The occurrence of atrial fibrillation, circadian fluctuation in blood pressure, and oxygen desaturation at night is likely associated with the pathophysiology of wake-up stroke. Whether patients who experience wake-up strokes are candidates for thrombolysis treatment is a serious dilemma. The aim is to investigate the association between risk factors and wake-up stroke and to determine variations that are associated with the pathophysiology of wake-up stroke. Five major electronic databases were searched using a fitted search strategy to identify relevant studies. Odds ratios with 95% CIs were used to calculate estimates, and the Quality Assessment for Diagnostic Accuracy Studies-2 tool was used to conduct the assessment quality. A total of 29 studies were included in this meta-analysis. Hypertension is not associated with wake-up stroke (odds ratio, 1.14 [95% CI, 0.94–1.37]; P = .18). Atrial fibrillation is an independent risk factor to wake-up stroke, with a statistically significant difference (odds ratio, 1.28 [95% CI, 1.06–1.55]; P = .01). Subgroup analysis showed a different result in patients with sleep-disordered breathing, although no significant difference was assessed. This study revealed that atrial fibrillation is an independent risk factor for wake-up stroke and that patients with atrial fibrillation who also experience sleep-disordered breathing tend to have fewer wake-up strokes.Abstract
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For patients with non–ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated. Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed. This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71–0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68–0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97–1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66–0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00–1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24). Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS.Abstract
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Left ventricular diastolic dysfunction and nocturnal “nondipping” of blood pressure detected via ambulatory blood pressure monitoring are predictors of increased cardiovascular morbidity. A prospective cohort study including normotensive women with a history of preeclampsia in their current pregnancy was conducted. All cases were subjected to 24-hour ambulatory blood pressure monitoring and 2-dimensional transthoracic echocardiography 3 months after delivery. This study included 128 women with a mean (SD) age of 28.6 (5.1) years and a mean (SD) basal blood pressure of 123.1 (6.4)/74.6 (5.9) mm Hg. Among the participants, 90 (70.3%) exhibited an ambulatory blood pressure monitoring profile illustrating nocturnal blood pressure “dipping” (the mean night to day time blood pressure ratio ≤ 0.9), whereas 38 (29.7%) were nondippers. Diastolic dysfunction (impaired left ventricular relaxation) was present in 28 nondippers (73.7%), whereas none of the dippers exhibited diastolic dysfunction. Women with severe preeclampsia were more frequently nondippers (35.5% vs 24.2%; P = .02) and experienced diastolic dysfunction (29% vs 15%; P = .01) than were those with mild preeclampsia. Severe preeclampsia (odds ratio [OR], 1.08; 95% CI, 1.05–10.56; P < .001) and history of recurrent preeclampsia (OR, 1.36; 95% CI, 1.3–4.26; P ≤ .001) were significant predictors for nondipping status and diastolic dysfunction (OR, 1.55; 95% CI, 1.1–2.2; and OR, 1.23; 95% CI, 1.2–2.2, respectively; P < .05). Women with a history of preeclampsia were at higher risk for developing late cardiovascular events. The severity and recurrence of preeclampsia were significant predictors of both nondipping profile and diastolic dysfunction.Abstract
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This study assessed in-hospital outcomes of patients with chronic systolic, diastolic, or mixed heart failure (HF) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). The Nationwide Inpatient Sample database was used to identify patients with aortic stenosis and chronic HF who underwent TAVR or SAVR between 2012 and 2015. Propensity score matching and multivariate logistic regression were used to determine outcome risk. A cohort of 9,879 patients with systolic (27.2%), diastolic (52.2%), and mixed (20.6%) chronic HF were included. No statistically significant differences in hospital mortality were noted. Overall, patients with diastolic HF had the shortest hospital stays and lowest costs. Compared with patients with diastolic