDL cholesterol levels were reduced to a median of 30 mg/dL in the trial, more than more than one in 10 patients in both groups experienced the primary efficacy endpoint.
“As a society, do we want to continue to invest heavily in treatment of disease once it already occurs?” asked Foy. “As this trial shows to some extent, we may not have much further to go. . . . Should we declare victory from a medical standpoint and start thinking about how to invest as a society in disease prevention, which gets us away from the doctor’s office and puts resources back into the community?”
While there was a lot of exuberance over FOURIER, investment in primary prevention, with walkable cities and cycling infrastructure, for example, would likely go a lot further than spending billions of dollars for an additional therapy in patients with cardiovascular disease, suggested Foy.
To TCTMD, Khurram Nasir, MD (Baptist Health South Florida, Miami), also cited the FOURIER trial, and like Foy argued that hard decisions need to be made about how much payers are willing to spend for an expensive medical therapy that yields solidly effective, but not miraculous, gains. “The benefit will seem substantial to some and modest to others,” said Nasir. “However, it reignited the debate on issues related to its pricing, cost, and value.”
The American Heart Association (AHA), the American College of Cardiology (ACC), and other societies can play leadership roles to resolve cost-related issues, he added. “Moving forward, rather than debate whether a PCSK9 inhibitor is or is not affordable, we need a conversation about whether it represents value for money,” said Nasir.
Several experts also pointed to the importance of the new hypertension guidelines from the AHA, ACC, and nine other partnering organizations that redefined hypertension as starting at a blood pressure of 130/80 mm Hg.
“The idea that we should be more aggressive about treating hypertension would be a big change in terms of getting a lot more patients on therapy,” Anne Curtis, MD (University at Buffalo, NY), told TCTMD.
She said she’d still be wary of aiming for aggressively low blood pressure goals in older patients, and wouldn’t, for example, try to get an 85-year-old’s readings down to 120/80 mm Hg. “The reason I say that is that a lot of times they have pretty stiff vessels and once you start trying to get too aggressive in lowering the blood pressure you can have problems with orthostatic hypotension or getting them dizzy.”
Stephen Little, MD (DeBakey Heart & Vascular Center, Houston, TX), also told TCTMD that he was happy to see the renewed antisodium message that came along with the revised guidelines because it “really sort of doubles down” on what physicians in the past have advocated.
“Every month or so we hear about new pharmaceuticals to [lower blood pressure], but it’s nice to see that people have gone back to the basics,” Little said. “It’s not particularly sexy, but in terms of clinical utility, it’s easy . . . not to burden patients with insurance or economic challenges with new therapies” and instead simply place them on a low-salt diet.
Curtis told TCTMD that the “coolest thing” this year in the realm of heart rhythm is a small study looking at noninvasive cardiac radiation for ablation of ventricular tachycardia. Though the study included only five patients who had failed other treatments, the approach provided “amazingly good results” by reducing episodes of ventricular tachycardia by 99.9%, Curtis said. “It potentially has a huge amount of promise—it’s going to require a lot more work and they’re doing prospective trials on it—but . . . if you could stop having to use catheters to push around the heart to figure out where to fix these things, it would just be a revolution in the management of these arrhythmias.”
The CASTLE-AF trial was another important development in electrophysiology, said Curtis. The trial randomized patients with heart failure and A-fib to either conventional drug treatment or catheter ablation. The primary endpoint of all-cause death or unplanned hospitalization for worsening heart failure strongly favored the ablation arm.
“There seems to be increasing evidence that when patients have A-fib and heart failure, if you can fix the A-fib, you can improve outcomes,” Curtis said, adding that the trial could have an impact on practice by making clinicians choose ablation earlier in that patient subset.
And finally, Curtis pointed to studies of His-bundle pacing as a major development. With permanent pacemakers, the lead typically goes in the right ventricle, requiring the impulse to travel through myocardium. His-bundle pacing, however, uses a very small lead placed on the septum to recruit the His-Purkinje system to pace the ventricles. That approach has yielded success rates of 85% to 90%, although information on longer-term outcomes is still needed, Curtis said.
