Prosthetic Aortic Valve Thrombosis

Prosthetic valve thrombosis is the second leading cause of prosthetic valve deterioration and is being more readily diagnosed with the use of echocardiography and multidetector cardiac CT. Presentation of valve thrombosis can be acute or subacute and any change in clinical status of a patient with a prosthetic valve should raise a suspicion of prosthetic valve thrombosis. Diagnosis entails detailed clinical examination and comprehensive imaging. The choice of therapeutic options includes anticoagulation, fibrinolytic therapy, or valve replacement. Antiplatelet and anticoagulation therapy remain the mainstay of thrombosis prevention in patients with a prosthetic valve and a personalized approach is required to optimize prosthetic valve function and minimize the risk of bleeding.

Quantitative Assessment of Cardiac Hypermetabolism and Perfusion for Diagnosis of Cardiac Sarcoidosis

BACKGROUND

Quantitative assessment of cardiac hypermetabolism from 18Flourodeoxy glucose (FDG) positron emission tomography (PET) may improve diagnosis of cardiac sarcoidosis (CS). We assessed different approaches for quantification of cardiac hypermetabolism and perfusion in patients with suspected CS.

METHODS AND RESULTS

Consecutive patients undergoing 18FDG PET assessment for possible CS between January 2014 and March 2019 were included. Cardiac hypermetabolism was quantified using maximal standardized uptake value (SUVMAX), cardiometabolic activity (CMA) and volume of inflammation, using relative thresholds (1.3× and 1.5× left ventricular blood pool [LVBP] activity), and absolute thresholds (SUVMAX > 2.7 and 4.1). Diagnosis of CS was established using the Japanese Ministry of Health and Wellness criteria. In total, 69 patients were studied, with definite or possible CS in 29(42.0%) patients. CMA above 1.5× LVBP SUVMAX had the highest area under the receiver operating characteristic curve (AUC 0.92). Quantitative parameters using relative thresholds had higher AUC compared to absolute thresholds (p < 0.01). Interobserver variability was low for CMA, with excellent agreement regarding absence of activity (Kappa 0.970).

CONCLUSIONS

Quantitation with scan-specific thresholds has superior diagnostic accuracy compared to absolute thresholds. Based on the potential clinical benefit, programs should consider quantification of cardiac hypermetabolism when interpreting 18F-FDG PET studies for CS.

Diagnostic and prognostic value of Technetium-99m pyrophosphate uptake quantitation for transthyretin cardiac amyloidosis

BACKGROUND

99mTc-pyrophosphate imaging has emerged as an important non-invasive method to diagnose transthyretin cardiac amyloidosis (ATTR-CM). Quantitation of 99mTc-pyrophosphate activity, on SPECT images, could be a marker of ATTR-CM disease burden. We assessed the diagnostic accuracy and clinical significance of 99mTc-pyrophosphate quantitation.

METHODS AND RESULTS

Patients who underwent 99mTc-pyrophosphate imaging for suspected ATTR-CM were included. Using SPECT images, radiotracer activity in the myocardium was calculated using cardiac pyrophosphate activity (CPA) and volume of involvement (VOI), with thresholds for abnormal activity derived from LVBP activity. Diagnostic accuracy was assessed using area under the receiver operating characteristic curve (AUC). In total, 124 patients were identified, mean age 73.9 ± 11.4, with ATTR-CM diagnosed in 43 (34.7%) patients. CPA had the highest diagnostic accuracy (AUC .996, 95% CI .987-1.00), and was significantly higher compared to the Perugini score (AUC .952, P = .016). In patients with ATTR-CM, CPA was associated with reduced left ventricular ejection fraction (adjusted odds ratio 1.28, P = .035) and heart failure hospitalizations (adjusted hazard ratio 1.29, P = .006).

CONCLUSION

Quantitative assessment of myocardial radiotracer activity with CPA or VOI have high diagnostic accuracy for ATTR-CM. Both measures are potential non-invasive markers to follow progression of disease or response to therapy.

Cardiac involvement in hospitalized patients with COVID-19 and its incremental value in outcomes prediction

Recent reports linked acute COVID-19 infection in hospitalized patients to cardiac abnormalities. Studies have not evaluated presence of abnormal cardiac structure and function before scanning in setting of COVD-19 infection. We sought to examine cardiac abnormalities in consecutive group of patients with acute COVID-19 infection according to the presence or absence of cardiac disease based on review of health records and cardiovascular imaging studies. We looked at independent contribution of imaging findings to clinical outcomes. After excluding patients with previous left ventricular (LV) systolic dysfunction (global and/or segmental), 724 patients were included. Machine learning identified predictors of in-hospital mortality and in-hospital mortality + ECMO. In patients without previous cardiovascular disease, LV EF < 50% occurred in 3.4%, abnormal LV global longitudinal strain (< 16%) in 24%, and diastolic dysfunction in 20%. Right ventricular systolic dysfunction (RV free wall strain < 20%) was noted in 18%. Moderate and large pericardial effusion were uncommon with an incidence of 0.4% for each category. Forty patients received ECMO support, and 79 died (10.9%). A stepwise increase in AUC was observed with addition of vital signs and laboratory measurements to baseline clinical characteristics, and a further significant increase (AUC 0.91) was observed when echocardiographic measurements were added. The performance of an optimized prediction model was similar to the model including baseline characteristics + vital signs and laboratory results + echocardiographic measurements.

