Incidence and predictors of atrial fibrillation after aortic repairs

The incidence of atrial fibrillation and the clinical predictors for its development were studied in 153 patients who underwent thoracic and abdominal aortic repair.

Pathophysiology, Diagnosis, and Management of Coronary No-Reflow Phenomenon

Coronary no-reflow phenomenon is a lethal mechanism of ongoing myocardial injury, following successful revascularization of an infarct-related coronary artery. Incidence of this phenomenon is high following percutaneous intervention, and is associated with adverse in-hospital and long-term outcomes. Several mechanisms such as ischemia-reperfusion injury and distal microthromboembolism in genetically susceptible patients and those with preexisting endothelial dysfunction have been implicated. However, the exact mechanism in humans is still poorly understood. Several investigative and treatment strategies within and outside the cardiac catheterization laboratory have been proposed, but have not uniformly shown success in reducing mortality or in preventing adverse left ventricular remodeling resulting from this condition. The aim of this article is to provide a brief and concise review of the current understanding of the pathophysiology, clinical predictors, and investigations and management of coronary no-reflow phenomenon.

Echocardiographic evaluation of patent foramen ovale and atrial septal defect

Patent foramen ovale (PFO) is a common variant present in up to 25% of the population. Atrial septal defect (ASD) is a direct communication between the 2 atrial chambers, of which the ostium secundum variety is the most common. This manuscript is an in depth review of the complex atrial septation, the diagnosis of PFO and ASD and its clinical and therapeutic implications.

Echocardiographic evaluation of tetralogy of Fallot

Tetralogy of Fallot (TOF) is a cyanotic heart disease consisting of nonrestrictive ventricular septal defect, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. Early total correction is the treatment of choice and these patients with repaired TOF are increasingly seen in adult practice. This review addresses echocardiographic evaluation of TOF, corrected TOF, its sequelae and various complications. A working knowledge of TOF assessment is essential for all adult cardiologists and sonographers.

Usefulness of Statins for Prevention of Venous Thromboembolism

Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, is common with an annual incidence of 1 to 5 per 1,000, resulting in major morbidity, mortality, and increased health care costs. It is more common in the elderly, obese, those with cancer, those undergoing surgery, and those with previous VTE. Strategy to reduce its occurrence has important public health implications. Pleotropic effects of statins may have beneficial effects on a number of potential targets associated with VTE. Statins have excellent safety profile and seem to be associated with beneficial effects in VTE in case-control studies, large observational studies, meta-analyses, and a randomized trial. In conclusion, after critically reviewing the clinical data supporting statin use in the prevention of VTE, we presented clinical recommendations for the use of statins in reducing VTE occurrence, especially in high-risk situations.

Factors affecting regression of mitral regurgitation following isolated coronary artery bypass surgery

OBJECTIVE

Fate of MR following CABG is variable. Predictors of MR regression following CABG alone are not known.

METHODS

From our surgical registry, CABG patients with both pre-operative and post-operative resting echocardiograms at our institution were screened. Of the 523 patients identified, 92 had 3+ (n = 65) or 4+ (n = 27) MR on the pre-operative echocardiogram on a 0-4 scale, who had isolated CABG. MR regression was correlated with clinical, operative, electrocardiographic and echocardiographic variables.

PATIENT CHARACTERISTICS

age 68+/-11 years, 62% male, and LVEF 37+/-15%. MR grade decreased from 3.3+/-0.5 to 2.3+/-1.2 post-CABG. Residual 3 or 4+ MR post-CABG was present in 43 (47%) patients. Regression of MR (n=49) was associated with reductions in LV end-diastolic (P = 0.006) and end-systolic (P = 0.0005) dimensions, improvement in LVEF (P = 0.01), longer cross-clamp time (P = 0.04), use of beta-blockers (P = 0.04) and lower presence of CVA as a possible marker of lower atherosclerotic burden (P = 0.03). There was a trend towards increased mortality (P = 0.3) with residual 3-4+ MR over a mean follow-up of 3.9 years.

CONCLUSIONS

In nearly half of patients with 3-4+ MR, MR does not regress with CABG alone. Residual MR may be associated with increased mortality. Regression of MR is related to LV size reduction and improvement in LV function. Presence of myocardial viability, adequate revascularization, lack of excessive atherosclerotic burden and therapy with beta-blockers and ace-inhibitors may be critical for MR regression following CABG alone.