Structural Heart Disease
Ted Feldman, MD (NorthShore University HealthSystem, Evanston, IL), said the single biggest thing to move the dial in 2017 is the New England Journal of Medicine’s decision to publish, in a single issue, three randomized trials supporting PFO closure for stroke prevention. “After more than a decade of struggling with trying to convince the noninvasive world that PFO closure prevents recurrent cryptogenic stroke, there’s now no ambiguity. The three trials, RESPECT, CLOSE, and REDUCE, represent significant advances for the field, and most importantly those advances will have a positive impact on patients,” he said.
Mayra Guerrero, MD (NorthShore University HealthSystem), similarly placed PFO closure among the top news. “It really got our attention, but it did not surprise me,” she said. “Many of us knew that this would be positive and would just take time.”
Five-year findings from PREVAIL and PROTECT AF on the Watchman LAA closure device (Boston Scientific) also were a “highlight,” Guerrero observed.
Lars G. Svensson, MD, PhD (Cleveland Clinic, OH), told TCTMD that, for his center, the “most striking thing” is performing their first percutaneous tricuspid valve replacement. “We’ve done a number of patients now under compassionate use, and we’re now working with the [US Food and Drug Administration (FDA)] on a feasibility trial,” he said, adding, “That’s the big one for us.”
Moreover, “of course there’s a tremendous number of various devices that have popped up this last year both for the mitral valve and the tricuspid valve,” Svensson noted. “That’s a very exciting area of growth with transcatheter devices over time.”
An incremental advance that continued to be felt this year, Feldman agreed, is the growing momentum of transcatheter mitral valve replacement (TMVR). “We have seen and continue to see small strides being made by a variety of technologies to make the procedures more reproducible, and more often transseptal rather than transapical,” he said. Improvements in imaging have been critical here, he added. “With every endeavor we’ve ever had, imaging has led the way because you can’t go where you can’t see. We’re understanding how to look at those scans better and evaluate all the complexities of the mitral apparatus.”
Guerrero, too, cited early feasibility trials of TMVR, including her own MITRAL study, as well as results with the Tendyne and Intrepid valves. “Compared with other years, I think the common theme is that the findings of the recent trials [show better outcomes] than before with prior devices or prior attempts,” she said, echoing Feldman’s idea that “transseptal is a better way to go whenever possible” in mitral cases.
One milestone, Guerrero said, was the expanded FDA indications for Sapien 3 (Edwards Lifesciences), permitting its use in in mitral valve-in-valve procedures.
Another intriguing development, Svensson said, is the potential to combine multiple transcatheter devices in the same procedure. For example, the WATCH-TAVRmultinational study, just getting underway, is pairing the Watchman device with TAVR for patients who have both A-fib and aortic stenosis. Until recently, it was impossible to formally test these options, Svensson explained, because more than one investigational device cannot be combined in a single trial. Now, as more devices become FDA approved, it’s possible to study the effects of adding a newer contender to an existing therapy, he said.
Regarding the TAVR space, Guerrero said while there was no earth-shattering news, the accumulating trial data on lower-risk patients and initial forays into treating asymptomatic patients has kept the field’s interest. Specifically, the ongoing EARLY TAVR trial is changing clinicians’ perspectives, she commented. “We no longer have to wait for symptoms. We can take those patients with severe aortic stenosis and talk to them about early TAVR” with the hope of easier recovery and lower risk than surgery.
In the realm of cardiovascular imaging, Little told TCTMD that one of the most interesting topics explored in 2017 is the connection between cardiac amyloidosis and aortic stenosis as viewed on a new cardiac nuclear study called technetium pyrophosphate. “The gist of it is that there’s this phenotype of patients that we see with aortic stenosis that we send for TAVR and they have small ventricles, thick hearts, and a lot of diastolic dysfunction and it always gets ascribed to being elderly and having aortic stenosis,” he explained.
