In the endocardial LAA device group, when compared with baseline blood adrenaline, noradrenaline and aldosterone were significantly lower at 24 hours and three months. There was no significant change in these levels post endocardial LAA device implantation. After epicardial LAA device implantation, significant increases were seen in adiponectin and insulin, with decreased free fatty acids at three months, while there was no significant change in these levels after an endocardial procedure.

In the epicardial group, N-terminal pro-A-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide were significantly decreased in the acute phase and normalized at three months. In the endocardial group, these levels increased immediately and normalized after 24 hours. Systemic blood pressure was significantly lower at all time points in the epicardial group but not in the endocardial group.

The authors say this study suggests that exclusion of the LAA with an epicardial LAA device may attenuate the release of adrenaline via a negative feedback mechanism. Further studies are required to elucidate the underlying mechanism and clinical relevance of these physiological changes.

Lakkireddy D, Turagam M, Afzal MR, et al. J Am Coll Cardiol 2018;71:135-44.

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The median clinical follow-up duration for the entire cohort was 173 days. During this time there were seven deaths (14 percent) within 30 days. Four additional patients died after 30 days (between days 54 and 122) but there were no deaths after four months.

Among all alive patients with 30-day echocardiographic follow-up (n = 42), significant reductions in mitral regurgitation (MR) severity and improvements in symptoms occurred. MR was either absent (grade 0) or mild (grade 1) at the last clinical evaluation in patients who received implants (n = 42; 100 percent), with no evidence of left ventricular outflow tract (LVOT) obstruction (change in peak LVOT gradient, 0.4 ± 4.5 mm Hg) or mitral stenosis (final mean gradient, 4.1 ± 1.3 mm Hg). Among patients with MR, all cases were mild. There also was a decrease in left ventricular ejection fraction (43.6 vs. 36.2 percent; p < 0.0001) and an increase in left ventricular end-systolic dimension (4.8 ± 1.0 cm at baseline vs. 5.1 ± 0.9 cm at follow-up; p = 0.0007), without significant changes in left ventricular end-diastolic dimension (5.9 ± 0.7 cm at baseline vs. 5.9 ± 0.8 cm at follow-up; p = 0.94). In all implanted patients, there were no instances of hemolysis, device embolization or thrombosis.

According to the authors, the valve design was shown to be advantageous. They conclude these results could help inform trial design of TMVR in lower-risk patients with severe MV regurgitation.

Bapat V, Rajagopal V, Meduri C, et al. J Am Coll Cardiol 2018:71:12-21.

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When compared with coronary angiography, IVUS-guided PCI was associated with lower odds of all-cause death (odds ratio [OR], 0.74), MI (OR, 0.72), target lesion revascularization (OR, 0.74) and stent thrombosis (OR, 0.42). Optical coherence tomography (OCT) or IVUS were associated with lower rates of MACE and cardiovascular death. There was no difference in efficacy between IVUS or OCT. All-cause mortality benefit associated with IVUS was not seen when the analysis was restricted to randomized controlled trials only; however, cardiovascular death remained significantly lower regardless of the type of study.

According to the authors, this is the first meta-analysis to explore the results of OCT studies for PCI guidance.

Buccheri S, Franchina G, Romano S, et al. JACC Cardiovasc Interv 2017;10:2488-98.

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Gregory J. Dehmer, MD, MACC

Results showed that out of 509,153 PCIs at 654 hospitals – of which 10.9 percent were at 44 top-ranked hospitals – PCIs performed at top-ranked hospitals had similar odds of in-hospital mortality, AKI and bleeding after adjusting for case mix. Top-ranked hospitals had a “slightly lower proportion of appropriate PCI compared with non-ranked hospitals (89.2 percent vs. 92.8 percent).”

The authors explain “these findings should reassure patients that safe and appropriate PCI is being performed across the nation in hospitals participating in the CathPCI Registry…” They add that moving forward, “much like the initiatives by the ACC and Society of Thoracic Surgeons, we believe it is incumbent upon hospitals, clinical registries and national professional organizations to assist in public reporting efforts aimed at improving transparency, accountability, and quality in health care.”

In a related editorial comment, Gregory J. Dehmer, MD, MACC, explains “this study addresses what is often the foremost question of a patient and their family in their hometown – Is my local hospital doing a good job? To the extent measured by variables in this study, it is reassuring that the answer appears to be ‘yes.’”

Sukul D, Bhatt DL, Seth M, et al. JACC Cardiovasc Interv 2017; Nov 12:[Epub ahead of print]

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