Association of the COVID-19 Pandemic on Treatment Times for ST-Elevation Myocardial Infarction: Observations from the Los Angeles County Regional System

Previous studies have documented longer treatment times and worse outcomes for patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) during the COVID-19 pandemic. The objective of the present study was to evaluate the impact of the COVID-19 pandemic on treatment times and outcomes for patients with STEMI who underwent primary PCI within a regional system of care. This was a retrospective study using data from the Los Angeles County Emergency Medical Services Agency. Data on the emergency medical service activations were abstracted for patients with STEMI from March 19, 2020 to January 31, 2021, during the COVID-19 pandemic and for the same interval the previous year. All adult patients (≥18 years) with STEMI who underwent emergent coronary angiography were included. The primary end point was the first medical contact (FMC) to device time. The secondary end points included treatment time intervals, vascular complications, need for emergent coronary artery bypass surgery, length of hospital stay, and in-hospital mortality. During the study period, 3,017 patients underwent coronary angiography for STEMI, 1,893 patients pre-COVID-19 and 1,124 patients during COVID-19 (40% lower). A total of 2,334 patients (77%) underwent PCI. During the COVID-19 period, rates of PCI were significantly lower compared with the control period (75.1% vs 78.7%, p = 0.02). FMC to device time was shorter during the COVID-19 period compared with the control period (median 77.0 vs 81.0 minutes, p = 0.004). For patients with STEMI complicated by out-of-hospital cardiac arrest, FMC to device time was similar during the COVID-19 period compared with the control period (median 95.0 [33.0] vs 100.0 [40.0] minutes, p = 0.34). Vascular complications, the need for emergent bypass surgery, length of hospital stay, and in-hospital mortality were similar between the periods. In conclusion, in this large regional system of care, we found a relatively small but significant decrease in treatment times, yet overall, similar clinical outcomes for patients with STEMI who underwent primary PCI and were treated during the COVID-19 period compared with a control period. These findings suggest that mature cardiac systems of care were able to maintain efficient care despite the challenges of the COVID-19 pandemic.

An Unusual Case of Left Ventricular Outflow Tract Pseudoaneurysm

Left ventricular outflow tract (LVOT) pseudoaneurysm is a rare condition with a wide range of causes and various clinical outcomes. The causes range from infections, trauma to the chest wall, and iatrogenic origins. We present a unique case of idiopathic LVOT pseudoaneurysm in a patient with no obvious clinical risk factors. (Level of Difficulty: Advanced.).

Impact of frailty on mortality and quality of life in patients with a history of cancer undergoing transcatheter aortic valve replacement

Background

Transcatheter aortic valve replacement (TAVR) is increasingly offered for aortic stenosis (AS) treatment in patients with a history of cancer. The impact of frailty on outcomes in this specific patient population is not well described.

Hypothesis

Frailty is associated with mortality and poorer quality of life (QOL) outcomes in patients undergoing TAVR with a history of cancer.

Methods

This retrospective single center cohort study included AS patients who underwent TAVR from August 1, 2012 to May 15, 2020. Frailty was measured using serum albumin, hemoglobin, gait speed, functional dependence, and cognitive impairment. The primary outcome was a composite of all‐cause mortality and QOL at 1 year. A poor primary outcome was defined as either all‐cause mortality, Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ‐OS) score <45 or a KCCQ‐OS score decline of ≥10 points from baseline. Regression analysis was used to determine the impact of frailty on the primary outcome.

Results

The study population was stratified into active/recent cancer (n = 107), remote cancer (n = 85), and non‐cancer (n = 448). Univariate analysis of each cohort showed that frailty was associated with the primary outcome only in the non‐cancer cohort (p = .004). Multivariate analysis showed that cancer history was not associated with a poor primary outcome, whereas frailty was (1.7 odds ratio, 95% confidence interval [CI]: 1.1–2.8; p = .028).

Conclusions

Frailty is associated with mortality and poor QOL in the overall and non‐cancer cohorts. Further investigation is warranted to understand frailty's effect on the cancer population. Frailty should be heavily considered during TAVR evaluation.

The Correlation Between COVID-19 Hospitalizations and Emergency Medical Services Responses for Time-Sensitive Emergencies During the COVID-19 Pandemic

OBJECTIVE

COVID-19 has had significant secondary effects on health care systems, including effects on emergency medical services (EMS) responses for time-sensitive emergencies. We evaluated the correlation between COVID-19 hospitalizations and EMS responses for time-sensitive emergencies in a large EMS system.

