Are Outcomes of TAVR Better in Teaching Hospitals?

Transcatheter aortic valve replacement (TAVR) has become a cornerstone in the management of severe aortic stenosis. Large-scale nationwide data on factors impacting outcomes and complications of this new procedure, however, are sparse. In this month’s issue of the Journal of Invasive Cardiology, from a retrospective analysis using data from the Nationwide Inpatient Sample (NIS), the largest all-payer database of hospital inpatient stay available in the United States, we reported the impact of institutional design on TAVR outcome.(1)

Analysis of 7405 procedures performed throughout 2012 revealed that the majority of procedures were performed in teaching hospitals. While there was no difference in the in-hospital mortality, there was a statistically significant difference in the complication rates based on institutional design. Patients in teaching hospitals had fewer complication rates when compared with their counterparts in non-teaching hospital. Of note in the current study, the majority (88%) of these procedures were performed in teaching hospitals, hence it was hypothesized that teaching hospitals could be high-volume centers with operators gaining more experience in such settings, perhaps resulting in lower complication rates. While TAVR indications and utilization are expanding, it becomes important to understand the factors impacting the outcomes, risk mitigation strategy, and appropriate planning to maximize TAVR care and reduce cost. In an accompanying commentary, Balan et al provide an example of the “hub-and-spoke” model for TAVR care in British Columbia and how this approach helped maximize TAVR access in the region, yet maintained good outcomes.(2,3) While it’s not entirely fair to compare these two different healthcare systems, it is time to develop a model at the regional and national levels to provide competent and cost-effective TAVR care in the United States. We believe data from the TAVR registry may be a great resource in developing and monitoring such a system.

Sadip Pant, MD; University of Louisville School of Medicine, Louisville, KY

Kanishk Agnihotri, MD; Saint Peter’s University Hospital, Jersey City, NJ

Michael P. Flaherty, MD; University of Louisville School of Medicine, Louisville, KY

References
(1) Pant S, Patel S, Golwala H, et al. Transcatheter aortic valve replacement complication rates in teaching vs non-teaching centers in the United States. J Invasive Cardiol. 2016;28:67-70.
(2) Balan P, Anderson HV, Helmy T. How to Build a Better TAVR. J Invasive Cardiol. 2016;28:71-72.
(3) Stub D, Lauck S, Lee M, et al. Regional systems of care to optimize outcomes in patients undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2015;8:1944-1951.

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A Step Forward: The Use of the CrossLock Catheter in a Patient with Critical Limb Ischemia and a Popliteal Occlusion

Richard R. Heuser, MD;  Kerry Zang, DPM;  Arthur Mollen, MD

Every 30 seconds a limb is lost to diabetes mellitus. If a patient has an amputation, the family as well as the patient can look forward to a 40% mortality in the first year and a 80% mortality in 5 years. Diabetic foot ulcers affect over 1.5 million people annually at a cost of $6-$10 billion (1-3). In this month’s Journal of Invasive Cardiology, we describe the case of a 75-year-old diabetic lady who presented with critical limb ischemia, but fortunately because of a quick thinking primary care physician as well as podiatrist, she had not yet suffered an ulcer. When the angiogram reveals a popliteal occlusion, this presents a challenge to the interventionist; however, success rates approach 85% in these patients and no matter how you open the vessel — whether with ballooning, laser, atherectomy or stents — the recanalization success will most likely prevent an amputation. To cross a 100% occlusion, we have been impressed by the Prodigy catheter and its ability to keep the wire lumen in the true channel of the vessel when passing the wire with the Prodigy balloon inflated (4).
Until we developed the CrossLock catheter, we were not able to keep a support catheter close to a peripheral total occlusion, particularly when we wanted to pass balloons, lasers, atherectomy devices, or stents. The advantage of the CrossLock is that it is only 6 Fr compatible, making the antegrade approach as well as retrograde approach an acceptable risk to the patient.
Interventionists need new devices to aid in limb salvage. The CrossLock, with its centering balloon and super support, is unique and is intuitively obvious for the operator. Whether this will be a device of choice for the peripheral interventionist requires more operators to utilize the device, experience with SFA-CTO, as well as experience with retrograde and antegrade approaches. We do think this is a unique device and have been very happy with our results at this stage.
Limb salvage requires a multidisciplinary team. The total team effort is important because diabetes and vascular disease affect every system in the body.