But studies this year have shown that amyloidosis is “very common” in those with aortic stenosis, who are often sent to undergo TAVR. At the moment, the data are merely “thought provoking,” Little said, but it’s likely going to lead to a more research given the lack of knowledge regarding the appropriateness of TAVR for these patients.
“One of the hardest things we do in the TAVR environment is deciding who’s not going to benefit from the therapy, but if somebody clearly has a burden of cardiac amyloid, then a TAVR is not going to fix that in any way,” he said. “Maybe there should be a discussion around futility and sort of potentially improving patient selection.”
Kevin Harris, MD (Minneapolis Heart Institute Foundation, MN), on the other hand, cited a very recent study that identified myocardial fibrosis in competitive male triathletes. In that study, the scarring detected by late gadolinium enhancement by cardiac magnetic resonance imaging was particularly pronounced in athletes who participated in long-distance events, such as Ironman triathlons.
Additionally, Harris pointed to a recent study that highlighted a subset of patients with hypertrophic cardiomyopathy (HCM) who have left ventricular apical aneurysms.
“It’s an interesting paper and gives us some good insights into a subset of patients with hypertrophic cardiomyopathy who are at a higher than expected risk [for arrhythmic sudden death],” said Harris. Additionally, HCM patients with left ventricular apical aneurysms were also at a higher risk of thromboembolic events.
Finally, Harris also cited a CT imaging study of patients with uncomplicated acute aortic dissection. In that study, imaging-based morphological features were combined into a prediction model to identify patients at high risk for late adverse events after an uncomplicated type B aortic dissection.
“The biggest trial of the year by far in my opinion was the recently-published ATTRACT trial, which did not hit its primary endpoint,” said Michael R. Jaff, DO (Newton-Wellesley Hospital, Boston, MA). “This was a highly anticipated trial that had been ongoing for many years and it’s a highly controversial area of therapy.”
Jaff also pointed to 12-month results of the ILLUMENATEtrial. The low-dose paclitaxel-coated Stellarex balloon (Spectranetics) showed superior safety and efficacy compared with angioplasty alone in a multicenter trial of 300 PAD patients with claudication. Stellarex “became the third to the market as a result of this trial,” Jaff noted. “Overall, it was a very impressive time course from invention to FDA approval.”
Finally, Jaff said the finding that carotid stent fractures are not associated with adverse events, as reported in the ACT I trial, was another important advance in endovascular medicine. “Everybody kind of believed that if you have a stent fracture it results in a higher risk of stroke and death and need for repeat interventions. But it turned out that none of those were the case,” he remarked.
Among the big news in heart failure this year, Paul Hauptman, MD (Saint Louis University School of Medicine, MO), pointed to the emergence of antidiabetic medications as therapies for reducing cardiovascular risk. In August, liraglutide (Victoza; Novo Nordisk), a glucagon-like peptide-1 receptor agonist, received an indication for reducing risks of MI, stroke, and cardiovascular death in adults with type 2 diabetes and established cardiovascular disease. That follows a similar decision for empagliflozin (Jardiance; Boehringer Ingelheim/Lilly), a sodium glucose cotransporter-2 inhibitor thatreceived an indication at the end of 2016 for reducing the risk of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease.
“It used to be thought of as maybe it’s just an issue of safety, but now it looks like . . . some of these drugs actually have favorable effects on the heart,” Hauptman told TCTMD, noting that there has been a resurgence of interest in diabetes in the heart failure community.
He pointed out that two new trials were launched in 2017 to look at use of empagliflozin in patients with heart failure and either preserved ejection fraction (EMPEROR-Preserved) or reduced ejection fraction (EMPEROR-Reduced); patients are not required to have diabetes. “It’s a first attempt now to extend findings from a main diabetes study to see whether or not—in this particular case—empagliflozin could actually be a heart failure drug in addition to being a diabetes drug,” Hauptman said.
