Iatrogenic mitral stenosis is a rare complication of the MitraClip procedure for which limited therapeutic options exist. We present a unique case using real-time echocardiographic and hemodynamic data demonstrating a potential role for interatrial septostomy creation as a percutaneous management option in this challenging population.

BACKGROUND: Although the prognosis and management of severe aortic stenosis has been extensively studied, the risk stratification and outcomes of patients with moderate aortic stenosis remain elusive. METHODS: This study included 674 patients from the Cleveland Clinic Health System with moderate aortic stenosis (aortic valve area, 1–1.5 cm 2 ; mean gradient, 20–40 mm Hg; and peak velocity <4 m/s) and an NT-proBNP (N-terminal pro-B-type natriuretic peptide) level within 3 months of index diagnosis. The primary outcome of major adverse cardiovascular events (defined as the composite outcome of progression to severe aortic stenosis requiring aortic valve replacement, heart failure hospitalization, or death) was extracted from the electronic medical record. RESULTS: The mean age was 75.3±12 years, and 57% were men. During a median follow-up of 316 days, the composite end point occurred in 305 patients. There were 132 (19.6%) deaths, 144 (21.4%) heart failure hospitalizations, and 114 (16.9%) patients underwent aortic valve replacement. Elevated NT-proBNP (1.41 [95% CI, 1.01–1.95]; P =0.048), diabetes (1.46 [95% CI, 1.08–1.96]; P =0.01), elevated averaged mitral valve E/e′ ratio (hazard ratio, 1.57 [95% CI, 1.18–2.10]; P <0.01), and presence atrial fibrillation at the time of index echocardiogram (hazard ratio, 1.83 [95% CI, 1.15–2.91]; P =0.01) were each independently associated with an increased hazard for the composite outcome and when taken collectively, each of these factors incrementally increased risk. CONCLUSIONS: These results further elucidate the relatively poor short-medium term outcomes and risk stratification of patients with moderate aortic stenosis, supporting randomized trials assessing the efficacy of transcatheter aortic valve replacement in this population.

Obstructive sleep apnea (OSA) is a common, potentially modifiable condition implicated in the pathogenesis of atrial fibrillation (AF). The presence and severity of OSA is largely sleep position–dependent, yet there is high variability in positional dependence among patients with OSA. We investigated the prevalence of positional OSA (POSA) and examined associated factors in patients with AF. We recruited an equal number of patients with and without AF who underwent diagnostic polysomnography. Patients included had ≥ 120 min of total sleep time with 30 min of sleep in both supine and lateral positions. POSA was defined as an overall apnea hypopnea index (AHI) ≥ 5/h, supine AHI (sAHI) ≥ 5/h, and sAHI greater than twice the non-supine AHI. POSA prevalence was compared in patients with and without AF adjusting for age, sex, OSA severity, and heart failure. A total of patients (male: 56