Prosthetic valve thrombosis presenting as an acute embolic myocardial infarction in a pregnant patient: issues on anticoagulation regimens and thrombolytic therapy

Mechanical valves are inherently thrombogenic and require meticulous anticoagulation. Pregnancy produces a hypercoagulable state and achieving adequate anticoagulation is difficult. We present a pregnant patient who had a nonobstructive thrombus of mechanical mitral valve causing embolic acute myocardial infarction. Issues surrounding management of anticoagulation and use of thrombolytic therapy during pregnancy are discussed. Education regarding the critical nature of adequate anticoagulation in these patients is important.

A case of mitral-aortic intervalvular fibrosa aneurysm with unique flow patterns and long-term natural survival

We report a patient with a large aneurysm of mitral-aortic intervalvular fibrosa as a complication of prosthetic aortic valve endocarditis diagnosed on transthoracic echocardiography. This aneurysm began to expand with atrial systole, filled fully during ventricular systole, and collapsed in diastole on transesophageal examination. The patient refused corrective surgery and has survived on medical treatment for close to 2 years.

Dobutamine stress echocardiography for the diagnosis and management of coronary artery disease

Infusion of dobutamine in low and high doses in combination with echocardiography can be used for the assessment of myocardial viability and functional significance of coronary artery disease. Improvement of contractile function of hypokinetic or akinetic ventricular wall segment with low-dose dobutamine has a high predictive value for the detection of hibernating and stunned myocardium. High-dose dobutamine stress is of value for noninvasive diagnosis of coronary disease, assessment of its clinical significance, risk stratification of patients after myocardial infarction, preoperative evaluation of patients undergoing major noncardiac surgery, and assessment of the efficacy of coronary revascularization. It has an excellent safety record even in the immediate postmyocardial infarction period.

Clinical and echocardiographic correlates of mitral E-wave transmission inside the left ventricle: potential insights into left ventricular diastolic function

The mitral inflow wave is initially directed to the left ventricular apex and then turns around facing the left ventricular outflow tract. The E and A waves are transmitted to the left ventricular outflow tract where they are registered as Er and Ar waves, respectively. We hypothesized that the E-wave transit time to the left ventricular outflow tract recorded as the E-Er interval may depend on left ventricular early diastolic performance such as relaxation. This hypothesis was tested in clinical settings known to have abnormal left ventricular relaxation. Mitral E and left ventricular outflow tract Er waves were recorded with pulsed wave Doppler technique in 63 subjects: 25 healthy subjects, 18 patients with secondary left ventricular hypertrophy, and 20 patients with hypertrophic cardiomyopathy. The E-Er interval was measured from the onset of E wave to the onset of Er wave timed to the R wave of the electrocardiogram. The E-Er interval ranged from 45 to 300 msec: 96 +/- 28 msec in the controls, 127 +/- 46 msec in patients with left ventricular hypertrophy (p = 0.0091 versus controls), and 179 +/- 57 msec in patients with hypertrophic cardiomyopathy (p < 0.0001 versus controls). It correlated with left ventricular free wall thickness (r = 0.42, p = 0.0006), thickness of the ventricular septum (r = 0.43, p = 0.0004), left ventricular end-diastolic diameter (r = -0.38, p = 0.0022), left ventricular end-systolic diameter (r = -0.55, p < 0.0001), left ventricular isovolumic relaxation time (r = 0.39, p = 0.0063), RR interval (r = 0.28, p = 0.045), mitral E/A velocity ratio (r = -0.33, p = 0.010), and E-wave deceleration time (r = 0.38, p < 0.0044) but not with age. Multivariate analysis with all the previously mentioned variables and the group the patient belonged to as the dichotomous variable showed that the grouping variable was the sole independent determinant of the E-Er interval (multiple r = 0.74). The E-Er interval is an easily measurable Doppler parameter which is increased in left ventricular hypertrophy and hypertrophic cardiomyopathy. It is related to left ventricular wall thickness, left ventricular isovolumic relaxation time, mitral E/A velocity ratio, and E-wave deceleration time and may provide useful insight into left ventricular early diastolic performance-possibly the relaxation process.

