Dr Rahul P. Sharma, MBBS, FRACP is the Director of Structural Interventions at Stanford Healthcare and Clinical Assistant Professor of Medicine at Stanford University.
Dr Sharma graduated from Monash University and completed his medicine and cardiology training at the Alfred Hospital in Melbourne, Australia. He completed an advanced interventional and structural fellowship at Cedars Sinai Medical Center in Los Angeles, California in 2015 before joining Cedars Sinai as Clinical Faculty, Director of the Structural Imaging Core Laboratory and Associate Director of Interventional Cardiology Research until 2019, before joining Stanford Healthcare.
Dr Sharma is an Interventional Cardiologist with specialized clinical and research interests in structural heart disease, particularly transcatheter valve therapy. He has a large volume of expertise in transcatheter aortic, mitral and tricuspid replacement, percutaneous mitral valve repair, left atrial appendage occlusion, PFO/ASD/VSD closure, alcohol septal ablation and cerebral protection. He also has expertise in CT imaging for structural heart disease. He is a clinical investigator in ongoing national multi-center research studies and clinical trials and has co-authored numerous peer reviewed, scientific articles and book chapters. Dr Sharma also serves as a national and international clinical proctor for transcatheter aortic and mitral valve implantation and percutaneous mitral valve repair and speaks regularly at major national and international cardiology meetings.
- Cardiovascular Disease
- Coronary Artery Disease
- Coronary Artery Stenosis
- Percutaneous Coronary Intervention
- Aortic Valve Stenosis
- Aortic Valve Insufficiency
- Mitral Valve Insufficiency
- Mitral Valve Prolapse
- Mitral Valve Stenosis
- Tricuspid Valve
- Tricuspid Valve Insufficiency
- Tricuspid Valve Stenosis
- Atrial Septal Defect
- Ventricular Septal Defect
- Atrial Appendage
- Cardiomyopathy, Hypertrophic
- Transcatheter aortic valve replacement
- Transcatheter mitral valve replacement
- Tricuspid clip
- Transcatheter tricuspid valve replacement
- Alcohol septal ablation
- Left atrial appendage closure
- PFO closure
- ASD/VSD closure
- Paravalvular leak closure
Clinical Assistant Professor, Medicine - Cardiovascular Medicine
Interventional Cardiologist, Stanford Health Care (2019 - Present)
Clinical Assistant Professor, Stanford University (2019 - Present)
Director of Structural Interventions, Stanford Healthcare (2019 - Present)
Interventional Cardiologist, Cedars-Sinai Medical Center (2017 - 2019)
Research Scientist II, Department of Medicine, Cedars Sinai Medical Center (2016 - 2017)
Affiliate Member, Cardiac Society of Australia and New Zealand (2014 - Present)
Fellow, Royal Australasian College of Physicians (2012 - Present)
Representative, Royal Australasian College of Physicians Victorian and Tasmanian Training Committee, Australia (2011 - 2016)
Founder and President, Association of Victorian Cardiology Advanced Trainees, Australia (2011 - 2014)
Honors & Awards
Excellence in Teaching Award 2017-2018, Cedars Sinai Medical Center (2018)
Recipient of Academic Scholarship for Masters in Health Delivery Sciences, - (2018)
Winner – “Medtech’s Got Talent” Innovation Award, - (2014)
Finalist – Royal Australian College of Physicians Research Prize, - (2012)
Winner – Alfred Health Senior Medical Staff Research Scholarship, - (2012)
Winner – Alfred Health Teacher of the Year Award, - (2012)
Winner – Anglican Church Grammar School Old Boy’s Association Scholarship, - (2012)
Finalist – Alfred Health Research Prize, - (2011)
No. 1 ranked candidate overall for entrance to Cardiology Fellowship, - (2011)
Winner – Alfred Health Teacher of the Year Award, - (2011)
Winner – Monash University Medical Students Teaching Award, - (2011)
Winner – Victoria Cardiology Registrar’s Research Prize, Cardiac Society of Australia and New Zealand (2011)
Winner – Alfred Health Teaching Supervisors Award, - (2010)
Winner – Novartis research travel scholarship, - (2009)
Winner – Baker IDI research travel scholarship, - (2007)
Finalist – Australian and New Zealand Society for Geriatric Medicine Prize, - (2006)
Finalist – Prince Henry’s Institute Surgical Prize, - (2006)
Winner – Monash University overseas elective scholarship, - (2006)
Boards, Advisory Committees, Professional Organizations
Fellow, Cardiac Society of Australia and New Zealand (2014 - Present)
Fellow, Royal Australian College of Physicians (2014 - Present)
Board Certification: Royal Australasian College of Physicians - Australia, Cardiology (2013)
Fellowship, Cedars Sinai Medical Center, Interventional and Structural Cardiology, Los Angeles, CA (2015)
Fellowship, Alfred Hospital, Cardiology Advanced Physician Training, Melbourne, Australia (2014)
Fellowship, Monash Medical Center, Melbourne, Australia (2014)
Fellowship, Royal Australasian College of Surgeons, Alfred Health, Melbourne, Australia (2013)
Residency, Alfred Hospital, General Medicine, Melbourne, Australia (2011)
Internship, Alfred Hospital, Melbourne, Australia (2011)
MBBS, Monash University, Bachelor of Medicine, Bachelor of Surgery, Melbourne, Australia (2006)
Current Research and Scholarly Interests
Transcatheter valve therapies, CT valve imaging, AI and device innovation
ACURATE IDE: Safety and Efficacy Study of Acurate Valve for Transcatheter Aortic Valve Replacement
To evaluate safety and effectiveness of the ACURATE Transfemoral Aortic Valve System for transcatheter aortic valve replacement (TAVR) in subjects with severe native aortic stenosis who are indicated for TAVR.
