Transcatheter aortic valve replacement has transformed the paradigm of care for patients with severe aortic stenosis (AS). With transcatheter aortic valve replacement now commercially approved for AS patients of all surgical risk, clinical decision-making regarding the initial mode of valve replacement (e.g. surgical versus transcatheter) and prosthesis type has become even more complex. The updated American College of Cardiology/American Heart Association and European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on valvular heart disease offer a strong foundation from which to address the nuances of the treatment of AS; however, there remain several clinical scenarios for which evidence and thus definitive societal recommendations are lacking. As such, the heart team continues to play an invaluable role in the management of the AS patient by combining available scientific evidence, expertise across disciplines, and the patient’s preferences to optimize individualized patient care and healthcare resource usage.
{"title":"The Evolving Role of the Multidisciplinary Heart Team in Aortic Stenosis","authors":"Sahoor Khan, W. Shi, T. Kaneko, S. Baron","doi":"10.15420/usc.2022.04","DOIUrl":"https://doi.org/10.15420/usc.2022.04","url":null,"abstract":"Transcatheter aortic valve replacement has transformed the paradigm of care for patients with severe aortic stenosis (AS). With transcatheter aortic valve replacement now commercially approved for AS patients of all surgical risk, clinical decision-making regarding the initial mode of valve replacement (e.g. surgical versus transcatheter) and prosthesis type has become even more complex. The updated American College of Cardiology/American Heart Association and European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on valvular heart disease offer a strong foundation from which to address the nuances of the treatment of AS; however, there remain several clinical scenarios for which evidence and thus definitive societal recommendations are lacking. As such, the heart team continues to play an invaluable role in the management of the AS patient by combining available scientific evidence, expertise across disciplines, and the patient’s preferences to optimize individualized patient care and healthcare resource usage.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47060149","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Aortic stenosis is a common form of acquired degenerative valvular disease associated with poor survival after the onset of symptoms. Treatment options for patients with aortic stenosis in addition to medical therapy include surgical aortic valve replacement (SAVR) with either tissue or mechanical valves, or transcatheter aortic valve replacement (TAVR) with either balloon-expandable or self-expanding valves via either transfemoral or alternative access routes. In this review, the authors discuss the current evidence and special considerations regarding the use of TAVR versus SAVR in the management of severe aortic stenosis in young (<65 years of age), low-risk patients, highlighting the history of aortic stenosis treatment, the current guidelines and recommendations, and important issues that remain to be addressed. Ultimately, until ongoing clinical trials with long-term follow-up data shed light on whether interventions for aortic stenosis can be broadened to a low-risk population, TAVR in young, low-risk patients should be undertaken with caution and with guidance from a multidisciplinary heart team.
{"title":"Transcatheter Versus Surgical Aortic Valve Replacement in Young, Low-risk Patients with Severe Aortic Stenosis","authors":"Q. Nguyen, J. Luc, T. MacGillivray, O. Preventza","doi":"10.15420/usc.2022.08","DOIUrl":"https://doi.org/10.15420/usc.2022.08","url":null,"abstract":"Aortic stenosis is a common form of acquired degenerative valvular disease associated with poor survival after the onset of symptoms. Treatment options for patients with aortic stenosis in addition to medical therapy include surgical aortic valve replacement (SAVR) with either tissue or mechanical valves, or transcatheter aortic valve replacement (TAVR) with either balloon-expandable or self-expanding valves via either transfemoral or alternative access routes. In this review, the authors discuss the current evidence and special considerations regarding the use of TAVR versus SAVR in the management of severe aortic stenosis in young (<65 years of age), low-risk patients, highlighting the history of aortic stenosis treatment, the current guidelines and recommendations, and important issues that remain to be addressed. Ultimately, until ongoing clinical trials with long-term follow-up data shed light on whether interventions for aortic stenosis can be broadened to a low-risk population, TAVR in young, low-risk patients should be undertaken with caution and with guidance from a multidisciplinary heart team.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46054411","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
P. Pournazari, S. Chang, S. Little, S. Goel, N. Faza
Prosthetic valve thrombosis is the second leading cause of prosthetic valve deterioration and is being more readily diagnosed with the use of echocardiography and multidetector cardiac CT. Presentation of valve thrombosis can be acute or subacute and any change in clinical status of a patient with a prosthetic valve should raise a suspicion of prosthetic valve thrombosis. Diagnosis entails detailed clinical examination and comprehensive imaging. The choice of therapeutic options includes anticoagulation, fibrinolytic therapy, or valve replacement. Antiplatelet and anticoagulation therapy remain the mainstay of thrombosis prevention in patients with a prosthetic valve and a personalized approach is required to optimize prosthetic valve function and minimize the risk of bleeding.