HF, the risk of acute myocardial infarction (TAVR odds ratio [OR], 1.95; 95% CI, 1.20–3.19; P = .008; SAVR OR, 1.38; 95% CI, 0.98–1.95; P = .067) and cardiogenic shock (TAVR OR, 2.15; 95% CI, 1.43–3.23; P < .001; SAVR OR, 1.89; 95% CI, 1.42–2.53; P ≤ .001) was higher in patients with systolic HF, whereas the risk of permanent pacemaker implantation (TAVR OR, 0.58; 95% CI, 0.45–0.76; P < .001; SAVR OR, 0.58; 95% CI, 0.40–0.84; P = .004) was lower following aortic valve procedures. In TAVR, the risk of acute deep vein thrombosis and kidney injury was higher, although not statistically significant, in patients with systolic HF than in those with diastolic HF. These outcomes suggest that chronic HF types do not incur statistically significant hospital mortality risk in patients undergoing TAVR or SAVR.Abstract
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This study aims to establish and validate a nomogram as a predictive model in patients with new-onset atrial fibrillation (AF) after dual-chamber cardiac implantable electronic device (pacemaker) implantation. A total of 1120 Chinese patients with new-onset AF after pacemaker implantation were included in this retrospective study. Patients had AF of at least 180/minute lasting 5 minutes or longer, detected by atrial lead and recorded at least 3 months after implantation. Patients with previous atrial tachyarrhythmias before device implantation were excluded. A total of 276 patients were ultimately enrolled, with 51 patients in the AF group and 225 patients in the non-AF group. Least absolute shrinkage and selection operator (LASSO) method was used to determine the best predictors. Through multivariate logistic regression analysis, a nomogram was drawn as a predictive model. Concordance index, calibration plot, and decision curve analyses were applied to evaluate model discrimination, calibration, and clinical applicability. Internal verification was performed using a bootstrap method. The LASSO method regression analysis found that variables including peripheral arterial disease, atrial pacing-ventricular pacing of at least 50%, atrial sense–ventricular sense of at least 50%, increased left atrium diameter, and age were important predictors of developing AF. In multivariate logistic regression, peripheral arterial disease, atrial pacing-ventricular pacing of at least 50%, and age were found to be independent predictors of new-onset AF. This nomogram may help physicians identify patients at high risk of new-onset AF after pacemaker implantation at an early stage in a Chinese population.Abstract
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Dual antiplatelet therapy (DAPT) has become standard first-line treatment of acute coronary syndrome; however, it increases the risk of bleeding complications. The aim of this study was to investigate the benefits of pooled platelet concentrate (PPC) in reducing postoperative bleeding in patients undergoing off-pump coronary artery bypass graft (CABG) after a DAPT loading dose. One hundred nine patients who underwent emergent CABG within the first 24 hours after receiving a DAPT loading dose were included in the study and divided into 2 groups: patients who were (group 1, n = 63) and were not (group 2, n = 46) given PPC during the surgery. The amount of bleeding in the postoperative period and the need for blood transfusions were recorded. The mean (SD) surgical drainage amounts were 475.39 (101.94) mL in group 1 and 679.34 (232.03) mL in group 2 (P = .001). The need for surgical revisions was 0% and 15.2% in groups 1 and 2, respectively (P = .002). The median (range) duration of hospitalization after surgery was 4 (4–6) days in group 1 and 6 (4–9) days in group 2 (P = .001). Total transfusions per patient were higher in group 2 than in group 1 (1 [range, 1–4] and 3 [range, 2–7] units, respectively; P = .001). Perioperative PPC in patients who had received DAPT reduces postoperative bleeding, the need for blood products, and hospital stay. As a result, it has beneficial effects for early mobilization and improves patient comfort.Abstract