Frequency of injuries associated with syncope in the prevention of syncope trials

AIMS

Syncope can lead to injuries. We determined the frequency, severity, and predictors of injuries due to syncope in cohorts of syncope patients.

METHODS AND RESULTS

Participants were enrolled in the POST2 (fludrocortisone) and POST4 (midodrine) vasovagal syncope (VVS) randomized trials, and POST3 enrolled patients with bifascicular block and syncope. Injury was defined as minor (bruising, abrasions), moderate (lacerations), and severe (fractures, burns, joint pain), and recorded up to 1 year after enrolment. A total of 459 patients (median 39 years) were analysed. There were 710 faints occurred in 186 patients during a 1-year follow-up. Fully 56/186 (30%) of patients were injured with syncope (12% of overall group). There were 102 injuries associated with the 710 faints (14%), of which 19% were moderate or severe injuries. Neither patient age, sex, nor the presence of prodromal symptoms associated with injury-free survival. Patients with bifascicular block were more prone to injury (relative risk 1.98, P = 0.018). Patients with ≥4 faints in the prior year had more injuries than those with fewer faints (relative risk 2.97, P < 0.0001), but this was due to more frequent syncope, and not more injuries per faint. In VVS patients, pharmacological therapy significantly reduced the likelihood of an injury due to a syncopal spell (relative risk 0.64, P = 0.015). Injury severity did not associate with age, sex, or prior-year syncope frequency.

CONCLUSION

Injuries are frequent in syncope patients, but only 4% of injuries were severe. None of age, sex, and prodromal symptoms associate with injury.

Characterization of Right Ventricular Deformation in Pulmonary Arterial Hypertension Using Three-Dimensional Principal Strain Analysis

BACKGROUND

Pulmonary arterial hypertension (PAH) can cause maladaptive right ventricular (RV) functional changes associated with adverse prognosis that are challenging to accurately quantify noninvasively. The aim of this study was to explore principal strain (PS) with contraction angle analysis using three-dimensional echocardiography to characterize RV deformation changes in patients with PAH.

METHODS

Three-dimensional echocardiography was performed in 37 patients with PAH and 20 healthy control subjects with two-component (primary and secondary) PS and principal contraction angle analysis. Patients were stratified according to World Health Organization (WHO) functional class.

RESULTS

Primary PS differed significantly between patients with PAH and healthy control subjects (-20.2 ± 3.3% vs -26.8 ± 3.3%, P = .01), while secondary PS was not significantly different (3.6 ± 5.1% vs -2.5 ± 4.7%, P = .12). Principal contraction angle was significantly lower in patients with PAH (63 ± 22° vs 71 ± 7°, P = .01), with the greatest reduction for the RV free wall. Primary PS and principal contraction angle differed significantly between WHO class I and II and class III and IV patients (-23.9 ± 4.7% vs -18.1 ± 4.8% [P = .03] and 69 ± 9° vs 58 ± 14° [P = .03], respectively), while secondary PS was not significantly different between groups (P = .13). Compared with healthy control subjects, septal principal contraction angle was not different in patients with WHO class I and II PAH (P = .62), but it was significantly reduced in those with WHO class III and IV PAH (P < .01). The area under the curve for primary PS to differentiate patients with PAH by WHO functional class was 0.81 (95% CI, 0.77-0.89; P = .01). Primary PS intraclass correlation coefficients for intraobserver and interobserver variability were 0.91 (95% CI, 0.88-0.93) and 0.86 (95% CI, 0.81-0.88), respectively.

CONCLUSIONS

PS analysis using three-dimensional echocardiography provides comprehensive quantification of RV deformation and characterizes alterations occurring in PAH that are associated with WHO functional class.

What is the Impact of Frailty on Prescription of Anticoagulation in Elderly Patients with Atrial Fibrillation? A Systematic Review and Meta-Analysis

Background

Atrial fibrillation (AF) and frailty are both associated with advanced age. Oral anticoagulants (OAC) effectively prevent strokes in AF patients but are underutilized in the elderly, possibly due to misperception of frailty.

Objective

We performed a systematic review to determine the prevalence of frailty in patients with AF, and whether frailty was associated with reduced prescription of OAC.