{"title":"Prosthetic Aortic Valve Thrombosis","authors":"P. Pournazari, S. Chang, S. Little, S. Goel, N. Faza","doi":"10.15420/usc.2021.19","DOIUrl":"https://doi.org/10.15420/usc.2021.19","url":null,"abstract":"Prosthetic valve thrombosis is the second leading cause of prosthetic valve deterioration and is being more readily diagnosed with the use of echocardiography and multidetector cardiac CT. Presentation of valve thrombosis can be acute or subacute and any change in clinical status of a patient with a prosthetic valve should raise a suspicion of prosthetic valve thrombosis. Diagnosis entails detailed clinical examination and comprehensive imaging. The choice of therapeutic options includes anticoagulation, fibrinolytic therapy, or valve replacement. Antiplatelet and anticoagulation therapy remain the mainstay of thrombosis prevention in patients with a prosthetic valve and a personalized approach is required to optimize prosthetic valve function and minimize the risk of bleeding.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47511777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Numerous advances have been made in the therapy of acute coronary syndromes. Despite these advances, acute coronary syndromes still cause significant morbidity and mortality. Decisions as to the best therapy vary depending on other patient factors, such as age, need for chronic anticoagulation, tolerability of medications, and the degree of myocardial damage. Recent evidence suggests that a shorter duration of therapy may be beneficial in decreasing bleeding events without compromising benefits of preventing ischemic complications. For those who have an indication for chronic anticoagulation, less intensive therapy may also be beneficial, again without increasing ischemic complications. Data regarding agents that inhibit the renin–angiotensin–aldosterone system are available and these data are reviewed. Knowledge of the pharmacology, potency, and pharmacokinetics of drugs, as well as adverse drug events, may direct clinicians in choosing the optimal pharmacotherapy strategy for their patients.
{"title":"Best Practices in Pharmacotherapy for Acute Coronary Syndromes","authors":"R. Barcelona","doi":"10.15420/usc.2022.05","DOIUrl":"https://doi.org/10.15420/usc.2022.05","url":null,"abstract":"Numerous advances have been made in the therapy of acute coronary syndromes. Despite these advances, acute coronary syndromes still cause significant morbidity and mortality. Decisions as to the best therapy vary depending on other patient factors, such as age, need for chronic anticoagulation, tolerability of medications, and the degree of myocardial damage. Recent evidence suggests that a shorter duration of therapy may be beneficial in decreasing bleeding events without compromising benefits of preventing ischemic complications. For those who have an indication for chronic anticoagulation, less intensive therapy may also be beneficial, again without increasing ischemic complications. Data regarding agents that inhibit the renin–angiotensin–aldosterone system are available and these data are reviewed. Knowledge of the pharmacology, potency, and pharmacokinetics of drugs, as well as adverse drug events, may direct clinicians in choosing the optimal pharmacotherapy strategy for their patients.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46985851","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
G. Petrossian, Denizhan Ozdemir, K. Galougahi, J. Scheiner, Susan V Thomas, R. Shlofmitz, Evan Shlofmitz, A. Jeremias, Ziad A. Ali
Intravascular imaging with optical coherence tomography (OCT) and intravascular ultrasound provides superior visualization of the culprit plaques for acute coronary syndromes (ACS) compared with coronary angiography. Combined with angiography, intravascular imaging can be used to instigate ‘precision therapy’ for ACS. Post-mortem histopathology identified atherothrombosis at the exposed surface of a ruptured fibrous cap as the main cause of ACS. Further histopathological studies identified intact fibrous caps and calcified nodules as other culprit lesions for ACS. These plaque types were subsequently also identified on intravascular imaging, particularly with the high-resolution OCT. The less-common non-atherothrombotic causes of ACS are coronary artery spasm, coronary artery dissection, and coronary embolism. In this review, the authors provide an overview of clinical studies using intravascular imaging with OCT in the diagnosis and management of ACS.
