Interview with Dr. Mario J. Garcia
Why did you feel that it was important to write a book on this topic? What does Multimodality Cardiovascular Imaging, 1st Edition add to the field?
Non-invasive cardiac imaging is fundamental for the initial diagnostic evaluation and therapy guidance for most cardiovascular pathologies. Cardiac imaging modalities provide complementary anatomical and functional information. Selecting the most appropriate diagnostic method in the clinical setting requires understanding of the values and limitations of each individual and combined imaging modalities.
What is the most exciting aspect of Multimodality Cardiovascular Imaging, 1st Edition? What chapter or topic covered are you most excited about?
Every chapter provides a comprehensive diagnostic imaging approach for specific cardiovascular clinical conditions, containing useful diagnostic algorithms and case examples.
Who will find the greatest value from Multimodality Cardiovascular Imaging, 1st Edition and why?
The Multimodality Cardiovascular Imaging, 1st Edition is useful for both clinical cardiologists and for cardiovascular imaging specialists. It contains all the information needed for test selection and provides guidelines for interpreting findings and guiding treatment in a variety of clinical scenarios.
What new ideas, practices, or procedures do you hope your readers take away from Multimodality Cardiovascular Imaging, 1st Edition?
The information available in Multimodality Cardiovascular Imaging, 1st Edition will support that in most circumstances a complete diagnostic evaluation and management recommendations can be provided based primarily on non-invasive imaging findings.
What problem do you hope the future generation of your specialty will be able to solve?
How to limit the use of unnecessary testing or arriving to inaccurate conclusions.
Is there anything else about Multimodality Cardiovascular Imaging, 1st Edition you’d like to say?
The first part of Multimodality Cardiovascular Imaging, 1st Edition covers the essential physical principles and instrumentation that must be known for improving the quality of imaging and interpretation. The final chapter contains a collection of real-life cases that demonstrate the complementary value of different imaging modalities.
About the Author
Dr. Mario J. Garcia is a highly respected non-invasive cardiologist known for his work in developing and implementing advanced cardiac diagnostic technologies. He earned his medical degree from Universidad Nacional Pedro Henriquez Urena in Santo Domingo and completed his training in internal medicine, cardiology, and cardiovascular imaging at St. Vincent’s Medical Center in Bridgeport, CT, Massachusetts General Hospital, and the Cleveland Clinic.
In 2010, he became the Chief of the Division of Cardiology at the Albert Einstein College of Medicine – Montefiore Medical Center. He holds the Pauline Levitt Endowed Chair in Medicine, is a Professor of Radiology, and serves as Co-Director of the Montefiore-Einstein Center for Heart and Vascular Care.
His research has focused on validating non-invasive imaging techniques to study cardiac structure and function. He was one of the first to adapt multi-detector CT technology for coronary imaging. His work has received support from organizations such as the National Space Biomedical Research Institute (NSBRI), NASA, the Department of Defense, the American Society of Echocardiography, the NHLBIH, and the American Heart Association.
He has also been involved in education, serving as a speaker and program director for major programs sponsored by the ACC, AHA, ASE, ASNC, and other organizations. Over the years, he has authored or co-authored several books, book chapters, and more than 250 publications in peer-reviewed journals.
Dr. Garcia has held leadership roles, including being a past member of the Boards of Directors of ASNC, ASE, and SCCT. He has also been part of the National Board of Echocardiography Exam Committee and previously chaired the ABIM Cardiovascular Exam Committee.
Purchase your copy of Multimodality Cardiovascular Imaging, 1st Edition here!
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 2 Vol Set, 12th Edition
By: Peter Libby, Robert O. Bonow, Douglas L. Mann, Gordon F. Tomaselli, Deepak Bhatt, Scott D. Solomon, and Eugene Braunwald
ISBN: 9780323722193
Pub Date: November 15, 2021
Reviewed By: Luna Khanal, MD (East Tennessee State University Quillen College of Medicine)
Description
This is the 12th edition of this leading textbook of cardiovascular medicine. The book provides a comprehensive, carefully curated, up-to-date overview of the fundamental pathophysiologic mechanisms in the field of cardiovascular disease.
Purpose
The purpose is to review the latest advances in the field of cardiovascular medicine in order to lay foundation and continue to build in the novel areas for optimal patient care.
Audience
The intended audience of this book includes cardiologists, internists, physicians in training, and midlevel providers. The chapter authors are national and international thought leaders in their respective fields.
