Mitral valve stenosis remains highly prevalent among the US population although with dramatically shifting demographics. The significance of rheumatic mitral disease in developing nations persists, despite improvements in preventative measures and early detection, and its presence in developed countries is still evident as observed through international migration. In addition, the substantial growth in the aging population with a heightened occurrence of concurrent cardiovascular risk factors is leading to an increased prevalence of chronic calcific degeneration and degeneration of previously repaired or replaced valves. This article aims to review various transcatheter therapies in the treatment of mitral valve stenosis.

Background. Despite an association between operator volumes and procedural success, there remains an incomplete understanding of the contemporary utilization and procedural volumes for mitral valve transcatheter edge-to-edge repair (MTEER). We aimed to identify annual operator procedural volumes, temporal trends, and geographic variability for MTEER among Medicare patients in the United States (US). Methods. We queried the National Medicare Provider Utilization and Payment Database for a CPT code (33418) specific for MitraClip device from 2015 through 2019. We analyzed annual operator procedural volumes and incidence and identified longitudinal and geographic trends in MTEER utilization. Results. From 2015 through 2019, a total of 27,034 MTEER procedures were performed among Medicare patients in the US. The nationwide incidence increased from 6.2 per 100,000 patients in 2015 to 23.8 per 100,000 patients in 2019, a 283% increase over the study period (Ptrend < 0.001). The incidence of MTEER by state varied by nearly 900% (range 5.5 to 54.9 per 100,000 person-years). In 2019, the mean annual MTEER operator annual volume was 9.1 MTEER procedures and had grown from 6.2 per year in 2015. Conclusions. In this nationwide study of Medicare beneficiaries in the United States, we identified a significant and sustained increase in the utilization of MTEER devices and operators and growth in annual procedural volumes from 2015 through 2019 with considerable variability in utilization by state. Further studies are needed to understand the clinical impact of variability in utilization and the optimal procedural volumes to ensure high efficacy outcomes and maintain critical access to MTEER therapies.

In the last half‐century, there have been few fields in medicine as dynamic and forward‐thinking as interventional cardiology. Such progress has generated a remarkable growth in the ability to care for increasingly sick and complex patients with heart disease via an ever‐expanding armamentarium of therapies, novel technology, and devices. In parallel, the expanding intricacies of our systems of care pose unique challenges in preparing interventional cardiology fellows to be successful as early‐career physicians. In this, the 100th volume of Catheterization and Cardiovascular Interventions, the journal reflects on an important milestone that serves as a point of celebration and reflection. It also affords an opportunity to look towards the future of our exceptional subspecialty. As a commitment to the future of interventional cardiology, we are pleased to announce the creation of a novel curriculum incorporated within Catheterization and Cardiovascular Interventions, CCI “FIT BITS”. CCI “FIT BITS” is a newly minted multimedia section within the journal focused on providing education, mentorship, and a goal to cultivate the opportunity for professional growth within the field with a particular focus aimed at fellows entering interventional cardiology. Much like the field of interventional cardiology the CCI FIT BITs section will remain dynamic. We look forward to offering opportunities to spotlight the scientific contributions of fellows‐in‐ training within CCI, as well as highlight publications of specific interest to learners via author interviews and journal clubs. In print, we hope to provide commentary on topics of clinical relevance, and personal perspectives with the aim to encourage professional growth. And finally, we aim to create opportunities for fellow engagement within the realm of academic publishing. On this noteworthy occasion, CCI reaffirms its commitment to the future of interventional cardiology. As the inaugural CCI FIT BIT Chief Fellows, we look forward to delivering upon that commitment.

BackgroundCardiac electrophysiology (EP) has few women physicians.ObjectiveThe purpose of this study was to determine temporal and geographical trends in the proportion of women EP operators in the United States.MethodsWe extracted data from the Medicare Provider Utilization and Payment Database from 2013 to 2019 using procedure codes for atrial fibrillation (AF) ablation, supraventricular tachycardia/atrial flutter (SVT/AFL) ablation, and cardiac device implantation. The Medicare Provider Utilization and Payment Database excludes operators who perform ≤10 procedures annually for a given individual procedure code. The proportion of women operators was compared across the 7-year period.ResultsOn average annually between 2013 and 2019, 5% (n = 187) of the 3524 EP operators were women. Procedure-specific analyses demonstrated a similarly low proportion of women EP operators across each procedure type. Despite a 137% increase in the total number of AF ablationists over the 7-year period, the proportion of women remained unchanged (P = .3966). The number of SVT/AFL ablationists and device operators remained constant over time as did the proportion of women operators (P = .9709 and .3583, respectively). In 2019, 10 states (20%) had no women EP operators who performed >10 of any given EP procedure annually, 20 states (39%) had no women who performed >10 of either AF or SVT/AFL ablation procedures annually, and 10 states (20%) had no women device operators who performed >10 of any given type of device implantation annually.ConclusionWomen EP operators remain underrepresented, and the proportion of women is stagnant even in areas of major clinical growth such as AF ablation. One-fifth of states had no women operators who performed >10 of any given EP procedure annually.