Clinical Trial to Evaluate the Safety and Effectiveness of Using the Tendyne Mitral Valve System for the Treatment of Symptomatic Mitral Regurgitation
Prospective, controlled, multicenter clinical investigation with three trial cohorts: Randomized, Non-Randomized, and Mitral Annular Calcification (MAC). Subjects in the Randomized cohort will be randomized in a 1:1 ratio to the trial device or to the MitraClip system. Subjects in the Non-Randomized and MAC cohorts will receive the trial device. The objective of the Clinical Trial to Evaluate the Safety and Effectiveness of Using the Tendyne Mitral Valve System for the Treatment of Symptomatic Mitral Regurgitation (SUMMIT) is to evaluate the safety and effectiveness of the Tendyne Mitral Valve System for the treatment of patients with symptomatic, moderate-to-severe or severe mitral regurgitation or for patients with symptomatic mitral valve disease due to severe mitral annular calcification. This randomized controlled trial will provide the opportunity to evaluate the safety and clinical benefits of the Tendyne Mitral Valve System compared to the MitraClip System in patients with symptomatic, moderate-to-severe or severe mitral regurgitation, within approved MitraClip indications. In addition, the safety and effectiveness of the Tendyne Mitral Valve System will be evaluated in patients with severe mitral annular calcification who are at prohibitive risk for mitral valve surgery. Patients who are not suitable for mitral valve surgery for reasons other than severe mitral annular calcification and are also not suitable for transcatheter repair with MitraClip, will be enrolled in the Non-randomized cohort. Subjects will be seen at screening, pre- and post-procedure, discharge, 30 days, 3 months, 6 months, and annually through 5 years.
Edwards PASCAL CLASP IID/IIF Pivotal Clinical Trial
To establish the safety and effectiveness of the Edwards PASCAL Transcatheter Valve Repair System in patients with degenerative mitral regurgitation (DMR) who have been determined to be at prohibitive risk for mitral valve surgery by the Heart Team, and in patients with functional mitral regurgitation (FMR) on guideline directed medical therapy (GDMT)
PARTNER 3 Trial: Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis
To establish the safety and effectiveness of the Edwards SAPIEN 3 Transcatheter Heart Valve in patients with severe, calcific aortic stenosis who are at low operative risk for standard aortic valve replacement (AVR).
Transcatheter Mitral Valve Replacement With the Medtronic Intrepid™ TMVR System in Patients With Severe Symptomatic Mitral Regurgitation
Multi-center, global, prospective, non-randomized, interventional, pre-market trial. All subjects enrolled with receive the study device.
Edwards PASCAL Transcatheter Valve Repair System Pivotal Clinical Trial
To establish the safety and effectiveness of the Edwards PASCAL Transcatheter Repair System in patients with symptomatic severe tricuspid regurgitation who have been determined to be at an intermediate or greater estimated risk of mortality with tricuspid valve surgery by the cardiac surgeon with concurrence by the local Heart Team
Stanford is currently not accepting patients for this trial.
Comparison of Valve Performance of the Intra-Annular Self-Expanding Portico (TM) Transcatheter Aortic Valve With Contemporary Supra-Annular Self-Expanding and Intra-Annular Balloon-Expandable Valves: Insights From the PORTICO IDE Trial
ELSEVIER SCIENCE INC. 2020: S46
View details for Web of Science ID 000513916500116
Timing and Outcomes of Percutaneous Coronary Intervention in Patients Who Underwent Transcatheter Aortic Valve Implantation.
The American journal of cardiology
Limited data exist regarding the timing of percutaneous coronary intervention (PCI) in patients with coronary artery disease who underwent transcatheter aortic valve implantation (TAVI). We aimed to investigate clinical outcomes of patients who underwent TAVI and planned PCI according to the timing of PCI in relation to the TAVI. Consecutive patients with severe aortic stenosis who underwent TAVI with planned PCI between January 2013 and November 2017 were included. Patients were divided according to the timing of PCI. The primary end point was major adverse cardiac and cerebrovascular events, defined as a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke. Among 1,756 patients who underwent TAVI, 258 patients underwent planned PCI either before TAVI (n = 143, 55.4%), concomitantly with TAVI (n = 77, 29.8%), or after TAVI (n = 38, 14.7%). All patients in the post-TAVI PCI group were treated using balloon-expandable valves, and neither hemodynamic instability during TAVI nor PCI-related complications were observed. In a multivariable analysis, the timing of PCI was not associated with 2-year major adverse cardiac and cerebrovascular events rate (concomitant vs pre-TAVI, hazard ratio [HR]: 0.92; 95% confidence interval [CI]: 0.52 to 1.66; p = 0.79; post- vs pre-TAVI, HR: 0.45; 95% CI: 0.18 to 1.16; p = 0.10). In conclusion, there were no significant differences in terms of mid-term outcomes among pre-TAVI, concomitant, and post-TAVI PCI groups when the timing of PCI was carefully selected by heart team.
