Future Therapy for Low-Risk Patients With Severe Aortic Stenosis—A Provider Survey

With the expansion of transcatheter aortic valve replacement in low-risk patients, we sought to explore current implanters' predictions on the future of this therapy by sending a survey to a sample of 8,261 healthcare professionals using Internet-based software. The survey contained six questions regarding physician specialty and experience, transcatheter aortic valve replacement age cutoff, optimal treatment for low-risk patients, transcatheter aortic valve replacement valve sequence, and transcatheter aortic valve replacement concerns. The majority, 29% percent, of all respondents felt that transcatheter aortic valve replacement will become the first-choice therapy for all patients, regardless of age and 70% felt that the optimal treatment would be transcatheter aortic valve replacement, with transcatheter aortic valve replacement valve-in-valve if the first valve degenerates. Regarding the sequence of transcatheter aortic valve replacement valves, 78% preferred the Edwards Sapien 3 valve (ES-3) as the first transcatheter aortic valve replacement valve followed by either a second ES-3 or Medtronic Evolut valve. Despite the high acceptance of transcatheter aortic valve replacement, many respondents (56%) felt that surgical aortic valve replacement might still remain the preferred treatment in low-risk patients due to an unknown durability of transcatheter aortic valve replacement valves. A majority of implanters see transcatheter aortic valve replacement followed by valve-in-valve transcatheter aortic valve replacement as the first-line therapy for low-risk patients with severe aortic stenosis, but long-term durability of transcatheter aortic valve replacement is an unanswered concern.

Health Status and Quality of Life of Patients Enrolled in a Specialized Refractory Angina Clinic

As the mortality of coronary artery disease improves and the population ages, an increasing number of patients with refractory angina are not candidates for percutaneous or surgical revascularization. We evaluated the impact of a dedicated refractory angina clinic on quality of life. In 76 patients who completed the Medical Outcomes Study 36-Item Short-Form Health Survey and Seattle Angina Questionnaire at baseline and 1 year, the Medical Outcomes Study results showed the proportion of patients who rated their health as “good” or “excellent” more than doubled from baseline to 1 year (15.8% vs. 42.2%; P < .001). Similarly, the Seattle Angina Questionnaire score was significantly improved at 1 year compared to baseline (P = .025), as were angina stability (P = 0.017) and angina frequency (P = .010). In conclusion, treatment in a dedicated clinic is associated with improved quality of life in patients with refractory angina.

Genetic Arrhythmia Center: Caring for Patients and Families at Risk for Sudden Cardiac Death and Advancing the Understanding of Rare Cardiomyopathies and Channelopathies

Although rare in the general population, genetic arrhythmia syndromes have a significant public health impact due to their contribution to the incidence of sudden cardiac death, particularly in children and young adults. When sudden cardiac death occurs in the absence of ischemic heart disease, a genetic cardiac condition may be suspected and clinical and genetic screening of family members is recommended. The Genetic Arrhythmia Center at the Minneapolis Heart Institute collaborates with local partners in the Sudden Cardiac Arrest network to connect patients and their family members with interdisciplinary care for diagnosis and treatment of these conditions. The most common conditions seen in the Genetic Arrhythmia Center include arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction, long QT syndrome, and Brugada syndrome. In addition to providing clinical care and genetic testing and counseling services, the Genetic Arrhythmia Center is working to advance the scientific understanding of the clinical presentation and natural history of these rare conditions.

Systemic Thrombolytic Therapy for Stroke After Transcaval Transcatheter Aortic Valve Replacement

An 80-year-old male with aortic stenosis underwent transcatheter aortic valve replacement through a transcaval approach. The aorta was closed with an Amplatzer device without retroperitoneal leak or fistula. The patient developed a stroke three hours after the procedure and was treated with tissue plasminogen activator. Imaging after thrombolytic therapy revealed no aortic extravasation from the puncture site. To our knowledge, this demonstrates the first case in which thrombolytic therapy was used after transcaval access to the abdominal aorta for transcatheter aortic valve replacement and suggests that patients without leak after transcaval aortic closure, thrombolytic therapy is not contraindicated.