Features
The book has 11 parts, each divided into multiple chapters. Part 1 focuses on foundations of cardiovascular medicine. Part 2 provides individualizing approaches to cardiovascular disease. Part 3 discusses patient evaluation with tried and tested evidence-based history and physical examination along with use of basic cardiovascular diagnostic tools like ECG, ECHO, cardiac imaging including cardiac CT and MRI, as well as invasive modalities like coronary angiography and intravascular imaging. Part 4 discusses preventive cardiology.
Part 5 focuses on atherosclerotic cardiovascular disease. Part 6 covers heart failure. Part 7 discusses arrythmias, sudden death, and syncope. Part 8 includes pathophysiology and management of valvular diseases while part 9 talks about myocardial, pericardial, and pulmonary vascular bed disease. Part 10 gives insight on cardiovascular disease in special populations including women, pregnancy, older adults, and ethically and racially diverse populations.
Lastly, part 11 focuses on cardiovascular disease and its relationship with disorders of other organ systems. It also includes a chapter on endemic and pandemic viral illness and cardiovascular disease, with focus on speculated areas of COVID-19 and its effect on the cardiovascular system. The new edition has an additional 12 chapters with two new chapters exclusively on cardio-oncology. Numerous evidence-based graphs, tables, and illustrations present detailed, easy-to-understand concepts.
Assessment
This book is excellent and will be a valuable resource for cardiologists, internists, physicians in training, and midlevel providers.
©Doody’s Review Service, 2022, Luna Khanal, MD (East Tennessee State University Quillen College of Medicine)
Doody’s Score: 92 – 4 Stars!
Braunwald’s Heart Disease, 2 Vol Set, 12th Edition
By: Peter Libby & Robert O. Bonow & Douglas L. Mann & Gordon F. Tomaselli & Deepak Bhatt & Scott D. Solomon & Eugene Braunwald
ISBN: 9780323722193
Pub Date: November 15, 2021
Reviewed By: Sai Karthik Kommineni, MBBS (East Tennessee State University Quillen College of Medicine)
Description
This is the 12th edition of this leading reference textbook on the current knowledge in cardiovascular medicine.
Purpose
This book is intended to provide a comprehensive, up-to-date, and evidence-based review of cardiovascular diseases.
Audience
The intended audience includes practicing physicians, cardiologists, internists, emergency medicine physicians, physicians in training, and medical students. The chapter authors are national and international leaders in their respective fields.
Features
The book is divided into multiple parts, with each part subdivided into various chapters focusing on a comprehensive review of cardiovascular diseases. The textbook provides a ready reference to update readers’ knowledge in areas of cardiovascular medicine. The 12th edition offers carefully curated and balanced information with updates on the latest advances in the field. The book reviews cardiovascular medicine foundations, patient evaluation, preventive cardiology, atherosclerotic cardiovascular disease, heart failure, arrhythmias, diseases of heart valves, and diseases of the myocardium, pericardium, and pulmonary vasculature bed. Across all chapters, the book has excellent schematic presentations and imaging to consolidate visual representation further. This book also has a chapter, “Impact of Health Care Policy on Quality and Outcomes of Cardiovascular Disease,” which emphasizes practical societal approaches to ensure that patients can benefit from the basic and clinical scientific advances in the field of cardiology. This is a well-written and critique-appraised textbook to confront patient problems.
Assessment
The quality and content of this book is unparalleled. This book is an invaluable resource for practicing physicians and all healthcare providers. It is a must-read book for anyone who wants to learn about cardiovascular diseases.
©Doody’s Review Service, 2022, Sai Karthik Kommineni, MBBS (East Tennessee State University Quillen College of Medicine)
Doody’s Score: 100 – 5 Stars!
ASE’s Comprehensive Strain Imaging, 1st Edition
By Thomas H. Marwick, MBBS, PhD, MPH and Theodore P. Abraham, M.D., F.A.C.C.
ISBN: 9780323759472
Pub Date: June 23, 2021
Reviewed by: Vindhya B Sriramoju, MD (East Tennessee State University Quillen College of Medicine)
Description
This is the American Society of Echocardiography’s book on comprehensive strain imaging.
Purpose
This book provides a sophisticated understanding of strain imaging, also known as speckle tracking echocardiography, and its application in various fields of cardiovascular medicine. The up-to-date information on strain imaging can guide physicians in dealing with simple to complex cases in both inpatient and outpatient settings.