View details for DOI 10.1016/j.amjcard.2020.01.043
View details for PubMedID 32106928
Variation in the Timing of Percutaneous Coronary Intervention and Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement
ELSEVIER SCIENCE INC. 2019: B670
View details for Web of Science ID 000487306300671
- Patching residual leaks following a MitraClip procedure EUROINTERVENTION 2019; 15 (6): E482–E483
Computed tomography characteristics of the aortic valve and the geometry of SAPIEN 3 transcatheter heart valve in patients with bicuspid aortic valve disease
EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING
2018; 19 (12): 1408–18
We assessed the geometry of transcatheter heart valve (THV) and valve function associated with SAPIEN 3 implantation in patients with bicuspid aortic valve (BAV) stenosis.We included 280 consecutive patients who had a contrast computed tomography (CT) before and after transcatheter aortic valve implantation (TAVI) in our institution. Each THV was assessed by CT at five cross-sectional levels: inflow, annulus, mid, sinus, and outflow. The geometry of THV was assessed for eccentricity (1 - minimum diameter/maximum diameter) and expansion (CT derived external valve area/nominal external valve area). CT measurements and transthoracic echocardiogram data were compared between BAV and tricuspid aortic valve (TAV). Among 280 patients, 41 patients were diagnosed as BAV. Compared to TAV, BAV was associated with lower expansion at mid-level, sinus-level, and outflow-level (mid 94.1 ± 6.8% vs. 98.1 ± 7.8%; P = 0.002, sinus 95.9 ± 7.2% vs. 101.6 ± 8.5%; P < 0.001, outflow 107.6 ± 6.2% vs. 109.9 ± 6.6%; P = 0.043), and higher eccentricity at all levels [inflow 3.5% (1.9-5.3) vs. 6.0% (3.2-7.5); P < 0.001, annulus 3.1% (1.6-5.2) vs. 5.4% (3.1-7.8); P = 0.002, mid 3.0% (1.4-4.9) vs. 6.0% (3.3-10.4); P < 0.001, sinus 3.0% (1.7-5.1) vs. 7.6% (4.0-11.4); P < 0.001, and outflow 2.5% (1.3-4.3) vs. 4.9% (2.2-7.5); P < 0.001]. There were no differences in frequency of paravalvular leak ≥ moderate and mean post-procedural gradient between BAV and TAV.BAV patients have greater THV eccentricity at all levels and lower THV expansion at mid, sinus, and outflow levels than the TAV patients. There were no differences in parameters of valve function between BAV and TAV patients. Despite the observed geometrical differences, TAVI with SAPIEN 3 in BAV patients allows for feasible valve function.
View details for DOI 10.1093/ehjci/jex333
View details for Web of Science ID 000455360200016
View details for PubMedID 29315371
Transcatheter aortic valve replacement in bicuspid aortic valve stenosis: where do we stand?
JOURNAL OF CARDIOVASCULAR SURGERY
2018; 59 (3): 381–91
Bicuspid aortic valve is the most common congenital cardiac defect in adults, and symptom typically develops in adulthood. In the majority of cases, bicuspid aortic valve disease progress with ages and surgical aortic valve replacement is performed with excellent operative outcomes. However, with the relatively slow progression of disease, surgical aortic valve replacement is required in elderly patients but the surgical risk often deemed extremely high due to old age and multiple comorbidities. Transcatheter aortic valve replacement (TAVR) has evolved from a novel technology to an established therapy for intermediate- and high-risk patients with symptomatic severe aortic valve stenosis (AS). Numerous studies have demonstrated the safety and efficacy of TAVR, and more than 250,000 patients have been treated with this technology. Although randomized trials have established TAVR as the standard treatment, these trials excluded congenital bicuspid AS due to its unique morphological features. Nevertheless, the growing experience, accumulated knowledge, and advancements of new technology lead to the expand use of TAVR to other pathologies or other populations such as bicuspid AS. With integration of imaging multimodalities (computed tomography and echocardiography), the diagnosis and classification of bicuspid aortic valve has been changing. Due to unfavorable anatomic features of bicuspid AS, the outcomes of TAVR in bicuspid AS was suboptimal, particularly when using the first-generation transcatheter valves. However, the newer-generation transcatheter valves significantly improved the outcomes of TAVR in bicuspid AS. Nonetheless, several issues still remain to be resolved. Given longer life expectancy in patients with bicuspid AS undergoing TAVR, durability of transcatheter valves is concerned. In addition, patients with bicuspid aortic valves often have concomitant dilatation of proximal part of ascending aorta (aortopathy), but limited data exist about the clinical prognosis of bicuspid aortic valve with concomitant aortopathy in elderly patients. Considering the expanding indication of TAVR to lower surgical risk and younger population, these issues should be evaluated in future studies.
