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Cardiovascular Disease from Challenges to Clearer Pathways

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Cardiovascular Disease from Challenges to Clearer Pathways Supplement to VOLUME 87 | SUPPLEMENT 1 | MAY 2020 | www.ccjm.org Cardiovascular Disease From challenges to clearer pathways Supplement Editor Maan A. Fares, MD VOLUME 87 | SUPPLEMENT 1 | MAY 2020 | www.ccjm.org Cardiovascular Disease From challenges to clearer pathways Supplement Editor Maan A. Fares, MD Heart, Vascular, and Thoracic Institute Cleveland Clinic Table of Contents From the editor 4 Functional tricuspid regurgitation: Feasibility of transcatheter interventions Despite advances in percutaneous interventions Vinayak Nagaraja, MD; Divyanshu Mohananey, MD; for many valve diseases, treatments for the Jose Navia, MD; Serge C. Harb, MD; Rhonda Miyasaka, MD; tricuspid valve remain elusive. In this Cleveland Amar Krishnaswamy, MD; and Samir Kapadia, MD Clinic Journal of Medicine supplement, Samir Kapadia, MD, and colleagues describe innova- 15 A practical approach to the cholesterol tions in percutaneous techniques that may guidelines and ASCVD prevention overcome the challenges associated with tricuspid Leslie Cho, MD valve repair. Many cardiologists and primary care physicians 21 New treatments for peripheral artery disease struggle to keep current with the constantly John Bartholomew, MD, and G. Jay Bishop, MD changing practice guidelines for the prevention of atherosclerotic cardiovascular disease. Cutting through the complexity of the latest guidelines, Leslie Cho, MD, manages to clarify them in a way that is easy to understand and implement in practice. Finally, John R. Bartholomew, MD, reviews the latest treatment guidelines for peripheral artery disease (PAD), a common, potentially morbid vascular disease. PAD is often asymptomatic and often overlooked. A simple diagnostic test and treatment is warranted to reduce the risk of Cleveland Clinic Topics and editors for supplements to the adverse cardiovascular events and limb events Journal of Medicine are determined by the Journal’s editor- in-chief and staff. Supplement editors are chosen for their associated with PAD. expertise in the topics discussed and are responsible for We hope this Cleveland Clinic Journal of Medicine the scientifi c quality of supplements, including the review cardiovascular supplement is useful to you in your process. The Journal ensures that supplement editors and authors fully disclose any relationships with industry, includ- clinical practice. ing the supplement underwriter. Maan A. Fares, MD Cleveland Clinic Journal of Medicine [ISSN 0891-1150 (print), ISSN 1939-2869 (online)] and organizations. Individual subscriptions must be in the names of, billed to, and paid by is published monthly by Cleveland Clinic. individuals. DISCLAIMER: Statements expressed in this supplement to the Cleveland Clinic Journal of SUBSCRIPTIONS, EDITORIAL, BILLING, AND PRODUCTION: Medicine are those of the authors and not necessarily of Cleveland Clinic or its Board of Cleveland Clinic Journal of Medicine, 1950 Richmond Road, TR4-04, Lyndhurst, OH 44124 Trustees. Phone (216) 444-2661 • Fax (216) 444-9385 • E-mail [email protected] • www.ccjm.org SUBSCRIPTIONS: U.S. and possessions: personal $155; institutional $183; single copy/ © 2020 THE CLEVELAND CLINIC FOUNDATION. ALL RIGHTS RESERVED. PRINTED IN U.S.A. back issue $20. Foreign: $200; single copy/back issue $20. Institutional (multiple-reader rate) applies to libraries, schools, hospitals, and federal, commercial, and private institutions CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 87 • NUMBER 5 • SUPPLEMENT 1 MAY 2020 3 Vinayak Nagaraja, MD Divyanshu Mohananey, MD Jose Navia, MD Serge C. Harb, MD Department of Cardiovascular Medicine, Division of Cardiovascular Medicine, Departments of Thoracic and Cardiovascular Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Medical College of Wisconsin Surgery, and Biomedical Engineering, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Cleveland Clinic Florida - Weston Cleveland Clinic Rhonda Miyasaka, MD Amar Krishnaswamy, MD Samir Kapadia, MD Department of Cardiovascular Medicine, Department of Cardiovascular Medicine, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Heart, Vascular, and Thoracic Institute, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Cleveland Clinic Cleveland Clinic Functional tricuspid regurgitation: Feasibility of transcatheter interventions ■ ABSTRACT cardial biopsy-related trauma, and intra-annular Functional tricuspid regurgitation (TR) develops secondary right ventricular (RV) pacemaker or implantable to annular dilation and leafl et tethering as a result of right cardiac defi brillator leads may result in more signifi - ventricular remodeling. Invasive surgery for isolated TR is cant primary TR. However, it is