Audience
This book is a valuable resource for cardiovascular physicians across all fields including non-invasive cardiology and interventional and structural cardiology, as well as for clinical and research fellows and research associates in the rapidly changing field of cardiovascular medicine. The chapter authors are national and international thought leaders in their respective fields.
Features
This book provides excellent and in-depth information on strain imaging applications and state-of-the-art techniques. The book first introduces the topic by explaining the physics and physiology of strain, acquisition, and processing of global longitudinal strains in transthoracic echocardiogram in different imaging systems. The chapters provide valuable information about how to detect subclinical cardiomyopathy especially in the high-risk patient subgroups with hypertension, diabetes mellitus, and receipt of chemotherapy, and detail a strain-guided approach in the prevention and early treatment of subclinical heart failure. The book also discusses evaluation of heart failure with preserved EF by discussing in detail the diagnoses of left ventricle (LV) left atrium (LA), and right ventricle (RV) strains. Various modalities and applications of strain imaging in diagnosis, treatment response monitoring, and prognosis in various pathologic entities, namely hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, and arrhythmogenic right ventricular cardiomyopathy, are outlined. The book also introduces the role of strain patterns in identifying patients who are likely to respond to cardiac resynchronization therapy. Among other topics, the book discusses in detail the role of LA strain in diastolic dysfunction, prediction of efficacy of ablation and cardioversion in atrial fibrillation, and the significance of LV and RV strain in valvular heart disease. The book illustrates components of strain imaging curve and its clinical application in ischemic heart disease. Extensive illustrations of the topics with relevant echocardiographic images assist readers with understanding more difficult concepts. Finally, the book summarizes major clinical trials and metanalyses, and gives future directions to researchers and physicians for advancing research and science in the field of cardiovascular medicine.
Assessment
The quality and content of the book is exceptional. It is ideal for cardiovascular physicians and researchers in the advanced stages of their cardiovascular training.
©Doody’s Review Service, 2021, Vindhya B Sriramoju, MD (East Tennessee State University Quillen College of Medicine) Doody’s Score: 98 – 5 Stars!
Debra L. Beck and Eugene Braunwald, MD
Date Published: 18 Oct 2019
Balancing ischemic risk and bleeding risk after percutaneous coronary intervention (PCI) is an important dilemma for clinicians. Reducing the duration of aspirin after PCI may allow for more prolonged use of potent P1Y12 inhibitors while avoiding aspirin-related bleeding risk. Monotherapy with a P2Y12 inhibitor after a minimum period of dual antiplatelet therapy (DAPT) is an emerging approach. In the TWILIGHT trial, Mehran et al studied the effect of ticagrelor alone as compared to ticagrelor plus aspirin in patients undergoing PCI who are at high risk for ischemic or hemorrhagic complications and who have completed a 3-month course of DAPT with ticagrelor plus aspirin.
In this double-blind trial, 7119 patients (mean age 65 years, 24% female) who had not had a major bleeding event or an ischemic event after the index PCI were randomized after three months of DAPT with ticagrelor (90 mg daily) plus aspirin (81 to 100 mg daily) to receive either ticagrelor alone or continued DAPT. Participants had to have at least one clinical and one angiographic feature associated with increased risk of ischemic or bleeding events.
The majority of participants presented with acute coronary syndrome (65%) and had multivessel coronary artery disease (63%). The trial was conducted at 187 sites in 11 countries in North American, Europe, and Asia.
For the primary endpoint of Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding, the incidence was 4.0% in the ticagrelor alone arm and 7.1% in the ticagrelor plus aspirin arm (hazard ratio HR], 0.56; p<0.001). The treatment effect for the primary endpoint was consistent across predefined subgroups.
BARC type 3 or 5 bleeding was seen in 1.0% of the ticagrelor monotherapy arm and in 2.0% of the DAPT arm (HR, 0.49; 95% confidence intervals, 0.33 – 0.74).
The key secondary endpoint, the composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke from 0 to 12 months after randomization, was evaluated with the use of a prespecified noninferiority hypothesis with an absolute margin of 1.6 percentage points. Incidence rates were 3.9% for both groups (HR, 0.99; p<0.001 for noninferiority).
Summary
The researchers concluded that, in high-risk patients who underwent PCI and were free from ischemic or bleeding events after 3 months of DAPT, ticagrelor monotherapy was associated with a lower incidence of clinically relevant bleeding than ticagrelor plus aspirin, with no higher risk of death, myocardial infarction, or stroke over a period of 1 year.
