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Introduction: Data on comparative outcomes between valve in valve transcatheter mitral valve replacement (ViV-TMVR) versus redo-surgical mitral valve replacement (SMVR) for degenerated bioprosthetic valves remain limited. Hypothesis: ViV TMVR is associated with lower in-hospital mortality and complication rates compared with redo SMVR. Methods: The MEDLINE (PubMed, Ovid) and Cochrane databases were queried with various combinations of medical subject headings (MeSH) to identify relevant articles. Eight studies evaluating comparative outcomes (ViV TMVR vs Redo SMVR) for patients with degenerated bioprosthetic valves were included in the analysis. Results: A total of 5,161 patients with degenerated prosthetic mitral valves underwent ViV TMVR (n = 1163) and redo SMVR (n = 3998) were included in the study. The mean age of patients was 76 versus 66 years for ViV TMVR versus the redo SMVR group, respectively (p<0.01). In terms of comorbidities, female gender (55% vs 53.4%), serum creatinine (1.52 vs 1.3), dialysis (6.4% vs 6.6% ), LVEF (55.56+/-9.5 vs 57.35+/-8.7), diabetes (20.2% vs 19.5%), hypertension (73.5% vs 63.4%), atrial fibrillation (64.5% vs 69% ), and mitral regurgitation (82.4% vs 80.5%) were similar between the ViV TMVR and redo SMVR groups respectively. Using a pooled analysis, in-hospital mortality, and major bleeding were significantly lower for patients undergoing ViV TMVR compared with redo SMVR. No significant difference was observed in the incidence of stroke. The length of stay was significantly lower in the ViV TMVR group compared with the redo SMVR group. Conclusions: ViV TMVR is associated with lower in-hospital mortality, complications, and length of hospital stay compared with redo SMVR for degenerated bioprosthetic valves.

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Introduction: Up to 20% of angiograms reveal no coronary artery disease (CAD). Repeat studies are often done for chest pain, dyspnea, or reduction in ejection fraction (EF), but little is known about the diagnostic yield of this practice. Methods: Retrospective cohort of patients with no or minimal CAD on their first angiography (<30% stenosis) and a repeat angiography in the last 5 years were included in the study. Results: There were 17 patients with no CAD and 26 patients with mild CAD on initial angiography, with 58 incidences of repeat angiography over an average follow-up of 5.4 years. The average time between procedures was 3.07 ± 1.83 years. Of these, 13 (30.2%) patients had demonstratable progression of CAD, and 8 (18.6%) patients ultimately required PCI. Findings on initial angiogram were associated with CAD progression (p=0.01) but not with intervention requirement (p=0.18), with the odds of new CAD in those with normal coronaries on first angiogram 0.07 (95% C.I. 0.008-0.634, p=0.005). Neither a low EF (<50%) (n=21) nor a drop in EF by >10% (n=17) was associated with CAD progression or PCI. The 8 patients that required PCI presented with STEMI (n=3), NSTEMI (n=3), and unstable angina (n=2). Only one patient with normal coronaries on initial angiography required PCI, after presenting with a STEMI 4 years later and found to have distal LAD thrombotic occlusion with otherwise no coronary atherosclerosis. Conclusions: Repeat angiography had a low yield in our patient population. A drop in EF by >10% was not associated with new findings on repeat angiography or revascularization. Larger studies are needed to investigate if a drop in EF requires invasive testing.

Background: Infectious endocarditis (IE) usually presents with variable imaging findings and is associated with high morbidity and mortality. Transesophageal echocardiography (TEE) is the gold standard method for diagnosing IE. However, the presence of prosthetic or calcified valves poses a diagnostic challenge for detection of IE and associated structural abnormalities. In recent years, there is growing literature supporting cardiac CT scan as an adjunct to TEE in such cases. Studies have also shown that cardiac CT has significantly high sensitivity for detecting peri-annular complications. Case A 79 year old male who underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis one year ago presented with a one week history of worsening confusion and fatigue. His prior medical history includes non-ischemic cardiomyopathy with low ejection fraction (30-35%), deep vein thrombosis (DVT) and pulmonary embolism (PE). Labs were notable for leucocytosis 27,300/uL and thrombocytopenia with platelet count 20,000/uL. Patient was bacteremic with blood cultures growing oxacillin-resistant Staphylococcus epidermidis. TEE revealed a small vegetation concerning for infection versus thrombus. A CT abdomen revealed a 3.8 cm splenic infarct. Tagged WBC scan was thereafter considered to help delineate, but came back negative. Decision Making In setting of thrombocytopenia, repeat TEE was deemed unsafe. Alternatively, the patient underwent cardiac CTA which revealed hypoattenuating leaflet thickening (HALT) involving >75% of aortic valve leaflets (Figure 1) with no perivalvular leak or abscess thereby confirming IE. Conclusion Cardiac CT offers distinct advantages and has emerged as a great adjunct to echocardiography for the workup of IE, especially in patients who have contraindications to TEE or with prosthetic valves where echocardiography is sub-optimal. The report further elucidates the role of cardiac CT as an imaging adjunct for IE.