OBJECTIVES:Transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) may be challenging in patients with peripheral arterial disease (PAD). Alternative access through intra- and extrathoracic approaches can be performed. Recently, a facilitated TF access strategy, which involves the use of intravascular lithotripsy to optimize the iliofemoral arteries prior to TAVR, has been utilized. The aim of this study was to evaluate early outcomes of facilitated TF access compared to alternative access in patients with severe PAD. METHODS:Patients with severe PAD who underwent TAVR from 2021 to 2023 were included in the study and were divided into 2 groups: facilitated and alternative access. The primary endpoint was a composite of mortality, stroke, and vascular complications. Mortality was evaluated in-hospital and at 1-month follow-up. RESULTS:Of 150 TAVR patients with severe PAD, 24 underwent facilitated access. Baseline characteristics including age, Society of Thoracic Surgeons score, and mean gradients were similar between the 2 groups. The most common alternative access was transsubclavian, followed by transcarotid. Primary outcomes were numerically higher in the alternative access group (14% vs 8%); however, this did not reach statistical significance (P = .49). General anesthesia use and postoperative length of stay were higher in the alternative access group. Postoperative and 1-month mortalities were similar between the 2 groups. CONCLUSIONS:Although the primary endpoint did not reach statistical significance, the numerical trend toward better outcomes in the facilitated TAVR group indicates a potential advantage. Large-scale prospective studies are required to determine the appropriate access strategy for TAVR in patients with severe PAD.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) can be performed through multiple access sites with the preferred approach being transfemoral. In patients with severe peripheral arterial disease and previous grafts, the safety of transfemoral access via direct graft puncture, especially when performed twice within a short period, remains unclear compared to alternative access methods. We present a case demonstrating the safety and efficacy of direct graft puncture for transfemoral access during balloon aortic valvuloplasty (BAV) and TAVR. CASE SUMMARY:An 82-year-old man presented with dyspnea on exertion. Echocardiogram was significant for severe aortic stenosis. Following a heart team discussion, the patient was scheduled for a balloon valvuloplasty followed by staged TAVR. Based on pre-TAVR computed tomography angiogram, the aortobifemoral graft was deemed as an appropriate access site. Micropuncture needle was used to access the right femoral artery graft, and the sheath was upscaled to 10 Fr. He underwent successful intervention to ostial left anterior descending and left circumflex arteries, and BAV with 22 mm Vida BAV balloon. Hemostasis was achieved using Perclose. For TAVR, an 8 Fr sheath was inserted via the right femoral bypass graft. The arteriotomy was pre-closed with two Perclose ProGlides and access was upsized to 18F Gore DrySeal. A 5Fr sheath was used for left femoral bypass graft access. Patient underwent successful TAVR with 29 mm CoreValve. Hemostasis was successfully achieved using 2 Perclose for right access site and one Perclose for left side with no postoperative bleeding complications. CONCLUSION:BAV and TAVR are feasible and safe through a direct puncture of the aortofemoral bypass graft with successful hemostasis using Perclose.

A 79-year-old man with a failed 25-mm CE Magna Ease 3300 surgical prosthesis and of high re-operative surgical risk (STS 8%) presented with dyspnea, NYHA III. Cardiac computed tomography angiography revealed anatomy that was high risk for coronary occlusion with a short right coronary artery height of 6 mm and a valve-to-coronary distance of 2 mm.