Other major developments, he added, were the approval of the HeartMate 3 left ventricular assist device (LVAD), the expanded destination therapy indication for the HeartWare LVAD, promising early study results for a novel drug for symptomatic hypertrophic obstructive cardiomyopathy from MyoKardia and an interarterial shuntfrom Corvia Medical, and continued refinements of heart failure guidelines.
Policy and Practice
For Frederick Masoudi, MD (University of Colorado Anschutz Medical Campus, Aurora), the biggest news of the year affecting everyone from physicians to patients, and hospitals to insurance companies has been “the fight over the Affordable Care Act,” or ACA. “It seemed like the ACA had nine lives at least at one point, although I think that’s probably changed fairly substantially with the new tax legislation that’s been approved by both the House and the Senate that eliminates the mandates as part of the ACA.”
Looking back over 2017, he said there were several times when “things were looking pretty good for the ACA despite a lot of attempts to undermine enrollment.” However, the “poor public understanding” of the reasons why it is necessary to maintain both coverage for preexisting conditions as well as mandates and subsidies has contributed to the success of the tax legislation, Masoudi commented, adding, “Certainly what’s happened here at the end of the year is I think bad news for the ACA.”
To TCTMD, Christopher Meduri, MD (Piedmont Heart Institute, Atlanta, GA), said one of the overarching themes of 2017 has been the growth of early feasibility studies in the United States.
“If I look back to just a few years, it really seemed like every US interventionalist at any major meeting was watching the revolution in valvular heart disease from the sidelines,” he said. “We always dreamed of being up there doing some of these cases, or being involved with the new technologies. Fortunately, not just for investigators, but also for patients, the FDA has really developed a collaborative atmosphere between sponsors and the sites doing the early feasibility work. Now, more and more technologies are being tested in the US.”
At TCT 2017, for example, there were presentations on several US-based, early feasibility valve-related trials, said Meduri. At his center, he has participated in two early feasibility studies, and at least three more valve-related technologies will be tested in the coming months. His institution has also been invited to participate in the FDA’s early feasibility trial network.
“I remember being a fellow and thinking, ‘You have to go to Europe to do anything.’ So I went to Europe for several months, trying to get my hands on some of these things I’d never get to do otherwise,” said Meduri. “Now, at some of the same places I trained at in Europe, there’s interest in coming over here [to the US] to watch us do things instead. It’s pretty crazy.”
This story was a collaboration by Caitlin E. Cox, L.A. McKeown, Michael O’Riordan, Todd Neale, and Yael L. Maxwell. Did we miss something? Let us know in the Comments section below what we left out, or have your say on Twitter using the hashtag #TopCardio2017.
Jeremias reports receiving institutional support from Philips/Volcano and Abbott Vascular and consulting for Philips/Volcano, Abbott Vascular, Boston Scientific, and Opsens.
Jang reports receiving educational grants and consulting fees from Abbott.
Wykrzykowska reports receiving grants/research support from Abbott Vascular and consulting for Abbott Vascular and St. Jude Medical.
Nasir reports serving on the advisory board for Quest Diagnostics and consulting for Regeneron.
Curtis reports receiving speaking honoraria from and serving on a data safety monitoring board for Medtronic and serving on the medical advisory board and adjudicating clinical trial results for Abbott (St. Jude Medical).
Masoudi reports serving as the chief science officer of the National Cardiovascular Data Registry. Guerrero reports receiving research grant support from Edwards Lifesciences, serving as a consultant/speaker for Abbott, and serving on the speaker’s bureau for Boston Scientific.
Svensson reports being an unpaid member of the executive committee for PARTNER trials I and II, chairman of the PARTNER publication committee, and an unpaid member of the executive committee of the COMMENCE trial, sponsored by Edwards Lifesciences.
Feldman reports consulting for Abbott, Boston Scientific, Edwards Lifesciences, and Gore.
Jaff reports consulting for Micell, Primacea, Vactronix, Venarum, and Volcano/Philips.
Foy, Miller, Little, Harris, and Meduri report no relevant conflicts of interest.