Iatrogenic mitral stenosis (MS) is an important factor when determining candidates for MitraClip, particularly when requiring multiple clips or in patients with preexisting MS. We present an 87-year-old woman with severe mitral regurgitation (MR). Pre-echocardiogram noted preserved biventricular function, moderate tricuspid regurgitation, and right ventricular systolic pressure of 47 mm Hg. MR mechanism was P2 prolapse with mean mitral gradient (MG) of 5 mm Hg and severe posterior mitral annular calcification. Invasive hemodynamics noted left atrial (LA) pressure of 20 mm Hg with V waves to 50 mm Hg and left ventricular end-diastolic pressure of 18 mm Hg. One NT MitraClip device was placed at the A2/P2 segments with trivial residual MR, but with MG of 9 mm Hg and mean LA pressure of 22 mm Hg (Figure 1). After removal of the MitraClip guide into the inferior vena cava, there was a left-to-right shunt across the interatrial septum with improved MG of 6 mm Hg, mean LA pressure of 12 mm Hg, V waves of 24 mm Hg, and pulmonary vein flow normalization. Follow-up transthoracic echocardiogram within 24 hours confirmed stable MG of 6 mm Hg. However, subsequent echocardiogram performed 2 months postprocedure revealed closure of the iatrogenic atrial septal defect with MG then at 13 mm Hg with a heart rate of 83 bpm. Six months postprocedure, the MG remained at 13 mm Hg (heart rate, 85 bpm). The REDUCE-LAP HF II study assessed the effect of an 8-mm interatrial shunt device (ISD) on heart failure patients with ejection fraction of ≥40% and exercise-induced pulmonary capillary wedge pressure of ≥25 mm Hg without right heart failure.1Shah S.J. Borlaug B.A. Chung E.S. et al.Atrial shunt device for heart failure with preserved and mildly reduced ejection fraction (REDUCE LAP-HF II): a randomised, multicentre, blinded, sham controlled trial.Lancet. 2022; 399: 1130-1140Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar After a 2-year follow-up, there was no difference in heart failure hospitalization between ISD placement and sham control. We believe that where REDUCE-LAP HF II failed, the ongoing RELIEVE-HF trial (NCT03499236) will succeed, as RELIEVE-HF will randomize patients to a smaller 5.1-mm V-Wave ISD and will include patients with significant systolic dysfunction. The therapeutic premise of ISDs in MS patients dates to the early 1900s, when Lutembacher2Lutembacher R. De la Stenose mitrale avec communication interauriculaire.Arch Mal Coeur. 1916; 9: 237-260Google Scholar described improved symptomatology among patients with MS and concomitant congenital secundum atrial septal defect (ASD). In this setting, the ASD functions as a “pop-off valve” for elevated LA pressures in patients with preserved right heart function. This case report demonstrates the acute hemodynamic benefit of creating an iatrogenic ASD in a patient with elevated MG after MitraClip, which then dissipated as the ASD closed over time. By creating a left-to-right shunt, the MG and LA pressure were both significantly lowered—which may be particularly beneficial at higher heart rates and dynamic conditions of left ventricular loading postprocedure. Although patients with MS will not be enrolled in RELIEVE-HF, they are often without treatment options and may benefit for similar reasons. Perhaps, the future of ISDs has come full circle, with potential application to patients with calcific MS without right heart failure or those who develop MS after MitraClip, as highlighted in this case. In addition to improving symptoms, this therapy may allow operators to better treat the MR with less concern of creating iatrogenic MS.3Koell B. Ludwig S. Weimann J. et al.Long-term outcomes of patients with elevated mitral valve pressure gradient after mitral valve edge-to-edge repair.JACC Cardiovasc Interv. 2022; 15: 922-934Crossref PubMed Scopus (17) Google Scholar,4Yoon S.H. Makar M. Kar S. et al.Prognostic value of increased mitral valve gradient after transcatheter edge-to-edge repair for primary mitral regurgitation.JACC Cardiovasc Interv. 2022; 15: 935-945Crossref PubMed Scopus (17) Google Scholar The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The aim of this study was to determine the relationship between ischemia testing prior to ablation for sustained monomorphic ventricular tachycardia (VT) (SMVT) and post-ablation mortality and VT recurrence. As SMVT is generally caused by myocardial scar and not active ischemia, the utility of ischemia testing prior to SMVT ablation is unclear. Patients who underwent ablation for SMVT at 2 tertiary care centers between January 2016 and July 2018 were included in a retrospective study. A Kaplan-Meier survival analysis was performed, stratifying patients by pre-ablation ischemia testing for the endpoints of mortality and VT recurrence. A Cox multivariable regression analysis was performed to identify predictors of post-ablation VT recurrence. A total of 163 patients were included, with 46 (28%) patients undergoing ischemia testing prior to ablation. Only 5 of the 46 patients (11%) received revascularization pre-ablation. After a median follow-up period of 625 days (interquartile range, 292-982 days) following ablation, 97 of 163 patients (60%) had VT recurrence, and 32 patients (20%) had died. There was no difference in mortality or VT recurrence between patients who did or did not experience ischemia testing or revascularization. In the multivariable regression analysis, predictors of VT recurrence were the number of anti-arrhythmics failed, non-ischemic cardiomyopathy, sex, and cardiac magnetic resonance imaging pre-ablation. Neither ischemia testing nor revascularization was a significant predictor of VT recurrence in univariable or multivariable regression analysis. In conclusion, ischemia testing is frequently ordered prior to SMVT ablation but infrequently leads to revascularization and is not associated with post-ablation outcomes. The findings support adopting an individualized approach rather than performing routine ischemia testing.