View details for DOI 10.23736/S0021-9509.18.10350-8
View details for Web of Science ID 000445207000014
View details for PubMedID 29332374
- Recurrent severe aortic stenosis after transfemoral transcatheter valve-in-valve-in-valve replacement JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 155 (5): E141–E144
Too little, too much or just right? Goldilocks revisited….
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
2018; 91 (5): 840–41
This study highlights the low rates of UCA in OHCA patients in a real-world setting Presentation with ST elevation, shockable rhythm and history of CAD were more likely to result in UCA for OHCA patients Further studies are required to help create a systematic and standardized approach to UCA in OHCA patients.
View details for DOI 10.1002/ccd.27613
View details for PubMedID 29634858
- Response by Sharma et al to Letter Regarding Article, "The Fluid Mechanics of Transcatheter Heart Valve Leaflet Thrombosis in the Neosinus". Circulation 2018; 137 (19): 2094–95
Relation Between Left Ventricular Outflow Tract Calcium and Mortality Following Transcatheter Aortic Valve Implantation
AMERICAN JOURNAL OF CARDIOLOGY
2017; 120 (11): 2017–24
Left ventricular outflow tract (LVOT) calcium is known to be associated with adverse procedural outcomes after transcatheter aortic valve implantation (TAVI), yet its effect on midterm outcomes has not been previously investigated. The aim of this study was to determine the influence of LVOT calcium on 2-year mortality after TAVI. A total of 537 consecutive patients underwent TAVI and 2 groups were established, stratified based on the severity of the LVOT calcium. The primary outcome was 2-year overall survival rate. The ≥moderate LVOT calcium group included 107 patients (19.9%) and the remaining 430 patients (80.1%) were included in the ≤mild LVOT calcium group. After a median follow-up of 717 days (interquartile range 484 to 828), the Kaplan-Meier analysis revealed that the 2-year overall survival probability was significantly lower in the ≥moderate LVOT calcium group than in the ≤mild LVOT calcium group (log-rank p = 0.001). On a Cox hazard model, ≥moderate LVOT calcium was associated with increased all-cause mortality after TAVI (hazard ratio 1.74, p = 0.009). In the subgroup analysis, based on valve designs, SAPIEN 3-TAVI done in the setting of ≥moderate LVOT calcium had a relatively similar survival probability as those of ≤mild LVOT calcium (log-rank p = 0.18), which is in contrast with older generation valves (log-rank p = 0.001). In conclusion, patients with ≥moderate LVOT calcium were shown to have a lower survival probability in the midterm follow-up after TAVI, compared with those with ≤mild LVOT calcium. Patients with high-grade LVOT calcium should be monitored with longer-term follow-ups after TAVI.
View details for DOI 10.1016/j.amjcard.2017.08.018
View details for Web of Science ID 000417889000018
View details for PubMedID 28941599
The Fluid Mechanics of Transcatheter Heart Valve Leaflet Thrombosis in the Neosinus
2017; 136 (17): 1598-+
Transcatheter heart valve (THV) thrombosis has been increasingly reported. In these studies, thrombus quantification has been based on a 2-dimensional assessment of a 3-dimensional phenomenon.Postprocedural, 4-dimensional, volume-rendered CT data of patients with CoreValve, Evolut R, and SAPIEN 3 transcatheter aortic valve replacement enrolled in the RESOLVE study (Assessment of Transcatheter and Surgical Aortic Bioprosthetic Valve Dysfunction With Multimodality Imaging and Its Treatment with Anticoagulation) were included in this analysis. Patients on anticoagulation were excluded. SAPIEN 3 and CoreValve/Evolut R patients with and without hypoattenuated leaflet thickening were included to study differences between groups. Patients were classified as having THV thrombosis if there was any evidence of hypoattenuated leaflet thickening. Anatomic and THV deployment geometries were analyzed, and thrombus volumes were computed through manual 3-dimensional reconstruction. We aimed to identify and evaluate risk factors that contribute to THV thrombosis through the combination of retrospective clinical data analysis and in vitro imaging in the space between the native and THV leaflets (neosinus).SAPIEN 3 valves with leaflet thrombosis were on average 10% further expanded (by diameter) than those without (95.5±5.2% versus 85.4±3.9%; P<0.001). However, this relationship was not evident with the CoreValve/Evolut R. In CoreValve/Evolut Rs with thrombosis, the thrombus volume increased linearly with implant depth (R2=0.7, P<0.001). This finding was not seen in the SAPIEN 3. The in vitro analysis showed that a supraannular THV deployment resulted in a nearly 7-fold decrease in stagnation zone size (velocities <0.1 m/s) when compared with an intraannular deployment. In addition, the in vitro model indicated that the size of the stagnation zone increased as cardiac output decreased.Although transcatheter aortic valve replacement thrombosis is a multifactorial process involving foreign materials, patient-specific blood chemistry, and complex flow patterns, our study indicates that deployed THV geometry may have implications on the occurrence of thrombosis. In addition, a supraannular neosinus may reduce thrombosis risk because of reduced flow stasis. Although additional prospective studies are needed to further develop strategies for minimizing thrombus burden, these results may help identify patients at higher thrombosis risk and aid in the development of next-generation devices with reduced thrombosis risk.