These results may not be generalizable to all patients undergoing PCI, given the requirements in this trial for both high-risk (clinical and angiographic) features and freedom from major adverse events after three months of DAPT. Also, the trial was underpowered to detect difference in important yet rare clinical events, such as stent thrombosis and stroke.
References
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring weekly Hot off the Press, periodic Late-Breaking Clinical Trials (including links to authors’ presentation slides), and monthly Focused Reviews.
Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.
Paris, August 31, 2019 – Elsevier, a global information analytics business specializing in science and health, is pleased to welcome Deepak L. Bhatt, M.D., M.P.H., and Scott D. Solomon, M.D., to the prestigious Braunwald’s Heart Disease Editorial team, as planning for the 12th edition begins.
Trusted by generations of cardiologists for the latest, most reliable guidance in the field, Braunwald’s Heart Disease continues to be one of the leading sources of information on rapidly changing clinical science, clinical and translational research, and evidence-based medicine.
The editors salute Dr. Douglas Zipes who contributed to Braunwald’s Heart Disease since the second edition and served as editor-in-chief for two editions. His energy, expertise and experience contributed enormously to the success of this book and its companions. As Prof. Zipes leaves the editorial group to pursue other interests, Dr. Gordon Tomaselli now leads the electrophysiology and arrhythmia sections of Heart Disease.
Drs. Bhatt and Solomon will join Braunwald’s Heart Disease as new co-editors for the 12th Edition. They both have made major contributions to contemporary cardiovascular medicine, and each has several areas of expertise that they bring to the editorial team.
“We are fortunate to have such talented, accomplished and experienced clinician-investigators and teachers join us. Their contributions will help us continue the tradition of excellence established by Dr. Braunwald and assure the high quality of the 12th edition and its usefulness to practitioners and trainees for learning and as the cardiovascular reference for their practices,” said Prof. Peter Libby, who will take the role as lead editor of the 12th edition.
Dr. Bhatt, Executive Director of Interventional Cardiovascular Programs, Brigham and Women’s Hospital Heart & Vascular Center, and Professor of Medicine, Harvard Medical School, has authored over 1250 publications and is the editor of Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease.
“What an incredible honor and joy it is to be joining this all-star team of Braunwald’s Heart Disease Editors,” Dr. Bhatt said.
Dr. Solomon is The Edward D. Frohlich Distinguished Chair, Professor of Medicine at Harvard Medical School and Senior Physician at Brigham and Women’s Hospital. Dr. Solomon has authored more than 600 peer-reviewed articles, reviews and editorials, three textbooks of cardiac imaging, including Essential Echocardiography, A Companion to Braunwald’s Heart Disease (2018), and the Echocardiography sections for the 10th and 11th edition of Braunwald’s Heart Disease.
“It is a distinct honor to join this extraordinary team on what is arguably the premiere educational source in cardiovascular medicine,” said Dr. Solomon.
Editors of Braunwald’s Heart Disease, 12th edition, also include:
Braunwald’s Heart Disease, 11th edition, is available to purchase in both single volume and two-volume formats. The print copy of the book includes the enhanced digital version e-book, also available via elsevierhealth.com for purchase by itself, and at industry events and conferences, including ESC 2019.
About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray’s Anatomy. Elsevier is part of RELX, a global provider of information-based analytics and decision tools for professional and business customers. www.elsevier.com
Debra L. Beck and Eugene Braunwald, MD
Date Published: July 12, 2019
In 2016, the United States had 26,203 confirmed and 36,429 probable cases of Lyme disease (LD), a tick-borne bacterial infection. It is estimated, however, that the true incidence approaches 300,000 cases annually. Lyme disease incidence is also dramatically increasing in Canada, carried by migratory birds that are affected by climate change. In this review, Yeung and Baranchuk discuss the diagnosis and treatment of Lyme carditis, an early disseminated manifestation of Lyme disease infection (within 1 to 2 months with a range of 1 to 28 weeks).
The pathophysiology of Lyme carditis involves the direct myocardial invasion by bacteria and a subsequent immunologic and exaggerated inflammatory response. High-degree atrioventricular (AV) block is the most common presentation (90%), but it is usually transient in nature and resolves with antibiotic therapy.
Lyme carditis can also present as sinus node disease, intra-atrial block, atrial fibrillation, supraventricular tachycardia, sinus node dysfunction, bundle branch block, and ventricular tachycardia and fibrillation. Acute myocarditis, pericarditis, endocarditis, and pancarditis have also been reported.