  1. American Diabetes Assocation Standards of Medical Care in Diabetes – 2009. Diabetes Care. 2009;32(Suppl 1):S13-S61.
  2. Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med. 2004;351(1):48-55.
  3. Diabetic Foot Pnline. Diabetic foot:  facts and figures.  http://diabeticfootonline.com/diabetic-foot-acts-and-figures/.
  4. Moualla S, Khan S, Heuser RR:  Anchoring improved:  Introduction of a new over-the-wire support balloon.  J Invasive Cardiol. 2014; (9):130-132.
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Percutaneous Closure of Intracardiac Defects in Adults

By Andres M. Pineda MD and Nirat Beohar MD

The number of adults with intracardiac defects is expected to rise over the next decade primarily as a result of the increasing prevalence of adult congenital heart disease and some acquired defects. Atrial septal defect (ASD), patent foramen ovale (PFO), ventricular septal defect (VSD), and prosthetic valve paravalvular regurgitation (PVR) are the most frequent intracardiac defects encountered in the adult population in current practice. Although in the past most of these defects were managed surgically, with the advances in cardiac imaging, device technology, and transcatheter techniques, percutaneous closure is now feasible and safe for most intracardiac defects in adults. Our manuscript in this month’s issues of the Journal of Invasive Cardiology is a comprehensive review of the current transcatheter management of the most common defects in adults. This review focuses on adult-specific clinical challenges, key technical aspects, the evidence for, current indications, and future directions of device closure of ASDs, PFOs, VSDs, and PVRs.

Device closure is currently considered first-line therapy for ostium secundum ASDs and muscular VSDs. It has also been used for patients with challenging anatomies or clinical scenarios, including those with ASD with deficient rims, older adults at risk for heart failure after ASD closure, or non-muscular VSDs. Percutaneous closure of PFOs has been successfully used for the treatment of major decompression illness in scuba divers, platypnea-orthodeoxia syndrome, and may reduce migraine episodes. In high-risk patients, PFO closure may also prevent recurrent cerebrovascular events after cryptogenic stroke. Transcatheter closure of PVR after transcatheter or surgical prosthetic valve replacement has been successfully performed and is an excellent alternative avoiding the high risk of surgical reintervention.

Read the entire review here:
Pineda AM, Mihos CG, Singla S, Santana O, Rhodes J, Sommer RJ, Rihal CS, Beohar N. Percutaneous closure of intracardiac defects in adults: state of the art. J Invasive Cardiol 2015;27(12):561-572.

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Pulmonary Valve Stenosis and Percutaneous Balloon Pulmonary Valvuloplasty: Are We All Clear About This Disease and Procedure?

Xiaodong Qian
Department of Cardiology
First Affiliated Hospital of Soochow University
Suzhou, People’s Republic of China

Pulmonary valve stenosis (PVS), which causes obstruction of the right ventricular outflow tract, is a relatively common congenital heart disease in children but is relatively rare in adults. The normal pulmonary valve has three cusps, which are completely separated at their junctions. The typical PVS usually has intact but thickened cusps, and the junctions of two cusps are fused. The traditional treatment for PVS is surgical valvotomy. In 1982, the technique of percutaneous balloon pulmonary valvuloplasty (PBPV) was introduced initially by Kan et al. Since then, many authors have reported the successful application of this technique to treat PVS. A large amount of data has shown that PBPV can provide good immediate, mid-term, and long-term results for children with PVS, but data about outcomes (especially long-term) for PBPV treating adult PVS are limited. The decision about the type of treatment should be made according to the degree of hemodynamic changes. Balloons whose diameters exceeded the ring measurement by 20% on angiography were shown to be safe and effective. However, some patients had less-optimal immediate results. Some had spontaneous reduction of peak systolic gradient to normal, and some required a repeat PBPV. Which factors can predict the long-term results of PBPV for adult PVS? What is the mechanism of the spontaneous reduction of of peak systolic gradient? What is the cut-off point of of peak systolic gradient for the indication of PBPV? We still need firm answers to these questions.

To read Dr. Qian’s 41-patient study on the long-term outcomes of PBPV in adult pulmonary valve stenosis patients, please visit:

Percutaneous Pulmonary Balloon Valvuloplasty Provides Good Long-Term Outcomes in Adults With Pulmonary Valve Stenosis, by Xiaodong Qian, MD;  Yunxia Qian, MD;  Yafeng Zhou, MD;  Xiangjun Yang, MD
J INVASIVE CARDIOL 2015;27(12)E291-E296. Epub 2015 August 25

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Chronic Statin Therapy and Postprocedural CIN in Non-Emergent PCI

Dmitriy N. Feldman, MD

Associate Professor of Medicine, Director of Endovascular Services, Weill Cornell Medical College, New York Presbyterian Hospital, Greenberg Division of Cardiology, 520 East 70th Street, Starr-434 Pavilion, New York, NY 10021. Email: dnf9001@med.cornell.edu

Recent evidence from trials suggests that preprocedural high-dose statin therapy prior to contrast exposure may reduce the incidence of contrast-induced nephropathy (CIN). The pleiotropic effects of statins, which include anti-inflammatory, antioxidant, and antithrombotic properties, are thought to be renally protective. While prior investigations on this topic have largely focused on higher-risk ACS patients, our study aimed to examine the effect of chronic statin therapy on the incidence of postprocedural CIN in a cohort of patients undergoing non-emergent PCI in the current interventional era. In our retrospective analysis of patients undergoing non-emergent PCI, chronic statin therapy significantly reduced the odds of developing CIN after adjusting for patient-related and procedure-related factors. Overall, 4.5% developed CIN following PCI and the incidence of CIN following PCI was not significantly different between patients on chronic statin therapy versus those not on chronic statin therapy (4.2% vs 5.4%; P=.42). However, after multivariate adjustment, chronic statin therapy was associated with a lower incidence of CIN (odds ratio 0.21; 95% CI, 0.05-0.94; P=.04).