[dropcap]H[/dropcap]ardin County’s former EMS director has filed an anti-discrimination suit claiming he was wrongfully discharged from his job.
John Malcomson, a Radcliff resident, was suspended in June and discharged in July about one year after returning to work following a health emergency, which left him with a disability requiring some work-related restrictions.
In the four-page lawsuit filed last week in Hardin Circuit Court, Malcomson names Hardin Fiscal Court and Judge-Executive Harry Berry as defendants
Malcolmson asks the court for compensatory damages, reimbursement of legal fees and “any other relief to which he may otherwise be properly entitled.” No dollar figure is mentioned in the suit.
When the holiday weekend began Friday, defendants had not yet been served with the suit. Regardless, Berry said the county government would maintain its practice of declining comment on pending litigation.
During a public meeting in which Fiscal Court approved Malcomson’s firing, Berry said his recommendation stemmed from “misbehavior and inappropriate activity within the department.” Berry also said low morale and high turnover influenced his decision.
“Mr. Malcomson’s focus on the operations and business of the department is lacking. His availability is limited and unpredictable,” Berry said. “He routinely misses meetings, fails to meet expenses, demonstrates serious mood swings and is frequently disrespectful in his tone and demeanor toward his superiors and his subordinates.”
Malcolmson became emergency medical services director in August of 2014. As a result of an aortic dissection suffered in January 2014, he missed nearly 18 months of work. A complication required a partial left foot amputation and, according to the lawsuit, he was regarded as disabled by county government upon returning to work.
The lawsuit described a reprimand presented by Bryce Shumate, his supervisor, and Deputy Judge-Executive Jim Roberts following Malcolmson’s return to work. He was cited for failing to provide documentation of employee training. He claims in the suit the documentation had not been required during his initial two years of employment.
Malcomson, who missed work again in May 2017 with further complications related to the aortic dissection, said he was notified of his suspension June 22 and told by Berry he “was not capable of performing his job responsibilities.”
A civil suit provides only one side of a dispute. The county will file a formal response before the case proceeds in Hardin Circuit Court.
[dropcap]A[/dropcap]fter an Horry County police officer was on duty patrolling last month, he suffered a traumatic heart injury and was rushed to a nearby hospital for life-saving surgery.
Now, 36-year-old KC Canterbury is home for recovery, but still faces a mound of medical bills as he heals.
“He’s one of those people that would literally do absolutely anything for anybody at any hour of the day,” said John Brantly, vice president of the Coastal Carolina Fraternal Order of Police Lodge #12. “He’s a very family oriented person, regardless of whether it’s blood family or blue family, you couldn’t find a better person.”
On the night of Nov. 25, Canterbury suffered from an aortic dissection and an aneurysm.
An aortic dissection is a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears, according to Mayo Clinic. Blood surges through the tear, which causes the inner and middle layers of the aorta to separate — or dissect, hence the name.
An aneurysm is an “abnormal bulge or ballooning in the wall of a blood vessel,” Mayo Clinic explains. An aneurysm can rupture, cause internal bleeding and lead to death.
Canterbury was in critical condition when he was rushed to the hospital that night before he underwent an intensive surgery. He was released from the hospital on Dec. 11.
“It’s going to be a long road of recovery for him,” Brantly said. “That procedure takes an extreme toll on the body.”
Brantly started a YouCaring page to raise money for Canterbury’s expensive medical bills. As of Dec. 22, community members have raised $12,173 out of the $20,000 goal.
“Speaking for his family, they ask for prayers and support for his full recovery and the response from the community so far, has been overwhelming and nothing but positive, they greatly appreciate that,” Brantly added.
Canterbury has been in law enforcement for around 12 years and is the president of the Coastal Carolina FOP Lodge #12.
Brantly said checks are also being accepted, which you can pay to the order of SC FOP Lodge 12 and in the memo section write “KC Relief.” Checks can be mailed to the following address: S.C. FOP 12 P.O. Box 8455, Myrtle Beach, S.C., 29578.