Yeung and Baranchuk outline a systematic approach to the diagnosis of Lyme carditis in patients with high-degree AV block to facilitate timely identification and avoid unnecessary implantation of permanent pacemakers in otherwise healthy young individuals. Their Suspicious Index in Lyme Carditis (SILC) score can be associated with the mnemonic “CO-STAR”, standing for Constitution symptoms, Outdoor activity/endemic area, Sex, Tick bit, Age, and Rash.
References
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring twice monthly updates including “Hot off the Press” and Late-Breaking Clinical Trials (links to authors’ presentation slides are also included).
Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.
Originally published January 4, 2019 as an update to Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th edition
Debra L. Beck and Eugene Braunwald, MD
Early identification of coronary artery disease (CAD) is difficult using traditional risk factors and risk scores. While it is well known that CAD has substantial heritability and a polygenic architecture, genomic risk scores to help predict early CAD have yet to be shown especially effective. In this study, Inouye et al constructed a genomic risk score based on 1.7 million single nucleotide polymorphisms (SNPs) to predict lifetime risk trajectories for CAD.
The researchers developed built a new genomic risk score for CAD (called metaGRS) using a meta-analytic approach to combine large-scale, genome-wide, and targeted genetic association data. The score was based on 3 other genetic risk scores and included 1.7 million genetic variants. They tested the score externally by itself and in combination with available data on conventional risk factors, in 22,242 CAD cases and 460,387 noncases from the UK Biobank.
For every 1 standard deviation increase in metaGRS the hazard ratio (HR) for CAD was 1.71 (95% confidence interval [CI]: 1.68 to 1.73), an association larger than any other externally tested genetic risk score previously published, and higher also than the degree of risk captured using any single conventional risk factor or combination of conventional risk factors. The metaGRS also had a higher C-index for incident CAD than any of the conventional risk factors.
The metaGRS stratified individuals into significantly different life course trajectories of CAD risk, with those in the top 20% of metaGRS distribution having an HR of 4.17 (95% CI: 3.97 to 4.38) compared with those in the bottom 20%. For contrast, the corresponding HR was 2.83 (95% CI: 2.61 to 3.07) among individuals on lipid-lowering or antihypertensive medications.
The author concluded that the genomic score developed and evaluated here “substantially advances the concept of using genomic information to stratify individuals with different trajectories of CAD risk and highlights the potential for genomic screening in early life to complement conventional risk prediction.”
In an editorial, Dr. P Natarajan noted that a polygenic risk score is stable from birth, only needs to be performed once (at a current cost of <$100), and can be used to “calculate polygenic risk for virtually any trait.” However, “precision prevention” still relies on the ability to motivate health behavior change, which has proven difficult.
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring twice monthly updates including “Hot off the Press” and Late-Breaking Clinical Trials (links to authors’ presentation slides are also included).
Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.
Originally published January 4, 2019 as an update to Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th edition
Debra L. Beck and Eugene Braunwald, MD
Increasing numbers of patients are presenting with bioprosthetic mitral valve degeneration. Transcatheter mitral valve replacement (TMVR) is an emerging treatment for patients with severe mitral valve disease at high risk for conventional mitral valve surgery. Yoon et al sought to evaluate the outcomes of TMVR in patients with degenerated bioprostheses (valve-in-valve [ViV]), failed annuloplasty rings (valve-in-ring [ViR]), and severe mitral annular calcification (valve-in-mitral annular calcification [ViMAC]).
Using data from the international, multicenter TMVR registry, procedural and clinical outcomes of ViV, ViR, and ViMAC were compared according to Mitral Valve Academic Research Consortium (MVARC) criteria. A total of 521 patients with mean Society of Thoracic Surgeons score of 9.0% underwent TMVR: 322 of them had ViV, 141 had ViR, and 58 had ViMAC. Trans-septal access was used in 39.5% and Sapien valves were used 90.0%.
Overall technical success was “excellent” at 87.1%. However, left ventricular outflow tract obstruction was seen in 39.7% of ViMAC procedures, compared with 5.0% for ViR and 2.2% for ViV (p<0.001), and second valve implantation was more frequent needed in ViR (12.1%) compared with ViMAC (5.2%) and ViV (2.5%; p<0.001), yielding technical success rates of 94.4% after ViV, compared with 80.9% after ViR and 62.1% after ViMAC (p<0.001).