Key Considerations For Integrating Sacubitril/Valsartan Into Chronic Heart Failure Management

Heart failure with reduced ejection fraction remains a prevalent clinical syndrome associated with significant morbidity and mortality. Despite significant advances in heart failure with reduced ejection fraction pharmacotherapy, 5-year mortality remains 50%. Sacubitril/valsartan is a first-in-class angiotensin-receptor-neprilysin inhibitor, Food and Drug Administration–approved to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure with reduced ejection fraction. Sacubitril/valsartan is recognized as a significant therapeutic advancement and endorsed by national guidelines, yet adoption into clinical practice has lagged across the United States. Recommendations for use differ greatly between the Prospective Comparison of Angiotensin-Receptor-Neprilysin Inhibitor with Angiotensin-Converting-Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure clinical trial, international guidelines, and the Food and Drug Administration-approved labeling, which can lead to uncertainty with prescribing. It is essential to establish an evidence-based, pragmatic approach to patient selection and management of sacubitril-valsartan facilitate integration into clinical practice. This review summarizes the pharmacology of sacubitril/valsartan, its known benefits and risks, and important considerations for incorporating sacubitril/valsartan into chronic heart failure management.

Influence of Epidemiologic and Clinical Trends on Risk Stratification and Net Clinical Benefit of Long-term Oral Anticoagulation for Nonvalvular Atrial Fibrillation

The prevalence of atrial fibrillation without rheumatic valvular disease, nonvalvular atrial fibrillation (NVAF), increases with age and independently predicts future stroke and systemic embolism. Randomized controlled trials of long-term oral anticoagulation for NVAF since the 1980s report a 67% risk reduction in stroke and systemic embolism. Data from these trials are used in risk calculators to predict stroke and bleeding; clinicians use these calculators to determine individualized net clinical benefit of oral anticoagulation. Over the past three decades, NVAF stroke rates have declined independent of oral anticoagulation. Newer asymptomatic (subclinical) NVAF populations are being identified, and clinical practice has changed with increasingly older patients (with higher fall and bleeding risk) receiving oral anticoagulation. These trends suggest contemporary patients with NVAF may derive a lower net benefit from oral anticoagulation compared with those in the original randomized controlled trial. Methods that evaluate for and continuously monitor net clinical benefit of oral anticoagulation for contemporary NVAF are necessary.

Improving Value Through Heart Failure Care Coordination: The Allina Health Experience

Reducing readmission following heart failure is emerging as a target of quality initiatives in the Centers for Medicare & Medicaid Services Hospital Readmission Reduction Program. In response to higher readmission rates than desired following heart failure (HF) hospitalization, Allina Health hospital's cardiovascular subspecialty care developed an HF nurse care coordinator program to reduce readmissions. The nurse HF care coordinator serves as the bridge to help manage care following hospital discharge and ensure adherence to protocols developed by the HF management program. This effort was initially developed and implemented at Mercy and Unity Hospital and was associated with a 4.3% reduction in HF readmissions. Subsequent expansion of the HF nurse care coordinator program to United and Abbott Northwestern Hospitals was associated similar reductions in HF readmissions. Concurrently, all-cause mortality at 6 months post-discharge was also significantly lower following implementation of the program (mortality pre-HF care coordinator program 12.6% vs. post-HF care coordinator program 18.8%, P = .047) in propensity matched analysis. The findings of this effort suggest the potential for care coordination programs to improve the care and outcomes of patients with HF.

Rationale and Design of an Evidence Based Tool to Guide Preoperative Evaluation and Management

In the United States, over testing and over treatment are recognized as the cause of both excess cost and patient harm. Healthcare value (defined as “health outcomes achieved relative to the costs of care”) has become a focus to improve the quality and affordability of healthcare. Perioperative evaluation and management of the surgical patient represents a clear opportunity to improve healthcare value. Herein, we describe the rationale for and the development of a standardized clinical decision support tool that has been distributed to over 600 clinicians performing preoperative evaluations. All patients undergoing this evaluation will be tracked, with the intent to publish both healthcare cost and safety outcomes. The use of a perioperative decision support tool is a unique approach to value in healthcare.