Reduced survival in patients with "coronary microvascular disease"

The syndrome of chest pain, abnormal stress test, and nonflow limiting coronary artery disease (CAD) is common and is attributed to coronary microvascular disease (µVD). It is associated with increased hospital admissions and health care costs. But its impact on long-term survival is not known. Of the 9941 consecutive patients who had an exercise stress test for evaluation of chest pain between May 1991 and July 2007, 935 had both a positive stress test and a coronary angiogram within 1 year of their stress test forming the study cohort. Significant angiographic CAD defined as ≥70% stenosis of an epicardial coronary artery or ≥50% stenosis of the left main coronary artery was present in 324 patients. Rest (n = 611) were considered to have coronary µVD. Compared with patients with significant epicardial CAD, patients with coronary µVD were younger (63 ± 11 vs. 65 ± 10 years, p = 0.002), and had lower left ventricular wall thickness (p < 0.02), systolic blood pressure (BP; p = 0.002), pulse pressure (0.0008), systolic BP with exercise (p = 0.0001), and pulse pressure with exercise (p < 0.0001). Those with coronary µVD had a better survival compared with those with significant epicardial CAD, but worse than that expected for age- and gender-matched population (p < 0.0001). Coronary µVD as a cause of chest pain and positive stress test is common. All-cause mortality in patients with coronary µVD is worse than in an age- and gender-matched population control, but better than those with significant epicardial CAD.

Echocardiographic characterization of a rare type of coronary artery fistula draining into superior vena cava

We describe an incidental finding of a rare type of anomalous coronary artery originating from the right coronary sinus of Valsalva and draining into the superior vena cava. This was suspected on transthoracic echocardiography but was further clarified with the use of coronary angiography and transesophageal echocardiography. Echocardiography was a major tool for delineating the origin of the fistula, its complicated course, and the drainage site.

Cardiovascular medications and risk of cancer

Cardiovascular disease and cancer are 2 of the leading causes of death globally. Certain cardiovascular medications have been linked to an increased risk for cancer. Although individual reviews of specific classes of cardiovascular medications have been published previously, a more complete review of several classes has not been performed. The aim of this review is to evaluate the associations of various cardiovascular agents with the risk for developing cancer and provide guidance for clinicians. A comprehensive search of published research was conducted using MEDLINE from 1994 to 2011. Three trials demonstrated an increased risk for cancer using angiotensin II receptor blockers. Additionally, risk for cancer was shown in a number of trials that included the use of angiotensin II receptor blockers in combination with angiotensin-converting enzyme inhibitors. Five trials suggested that diuretics increased the risk for specific cancers, especially in women and those who had been using diuretics for >4 years. Statins and ezetimibe, in contrast, did not show this increased risk. Prasugrel was shown to be associated with an increased risk for cancer in 1 study. It appears that the use of certain cardiovascular medications is associated with an increased risk for cancer. In conclusion, clinicians need to balance the risks and benefits of the use of these agents and provide the appropriate therapy on an individual basis.

The impact of cognitive impairment in patients with acute coronary syndrome undergoing percutaneous revascularization: a systematic review and meta-analysis

BACKGROUND

Cognitive impairment has been known to be associated with negative health impacts. Several studies recently demonstrated inconsistent outcomes among cognitive impaired patients with acute coronary syndrome (ACS). Our study aimed to determine the impact of cognitive impairment for patients with ACS.

METHODS

Databases were searched through October 2020. Studies reporting revascularization rates, short- and long-term mortality among ACS patients with cognitive impairment were included. Effect estimates from the individual studies were extracted and combined using random effect and generic inverse variance method of DerSimonian and Laird.

RESULTS

In total, 11 observational studies were included in the analysis consisting of 810 122 ACS patients, with 3.5% cognitive impairment patients. Our analysis suggested that cognitive impairment was associated with a lower rate of percutaneous coronary intervention (PCI) [odds ratio (OR), 0.63; 95% confidence interval (CI), 0.42-0.96; I2 = 98.5%; P = 0.033]. Among patients undergoing PCI, cognitive impairment was statistically associated with increased 30-day mortality (OR, 1.34; 95% CI, 1.14-1.57; I2 = 83.1%; P < 0.001) and long-term mortality (OR, 1.80; 95% CI, 1.04-3.11; I2 = 36.3%; P = 0.034).

CONCLUSION

Our study demonstrated that cognitive impairment was not only associated with lower rates of percutaneous revascularization but also with increased 30-day and long-term mortality.