Post-procedural mitral regurgitation ≥moderate was noted in 18.4% of the ViR group, compared to 13.8% and 5.6% of the ViMAC and ViV groups (p<0.001). Post-procedural left ventricular ejection fraction remained lowest in the ViR group compared to the other two groups.
All-cause mortality at 30 days was highest at 34.5% after ViMAC, compared with 9.9% after ViR and 6.2% after ViV (log-rank p<0.001). One-year mortality rates were 62.8%, 30.6%, and 14.0%, respectively (log-rank p<0.001). On multivariable analysis, patients with failed annuloplasty rings and severe MAC were at increased risk of mortality after TMVR (ViR vs. ViV, hazard ratio (HR), 1.99, p=0.003; ViMAC vs. ViV, HR 5.29, p<0.001).
The investigators concluded that TMVR provided “excellent outcomes” for patients with degenerated bioprostheses (ViV), but those with failed annuloplasty rings (ViR) and severe mitral annular calcification (ViMAC) were more likely to experience procedural complications and were at increased mortality after the procedure. “As the present large study is consistent with recent reports with comparable early- and mid-term mortality, TMVR is an attractive option for patients with degenerated bioprosthetic mitral valves,” wrote the authors, but “poses unique and serious procedural challenges for those with failed annuloplasty repair and severe MAC.”
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring twice monthly updates including “Hot off the Press” and Late-Breaking Clinical Trials (links to authors’ presentation slides are also included).
Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.
Originally published December 7, 2018 as an update to Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th edition
Debra L. Beck and Eugene Braunwald, MD
Increased left atrial pressure leading to pulmonary congestion is common in acute decompensated heart failure. The creation of an interatrial shunt for left atrial decompression has been successfully applied in selected patients, including in those with chronic HF, and has shown early promise. Rodes-Cabau et al reported first-in-human data on the V-Wave Interatrial Shunt, an hourglass-shaped implant containing a 1-way bioprosthetic valve that is implanted by transseptal catheterization.
In this single-arm, open-label study, 38 heart failure patients (mean age, 66 years; 30 with reduced ejection fraction and 8 with preserved ejection fraction) were implanted with the shunt device. Thirty-seven patients had NYHA class III symptoms and one patient had class IV symptoms.
The shunt was successfully implanted in all patients with transesophageal echocardiography-confirmation of correct positioning and unidirectional left-to-right flow through the shunt. There was no periprocedural mortality and 1 patient (2.6%) had a cardiac tamponade within hours of the procedure that was successfully treated. There were no other major device- or procedure-related complications within the first 12 months.
At 3 months, 78% of patients had improved from NYHA class III or IV at enrollment to NYHA class I or II. At 12 months, this figure was 60% (p<0.02). Quality of life improvement of >5 points improvement on one of two scales was seen in 74% at 3 months and 73% at 12 months (p<0.02). Six-minute walk distance showed a mean increase of 41 meters at 3 months and 28 meters at 12 months (p<0.02). However, no improvements were seen in objective measures of left- or right-sided function.
At 3 months, all shunts were patent. But by 12 months, 14% (5 of 36) had occluded and another 36% (13 of 36) were stenotic at the valve. Stenosis severity was assessed as subtotal in 7 cases.
Patients with widely patent shunts had better long-term outcomes than those with stenotic/occluded shunts: a lower rate of the composite of death, left ventricular assist device placement or heart transplantation (p = 0.001), and HF hospitalization (p = 0.008). They also had a significant reduction in pulmonary capillary wedge pressure from baseline to 12 months (p=0.011) compared to those with stenotic or occluded shunts.
Throughout a median follow-up of 28 months there were 10 deaths (8 cardiovascular) and two heart transplantations or LVAD implantations. Beyond 12 months, 10 patients with patent shunts survived to their 24-month anniversary. Of note, in this small feasibility study, these clinical outcomes should be considered only exploratory.
The investigators concluded that interatrial shunting with the novel V-Wave system was feasible and safe in patients with HF with reduced and preserved ejection fraction. Early improvements in clinical functioning were maintained at 12 months despite attenuation of shunt patency in one-half of the patients. “Implementing modifications that likely improve device patency duration while maintaining hemodynamic and functional benefits are worthwhile before launching a randomized trial to confirm these findings in a larger population,” wrote the authors.
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring twice monthly updates including “Hot off the Press” and Late-Breaking Clinical Trials (links to authors’ presentation slides are also included).
Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.