METHODS

This was a retrospective study using data from the Los Angeles County EMS Agency. We abstracted data on EMS encounters for stroke, ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest (OHCA), and trauma from April 5, 2020 to March 6, 2021 and for the same time period in the preceding year. We also abstracted daily hospital admissions and censuses (total and intensive care unit [ICU]) for COVID-19 patients. We designated November 29, 2020 to February 27, 2021 as the period of surge. We calculated Spearman's correlations between the weekly averages of daily hospital admissions and census and EMS responses overall and for stroke, STEMI, OHCA, and trauma.

RESULTS

During the study period, there were 70,616 patients admitted for confirmed COVID-19, including 12,467 (17.7%) patients admitted to the ICU. EMS responded to 899,794 calls, including 9,944 (1.1%) responses for stroke, 3,325 (0.4%) for STEMI, 11,207 (1.2%) for OHCA, and 114,846 (12.8%) for trauma. There was a significant correlation between total hospital COVID-19 positive patient admissions and EMS responses for all time-sensitive emergencies, including a positive correlation with stroke (0.41), STEMI (0.37), OHCA (0.78), and overall EMS responses (0.37); and a negative correlation with EMS responses for trauma (-0.48). ICU COVID-19 positive patient admissions also correlated with increases in EMS responses for stroke (0.39), STEMI (0.39), and OHCA (0.81); and decreased for trauma (-0.53). Similar though slightly weaker correlations were found when evaluating inpatient census. During the period of surge, the correlation with overall EMS responses increased substantially (0.88) and was very strong with OHCA (0.95).

CONCLUSION

We found significant correlation between COVID-19 hospitalizations and the frequency of EMS responses for time-sensitive emergencies in this regional EMS system. EMS systems should consider the potential effects of this and future pandemics on EMS responses and prepare to meet non-pandemic resource needs during periods of surge, particularly for time-sensitive conditions.

Impact of cancer and cardiovascular disease on in-hospital outcomes of COVID-19 patients: results from the american heart association COVID-19 cardiovascular disease registry

Background

While pre-existing cardiovascular disease (CVD) appears to be associated with poor outcomes in patients with Coronavirus Disease 2019 (COVID-19), data on patients with CVD and concomitant cancer is limited. The purpose of this study is to evaluate the effect of underlying CVD and CVD risk factors with cancer history on in-hospital mortality in those with COVID-19.

Methods

Data from symptomatic adults hospitalized with COVID-19 at 86 hospitals in the US enrolled in the American Heart Association’s COVID-19 CVD Registry was analyzed. The primary exposure was cancer history. The primary outcome was in-hospital death. Multivariable logistic regression models were adjusted for demographics, CVD risk factors, and CVD. Interaction between history of cancer with concomitant CVD and CVD risk factors were tested.

Results

Among 8222 patients, 892 (10.8%) had a history of cancer and 1501 (18.3%) died. Cancer history had significant interaction with CVD risk factors of age, body mass index (BMI), and smoking history, but not underlying CVD itself. History of cancer was significantly associated with increased in-hospital death (among average age and BMI patients, adjusted odds ratio [aOR] = 3.60, 95% confidence interval [CI]: 2.07–6.24; p < 0.0001 in those with a smoking history and aOR = 1.33, 95%CI: 1.01—1.76; p = 0.04 in non-smokers). Among the cancer subgroup, prior use of chemotherapy within 2 weeks of admission was associated with in-hospital death (aOR = 1.72, 95%CI: 1.05–2.80; p = 0.03). Underlying CVD demonstrated a numerical but statistically nonsignificant trend toward increased mortality (aOR = 1.18, 95% CI: 0.99—1.41; p = 0.07).

Conclusion

Among hospitalized COVID-19 patients, cancer history was a predictor of in-hospital mortality. Notably, among cancer patients, recent use of chemotherapy, but not underlying CVD itself, was associated with worse survival. These findings have important implications in cancer therapy considerations and vaccine distribution in cancer patients with and without underlying CVD and CVD risk factors.

Impact of Cancer and Cardiovascular Disease on In-Hospital Outcomes of COVID-19 Patients: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry.. [PMID: 34127966 PMCID: PMC8202433 DOI: 10.21203/rs.3.rs-600795/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background:

While pre-existing cardiovascular disease (CVD) appears to be associated with poor outcomes in patients with Coronavirus Disease 2019 (COVID-19), data on patients with CVD and concomitant cancer is limited. Evaluate the effect of underlying CVD and CVD risk factors with cancer history on in-hospital mortality in those with COVID-19.