A 25 year old man presented with three days of cough, shortness of breath, and pleuritic chest pain. Initial vital signs in the ED were normal, and exam demonstrated tonsillar erythema without exudate. Labs revealed a leukocytosis of 18.9k/μL, D-dimer of 690 ng/mL, C-reactive protein of 5.7 mg/dL, and lactate elevated to 2.9 mmol/L. High-sensitivity troponin, NT-proBNP, and SARS-CoV-2 RT-PCR were all negative. Presenting electrocardiogram demonstrated PR elevation in aVR with diffuse ST-segment elevation in the inferior and anterolateral leads. Point-of-care echocardiogram demonstrated normal biventricular function without pericardial effusion. CTPA was negative for pulmonary embolism, and he was observed for presumed acute viral pericarditis. Fourteen-hours later, he became febrile to 38.3°C, tachycardic to 133 bpm, and hypotensive to 97/65 mmHg with diffuse abdominal pain. Repeat lactate was 9.0 mmol/L. This prompted an emergent CT scan which now showed a new large pericardial effusion and bilateral pleural effusions ( Panel A ). Repeat echocardiogram confirmed a large circumferential pericardial effusion with early signs of tamponade including right atrial inversion in late diastole ( Panel B ). Emergent pericardiocentesis yielded 560 mL of brown, purulent fluid ( Panel C ) with immediate improvement in hemodynamics. Bacterial gram stain and culture grew Haemophilus influenzae ( Panel D ). Immunodeficiency screening was negative. Transient severe biventricular systolic dysfunction was noted, consistent with sepsis-induced cardiomyopathy. He completed a targeted antibiotic course with partial recovery of his ejection fraction by discharge. Purulent pericarditis is rare in developed countries, and invasive H. influenzae in a young, immunocompetent adult is particularly unusual. This case illustrates the importance of early diagnosis and management of purulent pericarditis given its potential for rapid progression and high mortality.

To review myocarditis and pericarditis developing after COVID-19 vaccinations and identify the management strategies. COVID-19 mRNA vaccines are safe and effective. Systemic side effects of the vaccines are usually mild and transient. The incidence of acute myocarditis/pericarditis following COVID-19 vaccination is extremely low and ranges 2–20 per 100,000. The absolute number of myocarditis events is 1–10 per million after COVID-19 vaccination as compared to 40 per million after a COVID-19 infection. Higher rates are reported for pericarditis and myocarditis in COVID-19 infection as compared to COVID-19 vaccines. COVID-19 vaccine–related inflammatory heart conditions are transient and self-limiting in most cases. Patients present with chest pain, shortness of breath, and fever. Most patients have elevated cardiac enzymes and diffuse ST-segment elevation on electrocardiogram. Presence of myocardial edema on T2 mapping and evidence of late gadolinium enhancement on cardiac magnetic resonance imaging are also helpful additional findings. Patients were treated with non-steroidal anti-inflammatory drugs and colchicine with corticosteroids reserved for refractory cases. At least 3–6 months of exercise abstinence is recommended in athletes diagnosed with vaccine-related myocarditis. COVID-19 vaccination is recommended in all age groups for the overall benefits of preventing hospitalizations and severe COVID-19 infection sequela.