{"title":"Role of Intracoronary Imaging in Acute Coronary Syndromes","authors":"G. Petrossian, Denizhan Ozdemir, K. Galougahi, J. Scheiner, Susan V Thomas, R. Shlofmitz, Evan Shlofmitz, A. Jeremias, Ziad A. Ali","doi":"10.15420/usc.2022.03","DOIUrl":"https://doi.org/10.15420/usc.2022.03","url":null,"abstract":"Intravascular imaging with optical coherence tomography (OCT) and intravascular ultrasound provides superior visualization of the culprit plaques for acute coronary syndromes (ACS) compared with coronary angiography. Combined with angiography, intravascular imaging can be used to instigate ‘precision therapy’ for ACS. Post-mortem histopathology identified atherothrombosis at the exposed surface of a ruptured fibrous cap as the main cause of ACS. Further histopathological studies identified intact fibrous caps and calcified nodules as other culprit lesions for ACS. These plaque types were subsequently also identified on intravascular imaging, particularly with the high-resolution OCT. The less-common non-atherothrombotic causes of ACS are coronary artery spasm, coronary artery dissection, and coronary embolism. In this review, the authors provide an overview of clinical studies using intravascular imaging with OCT in the diagnosis and management of ACS.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48751102","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"The Final Word: Current Strategies for the Lifetime Management of Patients with Aortic Valve Stenosis","authors":"A. Tavenier, J. Nicolas, R. Mehran","doi":"10.15420/usc.2022.07","DOIUrl":"https://doi.org/10.15420/usc.2022.07","url":null,"abstract":"","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-05-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46005115","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Rali, Amy Butcher, R. Tedford, S. Sinha, Pakinam Mekki, H. V. Van Spall, Andrew J. Sauer
Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.
{"title":"Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting","authors":"A. Rali, Amy Butcher, R. Tedford, S. Sinha, Pakinam Mekki, H. V. Van Spall, Andrew J. Sauer","doi":"10.15420/usc.2021.34","DOIUrl":"https://doi.org/10.15420/usc.2021.34","url":null,"abstract":"Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48022269","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
As transcatheter aortic valve replacement (TAVR) rapidly expands to younger patients and those at low surgical risk, there is a compelling need to identify patients at increased risk of post-procedural complications, such as paravalvular leak, prosthesis–patient mismatch, and conduction abnormalities. This review highlights the incidence and risk factors of these procedural complications, and focuses on novel methods to reduce them by using newer generation transcatheter heart valves and the innovative cusp-overlap technique, which provides optimal fluoroscopic imaging projection to allow for precise implantation depth which minimizes interaction with the conduction system. Preserving coronary access after TAVR is another important consideration in younger patients. This paper reviews the significance of commissural alignment to allow coronary cannulation after TAVR and discusses recently published data on modified delivery techniques to improve commissural alignment.