View details for DOI 10.1161/CIRCULATIONAHA.117.029479
View details for Web of Science ID 000413496200006
View details for PubMedID 28724752
Effect of ascending aortic dimension on acute procedural success following self-expanding transcatheter aortic valve replacement A multicenter retrospective analysis
INTERNATIONAL JOURNAL OF CARDIOLOGY
2017; 244: 100–105
Self-expanding (SE) valves are characterized with long stent frame design and the radial force of the device exists both in the inflow and outflow level. Therefore, we hypothesized that device success of SE-valves may be influenced by ascending aortic dimensions (AAD). The aim of this study was to determine the influence of AAD on acute device success rates following SE transcatheter aortic valve replacement (TAVR).In 4 centers in the United States and Asia, 214 consecutive patients underwent SE-TAVR. Outcomes were assessed in line with Valve Academic Research Consortium criteria. AAD was defined as the sum of the short and long axis aortic diameter divided by 2. Overall, device success rate was 85.0%. Multivariate analysis revealed that increased AAD (Odds ratio 1.27) and % oversizing (Odds ratio 0.88) were found to be independent predictors of unsuccessful device implantation. The c-statistic of the model for device success was area under the curve 0.79, sensitivity 81.3% and specificity 44.0%. Co-existence of several risk factors was associated with an exponential fall to 64.2% in device success rate. For a large AAD, however, optimally oversized SE-valves (threshold 16.2%) resulted with high device success rates compared to suboptimal oversizing (88.6% vs. 64.2%, p=0.005).Larger AAD and smaller degrees of oversizing were confirmed to be the most relevant predictors of unsuccessful device implantation following SE-valve implantations. Optimal oversizing of great significance was noted, particularly that with a large AAD.
View details for DOI 10.1016/j.ijcard.2017.05.120
View details for Web of Science ID 000406943600018
View details for PubMedID 28622944
Clinical outcomes and prognostic factors of transcatheter aortic valve implantation in bicuspid aortic valve patients
ANNALS OF CARDIOTHORACIC SURGERY
2017; 6 (5): 463–72
The purpose of this study was to evaluate the outcomes of transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve stenosis (AS).From April 2012 and December 2016, 108 patients with bicuspid AS underwent TAVR using the Sapien XT (34 patients) and Sapien 3 (74 patients) valves. Procedural and clinical outcomes were assessed according to VARC-2 criteria and compared between the two devices.In the overall cohort, the majority of patients were male (71.3%) with an intermediate surgical risk and a mean Society of Thoracic Surgeons (STS) score of 5.2%. Compared to the Sapien XT group, the Sapien 3 group had a significantly lower STS score (3.3%±2.0% vs. 6.7%±3.6%; P=0.001). Compared to the Sapien XT group, the Sapien 3 group had a significantly lower rate of moderate or severe paravalvular leak (2.7% vs. 14.7%; P=0.03) and higher device success (97.3% vs. 82.4%; P=0.006). There were no significant differences between the two groups in terms of 30-day all-cause mortality, stroke, life-threatening bleeding, major vascular complication and acute kidney injury (stage 2 or 3). Cumulative all-cause mortality at 1-year follow-up was 6.9%. There were no significant differences in cumulative event rates for all-cause mortality at 1-year follow-up between the two groups (9.4% vs. 4.6%; log-rank P=0.47). By univariate analysis, major vascular complication was significantly associated with overall all-cause mortality [hazard ratios (HR): 7.57; 95% confidence interval (CI): 1.51-37.86; P=0.014].TAVR using the balloon-expandable valves provided acceptable procedural and clinical outcomes in patients with bicuspid AS. The new-generation Sapien 3 valves showed improved procedural outcomes compared to the early-generation Sapien XT valves.
View details for DOI 10.21037/acs.2017.09.03
View details for Web of Science ID 000418471200006
View details for PubMedID 29062741
View details for PubMedCentralID PMC5639233
Advanced Imaging of Intracranial Atherosclerosis: Lessons from Interventional Cardiology
FRONTIERS IN NEUROLOGY
2017; 8: 387
Intracranial atherosclerosis is a major cause of ischemic stroke. Patients with a high degree of stenosis have a significant rate of stroke despite medical therapy. Two randomized trials of stenting have failed to show benefit. Improving periprocedural complication rates and patient selection may improve stenting outcomes. Fractional flow reserve (FFR), intravascular ultrasound (IVUS), and optical coherence tomography (OCT) are intravascular imaging techniques employed to improve patient selection and stent placement in interventional cardiology. FFR has been shown to improve cardiovascular outcomes when used in patient selection for intervention. Studies of FFR in intracranial atherosclerosis show that the measure may predict which plaques lead to stroke. IVUS is used in cardiology to quantify stenosis and assist with stent placement. Comparisons with histology show that it can reliably characterize plaques. Several case reports of IVUS in intracranial arteries show the technique to be feasible and indicate it may improve stent placement. Plaque characteristics on IVUS may help identify vulnerable plaques. In interventional cardiology, OCT provides excellent visualization of vessel geometry and is useful periprocedurally. Images reliably identify thin-capped fibroatheromas and other plaque features. Case reports indicate that OCT is safe for use in intracranial arteries. OCT can be used to identify perforator vessels and so may be useful in avoiding perforator strokes, a common complication of stenting. Plaque characteristics on OCT may be useful in patient selection.