BACKGROUND:There is a paucity of data on cardiogenic shock (CS) incidence and outcomes among patients with spontaneous coronary artery dissection (SCAD).METHODS:Women admitted to the hospital for acute myocardial infarction (AMI) with and without SCAD were identified from the United States National Readmission Database from October 1, 2015 to December 31, 2018. We calculated the incidence of CS among women with AMI with and without SCAD and odds for developing CS after adjusting for baseline characteristics. In addition, we report the utilization of percutaneous coronary intervention, mechanical circulatory support, severe disability surrogates, and 30-day readmission rates.RESULTS:A total of 664,292 patients admitted for AMI were eligible for analysis, including 6643 patients with SCAD and 657,649 without SCAD. Patients with SCAD were younger (57 years [interquartile range, IQR 48-68] vs. 71 years [IQR 60-81], p < 0.01) and had fewer comorbidities yet had a higher incidence of CS as compared to patients without SCAD (9% vs. 5%, p < 0.01) and remained at elevated risk after adjusting for baseline comorbidities (adjusted odds ratio 1.5 [95% confidence interval, CI 1.2-1.7]). Among patients who developed CS, those with SCAD had lower in-hospital mortality than non-SCAD (31% vs. 39%, p < 0.01), and were more likely to receive mechanical circulatory support.CONCLUSIONS:In a nationally representative sample of women admitted for AMI, we found that patients with SCAD had a higher risk of developing CS and required more frequent use of mechanical circulatory support but were more likely to survive to discharge than women suffering AMI from causes other than SCAD.

OBJECTIVES:To evaluate transcatheter aortic valve replacement (TAVR) operator procedural volumes, and describe temporal and geographic trends.BACKGROUND:TAVR is the standard of care for most patients with severe symptomatic aortic stenosis. Despite an association between operator procedural volume and outcomes, nationwide TAVR operator volumes have been incompletely described.METHODS:We queried the National Medicare Provider Utilization and Payment Database for transfemoral TAVRs from 2014 to 2018. Annual operator volume, state and regional volumes, and longitudinal trends were extracted and analyzed using descriptive statistics.RESULTS:In 2018, the mean annual operator volume was 23.6 TAVRs. The highest 1% of operators by volume performed 7.6% of total TAVR procedures in the United States, while 35.7% of operators performed 10 or fewer TAVRs per year. From 2014 to 2018, there was a 53.9% annualized increase in TAVRs, and the mean annual volume per operator grew from 12.5 to 23.6. There was more than five-fold variability in the density of operators (range 0.35-1.79 operators per 100,000 population) and mean operator volume by state (range 14.2-52.4 TAVRs per operator).CONCLUSIONS:In this nationally representative study of operators performing transfemoral TAVRs among Medicare patients, we found the mean annual volume of TAVR in 2018 to be 23.6 and has increased since 2014. There was considerable variability in operator density and procedural volumes, with a significant proportion of operators performing 10 or fewer TAVRs per year. Ambiguity remains in regard to the optimal balance of procedural requirements to sustain high efficacy outcomes and ensure critical access to TAVR therapies.

Bicuspid aortic valve (BAV) is the most common congenital cardiac anomaly and the need for aortic valve (AV) intervention is common in these patients because of altered structural and geometric changes leading to altered blood flow across the valve. 1 Mahadevia R Barker A Schnell S Entezari P Kansal P Fedak P Malaisrie S McCarthy P Collins J Carr J Markl M. Bicuspid aortic cusp fusion morphology alters aortic three-dimensional outflow patterns, wall shear stress, and expression of aortopathy. Circulation. 2014; 129: 673-682 Google Scholar Concurrent mitral regurgitation (MR) with bicuspid aortic stenosis (AS) is common and leads to a complex interplay between hemodynamic conditions and loading conditions on the ventricle. 2 Witberg G Codner P Landes U Schwartzenberg S Barbanti M Valvo R De Backer O Ooms JF Islas F Marroquin L Sedaghat A Sugiura A Masiero G Werner P Armario X Fiorina C Arzamendi D Santos-Martinez S Fernández-Vázquez F Baz J Steblovnik K Mauri V Adam M Merdler I Hein M Ruile P Grasso C Branca L Estévez-Loureiro R Benito-González T Amat-Santos I Mylotte D Andreas M Bunc M Tarantini G Sinning J Nombela-Franco L Søndergaard L Van Mieghem N Finkelstein A Kornowski R. Effect of transcatheter aortic valve replacement on concomitant mitral regurgitation and its impact on mortality. JACC Cardiovasc Interv. 2021; 14: 1181-1192 Google Scholar Transcatheter AV implantation (TAVI) is associated with improvement of MR in >50% of patients with the degree of residual MR after TAVI associated with higher mortality. 3 Cortés C Amat-Santos I Nombela-Franco L Muñoz-Garcia A Gutiérrez-Ibanes E De La Torre Hernandez J Córdoba-Soriano J Jimenez-Quevedo P Hernández-García J Gonzalez-Mansilla A Ruano J Jimenez-Mazuecos J Castrodeza J Tobar J Islas F Revilla A Puri R Puerto A Gómez I Rodés-Cabau J San Román JA Mitral regurgitation after transcatheter aortic valve replacement: prognosis, imaging predictors, and potential management. JACC Cardiovasc Interv. 2016; 9: 1603-1614 Google Scholar Although data exists on the changes in MR after TAVI, there is no dedicated data in bicuspid AS. Our study aimed to evaluate the changes in MR severity after TAVI in bicuspid AS.