{"title":"Transcatheter Aortic Valve Replacement Optimization Strategies: Cusp Overlap, Commissural Alignment, Sizing, and Positioning","authors":"S. Siddique, Resha Khanal, A. Vora, H. Gada","doi":"10.15420/usc.2021.24","DOIUrl":"https://doi.org/10.15420/usc.2021.24","url":null,"abstract":"As transcatheter aortic valve replacement (TAVR) rapidly expands to younger patients and those at low surgical risk, there is a compelling need to identify patients at increased risk of post-procedural complications, such as paravalvular leak, prosthesis–patient mismatch, and conduction abnormalities. This review highlights the incidence and risk factors of these procedural complications, and focuses on novel methods to reduce them by using newer generation transcatheter heart valves and the innovative cusp-overlap technique, which provides optimal fluoroscopic imaging projection to allow for precise implantation depth which minimizes interaction with the conduction system. Preserving coronary access after TAVR is another important consideration in younger patients. This paper reviews the significance of commissural alignment to allow coronary cannulation after TAVR and discusses recently published data on modified delivery techniques to improve commissural alignment.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-04-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45231487","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
While redo surgical aortic valve replacement has traditionally been the gold standard for the treatment of failed surgical valves, valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has arisen as a viable, less invasive option with the potential for improved short-term morbidity and mortality. Retrospective registry data regarding ViV TAVR outcomes have been encouraging, with excellent 1-year mortality, and sustained valve performance and quality of life improvement out to 3 years. Operators must be comfortable with CT analysis for procedural planning, and be able to identify and troubleshoot patients who are at risk for coronary obstruction and patient prosthesis mismatch. The authors provide a review of clinical outcomes associated with ViV TAVR, procedural planning recommendations, and strategies to overcome technical challenges that can occur during ViV TAVR.
{"title":"Valve-in-valve Transcatheter Aortic Valve Replacement for Failed Surgical Valves and Adjunctive Therapies","authors":"Emily Perdoncin, G. Paone, Isida Byku","doi":"10.15420/usc.2021.20","DOIUrl":"https://doi.org/10.15420/usc.2021.20","url":null,"abstract":"While redo surgical aortic valve replacement has traditionally been the gold standard for the treatment of failed surgical valves, valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has arisen as a viable, less invasive option with the potential for improved short-term morbidity and mortality. Retrospective registry data regarding ViV TAVR outcomes have been encouraging, with excellent 1-year mortality, and sustained valve performance and quality of life improvement out to 3 years. Operators must be comfortable with CT analysis for procedural planning, and be able to identify and troubleshoot patients who are at risk for coronary obstruction and patient prosthesis mismatch. The authors provide a review of clinical outcomes associated with ViV TAVR, procedural planning recommendations, and strategies to overcome technical challenges that can occur during ViV TAVR.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46443065","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The significance of the right ventricle (RV) as a predictor of outcome in a series of cardiac conditions has recently been recognized. Consequently, more studies are now focusing on improving the assessment of the RV. Its primary function is to support adequate pulmonary perfusion pressure in different circulatory and loading situations and to ensure that there is a low systemic venous pressure. Echocardiography is the first-line method of choice due to its accuracy when assessing RV structure and function, as well as its wide availability. The geometry of the RV is complex and its evaluation can be difficult. Integrating and combining multiple parameters may be a more reliable way to determine normal or abnormal function. Novel techniques are increasingly being performed more routinely in clinical practice and are facilitating diagnosis and treatment choices.
{"title":"Echocardiography in the Evaluation of the Right Heart","authors":"A. Tsipis, E. Petropoulou","doi":"10.15420/usc.2021.03","DOIUrl":"https://doi.org/10.15420/usc.2021.03","url":null,"abstract":"The significance of the right ventricle (RV) as a predictor of outcome in a series of cardiac conditions has recently been recognized. Consequently, more studies are now focusing on improving the assessment of the RV. Its primary function is to support adequate pulmonary perfusion pressure in different circulatory and loading situations and to ensure that there is a low systemic venous pressure. Echocardiography is the first-line method of choice due to its accuracy when assessing RV structure and function, as well as its wide availability. The geometry of the RV is complex and its evaluation can be difficult. Integrating and combining multiple parameters may be a more reliable way to determine normal or abnormal function. Novel techniques are increasingly being performed more routinely in clinical practice and are facilitating diagnosis and treatment choices.","PeriodicalId":37809,"journal":{"name":"US Cardiology Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-04-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42895263","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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