A 22-year-old male presented with chest pain 3 days after his second dose of the COVID-19 vaccine. Cardiac magnetic resonance imaging demonstrated myocardial and pericardial enhancement. Given imaging and clinical findings, he was diagnosed with perimyocarditis. He was treated with a multitude of medications including NSAIDs, colchicine, and steroids. Fortunately, he was able to achieve symptom improvement. Due to COVID-19 vaccination novelty, further research is needed to identify side effects.

Background: Sudden cardiac death (SCD) is a major driver of mortality in patients with end-stage renal disease (ESRD) on hemodialysis (HD). The degree to which ventricular arrhythmias (VA) play a role in SCD in ESRD patients is unclear. Objective: Use cardiac implantable electronic devices (CIEDs) to clarify VA burden in ESRD patients overall and in relation to interdialytic cycle. Methods: We identified 44 patients at a single academic center with CIEDs, 22 on HD, along with 22 age- and sex-matched controls. Device interrogations from 11/13/14 – 4/8/19 were reviewed. Results: Overall, there were no differences in HD patients and controls in adjusted overall event rate (HD 9.81 x 10-5 ± 1.5 x 10-3 events/patient-hours vs control 3.71 x 10-5 ± 9.1 x 10-4 events/patient-hours, p = 0.902), or proportion of patients experiencing VA event (HD 45.4% vs control 63.6%, p = 0.226). There was no difference in ventricular pacing burden. Controls were more likely to require device therapy for VT/VF episodes (total ATP episodes 2/38 in HD vs 10/22 in controls, p < 0.01, total ICD shocks 10/38 in HD vs 17/22 in controls, p < 0.01). HD patients were most likely to experience VA within 12-hours of HD completion (p < 0.01), and the vast majority of events were NSVT. Conclusion: VA and ventricular pacing burden was similar by CIED analysis between groups. In HD patients, VA were likely to occur within the first 12 hours post-dialysis, were primarily NSVT, and were unlikely to require device therapy.

BACKGROUND AND OBJECTIVE:The association between obstructive sleep apnea (OSA) and atrial fibrillation (AF) has been closely studied. However, obesity is a powerful confounder in the causal relationship between OSA and cardiovascular disease. The contribution of obesity in the relationship between OSA and AF remains unclear. METHODS:We recruited 457 consecutive patients equally with and without AF who underwent clinically indicated diagnostic polysomnography at a single academic sleep center. Multivariable logistic regression adjusting for age, sex, hypertension, and heart failure was performed to study the independent association between OSA and AF stratified by obesity. RESULTS:A total of 457 patients (male: 56.2%, mean age 63.1 ± 13.3 years) was included. OSA prevalence was similar between those with and without AF (52.6% vs. 47.4%, respectively; p = 0.24). In multivariable analysis, no association was found between AF and OSA regardless of obesity status. When severe OSA (vs. non-severe OSA) was modeled as a dependent variable, AF was associated with a higher likelihood of severe OSA in non-obese patients [odds ratio (OR): 2.29, 95% confidence interval (CI): 1.23-4.35, p = 0.01], but not in obese patients (OR: 0.95, 95% CI: 0.48-1.90, p = 0.89). CONCLUSION:The association of OSA with AF was present only in the non-obese and was limited to severe OSA patients. In contrast, no association was found in obese patients. The association between OSA and AF is partly dependent on the body habitus.