Percutaneous left atrial appendage closure (LAAC) offers a feasible option for stroke prevention in patients with atrial fibrillation (AF), but the optimal antithrombotic treatment strategy for patients with strict contraindications to oral anticoagulation (OAC) remains uncertain. We sought to evaluate short- and long-term outcome after percutaneous LAAC in these very patients discharged on single antiplatelet therapy (SAPT) alone. All consenting AF patients who underwent LAAC from February 2009 to August 2018 in Turku University Hospital, Finland, were enrolled into a prospectively maintained registry. Only patients discharged on SAPT alone were considered for the present analysis. Patients were prospectively followed up to 5 years. The primary end points were thromboembolic event (stroke, transient ischemic attack, or systemic embolism) and intracranial bleeding. Of the 165 LAAC patients, 81 patients (mean age 75 ± 7 years; 44% women; CHA₂DS₂-VASc 4.8 ± 1.4; HAS-BLED 3.2 ± 0.8) were discharged on SAPT only (77 with aspirin 100 mg) after successful LAAC using Amplatzer devices. The duration of SAPT was ≤6 months in 61 (75%) patients. The most common contraindication to OAC was previous intracranial bleeding in 48 (59%) patients. During a mean follow-up of 2.9 years, there were 6 thromboembolic events (2.7 of 100 patient-years; 73% lower-than-predicted rate of thromboembolism). Eight patients (3.6 of 100 patient-years) had a major bleeding event after discharge, and 4 patients had intracerebral bleeding (1.7 of 100 patient-years). At 6-month landmark analysis, freedom from thromboembolism and intracranial bleeding at 3-year follow-up was similar in those with discontinued and life-long SAPT (95.1% vs 88.9% and 97.6% vs 91.7%, respectively). In conclusion, long-term outcome is satisfactory after LAAC in selected AF patients with strict contraindications to OAC receiving short-term SAPT. However, adverse events are not infrequent during early postoperative months.

Background:There is an incomplete understanding of the predictors of morbidity and mortality in patients with severe tricuspid regurgitation (TR). This study sought to identify key risk factors for all-cause mortality and heart failure (HF) hospitalization among patients with severe TR. Methods:Patients with severe TR were identified from 2 centers, Oregon Health & Science University and Abrazo Health, from January 01, 2016 to December 31, 2018. Patients with any concomitant severe valvular diseases or prior valvular intervention were excluded. Multivariable regression was utilized to identify demographic, clinical, and echocardiographic variables independently associated with all-cause mortality or HF hospitalization. Results:435 patients with severe TR were followed for a median of 2.8 years. The mean age of the population was 66.9 ± 18.5 years and 58% were female. All-cause mortality was identified in 20.5% of the population. Of the cohort, 35.4% of patients were hospitalized for HF. Isolated tricuspid valve intervention was performed in 2.5% of patients. Independent predictors of all-cause mortality included history of solid tumor (odds ratio [OR] 6.6, 95% confidence interval [CI] 2.1-19.1, p = 0.001), history of peripheral artery disease (OR 3.5, 95% CI 1.2-9.4, p = 0.013), and elevated international normalized ratio in the absence of anticoagulation (OR 1.9, 95% CI 1.2-3.2, p = 0.008). Predictors of HF hospitalization included history of diabetes mellitus (OR 2.2, 95% CI 1.1-4.0, p = 0.014) and history of reduced left ventricular ejection fraction (OR 5.7, 95% CI 2.9-11.7, p < 0.0001). Conclusions:Severe untreated TR is associated with high mortality and frequent HF hospitalizations. Understanding predictors of these outcomes is important to identify patients who may benefit from early tricuspid valve intervention to help improve outcomes in this patient population.