Methods:

Data from symptomatic adults hospitalized with COVID-19 at 86 hospitals in the US enrolled in the American Heart Association’s COVID-19 CVD Registry was analyzed. The primary exposure was cancer history. The primary outcome was in-hospital death. Multivariable logistic regression models were adjusted for demographics, CVD risk factors, and CVD. Interaction between history of cancer with concomitant CVD and CVD risk factors were tested.

Results:

Among 8222 patients, 892 (10.8%) had a history of cancer and 1501 (18.3%) died. Cancer history had significant interaction with CVD risk factors of age, body mass index (BMI), and smoking history, but not underlying CVD itself. History of cancer was significantly associated with increased in-hospital death (among average age and BMI patients, adjusted odds ratio [aOR]=3.60, 95% confidence interval [CI]: 2.07–6.24; p<0.0001 in those with a smoking history and aOR=1.33, 95%CI: 1.01 – 1.76; p=0.04 in non-smokers). Among the cancer subgroup, prior use of chemotherapy within 2 weeks of admission was associated with in-hospital death (aOR=1.72, 95%CI: 1.05–2.80; p=0.03). Underlying CVD demonstrated a numerical but statistically nonsignificant trend toward increased mortality (aOR=1.18, 95% CI: 0.99 – 1.41; p=0.07).

Conclusion:

Among hospitalized COVID-19 patients, cancer history was a predictor of in-hospital mortality. Notably, among cancer patients, recent use of chemotherapy, but not underlying CVD itself, was associated with worse survival. These findings have important implications in cancer therapy considerations and vaccine distribution in cancer patients with and without underlying CVD and CVD risk factors.

Emergency Medical Services Responses to Out-of-Hospital Cardiac Arrest and Suspected ST-Segment-Elevation Myocardial Infarction During the COVID-19 Pandemic in Los Angeles County

Background Public health emergencies may significantly impact emergency medical services responses to cardiovascular emergencies. We compared emergency medical services responses to out-of-hospital cardiac arrest (OHCA) and ST-segment‒elevation myocardial infarction (STEMI) during the 2020 COVID-19 pandemic to 2018 to 2019 and evaluated the impact of California's March 19, 2020 stay-at-home order. Methods and Results We conducted a population-based cross-sectional study using Los Angeles County emergency medical services registry data for adult patients with paramedic provider impression (PI) of OHCA or STEMI from February through May in 2018 to 2020. After March 19, 2020, weekly counts for PI-OHCA were higher (173 versus 135; incidence rate ratios, 1.28; 95% CI, 1.19‒1.37; P<0.001) while PI-STEMI were lower (57 versus 65; incidence rate ratios, 0.87; 95% CI, 0.78‒0.97; P=0.02) compared with 2018 and 2019. After adjusting for seasonal variation in PI-OHCA and decreased PI-STEMI, the increase in PI-OHCA observed after March 19, 2020 remained significant (P=0.02). The proportion of PI-OHCA who received defibrillation (16% versus 23%; risk difference [RD], -6.91%; 95% CI, -9.55% to -4.26%; P<0.001) and had return of spontaneous circulation (17% versus 29%; RD, -11.98%; 95% CI, -14.76% to -9.18%; P<0.001) were lower after March 19 in 2020 compared with 2018 and 2019. There was also a significant increase in dead on arrival emergency medical services responses in 2020 compared with 2018 and 2019, starting around the time of the stay-at-home order (P<0.001). Conclusions Paramedics in Los Angeles County, CA responded to increased PI-OHCA and decreased PI-STEMI following the stay-at-home order. The increased PI-OHCA was not fully explained by the reduction in PI-STEMI. Field defibrillation and return of spontaneous circulation were lower. It is critical that public health messaging stress that emergency care should not be delayed.

Trajectory of Cardiac Catheterization for Acute Coronary Syndrome and Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic

Background

We sought to investigate the trajectory of cardiac catheterizations for acute coronary syndrome (ACS) and out-of-hospital cardiac arrest (OHCA) during the pre-isolation (PI), strict-isolation (SI), and relaxed-isolation (RI) periods of the coronavirus disease 2019 (COVID-19) pandemic at three hospitals in Los Angeles, CA, USA.

