Case Presentation: A 64-year-old woman with presented to the hospital with chest pain and hypotension during hemodialyis. Three months prior to presentation, she had underwent transcatheter aortic valve implantation (TAVI) and received a 26 mm CoreValve Evolut Pro (Medtronic, MN) for severe aortic stenosis. She was admitted to the cardiac intensive care unit and underwent diagnostic testing. Transthoracic echocardiography demonstrated a new mean transaortic valve gradient of 55 mm Hg (Figure 1A), increased from her post-procedural gradient of 12 mm Hg. Despite empiric treatment with heparin anticoagulation and antibiotics, the patient did not improve clinically. CT imaging did not reveal valve thrombosis, endocarditis, or any other structural deformities (Figure 1B), and the patient’s mean transaortic valve gradient worsened to 73 mm Hg. After a multidisciplinary discussion, a decision was made to offer a valve-in-valve TAVI for early valve degeneration with a 23 mm Sapien S3 (Edwards, CA) valve (Figure 1C). After her procedure, the patient’s symptoms resolved and she was discharged from the hospital. The patient’s mean transaortic valve gradient improved to 12.6 mm Hg at her 4 month follow up visit (Figure 1D). Discussion: Early TAVI valve dysfunction is typically attributed to thrombus or infection of the valve. Here we present a case of valve dysfunction that was not related to either of these etiologies. Delineating the cause of her valve dysfunction was vital to her therapeutic decision making. Since the patient was not a surgical candidate, valve-in-valve TAVI was offered when thrombus and endocarditis were eliminated as the etiology of her valve dysfunction.
Introduction: Left ventricular assist devices (LVAD) may lead to left ventricular (LV) recovery in patients with heart failure with reduced ejection fraction (HFrEF) via LV offloading and subsequent positive remodeling. Current echocardiographic markers of LV recovery in LVAD patients are not well defined. The peak systolic slope, also known as systolic acceleration, of the outflow cannula has recently been shown to be a marker of underlying LV contractility and a tool to assess for LV recovery. We hypothesized that variations in the systolic slope would predict heart failure (HF) admissions. Methods: A total of 63 unique patients with LVAD at The University of Chicago Medical Center had HeartMate 3 (HM3) outflow tract Doppler signals obtained during routine transthoracic echocardiography (TTE) of suitable quality between 2015 and 2022. Systolic acceleration, systolic deceleration, diastolic acceleration, and the presence of flow reversal were measured. Mortality and HF admissions were recorded up to one year from the date of the TTE. Results: Increased systolic acceleration through the HM3 outflow cannula was associated with a decreased 1-year HF admission risk (352.8 [241.9, 515.8] cm/sec 2 vs 249.2 [164.0, 316.5] cm/sec 2 among readmitted patients, p = 0.03; Figure 1A). Systolic deceleration also predicted 1-year HF admission (-318.6 [-477.9, -244.0] cm/sec 2 vs -217.8 [-304.5, -188.8] cm/sec 2 among readmitted patients, p = 0.04; Figure 1B). Other variables, including the presence of flow reversal and diastolic acceleration, were not significantly associated with HF admission risk. Conclusions: Systolic acceleration, which reflects LV contractility, and systolic deceleration, which represents LV relaxation, are predictive of HF admission in patients with the HM3 LVAD.
Introduction: Our analysis seeks to determine whether it or advanced hemodynamic variables, including aortic pulsatility index (API), pulmonary artery pulsatility index (PAPI), left ventricular stroke work index (LVSWI), or right ventricular stroke work index (RVSWI), correlated more strongly than traditional metrics with waitlist mortality for heart transplant. Hypothesis: Advanced hemodynamic markers of cardiac function, including API and PAPI, correlate more strongly with waitlist mortality than traditional hemodynamic criteria, including SBP and PCWP. Methods: This retrospective analysis of the Scientific Registry of Transplant Candidates (SRTR) included adults listed at all Statuses after the new heart allocation system in 2018. Hemodynamic data was obtained for patients listed after the 2018 policy change. Kaplan-Meier survival analysis was completed, with API, PAPI, LVSWI, and RVSWI as the independent variable stratified into quintiles. Results: There were 9,418 patients listed for heart transplant since the new policy implementation, with 8,636 patients with complete hemodynamic data at listing. Kaplan-Meier survival analysis revealed that API and LVSWI were best at stratifying patients appropriately in terms of waitlist survival with homogeneity of dispersion between groups (Figure 1), (lowest API quintile to highest: HR 2.04, 95%CI 1.94 - 2.15; HR 1.70, 1.59 - 1.81; HR 1.40, 1.29-1.51; HR 1.19, 1.08 - 1.30). The traditional parameters of PCWP, CO and systolic blood pressure had considerable dispersion of risk between quintiles while the right-sided parameters of PAPI and RVSWI did not. Conclusions: Advanced left-sided hemodynamic parameters better risk strategy waitlist mortality and the urgent need for heart transplantation than traditional metrics or right-sided advanced parameters.
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