View details for DOI 10.3389/fneur.2017.00387
View details for Web of Science ID 000407590300001
View details for PubMedID 28855886
View details for PubMedCentralID PMC5557768
Outcomes in Transcatheter Aortic Valve Replacement for Bicuspid Versus Tricuspid Aortic Valve Stenosis
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2017; 69 (21): 2579–89
Transcatheter aortic valve replacement (TAVR) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS).This study sought to compare the procedural and clinical outcomes in patients with bicuspid versus tricuspid AS from the Bicuspid AS TAVR multicenter registry.Outcomes of 561 patients with bicuspid AS and 4,546 patients with tricuspid AS were compared after propensity score matching, assembling 546 pairs of patients with similar baseline characteristics. Procedural and clinical outcomes were recorded according to Valve Academic Research Consortium-2 criteria.Compared with patients with tricuspid AS, patients with bicuspid AS had more frequent conversion to surgery (2.0% vs. 0.2%; p = 0.006) and a significantly lower device success rate (85.3% vs. 91.4%; p = 0.002). Early-generation devices were implanted in 320 patients with bicuspid and 321 patients with tricuspid AS, whereas new-generation devices were implanted in 226 and 225 patients with bicuspid and tricuspid AS, respectively. Within the group receiving early-generation devices, bicuspid AS had more frequent aortic root injury (4.5% vs. 0.0%; p = 0.015) when receiving the balloon-expanding device, and moderate-to-severe paravalvular leak (19.4% vs. 10.5%; p = 0.02) when receiving the self-expanding device. Among patients with new-generation devices, however, procedural results were comparable across different prostheses. The cumulative all-cause mortality rates at 2 years were comparable between bicuspid and tricuspid AS (17.2% vs. 19.4%; p = 0.28).Compared with tricuspid AS, TAVR in bicuspid AS was associated with a similar prognosis, but lower device success rate. Procedural differences were observed in patients treated with the early-generation devices, whereas no differences were observed with the new-generation devices.
View details for DOI 10.1016/j.jacc.2017.03.017
View details for Web of Science ID 000401695900001
View details for PubMedID 28330793
Optimal sizing for SAPIEN 3 transcatheter aortic valve replacement in patients with or without left ventricular outflow tract calcification
2017; 12 (18): E2177–E2185
The impact of left ventricular outflow tract calcification (LVOT-CA) on SAPIEN 3 transcatheter aortic valve replacement (S3-TAVR) is not well understood. The aims of the present study were to determine optimal device sizing for S3-TAVR in patients with or without LVOT-CA and to evaluate the influence of residual paravalvular leak (PVL) on survival after S3-TAVR in these patients.This study analysed 280 patients (LVOT-CA=144, no LVOT-CA=136) undergoing S3-TAVR. Optimal annular area sizing was defined as % annular area sizing related to lower rates of ≥mild PVL. Annular area sizing was determined as follows: (prosthesis area/CT annulus area-1)×100. Overall, ≥mild PVL was present in 25.7%. Receiver operating characteristic curve analysis for prediction of ≥mild PVL in patients with LVOT-CA showed that 7.2% annular area sizing was identified as the optimal threshold (area under the curve [AUC] 0.71). Conversely, annular area sizing for no LVOT-CA appeared unrelated to PVL (AUC 0.58). Aortic annular injury was seen in four patients (average 15.5% annular area oversizing), three of whom had LVOT-CA. Although there was no difference in one-year survival between patients with ≥mild PVL and without PVL (log-rank p=0.91), subgroup analysis demonstrated that patients with ≥moderate LVOT-CA who had ≥mild PVL had lower survival compared to patients with ≥mild PVL and none or mild LVOT-CA (log-rank p=0.010).In the setting of LVOT-CA, an optimally sized S3 valve is required to reduce PVL and to increase survival following TAVR.
View details for Web of Science ID 000400782100005
View details for PubMedID 28117281
Transcatheter Mitral Valve Replacement for Degenerated Bioprosthetic Valves and Failed Annuloplasty Rings.