Methods

A retrospective analysis was conducted on adult patients undergoing urgent or emergent cardiac catheterization for suspected ACS or OHCA between January 1, 2020 and June 2, 2020 at three hospitals in Los Angeles, CA, USA. We designated January 1, 2020 to March 17, 2020 as the PI COVID-19 period, March 18, 2020 to May 5, 2020 as the SI COVID-19 period, and May 6, 2020 to June 2, 2020 as the RI COVID-19 period.

Results

From PI to SI, there was a significant reduction in mean weekly cases of catheterizations for non-ST elevation myocardial infarction/unstable angina (NSTEMI/UA) (8.29 vs. 12.5, P = 0.019), with all other clinical categories trending downwards. From SI to RI, mean weekly cases of catheterizations for total ACS increased by 17%, NSTEMI/UA increased by 27%, and OHCA increased by 32%, demonstrating a “rebound effect”.

Conclusions

Cardiac catheterizations for ACS and NSTEMI/UA exhibited a “rebound effect” once social isolation was relaxed.

Paravalvular Leak Assessment: Challenges in Assessing Severity and Interventional Approaches

PURPOSE OF REVIEW

With increasing use of prosthetic valves to treat degenerative valvular heart disease (VHD) in an aging population, the incidence and adverse consequences of paravalvular leaks (PVL) are better recognized. The present work aims to provide a cohesive review of the available literature in order to better guide the evaluation and management of PVL.

RECENT FINDINGS

Despite gains in operator experience and design innovation, significant PVL remains a significant complication that may present with congestive heart failure and/or hemolytic anemia. To date, clear consensus or guidelines on the evaluation and management of PVL remain lacking. Although the evolution of transcatheter valve therapies has had a tremendous impact on the management of patients with VHD, the limitations and complications of such techniques, including PVL, present further challenges. Incidence of PVL, graded as moderate or greater, ranges from 4 to 7.4% in surgical and transcatheter valve replacements, respectively. Improved imaging modalities and the advent of novel surgical and percutaneous therapies have undoubtedly yielded a better understanding of PVL including its anatomical location, mechanism, severity, and treatment options. Echocardiography, used in conjunction with cardiac computed tomography and cardiac magnetic resonance, provides essential details for diagnosis and management of PVL. Transcatheter intervention has become a favored approach in lieu of surgical intervention in select patients after previous surgical or percutaneous valve replacement. PVL treatment with vascular plugs, balloon post-dilation, and the valve-in-valve methods have shown technical success with promising clinical outcomes in appropriately selected patients.

Angiotensin Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use Among Outpatients Diagnosed With COVID-19

Coronavirus disease 2019 (COVID-19) is a viral pandemic precipitated by the severe acute respiratory syndrome coronavirus 2. Since previous reports suggested that viral entry into cells may involve angiotensin converting enzyme 2, there has been growing concern that angiotensin converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) use may exacerbate the disease severity. In this retrospective, single-center US study of adult patients diagnosed with COVID-19, we evaluated the association of ACEI/ARB use with hospital admission. Secondary outcomes included: ICU admission, mechanical ventilation, length of hospital stay, use of inotropes, and all-cause mortality. Propensity score matching was performed to account for potential confounders. Among 590 unmatched patients diagnosed with COVID-19, 78 patients were receiving ACEI/ARB (median age 63 years and 59.7% male) and 512 patients were non-users (median age 42 years and 47.1% male). In the propensity matched population, multivariate logistic regression analysis adjusting for age, gender and comorbidities demonstrated that ACEI/ARB use was not associated with hospital admission (OR 1.2, 95%CI 0.5 to 2.7, p = 0.652). CAD and CKD/end stage renal disease [ESRD] remained independently associated with admission to hospital. All-cause mortality, ICU stay, need for ventilation, and inotrope use was not significantly different between the 2 study groups. In conclusion, among patients who were diagnosed with COVID-19, ACEI/ARB use was not associated with increased risk of hospital admission.

The Role of Medical Therapy in Moderate to Severe Degenerative Mitral Regurgitation

Mitral regurgitation (MR) is a common valvular disorder that has important health and economic consequences. Standardized guidelines exist regarding when and in whom to perform mitral valve surgery, but little information is available regarding medical treatment of MR. Many patients with moderate or severe MR do not meet criteria for surgery or are deemed to be at high risk for surgical therapy. We reviewed the available published data on medical therapy in the treatment of patients with primary MR. b-blockers and renin-angiotensin-aldosterone system inhibitors had the strongest supporting evidence for providing beneficial effects. b-blockers appear to lessen MR, prevent deterioration of left ventricular function, and improve survival in asymptomatic patients with moderate to severe primary MR. Angiotensin-converting enzyme inhibitor and angiotensin receptor blocker therapy reduces MR, especially in asymptomatic patients. However, in the setting of hypertrophic cardiomyopathy or mitral valve prolapse, vasodilators can increase the severity of MR. To define the precise role of medical therapy, a larger randomized controlled trial is needed to confirm benefit and assess in which subsets of patients medical therapy is most useful. Medical therapy in some patients improves symptoms, lessens MR, and may delay the need for surgical intervention.