important to note rarely performed due to high inpatient mortality. Transcath- that close to 80% of TR cases are “functional” rather eter tricuspid valve intervention is an appealing solution than primary. but is challenging as crucial structures are closely related Functional TR occurs secondary to annular dila- to the tricuspid valve, and intracardiac devices pose further tion and leafl et tethering as a result of RV remodel- 1 challenges to device delivery and implantation. ing from either volume or pressure overload. The prevalence of functional TR in the United States ■ KEY POINTS is 1.6 million.2–4 Such RV remodeling and resulting TR frequently occur as a complication of left-sided Preprocedural multimodality imaging is essential to identify valvular disease, with mitral valve disease being the the appropriate device and to ensure procedural success. most common culprit. Severe TR is associated with poor prognosis independent of age and biventricular Transcatheter tricuspid valve devices can be classifi ed function.5 Early studies in the 1960s suggested that based on the mechanism of action. treatment of left-sided valvular pathology (particu- larly mitral) may reverse pulmonary hypertension To date, the MitraClip in the tricuspid position (TriClip) and therefore TR. However, more contemporary lit- is the most utilized device for tricuspid valve repair. erature reveals that this process is gradual and often Modifi cations to the TriClip and Pascal device may unpredictable.6 improve applicability and outcomes. Currently, surgical techniques are the mainstay of treatment for progressive or severe functional TR. Transcatheter tricuspid valve interventions appear to be However, with the advent and success of transcath- associated with improvement in patient quality of life. ■ INTRODUCTION Primary tricuspid regurgitation (TR) occurs as a result of an anatomically abnormal tricuspid valve. Trace or mild TR is common even in anatomically normal- looking valves and has no pathological implications. Anterior leafl et Posterior Certain etiologies such as rheumatic heart disease, leafl et prolapse, congenital disease (Ebstein anomaly), Septal leafl et infective endocarditis, blunt wall trauma, endomyo- All authors reported no fi nancial interests or relationships that pose a potential Figure 1. Schematic representation of the anatomy of the tricuspid confl ict of interest with this article. annulus. The arrows represent annular dilation resulting in an increased doi:10.3949/ccjm.87.s1.01 anteroposterior diameter in functional tricuspid regurgitation. 4 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 87 • NUMBER 5 • SUPPLEMENT 1 MAY 2020 NAGARAJA AND COLLEAGUES eter techniques for severe aortic ste- nosis and mitral regurgitation, there is newfound interest in creating safe and effective methods for minimally inva- sive management of functional TR. Q ANATOMY, PATHOPHYSIOLOGY Located between the right atrium and the RV, the tricuspid valve is slightly more apical than the mitral valve and consists of an annulus, leafl ets, papil- lary muscles, and chordae tendinae (Figure 1).7 (A–C) (D–F) The tricuspid valve is oriented at a Figure 2. Transthoracic echocardiography (TTE) views and transesophageal echocardiography (TEE) views of the tricuspid valve (TV). (A) TTE 4-chamber view: The septal 45-degree angle to the sagittal plane leafl et is shown in red. The other leafl et (orange) could be the anterior leafl et (if probe is an- facing anterolaterally and inferiorly gled anteriorly and the aortic valve is brought into view, ie, 5-chamber view) or the posterior toward the left side. The annulus of leafl et (if probe is angled posteriorly and coronary sinus brought into view). (B) TTE RV infl ow the tricuspid valve is a nonplanar view: The anterior leafl et is shown in blue. The other leafl et (in green) could be the posterior (C) structure with a distinct bimodal or leafl et or the septal leafl et. TTE 3D focused on the tricuspid valve. Three orthogonal planes centered on the TV are cross-referenced (inlets on the left), allowing easier identifi cation of saddle-shaped pattern having 2 high the different leafl ets. (D) TEE 4-chamber view: As in the TTE 4-chamber view, the septal leafl et points (oriented superiorly toward the (in red) is identifi ed, and the other leafl et (orange) could be either the anterior or posterior. right atrium) and 2 low points (ori- (E) TEE RV infl ow view: The posterior leafl et is shown in purple, the other leafl et (in grey) could ented inferiorly toward the RV). The be either the anterior or septal leafl et. (F) TEE 3D focused on the tricuspid valve. As in the 3D tricuspid annular area on 3-dimen- TTE, 3 orthogonal planes are cross-referenced. The different leafl ets are easier to identify. sional (3D) echocardiography has been estimated as 9.72 ± 2.08 cm2 in normal
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