BackgroundHemostasis for transfemoral transcatheter aortic valve replacement (TAVR) is typically achieved using a suture-mediated vascular closure device (VCD) prior to large bore sheath insertion (preclosure technique). Recently, the addition of a hybrid closure technique using a preclose technique with the addition of a collagen-plug VCD after sheath removal in cases of failed hemostasis has been utilized.MethodsData were collected from the Northwell TAVR registry, including 3 high volume TAVR centers. We evaluated a preclose strategy with suture-mediated vascular closure alone (“legacy strategy”) and standard bailout techniques versus a contemporary hybrid strategy of suture-mediated closure with collagen-mediated closure bailout. The primary end point was major or minor vascular complications as defined by the VARC3 criteria.ResultsA total of 1327 patients were included, of which 791 patients underwent TAVR with suture-mediated closure alone and 536 with contemporary strategy. The primary end point (major or minor vascular complication) was lower in the contemporary strategy (5.44% vs 1.31%; P < .001). Both minor (3.92% vs 1.12%; P = .002) and major (1.14% vs 0.19%; P = .0196) vascular complications were reduced and the total length of stay was less in the contemporary strategy (median of 3 days vs 2 days; P < .0001). Using multivariate analysis, we observed that vascular management strategy significantly improved the composite primary outcome when adjusted for sheath size, peripheral artery disease, carotid disease, and site of procedure. In the contemporary group, bailout collagen-plug VCD with an Angioseal (Abbott Vascular Devices) was used in 68 patients (12.69%) and bailout MANTA (Teleflex) was required in 4 patients (0.75%). There were no major or minor vascular complications among the patients who received bailout collagen-plug VCD.ConclusionsA contemporary hybrid strategy of suture-mediated closure with collagen-mediated closure bailout reduces the risk of vascular complications among patients undergoing transfemoral TAVR.

BackgroundMitral annular calcification (MAC) has been an exclusion for many of the earlier pivotal trials that were instrumental in gaining device approval and indications for mitral transcatheter edge-to-edge repair (M-TEER).AimsTo evaluate the impact of MAC on the procedural durability and success of newer generation MitraClip (R) systems (G3 and G4 systems).MethodsData were collected from Northwell TEER registry. Patients that underwent M-TEER with third or fourth generation MitraClip device were included. Patients were divided into -MAC (none-mild) and +MAC (moderate-severe) groups. Procedural success was defined as <= grade 2 + mitral regurgitation (MR) postprocedure, and durability was defined as <= grade 2 + MR retention at 1 month and 1 year. Univariate analysis compared outcomes between groups.ResultsOf 260 M-TEER patients, 160 were -MAC and 100 were +MAC. Procedural success was comparable; however, there were three patients who required conversion to cardiac surgery during the index hospitalization in the +MAC group versus none in the -MAC group (though this was not statistically significant). At 1-month follow-up, there were no significant differences in MR severity. At 1-year follow-up, +MAC had higher moderate-severe MR (22.1% vs. 7.5%; p = 0.002) and higher mean transmitral gradients (5.3 vs. 4.0 mmHg; p = 0.001) with no differences in mortality, New York Heart Association functional class or ejection fraction.ConclusionIn selective patients with high burden of MAC, contemporary M-TEER is safe, and procedural success is similar to patients with none-mild MAC. However, a loss of procedural durability was seen in +MAC group at 1-year follow-up. Further studies with longer follow-ups are required to assess newer mTEER devices and their potential clinical implications in patients with a high burden of MAC.

The presence of concomitant aortic insufficiency (AI) and mitral regurgitation (MR) is common and may further accelerate cardiac dysfunction. However, there exists no US regulatory-approved transcatheter device for the treatment of AI. The effectiveness of isolated transcatheter mitral therapy in this population is not well-understood; thus, we aimed to evaluate outcomes for patients with combined AI and MR compared with isolated MR who underwent mitral transcatheter edge-to-edge repair (m-TEER). Retrospective data were obtained from the Northwell m-TEER registry. A total of 587 patients who underwent m-TEER at 4 high-volume transcatheter aortic valve replacement/transcatheter edge-to-edge repair centers within the Northwell Health system were included. All patients had severe MR and were divided into 2 groups: group 1 with ≥3+ AI (AI+) and the group 2 with <3+ AI (AI-). Echocardiographic outcomes were evaluated at 1 month. Clinical outcomes were evaluated at 1 month and 1 year. The primary end point was death or rehospitalization at 1 year. A total of 587 patients were included in the study, with 92 in the AI+ group. Baseline characteristics were similar in both groups. Approximately 2/3 of patients in the AI+ group demonstrated an improvement in AI severity after isolated mitral therapy. There was no difference in the primary outcome at 1 month or 1 year. There was also no significant difference in New York Heart Association functional class at 1 month between the groups. In conclusion, patients who underwent m-TEER with combined MR and AI (AI+ group) fared well compared with those with isolated mitral valve dysfunction (AI- group), with no discernible differences in survival, New York Heart Association class, or rehospitalization rates at 1 month or 1 year. Hence, isolated m-TEER is a reasonable treatment approach in patients with a high surgical risk with combined AI and MR.