Echo-Doppler determinants of outcomes in patients with unoperated significant mitral regurgitation in current era

Objective

One-half of patients with severe symptomatic mitral regurgitation (MR) do not undergo surgery due to comorbidities. We evaluated prognosticators of outcomes in patients with unoperated significant MR.

Methods

In this observational study, we retrospectively evaluated medical records of 75 consecutive patients with unoperated significant MR.

Results

All-cause mortality was 39% at 5 years. Non-survivors (n=29) versus survivors (n=46) were: older (77±9.8 vs 68±14, p=0.006), had higher New York Heart Association (NYHA) class (2.7±0.8 vs 2.3±0.8, p=0.037), higher brain natriuretic peptide (1157±717 vs 427±502 pg/mL, p=0.024, n=18), more coronary artery disease (61% vs 35%, p=0.031), more frequent left ventricular ejection fraction <50% (20.7% vs 4.3%, p=0.026), more functional MR (41% vs 22%, p=0.069), higher mitral E/E^′ (12.7±4.6 vs 9.8±4, p=0.008), higher pulmonary artery systolic pressure (PASP; 52.6±18.7 vs 36.7±14, p <0.001), more ≥3+ tricuspid regurgitation (28% vs 4%, p=0.005) and more right ventricular dysfunction (26% vs 6%, p=0.035). Significant predictors of 5-year mortality were PASP (p=0.001) and E/E^′ (p=0.011) using multivariate regression analysis.

Conclusions

Patients with unoperated significant MR have high mortality. Elevated PASP and mitral E/E^′ were the most significant predictors of 5-year survival in patients with unoperated significant MR. Current American College of Cardiology (ACC)/American Heart Association (AHA) guidelines provide a limited incorporation of echo-Doppler parameters in the preoperative risk stratification of patients with severe MR.

Transthoracic echocardiographic parameters in the estimation of pulmonary capillary wedge pressure in patients with present or previous heart failure

Multiple echocardiographic criteria are routinely used for the estimation of left heart filling pressures. We assessed the predictive value of various echocardiographic parameters to estimate the left heart filling pressure and proposed a simplified approach for its evaluation. We collected the clinical, echocardiographic, and invasive hemodynamic data from 93 patients with heart failure who underwent right-sided heart catheterization and transthoracic echocardiography within a 24-hour period. Of these 93 patients, 57% had a left ventricular ejection fraction <50% and 69% had an elevated mean pulmonary capillary wedge pressure of ≥ 15 mm Hg. A mitral E/E' of ≥ 15 had a sensitivity of 55% but a specificity of 96%. A left atrial area of ≥ 20 cm(2) had a sensitivity of 66% and specificity of 89%. A deceleration time <140 ms had a sensitivity of 51% and specificity of 93% to predict a pulmonary capillary wedge pressure of ≥ 15 mm Hg. The combination of E/E' ≥ 15 ± left atrial area of ≥ 20 cm(2) ± deceleration time <140 ms provided a sensitivity of 92% and specificity of 85%. On multivariate analysis, the combination of E/E' ≥ 15, left atrial area of ≥ 20 cm(2), and deceleration time <140 ms was the most significant predictor of a pulmonary capillary wedge pressure of ≥ 15 mm Hg (odds ratio 48, 95% confidence interval 10 to 289, p <0.001). In conclusion, this simplified approach using 3 echocardiographic parameters provides an accurate and a practical approach for the routine estimation of the elevated left heart filling pressure.

