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A Call for Standardization of Abbreviation Usage Among Cardiology and Cardiac Imaging Society Guidelines. J Am Soc Echocardiogr 2024; 37:574-575. [PMID: 38246516 DOI: 10.1016/j.echo.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024]
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Beyond conduction impairment: Unveiling the profound myocardial injury in left bundle branch block. Heart Rhythm 2024:S1547-5271(24)00256-X. [PMID: 38490601 DOI: 10.1016/j.hrthm.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Left bundle branch block (LBBB) represents a frequently encountered conduction system disorder. Despite its widespread occurrence, a continual dilemma persists regarding its intricate association with underlying cardiomyopathy and its pivotal role in the initiation of dilated cardiomyopathy. The pathologic alterations linked to LBBB-induced cardiomyopathy (LBBB-CM) have remained elusive. OBJECTIVE This study sought to investigate the chronologic dynamics of LBBB to left ventricular dysfunction and the pathologic mechanism of LBBB-CM. METHODS LBBB model was established through main left bundle branch trunk ablation in 14 canines. All LBBB dogs underwent transesophageal echocardiography and electrocardiography before ablation and at 1 month, 3 months, 6 months, and 12 months after LBBB induction. Single-photon emission computed tomography imaging was performed at 12 months. We then harvested the heart from all LBBB dogs and 14 healthy adult dogs as normal controls for anatomic observation, Purkinje fiber staining, histologic staining, and connexin43 protein expression quantitation. RESULTS LBBB induction caused significant fibrotic changes in the endocardium and mid-myocardium. Purkinje fibers exhibited fatty degeneration, vacuolization, and fibrosis along with downregulated connexin43 protein expression. During a 12-month follow-up, left ventricular dysfunction progressively worsened, peaking at the end of the observation period. The association between myocardial dysfunction, hypoperfusion, and fibrosis was observed in the LBBB-afflicted canines. CONCLUSION LBBB may lead to profound myocardial injury beyond its conduction impairment effects. The temporal progression of left ventricular dysfunction and the pathologic alterations observed shed light on the complex relationship between LBBB and cardiomyopathy. These findings offer insights into potential mechanisms and clinical implications of LBBB-CM.
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Management of Friedreich Ataxia-Associated Cardiomyopathy in Pregnancy: A Review of the Literature. Am J Cardiol 2024; 210:118-129. [PMID: 37838071 DOI: 10.1016/j.amjcard.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/26/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023]
Abstract
A major manifestation of Friedreich ataxia (FRDA) is cardiomyopathy, caused by mitochondrial proliferation in myocytes. Because the lifespan for patients with FRDA improves with better treatment modalities, more patients are becoming pregnant, meaning that more medical providers must know how to care for this population. This report provides a review of the literature on multidisciplinary management of pregnant patients with FRDA and cardiomyopathy from preconception through lactation. A cardio-obstetrics team, including cardiology, anesthesiology, and obstetrics, should be involved for this entire period. All patients should be counseled on pregnancy risk using elements of existing stratification systems, and contraception should be discussed, highlighting the safety of intrauterine devices. Electrocardiogram should be obtained at baseline and each trimester, looking for atrial arrhythmias and ST-segment changes, as should transthoracic echocardiogram, with a focus on left ventricular ejection fraction-which is typically normal in FRDA cardiomyopathy-and relative wall thickness and global longitudinal strain-which tend to decrease as cardiomyopathy progresses. Brain natriuretic peptide is also a helpful marker to detect adverse events. If heart failure develops, it should be treated like any other etiology of heart failure during pregnancy. Atrial arrhythmias should be treated with β blockers or electrical cardioversion and anticoagulation, as necessary. Most patients with FRDA can deliver vaginally, and neuraxial analgesia is recommended during labor because of the risks associated with general anesthesia. Breastfeeding is encouraged, even for those taking cardiac medications.