Recent ACC/AHA/ACCP/HRS guidelines suggest that patients with Atrial fibrillation (AF) at intermediate to low annual risk of ischemic stroke can benefit from consideration of factors that might modify their risk of stroke. The role of non-traditional risk factors such as primary hyperparathyroidism (PHPT) remains unexplored. In our study, we investigated the potential association between PHPT and the risk of ischemic stroke among patients with AF. Using data from the Nationwide Inpatient Sample Database, a retrospective cohort study focused on the adult population with AF and stratified them based on PHPT presence. Demographic information, comorbidities, and hospitalization details were extracted using ICD-10 codes. Propensity score matching was applied, encompassing over 20 confounding variables, including the risk factors outlined in the CHA2DS2-VASc score. Multivariate logistic regression analysis was executed after matching to assess the independent impact of PHPT as an ischemic stroke risk factor. Two thousand fifty-one out of the identified 395,249 AF patients had PHPT. The PHPT group had an average age of 74 and consisted of more females (66.1% vs. 53.0%). After matching, it was observed that the PHPT group had longer hospital stays (5 vs. 4 days) and higher hospitalization charges ($45,126 vs. $36,644). This group exhibited higher rates of ischemic stroke (6.0% vs. 4.4%) and mortality (6.3% vs. 4.9%). Adjusted outcomes showed a 1.4-fold increased risk for ischemic stroke and a 1.32-fold increased risk for mortality in the PHPT cohort. Subgroup analysis showed a higher incidence of mortality in males with a high CHA2DS2-VASc score. In conclusion, this study highlights a marked association between PHPT and ischemic stroke in AF patients independent of the conventional CHA2DS2-VASc score. The potential mechanisms implicated include vascular changes, cardiac dysfunction, and coagulation cascade alterations. The presence of primary hyperparathyroidism should be taken into consideration when deciding the assessment of thromboembolic risk.

Treatment of congestive heart failure (CHF) with left ventricular (LV) systolic dysfunction and severe aortic stenosis (AS) is challenging, yet transcatheter aortic valve replacement (TAVR) has emerged as a suitable treatment option in such patients. We compared the periprocedural outcomes of TAVR in patients with an ejection fraction (EF) of ≤20% (VLEF group) to patients with an EF > 20% to ≤40% (LEF group). We included patients with severe AS and reduced LV ejection fraction (LVEF ≤ 40%) who underwent TAVR at four centers within Northwell Health between January 2016 and December 2020. Over 2000 consecutive patients were analyzed, of which 355 patients met the inclusion criteria. The primary composite endpoint was in-hospital mortality, moderate or greater paravalvular (PVL), stroke, conversion to open surgery, aortic valve re-intervention, and/or need for PPM. Secondary endpoints were length of stay, NYHA classification at 1 month and 1 year, mortality at 1 month and 1 year, mean valve gradient at 1 month, KCCQ score at 1 month, and ≥ moderate PVL at 1 month. There was no difference in the primary composite endpoint between the two groups (23.6% for VLEF vs. 25.3% for LEF, p = 0.29). During TAVR placement, 40% of patients in the VLEF group required ≥1 vasopressors for hypotension lasting ≥30 min vs. only 21% of patients in the LEF group (p < 0.01). Intra-aortic balloon pump (IABP) use during procedure was greater in the VLEF group (9% vs. 1%, p < 0.01)-all placed post TAVR. Emergency ECMO use was higher in the VLEF group as well (5% vs. 0%). Total length of stay was significantly different between the two groups as well (6 days vs. 3 days, p < 0.01). Both groups had a change in LVEF of ~10%. One-year outcomes were similar between the groups. All-cause mortality at 1 year was not significantly different at 1 year (13% for VLEF vs. 11% for LEF), and KCC scores were also similar (77.54 vs. 74.97). Mean aortic valve gradients were also similar (12 mmHg vs. 11 mmHg, p = 0.48). Our study suggests that patients with EF ≤ 20% can safely have TAVR with similar periprocedural outcomes compared to patients with EF > 20% to ≤40% despite higher rates of vasopressor and mechanical support.