Frequency of recurrence of pericardial tamponade in patients with extended versus nonextended pericardial catheter drainage

Recurrence of pericardial tamponade is relatively common after pericardiocentesis. We evaluated the clinical and procedural predictors of recurrent pericardial tamponade after pericardiocentesis. We included 157 consecutive patients with pericardial tamponade (age 62 ± 18 years, 54% men) who had undergone pericardiocentesis from 2000 to 2007. An intrapericardial catheter was used for prolonged drainage of the pericardial effusion (78% of cases) at the discretion of the operator. The overall recurrence rate 11.8 ± 0.6 months after pericardiocentesis was 20% and the mean interval to recurrence was 1.2 ± 2.1 months. However, patients with extended catheter drainage had a reduced recurrence rate of 12% compared to 52% in patients without extended drainage (p <0.001). In the Cox regression modeling, absence of extended drainage (hazard ratio [HR] 4.1, 95% confidence interval [CI] 1.7 to 10, p = 0.002), incomplete drainage of pericardial effusion (HR 9.7, 95% CI 3.6 to 22.7, p <0.001), loculated effusion (HR 11.1, 95% CI 2.9 to 43, p = 0.001), and malignancy (HR 3.3, 95% CI 1.8 to 10.3, p = 0.037) independently correlated with recurrence at 1 year. In conclusion, extended pericardial drainage after catheter placement is associated with a reduced recurrence of pericardial tamponade after pericardiocentesis.

The acute hemodynamic effects of MitraClip therapy

OBJECTIVES

The objective of this study was to evaluate the acute hemodynamic consequences of mitral valve (MV) repair with the MitraClip device (Abbott Vascular, Menlo Park, California).

BACKGROUND

Whether surgical correction of mitral regurgitation (MR) results in a low cardiac output (CO) state because of an acute increase in afterload remains controversial. The acute hemodynamic consequences of MR reduction with the MitraClip device have not been studied.

METHODS

We evaluated 107 patients with cardiac catheterization before and immediately following percutaneous MV repair with the MitraClip device. In addition, pre- and post-procedural hemodynamic parameters were studied by transthoracic echocardiography.

RESULTS

MitraClip treatment was attempted in 107 patients, and in 96 (90%) patients, a MitraClip was deployed. Successful MitraClip treatment resulted in: 1) an increase in CO from 5.0 ± 2.0 l/min to 5.7 ± 1.9 l/min (p = 0.003); 2) an increase in forward stroke volume (FSV) from 57 ± 17 ml to 65 ± 18 ml (p < 0.001); and 3) a decrease in systemic vascular resistance from 1,226 ± 481 dyn·s/cm(5) to 1,004 ± 442 dyn·s/cm(5) (p < 0.001). In addition, there was left ventricular (LV) unloading manifested by a decrease in LV end-diastolic pressure from 11.4 ± 9.0 mm Hg to 8.8 ± 5.8 mm Hg (p = 0.016) and a decrease in LV end-diastolic volume from 172 ± 37 ml to 158 ± 38 ml (p < 0.001). None of the patients developed acute post-procedural low CO state.

CONCLUSIONS

Successful MV repair with the MitraClip system results in an immediate and significant improvement in FSV, CO, and LV loading conditions. There was no evidence of a low CO state following MitraClip treatment for MR. These favorable hemodynamic effects with the MitraClip appear to reduce the risk of developing a low CO state, a complication occasionally observed after surgical MV repair for severe MR.

Aortopathy is prevalent in relatives of bicuspid aortic valve patients

OBJECTIVES

This study aimed to determine the prevalence of dilation and abnormal elastic properties of aortic root in first-degree relatives (FDRs) of bicuspid aortic valve (BAV) patients.

BACKGROUND

Evidence indicates that BAV is a genetic disorder. Although FDRs of affected individuals have an increased prevalence of BAV, their risk of aortic root abnormalities is unknown.

METHODS

We studied dimensions as well as the elastic properties of the ascending aorta in 48 FDRs with morphologically normal tricuspid aortic valves, 54 BAV patients, and 45 control subjects using 2-dimensional echocardiography.

RESULTS

The prevalence of aortic root dilation was 32% in FDRs and 53% in BAV patients, whereas all control subjects showed normal aortic dimensions (p < 0.001). The FDRs and BAVs had significantly lower aortic distensibility (1.7 +/- 1.4 x 10(-3) mm Hg and 1.4 +/- 2.0 x 10(-3) mm Hg vs. 2.5 +/- 1.6 x 10(-3) mm Hg, p < 0.001) and greater aortic stiffness index (26.7 +/- 25.8 and 55.9 +/- 76.8 vs. 18.7 +/- 40.1, p = 0.001) compared with control subjects. This difference remained significant in subjects without aortic root dilation or hypertension (p = 0.002 and p = 0.004, respectively).

CONCLUSIONS

The aortic root is functionally abnormal and dilation is common (32%) in first-degree relatives of patients with BAV. Screening of FDRs by transthoracic 2-dimensional echocardiography should be considered for detection of aortic valve malformation and dilated ascending aorta.