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This study investigated the relationship between coronary collateral circulation (CCC) and non–high-density lipoprotein cholesterol (non–HDL-C) in patients with stable coronary artery disease (CAD). Coronary collateral circulation plays a critical role in supporting blood flow, particularly in the ischemic myocardium. Previous studies show that non–HDL-C plays a more important role in the formation and progression of atherosclerosis than do standard lipid parameters. A total of 226 patients with stable CAD and stenosis of more than 95% in at least 1 epicardial coronary artery were included in the study. Rentrop classification was used to assign patients into group 1 (n = 85; poor collateral) or 2 (n = 141; good collateral). To adjust for the observed imbalance in baseline covariates between study groups, propensity-score matching was used. Covariates were diabetes, Gensini score, and angiotensin-converting enzyme inhibitor use. In the propensity-matched population, the plasma non–HDL-C level (mean [SD], 177.86 [44.0] mg/dL vs 155.6 [46.21] mg/dL; P = .001) was statistically higher in the poor-collateral group. LDL-C (odds ratio [OR], 1.23; 95% CI, 1.11–1.30; P = .01), non–HDL-C (OR, 1.34; 95% CI, 1.20–1.51; P = .01), C-reactive protein (OR, 1.21; 95% CI, 1.11–1.32; P = .03), systemic immune-inflammation index (OR, 1.14; 95% CI, 1.05–1.21; P = .01), and C-reactive protein to albumin ratio (OR, 1.11; 95% CI, 1.06–1.17; P = .01) remained independent predictors of CCC in multivariate logistic regression analysis. Non–HDL-C was an independent risk factor for developing poor CCC in stable CAD.Abstract
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The year 2023 marks the 100th anniversary of the first successful valvotomy for mitral valve stenosis by Elliott C. Cutler in 1923. Closed-chest mitral valve commissurotomy developed further before being replaced by an open procedure after the advent of the heart-lung machine. Currently, because of the almost complete disappearance of rheumatic disease in the Western World, mitral commissurotomies are infrequently performed in those countries, although the procedure—either closed or open—is still performed in developing countries and select patients. This review retraces the 100-year journey from a historic operation to the current era—a milestone in the treatment of patients with mitral stenosis.Abstract
At a time when transplantable organs are in a shortage, few cases have noted the reuse of donor hearts in a second recipient in an effort to expand the donor network. Here, we present a case in which an O Rh-positive donor heart was first transplanted into a B Rh-positive recipient and later successfully retransplanted into a second O Rh-positive recipient 10 days after the initial transplant at the same medical center. On postoperative day 1, the first recipient, a 21-year-old man with nonischemic cardiomyopathy, sustained a devastating cerebrovascular accident with progression to brain death. With preserved left ventricle and mildly depressed right ventricle function, the heart was allocated to the second recipient, a 63-year-old male patient with familial restrictive cardiomyopathy. The bicaval technique was used, and the total ischemic time was 100 minutes. His postoperative course was uncomplicated with no evidence of rejection on 3 endomyocardial biopsies. Follow-up transthoracic echocardiogram revealed a left ventricular ejection fraction of 60% to 70%. Seven months posttransplant, the second recipient was doing well with appropriate left and right ventricular function. With careful organ selection, short ischemic time, and proper postoperative care, retransplant of donor hearts may be an option for select patients in need of heart transplant.Abstract
Catecholaminergic polymorphic ventricular tachycardia is a rare but lethal heritable arrhythmia syndrome associated with both atrial and ventricular arrhythmias. Treatment includes antiarrhythmics, sympathetic denervation, and implantable cardioverter-defibrillators. The use of atrioventricular nodal ablation as a treatment strategy to prevent ventricular arrhythmias in catecholaminergic polymorphic ventricular tachycardia was not found in the literature. This report describes a teenager with a presenting rhythm of atrial and ventricular fibrillation and cardiac arrest. Her clinical arrhythmia was predominantly atrial dysrhythmias, which delayed her diagnosis of catecholaminergic polymorphic ventricular tachycardia. Before her diagnosis, she underwent atrioventricular nodal ablation in an effort to prevent ventricular arrhythmias, which was ultimately ineffective. This report highlights the importance of recognizing atrial arrhythmias in catecholaminergic polymorphic ventricular tachycardia and provides evidence that atrioventricular nodal ablation is not an effective treatment strategy for this disease.Abstract