Our study in this month’s Journal of Invasive Cardiology adds to the body of data supporting importance and benefit of chronic statin therapy for the prevention of CIN, with extension to the non-emergent PCI setting. Given the potential benefits and minimal risks associated with periprocedural loading with statins, preprocedural loading with a high-dose statin should be strongly considered even in elective PCI, whether or not patients are receiving chronic statin therapy. Further studies are needed to demonstrate whether high-dose statin loading immediately before angiography in patients without clear indications for statins should be performed for the purpose of renal protection alone and whether periprocedural high-dose statin loading should be administered to patients already on chronic statin therapy.

Read Dr. Feldman’s entire article at http://www.invasivecardiology.com

A selection of JIC article highlighting Contrast-Induced Nephropathy:

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How Should We Manage PAR After TAVI?

Stefan Toggweiler, MD

Evidence indicates that postprocedural moderate or severe paravalvular regurgitation (PAR) reduces life expectancy in such a way that it may even nullify the beneficial effect of TAVI.
Due to improved implantation techniques, knowledge, and materials, the rates of moderate or severe PAR have dropped to less than 5%-10% in most recently published trials and registries, but mild PAR still occurs quite frequently. Many interventional cardiologists now aim for the “perfect” result, and even mild PAR seems to justify postdilatation of a transcatheter valve. However, we should keep in mind that postdilatation carries the risks of annular injury, valve displacement, and embolization of calcific debris.
In our study published in the month’s JIC, we investigated the natural course of PAR after implantation of the self-expandable CoreValve. Patients underwent transesophageal echocardiography after 30 days and 1 year. In most patients, PAR improved. Very small jets disappeared, and larger jets became smaller. Overall, we observed an impressive reduction by about 45% between 30 days and 1 year post TAVI. During the first minutes, hours, or days, PAR may lessen due to improved annular apposition and expansion of the frame. However, long-term improvement is more likely due to endothelialization of the frame (see illustration below).

ToggweilerFig1

Illustration: The natural course of paravalvular regurgitation after implantation of a self-expandable valve.

Accordingly, postdilation should only be performed in patients with hemodynamically relevant (more than mild) PAR, as mild PAR may spontaneously improve or disappear during the first year of follow-up. If relevant PAR is present after implantation of a self-expandable valve without obvious underexpansion or malpositioning, it is advisable to wait 5-10 minutes, observe hemodynamics, and perform another supravalvular injection of contrast dye. PAR will spontaneously improve in many patients.

Stefan Toggweiler, MD is the head of the interventional valve programme at the Heart Center Lucerne in Lucerne, Switzerland.

Read the entire article here:

Natural Course of Paravalvular Regurgitation After Implantation of the Self-Expanding CoreValve: Insights From Serial TEE Measurements, by Stefan Toggweiler, MD;  Bram van Schie, MD;  Michel Zuber, MD;  Zaid Sabti, MD;  Tardu Özkartal, MD;  Thomas F. Lüscher, MD;  Paul Erne, MD

J INVASIVE CARDIOL 2015;27(9):435-440

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LM-Bifurcation PCI: Stent Design and the Effects of Cardiac Flow

Robert S. Schwartz, MD, FACC, FAHA, FSCAI, FSCCT
Minneapolis Heart Institute and Foundation

Left main coronary artery stenting is commonplace in today’s PCI, but new questions arise as to safety. Specifically, the three-dimensional changes in space as the left main and its bifurcation change throughout the cardiac cycle have the capability of bringing novel stresses onto today’s thin metallic stents.
We believed it was important to understand this three-dimensional movement throughout the cardiac cycle, with special attention to the bifurcation angle. We took advantage of modern-day three-dimensional CTA imaging to help answer this question of bifurcation angles and their changes through time.
We first found marked absolute angle variability across patients. We then quantitated these numbers for reference and understanding which stents may in fact perform better for left main PCI. Interestingly, these angles had small angulation changes resulting from the cardiac cycle movement, suggesting less stringent requirements for stent torsion.
These results are clearly reassuring regarding left main PCI and our ability to stent this area with multiple stent designs. At this point, growing experience with left main stenting confirms the safety of modern-day stents in left main disease reasonably independent of stent design.

Read the entire study in this month’s Journal of Invasive Cardiology:

The Left Main Bifurcation Angle and Changes Throughout the Cardiac Cycle: Quantitative Implications for Left Main Bifurcation Stenting and Stents
Chauncy B. Handran, MD; Ross F. Garberich, MD; John R. Lesser, MD; Timothy D. Henry, MD; Michael Gilmore; Robert B. Schwartz, MD
J INVASIVE CARDIOL 2015;27(9):401-404. Epub 2015 May 15

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