Reduction in mitral regurgitation in patients undergoing cardiac resynchronization treatment: assessment of predictors by two-dimensional radial strain echocardiography

BACKGROUND

We utilized the novel approach of 2D radial strain (2-DRS) to evaluate whether left ventricular (LV) mechanical dyssynchrony in mid-LV segments corresponding to papillary muscles insertion sites can predict early mitral regurgitation (MR) reduction post-cardiac resynchronization therapy (CRT).

METHODS

We evaluated 32 patients undergoing CRT (mean age 64 +/- 17 years, 54% males) with MR grade > or =3 determined by the MR jet area/left atrial area ratio (JA/LAA).

RESULTS

Fifteen (47%) patients responded to CRT (JA/LAA) < 25%). Sixty-seven percent of responders had mild or no residual MR and 33% had mild-to-moderate MR, while 70% of nonresponders had grade 3 or 4 MR (P = 0.0001) post CRT. The percent reduction in LV end-systolic volume was significantly higher in responders (P = 0.03), as was improvement in LVEF (P = 0.007). Significant delay of time-to-peak 2-DRS in the midposterior and inferior segments prior to CRT was found in responders compared with nonresponders (580 +/- 58 vs. 486 +/- 94, P = 0.002 and 596 +/- 79 vs. 478 +/- 127 ms, P = 0.005, respectively). Responders also had higher peak positive systolic 2-DRS in the posterior and inferior segments compared to nonresponders (22 +/- 13 vs. 12 +/- 7%, P = 0.01 and 17 +/- 9 vs. 9 +/- 7%, P = 0.02, respectively). Logistic regression analysis showed that the differences in pre-CRT inferoanterior time-to-peak 2-DRS of >110 ms and MRJA/LAA <40% as well as 2-DRS >18% in the posterior wall were significant predictors of post-CRT improvement in MR.

CONCLUSION

The presence of a significant time-to-peak delay on 2-DRS between inferior and anterior LV segments, preserved strain of posterior wall, and MRJA/LAA <40% were found to be associated with significant MR reduction in patients post-CRT.

Value of medical therapy in patients >80 years of age with heart failure and preserved ejection fraction

Heart failure (HF) with preserved ejection fraction (EF) has a high prevalence in the geriatric population, and this cohort may be at risk of complications caused by polypharmacy. Effects of commonly used cardiac medications on long-term survival of patients >80 years with HF and preserved left ventricular EF were assessed. One hundred forty-two patients were evaluated. During a 5-year follow-up, 98 patients died (69%). There were no significant differences in baseline parameters in patients who died compared with those who survived at 5 years. None of the drug therapies appeared to make a significant difference in long-term survival, including beta blockers (p = 0.89), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (p = 0.91), calcium channel blockers (p = 0.69), diuretics (p = 0.30), digoxin (p = 0.22), and statins (p = 0.32). In conclusion, based on the present data, it appears that use of certain common cardiac medications may not be associated with a significant effect on long-term survival in octogenarians with HF and preserved EF.

A Novel Finding to Assess Ischemia in Pacing Stress Echocardiography (PASE)

BACKGROUND

Normalization of heart rate post-pacing stress echocardiography (PASE) could enable evaluation of effect of ischemia on diastolic function.

METHODS

We examined the effect of pacing on left ventricular (LV) filling in 55 patients who underwent a transesophageal PASE. Pulse wave Doppler of mitral inflow was obtained at baseline and during transition from peak pacing to up to three beats immediate post pacing.

RESULTS

Thirty-four patients (62%; 62 +/- 12 years) had normal (NL) PASE, wall motion score index (WMSI) 1 +/- 0 at baseline and during PASE. Sixteen patients (29%; 64 +/- 12 years) had ischemic (ISCH) PASE, WMSI 1.07 +/- 0.08 at baseline and 1.40 +/- 0.21 during PASE. Five patients (9%; 81 +/- 5 years) had abnormal (ABN) PASE, WMSI 1.55 +/- 0.34 at baseline and 1.55 +/- 0.34 during PASE. The ABN group had the most pronounced decrease in deceleration time (DT) seen in all three post-PASE beats (221 +/- 29 ms at baseline vs. 145 +/- 46, 144 +/- 26 and 144 +/- 18 ms at beats 1, 2, and 3, P < 0.005 from baseline for all). The DT reduced significantly at post-PASE beat 1 from baseline (234 +/- 45 ms vs. 158 +/- 36 ms, P = 0.02) in the ISCH group, whereas no significant change in DT occurred in the NL group (239 +/- 74 ms vs. 222 +/- 58 ms, P = 0.14) at beat 1.