Trisomy 13 is a rare chromosomal disorder in which all or a percentage (mosaicism) of cells contain an extra 13th chromosome. Sinus of Valsalva aneurysms are rare, with an incidence of 0.1% to 3.5% of all congenital heart defects. This article reports the case of a patient with trisomy 13 with a new systolic murmur found to have a ruptured sinus of Valsalva aneurysm diagnosed on coronary computed tomography angiography. This is the first case to report sinus of Valsalva aneurysm rupture secondary to Streptococcus viridans endocarditis in a patient with trisomy 13 syndrome and highlights the importance of coronary computed tomography angiography in noninvasive imaging and surgical planning.Abstract
A 47-year-old patient was experiencing dyspnea and fatigue concerning for right ventricular hypertension and new heart failure. Because of the risks associated with catheter entrapment, prosthetic valve leaflet damage, and valve thrombosis associated with crossing a mechanical valve, a novel technique was used for diagnostic left and right heart catheterization in a patient with mechanical tricuspid valve replacement and tortuous pulmonary arteries. Using a percutaneous subxiphoid approach to avoid traversing the mechanical valve without discontinuing anticoagulation, a Volcano fractional flow reserve pressure wire (Philips Volcano) was advanced for distal measurements of pressures and saturations.Abstract
A 54-year-old man with a history of HIV, substance use disorder, and hyperlipidemia presented at the emergency department with dyspnea worsening on exertion and lower-extremity edema. Electrocardiogram showed a new-onset bifascicular block, whereas the echocardiogram revealed a 24% left ventricular ejection fraction and a 4-leaf clover appearance of the aortic valve, with moderate to severe regurgitation. A quadricuspid aortic valve was discovered (Fig. 1).Case Description
On February 10, 2023, Dr Michael Nihill passed away peacefully at the age of 87 years. Those who were lucky enough to know him knew he was truly one of a kind. Born in 1936 in Haberfield, Australia, Dr Nihill completed his medical degree, internship, and pediatric residency in Sydney and then traveled to London, England, to work as a postgraduate student in internal medicine. Reflecting on this piece of his history, he once reported in typical fashion, “I took a job as the doctor on a cargo ship—at 10 cents a month—but I got free passage. It was there
In 2021, The Texas Heart Institute Board of Trustees created the James T. Willerson, MD, Editor's Choice Award to honor his standards for excellence in research and scientific publishing. That year, 3 groups of authors whose articles were published in The Texas Heart Institute Journal received an award. Going forward, 2 primary authors will be recognized annually for their work on a Clinical Investigation, Laboratory Investigation, or Systematic Review that has been published in The Journal. Each author, one of whom will be an early-career professional, will receive a certificate and $5,000. Authors can now apply
biventricular pacing cardiac resynchronization therapy conduction system pacing heart failure His bundle pacing left bundle branch pacing left ventricular ejection fraction randomized controlled trial Cardiac resynchronization therapy (CRT) is an established therapy for medically refractory heart failure (HF), with a reduction in hospitalization and mortality in addition to improved cardiac function and functional capacity shown in landmark clinical trials.1,2 Cardiac resynchronization therapy is also indicated for patients with systolic dysfunction requiring frequent ventricular pacing (>40%) to prevent deleterious remodeling and cardiomyopathy associated with ventricularAbbreviations and Acronyms
Introduction
acute mechanical circulatory support cardiogenic shock secondary to acute myocardial infarction cardiogenic shock intra-aortic balloon pump The prevalence of cardiogenic shock (CS) is high and involves approximately 1 in every 6 patients admitted to the cardiac intensive care unit. Despite the introduction of acute mechanical circulatory support (AMCS) and the institution of “shock teams,” in-hospital mortality for patients with CS remains between 30% and 40%.1 A striking paradox in the management of this critically ill population is that restoration of a more normal hemodynamic profile by means of mechanical circulatoryAbbreviations and Acronyms
Introduction