Coronary artery anomalies (CAAs) are known to be anatomical aberrations in the origin and structure. Due to the diverse anatomical variants, surgeons and angiographers have struggled when faced with patients who have CAA. To frame the complicated issues surrounding CAA, we present a case of a young patient found to have two CAAs, concurrently on coronary computed tomography angiography (CCTA), while in the emergency room being evaluated for chest pain. Patient was medically observed without any invasive procedure since he was deemed to have low cardiovascular risk. Subsequently, literature on prevalence, as well as high risk findings are reviewed. Further studies to evaluate pharmacological, angiographic, and surgical interventions may have additional benefit for both patients and practitioners. Our aim is to help shed the light on difficulties cardiologists are facing during angiography. Additionally, our paper offers some guidance for how to evaluate and follow patients with similar findings into the future.

Single coronary artery (SCA) is an unusual congenital anomaly, seen by diagnostic coronary angiography. Absence of the right coronary artery (RCA) is one of the rarest coronary artery anomalies occurring when the artery fails to develop in the right atrioventricular (AV) groove. Herein, we describe the case of a 58-year-old man presenting with new onset decompensated congestive heart failure found to have a congenitally absent right coronary ostium. The AV groove extended such that the left circumflex artery supplied the domain of the RCA. Such coronary artery anomalies are rare, and we aim to shed further insight into these congenital processes so that operators may remain vigilant of them in their practice.

BACKGROUND:Traditional open sternotomy coronary artery bypass grafting (CABG) utilizes highly invasive techniques that lead to several serious complications. In response, minimally invasive cardiac surgery CABG (MICS-CABG) was developed. MICS-CABG is safe, reproducible, and with fewer complications, while allowing for better postoperative recovery periods. There is a paucity of data exploring rates of repeat revascularization in patients post MICS-CABG compared to post traditional sternotomy CABG.METHODS:This was a retrospective billing database review examining 1468 CABG patients at a large university medical center from January 2005 to December 2017. The primary objective was to compare the rate of repeat revascularization events between MICS-CABG and traditional open sternotomy CABG over an eight-year follow-up period.RESULTS:Our study population consisted of 1468 patients, of whom 513 had MICS-CABG and 955 had traditional CABG. The number of patients undergoing repeat revascularization within the eight-year surveillance was 99 for MICS-CABG and 75 for traditional CABG. The Kaplan-Meier survival probability estimates for eight years were 0.86 for MICS-CABG and 0.91 for traditional CABG. The mean time until a repeat revascularization event was 84.1 months for MICS-CABG and 88.5 months for traditional CABG.CONCLUSIONS:Traditional CABG was found to have a statistically significantly longer time to repeat revascularization than MICS-CABG. Despite the technical challenges associated with MICS-CABG, the time to repeat revascularization was different by only about four months, which may not hold large clinical significance. This suggests that MICS-CABG may have a role to play due to previous findings showing a reduction in complications while allowing for better postoperative recovery periods.

We report herein the case of an elderly female who presented with myocardial infarction complicated by ventricular septal defect (VSD) that was evident on cardiac auscultation and contrast echocardiography using Lumason® (Bracco Diagnostics Inc, Monroe Township, USA). Patient underwent surgical repair for her VSD post-infarct along with coronary artery bypass grafting after being treated for cardiogenic shock. We also highlight the management strategies in patients with similar complications. In this report, we shed the light on the importance of using Lumason contrast for the identification of shunt and for the diagnosis of VSD. Lumason contrast is widely available and licensed.

Sutureless bioprosthetic valves such as the Sorin Perceval S valve (SPV) have been used in patients with aortic stenosis that require surgical aortic valve replacement (SAVR). These prostheses have been marketed on the basis of their rapid implantation techniques with avoidance of sutures and reduced aortic cross-clamp times. We report a case of an early failure of a SPV nearly 4 years after implantation in a 58-year-old woman who was low-risk. While the patient's symptoms initially improved with SAVR with a sutureless bioprosthetic valve, they progressively worsened as the valve degraded, and the leaflets became increasingly calcified and stenotic ultimately, requiring reoperative SAVR with a St. Jude mechanical valve. This case raises the issue of the lack of much-needed data describing the long-term durability and hemodynamic performance of these valves, particularly in a low-risk patient with excellent functional status. We hope to shed further insight into the lack of long-term studies on patients with SPV to assess their longevity and long-term effectiveness, as well as elucidation of possible prevention and monitoring of these potential complications. The use of newer generation prostheses, although attractive for their ease of implantation, potentially carries higher long-term risk due to shorter durability leading to reintervention to address valve deterioration. This is especially true in low-risk patients who are young and active. Cardiology and cardiothoracic surgery societies need to develop a universal registry with follow-up of all valves in order to track and study the durability of these valves, and to evaluate for incidence of known and potential complications.