Methods

We systematically searched Cochrane, MEDLINE, EMBASE, and PubMed databases. Search terms combined relevant words and MeSH headings: 1) atrial fibrillation, 2) frail elderly, and 3) geriatric assessments. Studies that measured frailty using a validated instrument, and involved OAC for AF in frail and non-frail patients were eligible for inclusion. Pooled odds ratios were calculated using random-effects model.

Results

Of 166 reviewed titles, only 3 studies (1204 patients) met the inclusion criteria. Two used the Reported Edmonton Frail Scale (total 509 patients), and one used the Canadian Study of Health and Aging Clinical Frailty Scale (682 patients). All 3 studies involved hospitalized patients with an average age of 85 ± 6 and 45% were male. The weighted mean prevalence of frailty in patients with atrial fibrillation was 39% (95%CI 36-42). The weighted mean rate of OAC use was 57±11%. Frailty was associated with non-prescription of OAC compared to non-frail (OR 0.49, 95% CI 0.32-0.74, I2 =45%).

Conclusion

The prevalence of frailty in hospitalized elderly patients with AF is high, and the use of OAC is low in these patients. Frail elderly are significantly less likely to receive OAC.

Acute myeloid leukaemia: expression of MYC protein and its association with cytogenetic risk profile and overall survival

Acute myeloid leukaemia (AML) is a clinically aggressive disease with marked genetic heterogeneity. Cytogenetic abnormalities provide the basis for risk stratification into clinically favourable, intermediate, and unfavourable groups. There are additional genetic mutations, which further influence the prognosis of patients with AML. Most of these result in molecular aberrations whose downstream target is MYC. It is therefore logical to study the relationship between MYC protein expression and cytogenetic risk groups. We studied MYC expression by immunohistochemistry in a large cohort (n = 199) of AML patients and correlated these results with cytogenetic risk profile and overall survival (OS). We illustrated differential expression of MYC protein across various cytogenetic risk groups (p = 0.03). Highest expression of MYC was noted in AML patients with favourable cytogenetic risk group. In univariate analysis, MYC expression showed significant negative influence of OS in favourable and intermediate cytogenetic risk group (p = 0.001). Interestingly, MYC expression had a protective effect in the unfavourable cytogenetic risk group. In multivariate analysis, while age and cytogenetic risk group were significant factors influencing survival, MYC expression by immunohistochemistry methods also showed some marginal impact (p = 0.069). In conclusion, we have identified differential expression of MYC protein in relation to cytogenetic risk groups in AML patients and documented its possible impact on OS in favourable and intermediate cytogenetic risk groups. These preliminary observations mandate additional studies to further investigate the routine clinical use of MYC protein expression in AML risk stratification. Copyright © 2016 John Wiley & Sons, Ltd.

Clinical improvement of vasovagal syncope in the absence of specific therapies: The Seinfeld effect

Vasovagal syncope can persist for decades and recur sporadically but many patients appear to improve after being seen in specialty clinics. The absence of specific and proven effective therapy raises the possibility that this might be due to regression to the mean or to a placebo effect. However, analysis using the Poisson distribution indicates the extreme unlikeliness that regression to the mean is the explanation. A main cause of the placebo effect is expectancy. Subject expectancy is the influence of the subject's anticipation of benefit on outcomes, and observer expectancy is the influence of investigator or physician attitudes and behavior on subject response. Ample data support the role of expectancy in outcomes of syncope patients. Moreover, expectancy can vary depending on the type of ineffective intervention. Interestingly, studies in which patients are blinded but the investigator is not show similar patient benefits compared with completely open label studies consistent with a strong observer expectancy effect due to physician-subject interaction. These results suggest the paramount importance of properly conducted randomized clinical trials in assessing biomedical interventions, and also illuminate the powerful potential of studies aimed at enhancing the expectancy effect on patient outcome.

CD10-positive mantle cell lymphoma: biologically distinct entity or an aberrant immunophenotype? Insight, through gene expression profile in a unique case series

Background

Mantle cell lymphoma (MCL) is an aggressive disease with genetic heterogeneity and discrete clinical subtypes. MCL is rarely CD10 positive. These cases raise the question whether a subset of MCL may be germinal centre (GC) derived, and have distinct clinicopathological characteristics.

Aims and methods

A series of nine CD10-positive MCL cases is described herein. The clinicopathological and immunophenotypic features, immunoglobulin somatic hypermutation (SHM) status and gene expression profile (GEP) data are detailed. These features were compared with two independent sets (n=20, each) of CD10-negative MCL cases (controls), which were randomly selected from our institutional registry.

Results

GEP showed distinct expression of a GC signature in CD10-positive MCL cases with minimal impact on downstream signalling pathways. There were no significant differences in the clinicopathological features or clinical outcome between our CD10-positive and CD10-negative MCL cases. The frequency of SHM was comparable with established data.

Conclusions

This study provides convincing evidence that CD10 expression is related to a distinct GC signature in MCL cases, but without clinical or biological implications.