Circulation: Clinical Summaries
Original Research Put Into Perspective for the Practicing Clinician
- Characteristics and Outcomes of Patients With Severe Bioprosthetic Aortic Valve Stenosis Undergoing Redo Surgical Aortic Valve Replacement
- Robotic Mitral Valve Repair for Simple and Complex Degenerative Disease: Midterm Clinical and Echocardiographic Quality Outcomes
- 9p21.3 Coronary Artery Disease Risk Variants Disrupt TEAD Transcription Factor–Dependent Transforming Growth Factor β Regulation of p16 Expression in Human Aortic Smooth Muscle Cells
- Ideal Cardiovascular Health During Adult Life and Cardiovascular Structure and Function Among the Elderly
- Association of Fruit and Vegetable Consumption During Early Adulthood With the Prevalence of Coronary Artery Calcium After 20 Years of Follow-Up: The Coronary Artery Risk Development in Young Adults (CARDIA) Study
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Characteristics and Outcomes of Patients With Severe Bioprosthetic Aortic Valve Stenosis Undergoing Redo Surgical Aortic Valve Replacement
The current study of 276 patients demonstrates that redo surgical aortic valve replacement (AVR) for bioprosthetic aortic stenosis (PAS) is associated with excellent 30-day and longer-term outcomes at an experienced center. Society of Thoracic Surgeons (STS) score, traditionally used to predict short-term perioperative outcomes, can potentially provide incremental utility in predicting longer-term outcomes. Patients with severe PAS should be closely monitored for occurrence of symptoms or changes in their functional class level, and redo AVR should ideally be planned in an elective manner at the onset of early symptoms. The low annualized event rate after redo surgical AVR could also potentially aid in the choice of prosthetic valve in patients undergoing primary AVR. Although implantation of bioprosthetic valves is generally the preferred approach to avoid the need for long-term anticoagulation, they come at the expense of faster prosthetic deterioration and a higher need for reoperation. However, the safety of reoperation can further support the use of bioprosthetic valves, even in potentially younger patients who prefer to avoid warfarin because of lifestyle issues. Additionally, with increasing sophistication of transcatheter AVR techniques, including valve-in-valve procedures, the burden of morbidity from redo AVR is likely to further decrease in the future. The results of this study may help identify patients who should be considered for future valve-in-valve transcatheter procedures. See p 1953.
Robotic Mitral Valve Repair for Simple and Complex Degenerative Disease: Midterm Clinical and Echocardiographic Quality Outcomes
Although the repair of simple single-scallop mitral valve disease is addressed via an open chest approach at many centers around the world with known results, the midterm quality outcomes of minimally invasive repair, particularly for more complex disease are unknown. We studied the midterm clinical and echocardiographic outcomes of 487 patients undergoing robotic repair of degenerative mitral valve disease in accordance with class IIa American College of Cardiology/American Heart Association Guideline recommendations, with follow-up that was 98% complete. The results reflect a 100% repair rate with 0.2% early mortality and 0.8% stroke risks, translating into excellent 5-year survival and very low likelihoods of MR recurrence or reoperation. The complexity of technical repair did not appear to influence MR recurrence or mitral valve reoperation risks. Together, these results support for the first time that a minimally invasive approach is capable of meeting quality mandates set forth in expert consensus statements detailing recommended management of stage C1 patients undergoing early correction of severe degenerative MR. See p 1961.
9p21.3 Coronary Artery Disease Risk Variants Disrupt TEAD Transcription Factor–Dependent Transforming Growth Factor β Regulation of p16 Expression in Human Aortic Smooth Muscle Cells
Seventy-five percent of the world population, except for those of black African descent, carries at least 1 copy of genetic variants of the 9p21.3 locus that increase the risk for coronary atherosclerosis and abdominal aortic aneurysm. Here, we show that certain risk alleles disrupt binding of TEAD transcription factors and cause loss of transforming growth factor β–dependent activation of the cell cycle suppressor p16 in smooth muscle cells. Reduced p16 leading to increased cellular proliferation may account for the elevated risk for atherosclerosis and abdominal aneurysm associated with the 9p21.3 risk alleles. Conversely, individuals who carry the nonrisk alleles of 9p21.3 may benefit from emerging cancer therapies that activate TEAD factors to inhibit cellular proliferation and thereby limit atherosclerosis progression and aneurysm. See p 1969.