Three-Dimensional Echocardiographic Reconstruction of the Left Ventricle by a Transesophageal Tomographic Technique: In Vitro and In Vivo Validation of its Volume Measurement

Accurate determination of left ventricular (LV) volume has important therapeutic and prognostic implications in patients with cardiac disease. Volume estimations by two-dimensional techniques are not very accurate due to geometric assumptions. OBJECTIVES: To validate LV volume determinations by a new transesophageal three-dimensional echocardiographic technique. We performed three-dimensional reconstruction of the LV using an echo-computed tomographic (CT) technique based on serial pullback parallel slice imaging technique in both in vitro and in vivo settings. Fourteen latex balloons with various sizes (30-235 mL) and shapes (conical, pear shaped, round, elliptical, and aneurysms in various locations) filled with known volumes of water were imaged in a water bath. From the static three-dimensional image, the LV long axis was defined and the LV was sectioned perpendicular to this axis into 2-mm slices. The volume of each slice was calculated with the observer blinded to the actual volume as the product of the slice thickness and the manually traced perimeter of the slice and the LV volume as the sum of the volumes of the slices (Simpson's method). The calculated LV volume closely correlated with the actual volume (r = 0.99, P < 0.0001, calculated volume = 1.06x - 11.3, Deltavolume = -5.7 +/- 10.0 cc). Using the same system, transesophageal echocardiographic (TEE) images of the LV were obtained in 15 patients gated to respiration and ECG. Satisfactory dynamic three-dimensional reconstruction of the LV was possible in ten patients. The three-dimensional LV volumes (systolic and diastolic) using Simpson's method correlated well with those obtained from biplane or multiplane TEE images using the area length method (r = 0.89, p < 0.0001, y = 12.7 + 0.84x, Deltavolume = 1.3 +/- 18.1 cc). The LV major-axis diameters by the two methods showed very close correlations as well (r = 0.86, P < 0.0001, y = 19 + 0.74x, Deltadiameter = 1.0 +/- 7.2 mm). We conclude that three-dimensional LV volume calculation by the echo-CT technique is intrinsically sound, is independent of LV geometry, and with some limitations, is applicable in vivo. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Biological correlates of QT interval and QT dispersion in 2,265 patients with left ventricular ejection fraction < or =40%

Increased QT interval and QT dispersion have been associated with increased mortality in a variety of cardiovascular disorders including heart failure. However, the biological correlates of these abnormalities are not clear. QTc and QTd were measured in an automated fashion from digitized electrocardiograms in 2,265 patients with an LV ejection fraction Collapse

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MESH Headings

• Aged
• Electrocardiography
• Female
• Heart Rate
• Humans
• Male
• Stroke Volume
• Ventricular Dysfunction, Left/physiopathology

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Grants Collapse

Collaborators Collapse

QT dispersion as a noninvasive predictor of inducible ventricular tachycardia

The QT dispersion (QTD) on the surface electrocardiogram is a noninvasive marker of heterogeneity of ventricular repolarization. An increased QTD has been associated with spontaneous ventricular arrhythmias. We investigated the relationship of QTD to inducible reentrant sustained ventricular tachycardia (VT) in 66 patients who underwent programmed electrical stimulation. Thirty-three patients had inducible VT and 33 had noninducible VT with up to three extra stimuli. The QTD was significantly longer in patients with inducible VT (79+/-30 ms) compared with those in whom VT was noninducible (50+/-20 ms, P < .0001). QTD of > or =70 ms had a sensitivity of 67%, a specificity of 94%, a positive predictive value of 92%, and a negative predictive value of 74% for inducible VT. We conclude that QTD is an easily measurable electrocardiographic index that is increased in patients with inducible VT, and a QTD of > or =70 ms is highly predictive of VT inducibility.

Constrictive pericarditis causing extrinsic mitral stenosis and a left heart mass

Constrictive pericarditis is a fibrotic process involving both layers of the pericardium and is known to give rise to obstruction to blood flow in the right heart. We report a patient with constrictive pericarditis who had echocardiographic features of mitral stenosis caused by a fibrocalcific mass lesion involving the mitral annulus with infiltration into the base of the posterior mitral leaflet. To our knowledge, this has not been reported in the literature.

Heart failure with normal ejection fraction: current diagnostic and management strategies

Heart failure with normal ejection fraction (HFNEF), previously known as diastolic heart failure (HF), is defined as a syndrome of HF with normal or near normal ejection fraction (≥ 50%) and evidence of abnormal left ventricular (LV) diastolic function. It represents about 50% of patients diagnosed with HF. HFNEF is not a benign disease as it carries a morbidity and mortality risk as high as that associated with HF and reduced ejection fraction (HFREF). HFNEF shares some risk factors, hemodynamic consequences and clinical presentations with HFREF, though they differ in the pathophysiology and cardiac morphology. Therapies such as β-blockers (BBs) and angiotensin-receptor blockers (ARBs), which are beneficial in HFREF have not shown a survival benefit in HFNEF. Therapies focus on control of hypertension, control of heart rate, revascularization in case of ischemia for long term management and use of diuretics in acute decompensated HFNEF. Exercise therapy improves performance in HFNEF.