Abstract Introduction Sleep apnea is highly prevalent in patients with atrial fibrillation (AF). Obstructive sleep apnea (OSA) is the most common type, and best studied in the context of AF. However, recent investigations have indicated that central sleep apnea (CSA) may be a risk factor for incident AF. We evaluated the burden of CSA events in patients referred for diagnostic polysomnography (PSG) and whether AF is associated with CSA. Methods We identified patients with and without a history of AF who underwent clinically indicated PSG in a matched manner. OSA was defined as obstructive apnea‐hypopnea index (AHI) ≥15/h, and CSA was defined as central apnea index (CAI) ≥5/h. The association between AF and CSA was evaluated using multivariable logistic regression. Results Among 465 patients included, mean AHI was 25.5/h, and mean CAI was 1.7/h. OSA prevalence was 53.3%, while CSA prevalence was 8.4%. The prevalence of OSA in the AF and non‐AF groups (54.7% vs 52.0%, P = .56) was similar. CSA was more common in the AF group (12.3% vs 4.4%, P = .002). In multivariable analysis, AF (OR: 2.19 [1.02, 5.03], P = .05), male gender (OR: 2.5 [1.17, 5.84], P = .02), and older age (OR: 2.44, [1.16, 5.46], P = .02) were associated with CSA. Conclusion Though CSA is much less common than OSA in patients with AF, the presence of AF is independently associated with CSA.

Temporal relationships exist between arrhythmia burden, sudden cardiac death (SCD), and hemodialysis (HD) schedule, which is divided into two short interdialytic periods (SIDP, 48 hr), and one long interdialytic period (LIDP, 72 hr). The LIDP is associated with increased arrhythmia risk. We

Amiodarone is a chemically-unique class III antiarrhythmic drug and is commonly-prescribed by internists and cardiologists alike. 1 Vassallo P Trohman RG Prescribing amiodarone: an evidence-based review of clinical indications. J Am Med Assoc. 2007; 298: 1312-1322 Crossref PubMed Scopus (304) Google Scholar In addition to its known blockade of myocardial outward potassium channels and resultant class III properties, amiodarone is pharmacologically complex and exhibits class I, II, and IV effects as well. Thus, it is a common choice in the management of both supraventricular and ventricular arrhythmias, especially in patients with underlying structural heart disease. 1 Vassallo P Trohman RG Prescribing amiodarone: an evidence-based review of clinical indications. J Am Med Assoc. 2007; 298: 1312-1322 Crossref PubMed Scopus (304) Google Scholar ,2 Dan GA Martinez-Rubio A Agewall S Boriani G Borgrefe M Gaita F van Gelder I Gorenek B Kaski JC Kjeldsen K Lip GY Merkely B Okumura K Piccini JP Potpara T Poulsen BK Saba M Savelieva I Tamargo JL Wolpert C Antiarrhythmic drugs-clinical use and clinical decision making: a consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Cardiovascular Pharmacology, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and International Society of Cardiovascular Pharmacotherapy (ISCP). Europace. 2018; 20: 731-732 PubMed Google Scholar

Objective: There is an unmet need for noninvasive continuous blood pressure (BP) monitoring technologies in various clinical settings. We examined the accuracy of noninvasive Caretaker device against invasively measured central aortic BP. Methods: Beat-to-beat BP by Caretaker was recorded simultaneously with central aortic BP measured in patients undergoing cardiac catheterization. We derived correlations and Bland-Altman comparisons, after calibrating the Caretaker with 20 seconds of the initial catheter readings, as well as trend analyses for both systolic (SBP) and diastolic BP (DBP). We also measured left ventricular ejection time (LVET) from both aortic pressure tracing and Caretaker and compared the two. Results: A total of 47 patients were included in the study. A total of 31,369 beats obtained during the diagnostic portion of coronary angiogram were used for analysis. The correlations for SBP and DBP were 0.89 and 0.78, respectively (p < 0.001 for both). The Bland-Altman comparison yielded overall mean differences of 2.11 mmHg (SD 7.40) for SBP and 1.46 mmHg (SD 6.12) for DBP respectively (p <0.001 for all comparisons). The trend analysis yielded concordances of 86% and 85% for SBP and DBP, respectively. The correlation and Bland-Altman analyses for the LVET comparison yielded 0.89 (p< 0.001) with a mean difference of 13.9 ms (SD 14.4 ms). Conclusion: Beat-to-beat BP by Caretaker showed excellent agreement and high concordance in the direction and the degree of BP change with central aortic BP. This study supports the satisfactory performance of the Caretaker device in continuous tracking of beat-to-beat BP and LVET measurements.