Introduction: Increasing number of patients are currently receiving hormonal therapies for a variety of conditions. Modulation of cardiac repolarization by sex hormones resulting in VT remains controversial. Anastrozole is an aromatase inhibitor (ANI), used as an anti-estrogen medication in women with breast cancer or as replacement therapy for hypogonadism. Arrhythmias associated with ANI are extremely rare and hence ANI is considered relatively safe to use. Case Presentation: We report two cases receiving ANI who presented with VT and long QT (LQT). Case 1, 71 year old female with breast cancer on ANI recently started on levofloxacin 750 mg qd, presented with monomorphic VT. Post-conversion ECG showed sinus rhythm (SR) QT 0.48s/QTc 0.56s. Case 2, 50 year old male with hypogonadism on ANI and clomiphene (CL) presented with monomorphic VT, post conversion ECG showed SR with QT 0.65s/QTc 0.59s. Both patients had normal electrolytes and coronaries. Discussion: Studies have shown that levofloxacin is not associated with significant LQT, however, a relationship between its concentration and the extent of LQT has been demonstrated. LQT in our first case can be explained by an increase in levofloxacin level resulting from inhibition of CYP by ANI. CL is a HERG inhibitor however has not been shown to prolong QT. ANI lower the estradiol level which blocks the membrane trafficking of KCNH2 channels, potentially lengthening the QT. LQT in the second case can be explained by the additive effect of both HERG and KCNH2 inhibition. Conclusion: Although reported as safe, ANI hormone therapy can be arrhythmogenic if combined with agents that potentially affect potassium currents. We recommend QT monitoring in such patients to prevent lethal arrhythmias.

Background: Septal infarct due to isolated occlusion of a perforator branch is extremely rare. Few reported cases only describe either the EKG findings, imaging abnormalities or revascularization techniques. Objective: We report a case of an isolated septal aneurysm (ISA) caused by the acute occlusion of the second septal perforator presenting with recurrent ventricular fibrillation (VF). Results: A 63 year old woman presented to the hospital with chest pain. EKG showed an ST segment elevation localized to lead V3 (Fig1A), troponin 18.23. Angiogram showed an isolated 95% tubular stenosis of large second septal branch of LAD (Fig1B). No revascularization was performed. The patient subsequently had cardiac arrest (VF) requiring cardioversion. Repeat angiogram was unchanged. Echo showed isolated mid septal dyskinetic segment (Fig1C). LVEF was 60%. The patient was discharged with an external defibrillator. Repeat echo showed unchanged EF but presence of the isolated dyskinetic segment. An electrophysiologic study (EPS) showed VF induced with 2 extra stimuli at 250 ms with a drive cycle of 600 ms (Fig1D). An ICD was implanted for prevention of SCD. Conclusion: We describe the first case of an arrhythmogenic ISA in the presence of normal LVEF. The interventricular septum is composed of right and left ventricular endocardium. Experiments have shown that acute septal ischemia produces trans-septal asymmetry in expression of membrane ion channels and action potentials in local conduction velocity and gradients. This results in trans-mural heterogeneity of tissue excitability, a substrate for transmural re-entry and ventricular tachyarrhythmias, in septal infarction. This also explains the persistence of enhanced arrhythmogenicity in our patient during the initial and chronic phases of ischemia. ISA is rare but potentially arrhythmogenic. ISA with preserved LVEF, EPS for arrhythmogenicity and ICD for secondary prevention of SCD should be considered in such cases.

Peripartum cardiomyopathy(PCM) is a disease entity wherein a patient develops systolic heart failure resembling non-ischemic dilated cardiomyopathy. The mechanism of peripartum cardiomyopathy remains fully unknown and controversial at best. Proposed pathophysiology varies from a viral infection,