Journal of the American College of Cardiology
2017; 70 (9): 1121–31
Limited data exist regarding transcatheter mitral valve replacement (TMVR) for patients with failed mitral valve replacement and repair.This study sought to evaluate the outcomes of TMVR in patients with failed mitral bioprosthetic valves (valve-in-valve [ViV]) and annuloplasty rings (valve-in-ring [ViR]).From the TMVR multicenter registry, procedural and clinical outcomes of mitral ViV and ViR were compared according to Mitral Valve Academic Research Consortium criteria.A total of 248 patients with mean Society of Thoracic Surgeons score of 8.9 ± 6.8% underwent TMVR. Transseptal access and the balloon-expandable valve were used in 33.1% and 89.9%, respectively. Compared with 176 patients undergoing ViV, 72 patients undergoing ViR had lower left ventricular ejection fraction (45.6 ± 17.4% vs. 55.3 ± 11.1%; p < 0.001). Overall technical and device success rates were acceptable, at 92.3% and 85.5%, respectively. However, compared with the ViV group, the ViR group had lower technical success (83.3% vs. 96.0%; p = 0.001) due to more frequent second valve implantation (11.1% vs. 2.8%; p = 0.008), and lower device success (76.4% vs. 89.2%; p = 0.009) due to more frequent reintervention (16.7% vs. 7.4%; p = 0.03). Mean mitral valve gradients were similar between groups (6.4 ± 2.3 mm Hg vs. 5.8 ± 2.7 mm Hg; p = 0.17), whereas the ViR group had more frequent post-procedural mitral regurgitation moderate or higher (19.4% vs. 6.8%; p = 0.003). Furthermore, the ViR group had more frequent life-threatening bleeding (8.3% vs. 2.3%; p = 0.03), acute kidney injury (11.1% vs. 4.0%; p = 0.03), and subsequent lower procedural success (58.3% vs. 79.5%; p = 0.001). The 1-year all-cause mortality rate was significantly higher in the ViR group compared with the ViV group (28.7% vs. 12.6%; log-rank test, p = 0.01). On multivariable analysis, failed annuloplasty ring was independently associated with all-cause mortality (hazard ratio: 2.70; 95% confidence interval: 1.34 to 5.43; p = 0.005).The TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral ViR was associated with higher rates of procedural complications and mid-term mortality compared with mitral ViV.
View details for PubMedID 28838360
Impact of Body Mass Index on the Outcomes Following Transcatheter Aortic Valve Implantation
CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS
2016; 88 (1): 127–34
To investigate the influence of body mass index (BMI) on short- and midterm outcomes following transcatheter aortic valve implantation (TAVI).Although obesity is a major risk factor for cardiovascular mortality, numerous studies reported a beneficial effect of obesity on survival in patients with cardiovascular disease and in patients after cardiac interventions. Moreover, all previous reports examining the relation between BMI and outcomes following TAVI have underscored the "obesity paradox" in these patients.During a 3 year period, 805 patients with severe aortic stenosis that underwent TAVI at our institute were evaluated. Based on baseline BMI, patients were classified as normal weight (18.5-24.9 kg/m(2) ), overweight (25.0-29.9 kg/m(2) ), or obese (≥30 kg/m(2) ). TAVI endpoints, device success, and adverse events were considered according to the Valve Academic Research Consortium (VARC)-2 definitions.Obese patients were significantly younger, had higher prevalence of diabetes mellitus and chronic lung disease, and had lower prevalence of frailty. Device success was similar between the 3 groups. All-cause mortality up to 30 days was 2.9% (10/340) vs 4.5% (12/268) vs 0.5% (1/186) in patients with normal weight, overweight, and obesity, respectively (p = 0.048). In a multivariable model, overweight and obese patients had similar overall mortality compared to patients with normal weight.We found no evidence for the existence of an obesity paradox following TAVI. Correction for possible confounders such as frailty in the present cohort may explain the discrepancy between the current report and the previous reports that suggested a protective effect for increased BMI following TAVI. © 2016 Wiley Periodicals, Inc.
View details for DOI 10.1002/ccd.26394
View details for Web of Science ID 000379984000028
View details for PubMedID 26756702
Outcomes in Patients With Transcatheter Aortic Valve Replacement and Left Main Stenting The TAVR- LM Registry
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2016; 67 (8): 951–60
A percutaneous approach with transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI) of the left main coronary artery (LM) is frequently used in high-risk patients with coexisting aortic stenosis and LM disease. Outcomes of TAVR plus LM PCI have not been previously reported.The primary objective of the TAVR-LM registry is to evaluate clinical outcomes in patients undergoing TAVR plus LM PCI.Clinical, echocardiographic, computed tomographic, and angiographic characteristics were retrospectively collected in 204 patients undergoing TAVR plus LM PCI. In total, 128 matched patient pairs were generated by performing 1:1 case-control matching between 167 patients with pre-existing LM stents undergoing TAVR and 1,188 control patients undergoing TAVR without LM revascularization.One-year mortality (9.4% vs. 10.2%, p = 0.83) was similar between the TAVR plus LM PCI cohort and matched controls. One-year mortality after TAVR plus LM PCI was not different in patients with unprotected compared with protected LMs (7.8% vs. 8.1%, p = 0.88), those undergoing LM PCI within 3 months compared with those with LM PCI greater than 3 months before TAVR (7.4% vs. 8.6%, p = 0.61), and those with ostial versus nonostial LM stents (10.3% vs. 15.6%, p = 0.20). Unplanned LM PCI performed because of TAVR-related coronary complication, compared with planned LM PCI performed for pre-existing LM disease, resulted in increased 30-day (15.8% vs. 3.4%, p = 0.013) and 1-year (21.1% vs. 8.0%, p = 0.071) mortality.Despite the anatomic proximity of the aortic annulus to the LM, TAVR plus LM PCI is safe and technically feasible, with short- and intermediate-term clinical outcomes comparable with those in patients undergoing TAVR alone. These results suggest that TAVR plus LM PCI is a reasonable option for patients who are at high risk for surgery.