CONCLUSION

In ISCH and ABN ventricles the duration of early diastolic filling decreased post-pacing. This new finding of a shortened deceleration time (DT) may be a marker of an ischemic response in PASE reflecting abnormal LV compliance.

Novel method of biventricular pacemaker optimization by radial artery tonometer. A case report

Echocardiographic guided pacemaker optimization leads to significant improvement in cardiac function among nonresponders to cardiac resynchronization treatment (CRT). Simpler, noninvasive determination of cardiac function during biventricular pacemaker programming may simplify this procedure. In this report we describe a 73 year old male patient who presented with recent onset NYHA class III symptoms 7 months post-CRT for ischemic cardiomyopathy. During pacemaker optimization using A-pacing at 60 bpm, optimal atrioventricular (AV) delay was found to be 290 ms by both pulsed wave (PW) echo Doppler as well as by the simultaneously measured radial artery pulse waveform analysis by tonometry. No discernable atrial mechanical activity was visible despite presence of sinus rhythm up to an AV delay of 190 ms. Further improvement in cardiac function and decrease in mechanical dyssynchrony was shown with VV optimization by tissue Doppler imaging (TDI). Our report emphasizes the need for individualized biventricular pacemaker optimization post-CRT and that concomitant assessment via radial artery pulse waveform analysis by tonometry along with PW and TDI may provide additional information during pacemaker programming to assist in pacemaker optimization.

Echo-driven V-V optimization determines clinical improvement in non responders to cardiac resynchronization treatment

Echocardiography plays an integral role in the detection of mechanical dyssynchrony in patients with congestive heart failure and in predicting beneficial response to cardiac resynchronization treatment. In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output. Some recent reports suggest that sequential ventricular pacing may further improve cardiac output. The mechanism whereby sequential ventricular pacing improves cardiac output is likely improved inter and possibly intraventricular synchrony, however these speculations have not been confirmed. In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT. Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

Novel insights on effect of atrioventricular programming of biventricular pacemaker in heart failure--a case series

Background

Echocardiography plays an integral role in the diagnosis of congestive heart failure including measurement of left heart pressure as well as mechanical dyssynchrony.

Methods

In this report we describe novel therapeutic uses of echo pulsed wave Doppler in atrioventricular pacemaker optimization in patients who had either not derived significant symptomatic benefit post biventricular pacemaker implantation or deteriorated after deriving initial benefit. In these patients atrioventricular optimization showed novel findings and improved cardiac output and symptoms.

Results

In 3 patients with Cheyne Stokes pattern of respiration echo Doppler showed worsening of mitral regurgitation during hyperpneac phase in one patient, marked E and A fusion in another patient and exaggerated ventricular interdependence in a third patient thus highlighting mechanisms of adverse effects of Cheyne Stokes respiration in patients with heart failure. All 3 patients required a very short atrioventricular delay programming for best cardiac output. In one patient with recurrent congestive heart failure post cardiac resynchronization, mitral inflow pulse wave Doppler showed no A wave until a sensed atrioventricular delay of 190 ms was reached and showed progressive improvement in mitral inflow pattern until an atrioventricular delay of 290 ms. In 2 patients atrioventricular delay as short as 50 ms was required to allow E and A separation and prevent diastolic mitral regurgitation. All patients developed marked improvement in congestive heart failure symptoms post echo-guided biv pacemaker optimization.

Conclusion

These findings highlight the value of echo-guided pacemaker optimization in symptomatic patients post cardiac resynchronization treatment.

Echocardiography in cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is a new treatment modality for eligible patients with congestive heart failure (CHF). The premise of CRT is that it decreases inter and intra ventricular inhomogeneity during systolic contraction thereby improving efficiency of cardiac pump function. Presence of cardiac dyssynchrony appears to be a prerequisite for a response to CRT. Traditionally this inhomogeneity in contraction has been determined by electrocardiographic QRS widening. More recently several echocardiographic methods of assessment of dyssynchrony have become available. These methods utilize conventional M-mode and pulsed wave (PW) Doppler as well tissue Doppler imaging (TDI) METHODS: These echocardiographic parameters have been shown to be more important predictors of response to CRT than conventional QRS widening. This article will discuss echocardiographic methods of assessment of dyssynchrony and their role in predicting response to CRT. In addition role of echocardiography in post CRT pacemaker programming will also be discussed.