HomeCirculation: Cardiovascular InterventionsVol. 14, No. 11Gender Disparity Among Transcatheter Aortic Valve Replacement Operators in the United States Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBGender Disparity Among Transcatheter Aortic Valve Replacement Operators in the United States Timothy F. Simpson, MD, PharmD, Tamara M. Atkinson, MD, Scott Chadderdon, MD, Joaquin E. Cigarroa, MD, Kendra J. Grubb, MD, MHA, Gurion Lantz, MD, Howard K. Song, MD, PhD, Firas Zahr, MD and Harsh Golwala, MD Timothy F. SimpsonTimothy F. Simpson https://orcid.org/0000-0002-8580-0773 Division of Cardiovascular Medicine (T.F.S., S.C., J.E.C., F.Z., H.G.), Knight Cardiovascular Institute, Oregon Health and Science University, Portland. , Tamara M. AtkinsonTamara M. Atkinson Division of Cardiology, Portland VA Medical Center, OR (T.M.A.). , Scott ChadderdonScott Chadderdon Division of Cardiovascular Medicine (T.F.S., S.C., J.E.C., F.Z., H.G.), Knight Cardiovascular Institute, Oregon Health and Science University, Portland. , Joaquin E. CigarroaJoaquin E. Cigarroa Division of Cardiovascular Medicine (T.F.S., S.C., J.E.C., F.Z., H.G.), Knight Cardiovascular Institute, Oregon Health and Science University, Portland. , Kendra J. GrubbKendra J. Grubb https://orcid.org/0000-0002-1369-5521 Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA (K.J.G.). , Gurion LantzGurion Lantz Division of Cardiothoracic Surgery (G.L., H.K.S.), Knight Cardiovascular Institute, Oregon Health and Science University, Portland. , Howard K. SongHoward K. Song Division of Cardiothoracic Surgery (G.L., H.K.S.), Knight Cardiovascular Institute, Oregon Health and Science University, Portland. , Firas ZahrFiras Zahr Division of Cardiovascular Medicine (T.F.S., S.C., J.E.C., F.Z., H.G.), Knight Cardiovascular Institute, Oregon Health and Science University, Portland. and Harsh GolwalaHarsh Golwala Correspondence to: Harsh Golwala, MD, Knight Cardiovascular Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, UHN-62, Portland, OR 97239. Email E-mail Address: [email protected] https://orcid.org/0000-0001-9873-7980 Division of Cardiovascular Medicine (T.F.S., S.C., J.E.C., F.Z., H.G.), Knight Cardiovascular Institute, Oregon Health and Science University, Portland. Originally published28 Sep 2021https://doi.org/10.1161/CIRCINTERVENTIONS.121.010659Circulation: Cardiovascular Interventions. 2021;14Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 28, 2021: Ahead of Print In the last 5 decades, the number of women in medicine has increased and now represents the majority (53.6%) of matriculating medical students in the United States.1 However, the proportion of women in cardiovascular specialties remains unbalanced, particularly, the procedural specialties of interventional cardiology and cardiothoracic surgery. In cardiovascular specialties, women physicians account for only 5% of percutaneous coronary intervention operators and 7% of practicing cardiothoracic surgeons.2,3 Despite tremendous growth in structural heart interventions in the United States, the understanding of gender disparity among transcatheter aortic valve replacement (TAVR) operators remains limited.4 Therefore, we aimed to (1) determine gender distribution of United States TAVR operators; (2) describe longitudinal and geographic trends in operator gender; and (3) evaluate TAVR volumes performed by women operators.The national Medicare Provider Utilization and Payment Database was queried for transfemoral TAVRs utilizing procedure codes (Current Procedural Terminology code 33361) from 2014 through 2018 to capture a period of stable billing codes through recent available data. Operators performing ≤10 procedures annually are excluded from Medicare Provider Utilization and Payment Database. Operators self-identified gender at the time of National Provider Identifier registration, annual procedural volumes, practice location, and specialty were captured. Descriptive statistics were applied and operator volumes compared using the Mann-Whitney U analysis.As this study utilized publicly available deidentified data, it was exempt from institutional review.In 2018, 1806 operators (both interventional cardiologists [ICs] and cardiac surgeons [CSs]) performed >10 TAVRs among Medicare beneficiaries, which included 70 (3.9%) women and 1736 (96.1%) men operators. Among women operators, 26 (37.1%) were IC and 44 (62.9%) were CS. By specialty, women constituted a lower proportion of ICs as compared with CS (2.7% versus 5.1%, respectively; P=0.009). From 2014 through 2018, there was a 58.7% annualized increase in total TAVR operators, without a considerable change in the proportion of women (Figure).Download figureDownload PowerPointFigure. Transcatheter aortic valve replacement (TAVR) operator gender in the United States. A, Number and gender of TAVR operators from 2014 to 2018. B, Number of TAVRs performed by men and women operators in 2018.Of the 61 675 TAVRs performed in 2018 included in this analysis, 2248 (3.6%) were performed by women (Figure). There was no difference in median annual TAVR procedural volume between women and men operators, respectively (women versus men: 2014: 17 [interquartile range (IQR), 13–25] versus 23 [IQR, 14–40], P=0.17; 2015: 24 [IQR, 12.8–41.3] versus 24 [IQR, 16–38], P=0.72; 2016: 21 [IQR, 16.5–33] versus 24 [IQR, 16–41], P=0.30; 2017: 27.5 [IQR, 18.3–33.8] versus 25 [IQR, 17–42], P=0.86; 2018: 24 [IQR, 15–43] versus 26 [IQR, 17–41], P=0.31).Nineteen (38.0%) states had no women TAVR operators as of 2018. There was variation in the proportion of women operators by state (range, 0%–25%) but no difference by region (South, 2.9%; West, 3.9%; Northeast, 4.2%; Midwest, 5.0%; P=0.39).In this nationwide study of operators performing transfemoral TAVRs