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A Practical Guide to Address Harassment and Bullying in Cardiology. JACC Case Rep 2023; 22:101988. [PMID: 37790768 PMCID: PMC10544275 DOI: 10.1016/j.jaccas.2023.101988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
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The (Heart and) Soul of a Human Creation: Designing Echocardiography for the Big Data Age. J Am Soc Echocardiogr 2023; 36:800-801. [PMID: 37191597 PMCID: PMC10913146 DOI: 10.1016/j.echo.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 05/17/2023]
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Outpatient intravenous diuresis in a rural setting: safety, efficacy, and outcomes. Front Cardiovasc Med 2023; 10:1155957. [PMID: 37304943 PMCID: PMC10248139 DOI: 10.3389/fcvm.2023.1155957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Purpose To evaluate the safety, efficacy, and outcomes of outpatient intravenous diuresis in a rural setting and compare it to urban outcomes. Methods A single-center study was conducted on 60 patients (131 visits) at the Dartmouth-Hitchcock Medical Center (DHMC) from 1/2021-12/2022. Demographics, visit data, and outcomes were collected and compared to urban outpatient IV centers, and inpatient HF hospitalizations from DHMC FY21 and national means. Descriptive statistics, T-tests and chi-squares were used. Results The mean age was 70 ± 13 years, 58% were male, and 83% were NYHA III-IV. Post-diuresis, 5% had mild-moderate hypokalemia, 16% had mild worsening of renal function, and 3% had severe worsening of renal function. No hospitalizations occurred due to adverse events. The mean infusion-visit urine output was 761 ± 521 ml, and post-visit weight loss was -3.9 ± 5.0 kg. No significant differences were observed between HFpEF and HFrEF groups. 30-day readmissions were similar to urban outpatient IV centers, DHMC FY21, and the national mean (23.3% vs. 23.5% vs. 22.2% vs. 22.6%, respectively; p = 0.949). 30-day mortality was similar to urban outpatient IV centers but lower than DHMC FY21 and the national means (1.7% vs. 2.5% vs. 12.3% vs. 10.7%, respectively; p < 0.001). At 60 days, 42% of patients had ≥1 clinic revisit, 41% had ≥1 infusion revisit, 33% were readmitted to the hospital, and two deaths occurred. The clinic avoided 21 hospitalizations, resulting in estimated cost savings of $426,111. Conclusion OP IV diuresis appears safe and effective for rural HF patients, potentially decreasing mortality rates and healthcare expenses while mitigating rural-urban disparities.
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Women’s Cardiovascular Health: Prioritizing the Majority Minority. J Cardiovasc Dev Dis 2023; 10:jcdd10030128. [PMID: 36975892 PMCID: PMC10057409 DOI: 10.3390/jcdd10030128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
Women make up the majority of the global population, and [...]
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Myocardial mechanics of percutaneous intramyocardial septal radiofrequency ablation. Heart 2023; 109:289-296. [PMID: 36270787 DOI: 10.1136/heartjnl-2022-321597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/07/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Echocardiography-guided Percutaneous IntraMyocardial Septal Radiofrequency Ablation (PIMSRA, Liwen procedure) is a novel treatment option for hypertrophic obstructive cardiomyopathy (HOCM). The impact of PIMSRA on myocardial mechanics is unknown. METHODS Between October 2016 and June 2019, PIMSRA and 3-dimentional speckle tracking echocardiography were performed in 82 patients. Echocardiographic imaging, qualitative and quantitative clinical assessment were completed at baseline, immediately postprocedure and 1-year follow-up. RESULTS There was a significant reduction in the peak left ventricular outflow tract (LVOT) gradients immediately following PIMSRA and at 1-year follow-up (resting gradients: from 83.50 (61.25) to 23.00 (41.75) mm Hg, p<0.001 and 13.50 (21.75) mm Hg, p<0.001, respectively; stress-induced gradients: from 118.25 (96.02) to 47.00 (74.50) mm Hg (1 year), p<0.001). There was an improvement in exercise time on stress echocardiography (p<0.001) and distance by 6 min walk test (p=0.034). Immediately after PIMSRA, there was a significant reduction in radial and circumferential strain in the ablated segments (p<0.001), with no change of longitudinal strain. At 1-year follow-up, the radial and circumferential strain recovered in the ablated segments. Meanwhile, left ventricular regional and global longitudinal strain had improved significantly (p<0.05). CONCLUSIONS PIMSRA is an effective treatment for symptomatic HOCM that resulted in a sustained improvement in exercise capacity, a persistent decrease in LVOT gradient, and a measurable increase in myocardial contractile function. TRIAL REGISTRATION NUMBER NCT04777188.