Ideal Cardiovascular Health During Adult Life and Cardiovascular Structure and Function Among the Elderly
Modifiable risk factors over the life course are powerful contributors to the population burden of cardiovascular disease. Seven of these factors have been identified as metrics of ideal cardiovascular health and integrated into the American Heart Association’s Cardiovascular Health Score. They include nonsmoking, body mass index <25 kg/m2, physical activity, ideal diet, untreated total cholesterol <200 mg/dL, untreated blood pressure <120/<80 mm Hg, and fasting blood glucose <100 mg/dL. Their attainment is associated with a lower risk of incident cardiovascular (CV) disease, including heart failure. However, few data exist on impact of attaining – and of changes in attaining – these metrics through midlife and late life on CV structure and function in the elderly. Among 6520 elderly community-dwelling persons with serial assessment of 6 of these metrics at 5 times in the previous 25 years (ideal diet not serially assessed), the attainment of ideal CV health typically declines with age. We demonstrate that greater cumulative health indicator attainment is associated with lower prevalence of CV disease, and better CV structure and function among those without prevalent CV disease, when elderly. Similarly, improvement in health indicator attainment over time is associated with less prevalent CV disease, and better measures of CV structure and function among those free of prevalent CV disease. These findings highlight the importance of consistent primordial and primary prevention efforts throughout midlife to late life as a potential intervention to decrease the burden of CV disease, and heart failure, in particular, among the elderly. See p 1979.
Association of Fruit and Vegetable Consumption During Early Adulthood With the Prevalence of Coronary Artery Calcium After 20 Years of Follow-Up: The Coronary Artery Risk Development in Young Adults (CARDIA) Study
A healthy diet is an essential component in the prevention of cardiovascular disease. A dietary pattern high in fruits and vegetables has been associated with reduced rates of cardiovascular disease outcomes in multiple observation cohorts of middle-aged and older adults. However, the cardiovascular impact of fruit and vegetable intake in younger adults is less clear. To evaluate this relationship, we studied 2506 young adults in the Coronary Artery Risk Development in Young Adults (CARDIA) study to determine the association between fruit and vegetable intake during young adulthood and subsequent development of coronary artery calcium 20 years later. After adjusting for age, sex, and lifestyle variables, including smoking and physical activity, we found an inverse relationship between fruit and vegetable and subsequent coronary artery calcium across tertiles of fruit and vegetable intake (P<0.001). Individuals in the top third of fruit and vegetable intake at baseline had 26% lower odds of developing calcified plaque 20 years later. This inverse linear relationship remained significant after adjusting for fruit and vegetable intake at year 20 as well as after adjustment for other dietary variables such as dairy, nuts, fish, salt, and refined grains. Our results reinforce the importance of establishing a healthy dietary pattern early in adulthood, and provide further credence for public health initiatives aimed at increasing F/V intake in adolescents and young adults. See p 1990.
The Contemporary Safety and Effectiveness of Lower Extremity Bypass Surgery and Peripheral Endovascular Interventions in the Treatment of Symptomatic Peripheral Arterial Disease
Treatment for symptomatic peripheral artery disease includes lower extremity bypass surgery (LEB) or peripheral vascular interventions (PVI). Given the paucity of randomized controlled trials in this area, there are limited data on the safety and effectiveness of LEB and PVI to help clinicians and patients decide on either therapy. In a large integrated healthcare system, we studied 975 patients undergoing LEB and 883 patients undergoing PVI for lower extremity claudication or chronic limb ischemia. The average patient was 70 years of age, and half of the patients were treated for claudication. The rates of target lesion revascularization were greater for PVI than for LEB in patients presenting with claudication and chronic limb ischemia; however, LEB was associated with an increased rate of complications up to 30 days following the procedure. There were no differences in amputation rates between the 2 groups. Therefore, although PVI is associated with fewer complications, rates of repeat revascularization are higher. Weighing the risks and benefits of each procedure will hopefully help clinicians and their patients decide on treatment. Future studies should focus on randomized comparisons and risk models that refine the risk/benefit ratio for each patient. See p 1999.
- © 2015 American Heart Association, Inc.
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