among Medicare patients, we found women IC and CS constitute the vast minority of United States TAVR operators without a significant change over the study period. While the proportion of women operators varied by state, ≈40% had no women TAVR operators. Despite constituting the minority of operators, women performed similar annual volumes of procedures as compared with men.This analysis was limited by the inability to control for differences in practices such as institutional setting and years in practice, which may affect procedural volumes. The restriction to Medicare claims may incompletely capture operator volumes; however, this effect should be similar and independent from operator gender.Women continue to be significantly underrepresented in cardiovascular subspecialties including IC and CS despite the awareness of gender imbalance in cardiovascular medicine.4 Studies have identified several factors, including the culture of procedural subspecialties and lack of same gender mentorship, which may dissuade women from pursuing a career in cardiovascular medicine.4,5 Our findings mandate further investigations and should drive intentional policies/efforts to enhance women representation and leadership in TAVR and structural heart subspecialties.4,5Article InformationSources of FundingNone.Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page 1162.Correspondence to: Harsh Golwala, MD, Knight Cardiovascular Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, UHN-62, Portland, OR 97239. Email [email protected]eduReferences1. Association of American Medical Colleges. Table A-7.2. Applications, first-time applicants, acceptees, and matriculants to US medical schools by sex, 2011-2012 through 2020-2021.Accessed January 2, 2020. https://www.aamc.org/media/9576/downloadGoogle Scholar2. Wang TY, Grines C, Ortega R, Dai D, Jacobs AK, Skelding KA, Mauri L, Mehran R. Women in interventional cardiology: update in percutaneous coronary intervention practice patterns and outcomes of female operators from the National Cardiovascular Data Registry®.Catheter Cardiovasc Interv. 2016; 87:663–668. doi: 10.1002/ccd.26118CrossrefMedlineGoogle Scholar3. Stephens EH, Robich MP, Walters DM, DeNino WF, Aftab M, Tchantchaleishvili V, Eilers AL, Rice RD, Goldstone AB, Shlestad RC, et al.. Gender and cardiothoracic surgery training: specialty interests, satisfaction, and career pathways.Ann Thorac Surg. 2016; 102:200–206. doi: 10.1016/j.athoracsur.2016.03.043CrossrefMedlineGoogle Scholar4. Burgess S, Shaw E, Ellenberger K, Thomas L, Grines C, Zaman S. Women in medicine: addressing the gender gap in interventional cardiology.J Am Coll Cardiol. 2018; 72:2663–2667. doi: 10.1016/j.jacc.2018.08.2198CrossrefMedlineGoogle Scholar5. Yong CM, Abnousi F, Rzeszut AK, Douglas PS, Harrington RA, Mehran R, Grines C, Altin SE, Duvernoy CS; American College of Cardiology Women in Cardiology Leadership Council (ACC WIC); Society for Cardiovascular Angiography and Interventions Women in Innovations (SCAI WIN). Sex differences in the pursuit of interventional cardiology as a subspecialty among cardiovascular fellows-in-training.JACC Cardiovasc Interv. 2019; 12:219–228. doi: 10.1016/j.jcin.2018.09.036CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails November 2021Vol 14, Issue 11Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.121.010659PMID: 34579538 Originally publishedSeptember 28, 2021 Keywordsmedicareaortic valvetranscatheter aortic valve replacementmedicinefemalePDF download Advertisement SubjectsAortic Valve Replacement/Transcatheter Aortic Valve ImplantationCardiovascular Surgery

BACKGROUND:Among patients with heart failure and left ventricular (LV) dysfunction despite guideline directed medical therapy, cardiac resynchronization (CRT) is an effective technology to reverse LV remodeling. Given that a large portion of patients are non-responders, alternatives to traditional LV-lead placement have been explored. A promising alternative is image targeted placement of an LV-lead to latest mechanically activated segment without scar. METHODS:Electronic database search for randomized controlled trials (RCTs) that evaluated the imaging-guided LV-lead placement on clinical, echocardiographic, and functional outcomes. The primary outcome was a composite of mortality and heart failure hospitalization. The secondary outcomes included CRT responders, New York Heart Association (NYHA), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and ejection fraction (EF) changes. RESULTS:Analysis included 4 RCTs of 691 patients with an average follow-up of 2 years (age 69.5 ± 10.3 years, 76% males, 54% ischemic cardiomyopathy, 81% with NYHA classes III/IV, and EF of 24.4% ± 8). The most common site for LV-lead paced segment was the anterolateral segment (45%) and at mid-LV (49%). Compared with the control, imaging-guided LV-lead placement was associated with a significant reduction of the primary outcome (hazard ratio [HR] = 0.60; 95% CI = 0.40-0.88; p = .01), higher CRT responders (odd ratio [OR] = 2.10; p < .01), more NYHA improvements by ≥1 (OR = 1.89; p = .01), increased 6MWT (mean difference [MD] = 25.78 feet; p < .01), and lower MLHFQ (MD = -4.04; p = .04), without significant differences in the LVEF (p = .08). CONCLUSIONS:In patients undergoing CRT, imaging-guided LV-lead placement was associated with improved clinical, echocardiographic, and functional status.

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) is a multiorgan syndrome with rare and heterogenous cardiac manifestations. We present the case of a man with pericardial effusion complicated by cardiac tamponade, new onset atrial fibrillation, and high-degree atrioventricular block leading to a diagnosis of POEMS syndrome. (Level of Difficulty: Advanced.)