View details for DOI 10.1016/j.jacc.2015.10.103
View details for Web of Science ID 000370490000009
View details for PubMedID 26916485
View details for PubMedCentralID PMC5091082
Controversies in Out of Hospital Cardiac Arrest?
Interventional cardiology clinics
2016; 5 (4): 551–59
Cardiac arrest is a major cause of morbidity and mortality and accounts for nearly 500,000 deaths annually in the United States. In patients suffering out-of-hospital cardiac arrest, survival is less than 15%, with considerable regional variation. Although most deaths occur during the initial resuscitation, an increasing proportion occur in patients hospitalized after initially successful resuscitation. In these patients, the significant subsequent morbidity and mortality is due to "post cardiac arrest syndrome." Until recently, most single interventions have yielded little improvement in rates of survival; however, there is growing recognition that optimal treatment strategies during the postresuscitation phase may improve outcomes.
View details for DOI 10.1016/j.iccl.2016.06.011
View details for PubMedID 28582003
Impact of Preprocedural B-Type Natriuretic Peptide Levels on the Outcomes After Transcatheter Aortic Valve Implantation
AMERICAN JOURNAL OF CARDIOLOGY
2015; 116 (12): 1904–9
There are limited data on the effect of baseline B-type natriuretic peptide (BNP) on the outcome after transcatheter aortic valve implantation (TAVI). We investigated the influence of baseline BNP levels on the short-term and midterm clinical outcomes after TAVI. During a 3-year period, 780 patients with severe aortic stenosis underwent TAVI at our institute and had baseline BNP levels. We compared the high, mid, and low tertiles of BNP levels. TAVI end points, device success, and adverse events were considered according to the Valve Academic Research Consortium 2 definitions. Device success was significantly lower for patients with high BNP (98.1% vs 96.2% vs 91.9% for the low, mid, and high BNP tertiles, respectively; p = 0.003). All-cause mortality up to 30 days was 1.2% (3 of 260) versus 2.3% (6 of 260) versus 5% (13 of 260), respectively (p = 0.03). Six-month mortality rate was 4.1% (10 of 241) for the low BNP tertile, 5% (12 of 239) for the mid BNP tertile, and 17.1% (40 of 234) for the high BNP tertile (p <0.001). In the multivariate model, high tertile of baseline BNP was found to be significantly associated with all-cause mortality (hazard ratio 3.3, 95% confidence interval 1.64 to 6.48; p = 0.001). In conclusion, elevated BNP levels are associated with increased short-term and midterm mortality after TAVI. We recommend measurement of baseline BNP as part of risk stratification models for TAVI.
View details for DOI 10.1016/j.amjcard.2015.09.031
View details for Web of Science ID 000366786500019
View details for PubMedID 26602075
- Unmasking of familial long QT syndrome type 2 with crystal methamphetamine exposure HEART RHYTHM 2014; 11 (10): 1836–38
Randomized double-blind placebo-controlled crossover study to determine the effects of esomeprazole on inhibition of platelet function by clopidogrel
JOURNAL OF THROMBOSIS AND HAEMOSTASIS
2011; 9 (8): 1582–89
Pharmacokinetic studies suggest that clopidogrel and esomeprazole are metabolized by similar hepatic enzymes; however, previous studies have not identified a biochemical interaction.To determine whether addition of esomeprazole to patients receiving aspirin and clopidogrel reduces the antiplatelet effects of clopidogrel.Patients with a history of an acute coronary syndrome who had previously received clopidogrel were recruited. Subjects were commenced on clopidogrel and randomized to one of two treatment arms (esomeprazole or placebo) for 6 weeks. Following a 2-week washout period for study medications, patients were crossed over onto the alternative treatment arm for a further 6 weeks. Platelet function tests were undertaken at baseline, following the first treatment period, after washout and following the second treatment period.Thirty-one patients were enrolled. Significant attenuation of clopidogrel's antiplatelet effects was seen with co-administration of esomeprazole compared with placebo. Vasodilator stimulated phosphoprotein (VASP), platelet aggregometry (area under the curve (AUC)) and VerifyNow results were 54.7% ± 2.8 platelet reactivity index (PRI), 66.3 ± 2.6 AUC units and 213.1 ± 14.1 platelet reactivity units (PRU) with esomeprazole vs. 47% ± 2.7 PRI, 59.7 ± 3.7 AUC units and 181.4 ± 14.6 PRU with placebo (P < 0.01 esomeprazole vs. placebo for all measures). There was no significant difference in platelet aggregometry (maximal aggregation) between the esomeprazole group (68.9% ± 2.7 units) and placebo-treated group (64.5% ± 4.1 units; P > 0.05).Esomeprazole when co-administered with aspirin and clopidogrel results in a significant attenuation of clopidogrel's antiplatelet effects.
View details for DOI 10.1111/j.1538-7836.2011.04414.x
View details for Web of Science ID 000293791400019
View details for PubMedID 21696537