bicuspid aortic valve left ventricular outflow tract transcatheter aortic valve implantation Bicuspid aortic valve (BAV) is the most common congenital heart defect, occurring in 1% to 2% of the general population.1 Compared with individuals having normal tricuspid aortic valves, those with BAVs are more likely to develop calcification on valve leaflets and raphe and dilation of the ascending aorta (aortopathy)—and at a much earlier age. For highly select patients with severe BAV stenosis, transcatheter aortic valve implantation (TAVI) may be a feasible alternative to surgical repair or replacement.2–4Abbreviations and Acronyms
Introduction
mitral regurgitation transcatheter edge-to-edge repair transcatheter mitral valve replacement tricuspid valvular regurgitation Mitral and tricuspid valvular disease have been managed surgically; however, multiple transcatheter technologies have diversified the therapeutic arsenal and expanded the number of patients eligible for treatment. These new technologies and active trials currently being performed at The Texas Heart Institute will be highlighted. Transcatheter edge-to-edge repair (TEER) with MitraClip (Abbott Structural Heart) plays an important role in the management of degenerative and functional mitral regurgitation (MR). Despite its success, the limitations of MitraClip include challengingAbbreviations and Acronyms
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Transcatheter Mitral Valve Repair
Albert Einstein once said, “The distinction between the past, present and future is only a stubbornly persistent illusion.” So much of what is done with complex aortic surgical interventions is a direct outgrowth of what has been done, what is being done, and what is intended to be accomplished. The first successful aortic aneurysm repair was performed by Dr Charles Dubost in 1951; he replaced an infrarenal abdominal aorta aneurysm using a cadaver homograft harvested weeks earlier.1 This surgery culminated substantial efforts to repair damaged aortas using various techniques, including wiring the aorta with materials to induce thrombosis;
coronary artery bypass grafting cardiopulmonary bypass guideline-directed medical therapy hazard ratio intra-aortic balloon pump low cardiac output syndrome left ventricular left ventricular ejection fraction Surgical Treatment for Ischemic Heart Failure Innovation is not necessarily about the “next big thing” according to Mehta.1 Instead, innovation can occur by combining existing technologies, developing small ideas that compound, or evolving to address problems that have arisen from previous innovations that yielded unpredictable consequences. Innovation in the field of cardiovascular surgery is no different. As the field becomes progressivelyAbbreviations and Acronyms
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internal thoracic artery left internal thoracic artery multiple arterial grafting radial artery When selecting conduits for coronary artery bypass, long-term patency, survival benefit, and patient factors such as coronary atherosclerotic burden and comorbid conditions are the primary influences on surgical decision-making (Fig. 1). Previous studies have shown that multiple arterial conduits offer a survival benefit,1 but the observational design of this work makes the findings subject to patient selection bias. The Arterial Revascularization Trial was a prospective, randomized trial comparing bilateral internal thoracic arteries (ITAs) with single ITA conduitsAbbreviations and Acronyms
In the article titled “‘Simple’ Transcatheter Aortic Valve Replacement With Conscious Sedation: Safety and Effectiveness in Real-World Practice,”1 published October 15, 2021, minor corrections to the final text should have been incorporated. Abstract, paragraph 3 Original The highest 30-day complication rate was associated with new permanent pacemaker implantation… Correction The most frequent complication at 30 days was new permanent pacemaker implantation… Introduction, paragraph 1, sentences 2 and 3 Original Improved prosthesis design has enabled percutaneous procedures through a femoral or radial approach, resulting in higher success rates and fewer complications. After TAVR
During the last decade, advancements in the scientific publication industry led to strategic business improvements at The Texas Heart Institute Journal, beginning with online-only publication in 2014. Seven years later, we began continuous publication, a model that enables articles to be published within 6 weeks of acceptance. As governance of the industry and best practices continue to evolve, The Journal is making pivotal changes to enhance author and reader experiences. Beginning 15 July 2023, The Journal will be fully Open Access (OA), allowing authors to retain copyright ownership under Creative Commons (CC) licenses.1