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 14, No. 8Ablation Versus Antiarrhythmic Drugs as First-Line Treatment of Paroxysmal Atrial Fibrillation: A Meta-Analysis of Randomized Trials Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBAblation Versus Antiarrhythmic Drugs as First-Line Treatment of Paroxysmal Atrial Fibrillation: A Meta-Analysis of Randomized Trials Babikir Kheiri, MD, MSc, MRCP Timothy F Simpson, MD, PharmD Ryle Przybylowicz, MD Miranda Merrill, MD Hani Alhamoud, MD Mohammed Osman, MD Khidir Dalouk, MD Eric Stecker, MD Charles A. Henrikson, MD, MPH Babak NazerMD Babikir KheiriBabikir Kheiri https://orcid.org/0000-0003-1747-2859 Knight Cardiovascular Institute, Oregon Health & Science University, Portland (B.K., T.F.S., R.P., M.M., K.D., E.S., C.A.H., B.N.). , Timothy F SimpsonTimothy F Simpson https://orcid.org/0000-0002-8580-0773 Knight Cardiovascular Institute, Oregon Health & Science University, Portland (B.K., T.F.S., R.P., M.M., K.D., E.S., C.A.H., B.N.). , Ryle PrzybylowiczRyle Przybylowicz https://orcid.org/0000-0002-1140-5164 Knight Cardiovascular Institute, Oregon Health & Science University, Portland (B.K., T.F.S., R.P., M.M., K.D., E.S., C.A.H., B.N.). , Miranda MerrillMiranda Merrill https://orcid.org/0000-0002-3996-6350 Knight Cardiovascular Institute, Oregon Health & Science University, Portland (B.K., T.F.S., R.P., M.M., K.D., E.S., C.A.H., B.N.). , Hani AlhamoudHani Alhamoud https://orcid.org/0000-0001-6439-6292 Division of Cardiology, West Virginia University School of Medicine, Morgantown (H.A., M.O.). , Mohammed OsmanMohammed Osman https://orcid.org/0000-0001-5097-5568 Division of Cardiology, West Virginia University School of Medicine, Morgantown (H.A., M.O.). , Khidir DaloukKhidir Dalouk Knight Cardiovascular Institute, Oregon Health & Science University, Portland (B.K., T.F.S., R.P., M.M., K.D., E.S., C.A.H., B.N.). , Eric SteckerEric Stecker Knight Cardiovascular Institute, Oregon Health & Science University, Portland (B.K., T.F.S., R.P., M.M., K.D., E.S., C.A.H., B.N.). , Charles A. HenriksonCharles A. Henrikson https://orcid.org/0000-0002-3381-8437 Knight Cardiovascular Institute, Oregon Health & Science University, Portland (B.K., T.F.S., R.P., M.M., K.D., E.S., C.A.H., B.N.). and Babak NazerBabak Nazer Correspondence to: Babak Nazer, MD, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239. Email E-mail Address: [email protected] https://orcid.org/0000-0002-4078-9064 Knight Cardiovascular Institute, Oregon Health & Science University, Portland (B.K., T.F.S., R.P., M.M., K.D., E.S., C.A.H., B.N.). Originally published16 Aug 2021https://doi.org/10.1161/CIRCEP.120.009692Circulation: Arrhythmia and Electrophysiology. 2021;14:e009692Atrial fibrillation (AF) is the most common cardiac arrhythmia in the world. In patients with symptomatic paroxysmal AF, current United States consensus guidelines recommend antiarrhythmic drugs (AADs) as the initial therapy for maintenance of sinus rhythm. However, given the substantial adverse effects of AADs and their limited efficacy in maintenance of sinus rhythm, catheter ablation is an attractive strategy. Therefore, we conducted a meta-analysis of all randomized controlled trials to evaluate the efficacy and safety of catheter ablation as initial therapy for patients with symptomatic paroxysmal AF.The authors declare that all supporting data are available within the article (and its supplementary files). We identified all randomized controlled trials and 3 authors (B.K., H.A., M.O.) extracted and analyzed the data using RevMan 5.3 and STATA v15.1 software. We calculated hazard ratios or risk ratios and their 95% CIs using a random-effects model. A unique Kaplan-Meier curve for trial-level treatment success was reconstructed and a Cox proportional-hazards model was calculated after testing the proportional-hazards assumption using the residual Schoenfeld test. Institutional Review Board approval was not required.We identified 5 randomized controlled trials1–5 which included 997 patients with paroxysmal AF without prior AADs use (mean age 57.3±10.8 years; 68.6% males; 40.6% with hypertension; 6.5% with coronary artery disease; 56.8% on anticoagulants; 52.5% on beta blockade; and the duration of AF was 1.3±2.4 years). The mean ejection fraction was 59.7±6.9%, and left atrium diameter was 39.6±5.8 mm. In the ablation group, the mean procedure duration was 139.1±68.7 minutes with 29.4±35.3 minutes of fluoroscopy time (cryoablation, n=258; radiofrequency ablation, n=244).In the AADs group, 34.1% crossed to ablation group after the blanking period. For the ablation group, 9.6% of the patients were placed on AADs beyond the blanking period, whereas 19.7% had a repeated ablation after the blanking period.Compared with AADs, ablation was associated with significantly reduced recurrence of any atrial tachyarrhythmia (risk ratio, 0.57 [95% CI, 0.43–0.75]; P<0.01), symptomatic recurrence (risk ratio, 0.45 [95% CI, 