Abstract Introduction Central sleep apnea (CSA) is unique sleep breathing phenotype in patients with advanced chronic heart failure (HF) and portend poor prognosis. The prevalence of CSA in HF patients under contemporary therapy is uncertain. Methods We reviewed consecutive HF patients on optimal medical therapy who underwent clinically indicated diagnostic in-lab polysomnography at a single academic center. Age, sex and BMI matched patients without HF were selected from sleep clinic as a control. Patients with atrial fibrillation were excluded from this study. Apnea subtypes were determined after careful scoring and confirmation by sleep physicians. ‘Any CSA’ was defined by central apnea index (CAI) >5 and >1/hr. ‘True CSA’ was defined if met both CAI≥5/hr and > obstructive apnea index (OAI). Obstructive sleep apnea (OSA) was defined if apnea hypopnea index >15 and OAI>CAI. Multivariate analysis was performed using logistic regression adjusting for age, sex, HF and systolic dysfunction as appropriate. Results In patients with HF (N=95, mean age 59, female: 50%), CSA was low and was comparable to control group (N=94) (HF vs. Non-HF; CSA: 5.3 vs. 4.3%, P=NS; Any CSA 14.7 vs. 17%, P=NS). Only 3 patients with HF had true CSA. In contrast, OSA was common in both groups regardless of obesity status (52.3 vs. 55.3%). In patients with HF, Cheyne Stokes respiration was more frequent in patients with Any CSA vs. without Any CSA (13.3 vs. 3.8%, p=0.04). In multivariate analysis, presence of OSA, but not HF, was associated with Any CSA in entire cohort (Any CSA OR: 3.1 [1.3, 8.1], p=0.02). In patients with HF, male sex was associated with Any CSA (OR: 5.3 [1.1, 40.8], p=0.05). Exclusion of patients with high BMI did not change the results. Conclusion CSA was rare in patients with stable HF on contemporary optimal medical therapy. Support None

Background: Recent randomized clinical trial data has supported catheter ablation (CA) of atrial fibrillation (AF) in patients with heart failure (HF). Ablation and fluid management strategies could impact periprocedural outcomes especially in HF patients. Methods: We conducted a single-center retrospective analysis of 200 consecutive patients with and without HF undergoing CA at a tertiary care academic center from July 2017 through June 2018. HF was defined as any EF < 40%, prior inpatient admission for HF exacerbation, or ambulatory management of HF confirmed by independent chart review. Diuretic regimens were reported as furosemide equivalent. Results: Among 200 patients, 65 (32.5%) had HF and 135 (67.5%) did not. HF patients had longer mean procedure times (299.8 ± 96 min vs 268.4 ± 96 min, p = 0.03) and were more likely to require mitral isthmus (p < 0.001), posterior wall isolation (p = 0.002), and cavotriscupid isthmus (p = 0.004) ablations. There were no differences between the HF vs. non-HF groups’ intraprocedural volume intake, intraprocedural volume output, net fluid status, or intraprocedural diuretic dose (Table 1). HF patients received higher doses of IV (41.5 ± 43.0 mg vs 23.6 ± 11.8 mg, p = 0.007) and PO (43.2 ± 16.7 mg vs 26.7 ± 10.0 mg, p < 0.001) postprocedural diuretic. There were no differences in the rates of major in-hospital complications (Table 1). In a multivariable regression analysis adjusted for procedural covariates, there were higher proportions of posterior wall isolation (p = 0.01) as well as postprocedural PO (p = 0.01) and IV diuretic (p = 0.002) administration in the HF cohort. Conclusion: Intraprocedural volume and diuretic management was similar between HF and non-HF patients undergoing CA of AF, though HF patients tended to receive more aggressive diuresis post procedurally with no difference in complications. Table 1. Intra- and post-procedural management and outcomes in HF vs non-HF patients undergoing CA for AF