0.25–0.80]; P<0.01), and hospitalization (risk ratio, 0.33 [95% CI, 0.21–0.52]; P<0.01; Figure). The incidence of death, stroke, transient ischemic attack, and serious adverse events were similar between groups (P>0.05; Figure). Overall, ablation was associated with a low incidence of pericardial tamponade (0.8%), pulmonary venous stenosis (0.6%), and transient phrenic nerve palsy (0.8%). Meta-regression analysis of the primary outcome based on the duration of AF, left atrium diameter, ejection fraction, and age did not suggest any significant effect modifier. In addition, subgroup analysis showed no significant interaction between the ablation techniques (cryoablation versus radiofrequency ablation).Download figureDownload PowerPointFigure. Clinical outcomes of first-line catheter ablation versus anti-arrhythmic drug therapy for paroxysmal atrial fibrillation. Kaplan-Meier curve for treatment success (A) and Forest plot (B) for clinical outcomes. Kaplan-Meier estimates of trial-level treatment success defined as follows: RAAFT 2005, freedom from atrial fibrillation; RAAFT-2 (Radiofrequency Ablation Versus Antiarrhythmic Drugs for Atrial Fibrillation Treatment) 2014, freedom from any atrial tachyarrhythmias; STOP AF (Cryoballoon Catheter Ablation in Antiarrhythmic Drug Naive Paroxysmal Atrial Fibrillation) 2020, freedom from initial failure of the procedure, any subsequent atrial fibrillation surgery or ablation in the left atrium, or atrial arrhythmia recurrence, cardioversion, or use of class I or III antiarrhythmic drugs (AAD; ablation group only) outside the 90-d blanking period; EARLY AF (Early Aggressive Invasive Intervention for Atrial Fibrillation) 2020, freedom from any atrial tachyarrhythmia. MANTRA-PAF indicates Medical Antiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation; M-H, Mantel-Haenszel; RAAFT, Radiofrequency Ablation versus Antiarrhythmic Drugs for Atrial Fibrillation Treatment; and TIA, transient ischemic attack.In this meta-analysis of patients with symptomatic paroxysmal AF, we found that rhythm control strategy with up-front catheter ablation was associated with a significantly lower incidence of recurrent atrial tachyarrhythmias and hospitalization compared with AADs, and similar risk of death, stroke/transient ischemic attack, or serious side effects.AF is typically triggered by ectopic foci within the pulmonary veins. As AF progresses, significant atrial remodeling occurs which may lead to permanent atrial myopathy. As AF ablation techniques have evolved, interest in preventing these irreversible structural changes has grown, with the hope that preventing these changes may translate into meaningful clinical outcomes. However, guidelines recommend a trial of AADs as initial therapy. In our analysis, we observed a 43% reduction in recurrent atrial tachyarrhythmia, 55% reduction in symptomatic recurrence, and 67% reduction in all-cause hospitalizations with ablation over first-line AAD therapy (Figure). Notably, these trials generally included younger (mean 57.3 years) patients with early symptomatic AF episodes, preserved ejection fraction (mean 59.7%), and left atrium diameter <5.5 cm, excluding those with persistent or long-standing persistent AF. Nevertheless, these findings are promising and may inform first-line therapy recommendations in future guidelines.Limitations of this study include a small sample size and infrequent events. The lack of patient-level data prevented analysis of individual classes of AADs on AF recurrence and assessing functional endpoints. Moreover, the impact of high cross-over rate from AADs to ablation on clinical outcomes is not reported. Finally, long-term randomized controlled trials evaluating long-term efficacy are needed.We hope that the result of CRYO-FIRST trial (Catheter Cryoablation Versus Antiarrhythmic Drug as First-Line Therapy of Paroxysmal Atrial Fibrillation; https://www.clinicaltrials.gov; Unique identifier: NCT01803438) provides further insights.In conclusion, among selected patients with symptomatic paroxysmal AF, catheter ablation as first-line rhythm control therapy was associated with lower incidence of atrial tachyarrhythmias recurrence and hospitalizations compared with AADs, with similar incidence of death, stroke/transient ischemic attack, and serious adverse effects.Sources of FundingNone.Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page 787.Correspondence to: Babak Nazer, MD, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239. Email [email protected]eduReferences1. Andrade JG, Wells GA, Deyell MW, Bennett M, Essebag V, Champagne J, Roux JF, Yung D, Skanes A, Khaykin Y, et al.; EARLY-AF Investigators. Cryoablation or drug therapy for initial treatment of atrial fibrillation.N Engl J Med. 2021; 384:305–315. doi: 10.1056/NEJMoa2029980CrossrefMedlineGoogle Scholar2. Wazni OM, Dandamudi G, Sood N, Hoyt R, Tyler J, Durrani S, Niebauer M, Makati K, Halperin B, Gauri A, et al.; STOP AF First Trial Investigators. Cryoballoon ablation as initial therapy for atrial fibrillation.N Engl J Med. 2021; 384:316–324. doi: 10.1056/NEJMoa2029554CrossrefMedlineGoogle Scholar3. Morillo CA, Verma A, Connolly SJ, Kuck KH, Nair GM, Champagne J, Sterns LD, Beresh H, Healey JS, Natale A; RAAFT-2 Investigators. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial.JAMA. 2014; 311:692–700. doi: 10.1001/jama.2014.467CrossrefMedlineGoogle Scholar4. Cosedis Nielsen J, Johannessen A, Raatikainen P, Hindricks G, Walfridsson H, Kongstad O, Pehrson S, Englund A, Hartikainen J, Mortensen LS, Hansen PS. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation.N Engl J Med. 2012; 367:1587–1595. doi: 10.1056/NEJMoa1113566CrossrefMedlineGoogle Scholar5. Wazni OM, Marrouche NF, Martin DO, Verma A, Bhargava M, Saliba W, Bash D, Schweikert R, Brachmann J, Gunther J, et al.. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial.JAMA. 2005; 293:2634–2640. doi: 10.1001/jama.293.21.2634CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 2021Vol 14, Issue 8Article InformationMetrics Download: 496 © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.120.009692PMID: 34397264 Originally publishedAugust 16, 2021 Keywordsrandomized controlled trialarrhythmiascatheter ablationmeta-analysisatrial fibrillationPDF download SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorAtrial Fibrillation

BACKGROUND:Mitral regurgitation is the most common form of valvular heart disease worldwide, however, there is an incomplete understanding of predictors of mortality in this population. This study sought to identify risk factors of mortality in a real-world population with mitral regurgitation.METHODS:All patients with moderate or severe mitral regurgitation were identified at a single center from January 1, 2016 to August 31, 2017. Multivariate regression was performed to evaluate variables independently associated with all-cause mortality.RESULTS:A total of 490 patients with moderate (76.3%) or severe (23.7%) mitral regurgitation due to primary (20.8%) or secondary (79.2%) etiology were identified. The mean age was 66.7 years; 50% were male. At a median follow-up of 3.1 years, the incidence of all-cause mortality was 30.1%, heart failure hospitalization 23.1%, and mitral valve intervention 11.6%. Of 117 variables, multivariate analysis demonstrated 5 that were independently predictive of mortality: baseline creatinine (hazard ratio [HR] 1.2; 95% CI, 1.0-1.3; P = .02), right atrial pressure by echocardiogram (HR 1.3; 95% CI, 1.07-1.55; P = .008), hemoglobin (HR 0.65; 95% CI, 0.52-0.83; P = .001), hospitalization for heart failure (HR 1.6; 95% CI, 1.1-2.4; P = .015), and mitral valve intervention (HR 0.40; 95% CI, 0.16-0.83; P = .049).CONCLUSION:In this retrospective, pragmatic analysis of patients with moderate or severe mitral regurgitation, admission for heart failure exacerbation, elevated right atrial pressure, renal dysfunction, anemia, and lack of mitral valve intervention were independently associated with increased risk of all-cause mortality. Whether these risk factors may better identify select patients who may benefit from more intensive monitoring or earlier intervention should be considered in future studies.

Background: A retrospective analysis of severe bicuspid aortic stenosis was performed to evaluate hemodynamic profiles and incidence of adverse conduction effects in Sievers Type 0 compared to Sievers Type 1 morphologies after transcatheter aortic valve replacement (TAVR) with a self-expanding prosthesis. In the past decade there has been a transition to treating lower risk patients with TAVR. While overall outcomes in patients with bicuspid aortic valves (BAV) have improved, hemodynamic and conduction system challenges still exist. Methods: Moderate- to high-risk patients with BAV who underwent TAVR with a self-expanding prosthesis from 01/01/2017 to 09/01/2019 were reviewed. Transthoracic echocardiographic (TTE) and electrocardiogram (ECG) data were analyzed at baseline and at 30-day follow-up. Computed tomography (CT) of the aortic annulus was analyzed in all patients pre-TAVR and in a subset of 10 patients post-TAVR. Results: The cohort consisted of 10 Sievers Type 0 and 20 Sievers Type 1 patients, mean age 68 y, and Society of Thoracic Surgeons (STS) risk 4.6 +/- 3.7%. Post-TAVR, Sievers Type 1 BAV had a superior hemodynamic profile, with lower gradients and less paravalvular leak compared to Type 0. Post-TAVR valve eccentricity was unchanged in Type 1 but markedly altered in Type 0 BAV. Conversely, Type 1 BAV demonstrated an increased incidence of new left bundle branch block (LBBB). Conclusions: Sievers Type 1 anatomy was associated with a superior hemodynamic profile but an increased incidence of LBBB when compared to Sievers Type 0 post-TAVR. As TAVR shifts to a lower risk cohort, understanding how BAV morphologies affect long-term hemodynamics and conduction abnormalities warrants continued study.