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Human Immunodeficiency Virus and Cardiac End-Organ Damage in Women: Findings From an Echocardiographic Study Across the United States. Clin Infect Dis 2023; 76:210-219. [PMID: 36184972 PMCID: PMC10202437 DOI: 10.1093/cid/ciac795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/23/2022] [Accepted: 09/28/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND People with human immunodeficiency virus (HIV) have been reported to have increased risk of clinical and subclinical cardiovascular disease. Existing studies have focused on men and often have been uncontrolled or lacked adequate HIV-negative comparators. METHODS We performed echocardiography in the Women's Interagency HIV Study to investigate associations of HIV and HIV-specific factors with cardiac phenotypes, including left ventricular systolic dysfunction (LVSD), isolated LV diastolic dysfunction (LVDD), left atrial enlargement (LAE), LV hypertrophy (LVH), and increased tricuspid regurgitation velocity (TRV). RESULTS Of 1654 participants (age 51 ± 9 years), 70% had HIV. Sixty-three (5.4%) women with HIV (WWH) had LVSD; 71 (6.5%) had isolated LVDD. Compared with women without HIV (WWOH), WWH had a near-significantly increased risk of LVSD (adjusted relative risk = 1.69; 95% confidence interval = 1.00 to 2.86; P = .051). No significant association was noted for HIV seropositivity with other phenotypes, but there was a risk gradient for decreasing CD4+ count among WWH that approached or reached significance for isolated LVDD, LAE, and LVH. WWH with CD4+ count <200 cells/mm3 had significantly higher prevalence of LAE, LVH, and high TRV than WWOH. There were no consistent associations for viral suppression or antiretroviral drug exposure. CONCLUSIONS This study suggests that WWH have a higher risk of LVSD compared with sociodemographically similar WWOH, but their risk for isolated LVDD, LAE, LVH, and high TRV is increased only with reduced CD4+ count. Although these findings warrant replication, they support the importance of cardiovascular risk-factor and HIV-disease control for heart disease prevention in this population.
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Lateral annular systolic excursion ratio: A novel measurement of right ventricular systolic function by two-dimensional echocardiography. Front Cardiovasc Med 2022; 9:971302. [PMID: 36119732 PMCID: PMC9479059 DOI: 10.3389/fcvm.2022.971302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAccurate assessment of right ventricular (RV) systolic function has prognostic and therapeutic implications in many disease states. Echocardiography remains the most frequently deployed imaging modality for this purpose, but estimation of RV systolic function remains challenging. The purpose of this study was to evaluate the diagnostic performance of a novel measurement of RV systolic function called lateral annular systolic excursion ratio (LASER), which is the fractional shortening of the lateral tricuspid annulus to apex distance, compared to right ventricular ejection fraction (RVEF) derived by cardiac magnetic resonance imaging (CMR).MethodsA retrospective cohort of 78 consecutive patients who underwent clinically indicated CMR and transthoracic echocardiography within 30 days were identified from a database. Parameters of RV function measured included: tricuspid annular plane systolic excursion (TAPSE) by M-mode, tissue Doppler S', fractional area change (FAC) and LASER. These measurements were compared to RVEF derived by CMR using Pearson's correlation coefficients and receiver operating characteristic curves.ResultsLASER was measurable in 75 (96%) of patients within the cohort. Right ventricular systolic dysfunction, by CMR measurement, was present in 37% (n = 29) of the population. LASER has moderate positive correlation with RVEF (r = 0.54) which was similar to FAC (r = 0.56), S' (r = 0.49) and TAPSE (r = 0.37). Receiver operating characteristic curves demonstrated that LASER (AUC = 0.865) outperformed fractional area change (AUC = 0.767), tissue Doppler S' (AUC = 0.744) and TAPSE (AUC = 0.645). A cohort derived dichotomous cutoff of 0.2 for LASER was shown to provide optimal diagnostic characteristics (sensitivity of 75%, specificity of 87% and accuracy of 83%) for identifying abnormal RV function. LASER had the highest sensitivity, accuracy, positive and negative predictive values among the parameters studied in the cohort.ConclusionsWithin the study cohort, LASER was shown to have moderate positive correlation with RVEF derived by CMR and more favorable diagnostic performance for detecting RV systolic dysfunction compared to conventional echocardiographic parameters while being simple to obtain and less dependent on image quality than FAC and emerging techniques.
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Exploring the Changes in Code Status During the COVID-19 Pandemic and the Implications for Future Pandemic Care. Am J Hosp Palliat Care 2022; 39:1364-1370. [PMID: 35452316 PMCID: PMC9038937 DOI: 10.1177/10499091221092699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective: We aim to explore patterns of inpatient code status during the COVID-19 pandemic compared with a similar timeframe the previous year, as well as utilization of palliative care services. Methods: This is a retrospective cohort study using data from the Montefiore Health system of all inpatient admissions between March 15-May 31, 2019 and March 15-May 31, 2020. Univariate logistic regression was performed with full code status as the outcome. All statistically significant variables were included in the multivariable logistic regression. Results: The total number of admissions declined during the pandemic (16844 vs 11637). A lower proportion of patients had full code status during the pandemic (85.1% vs 94%, P < .001) at the time of discharge/death. There was a 20% relative increase in the number of palliative care consultations during the pandemic (12.2% vs 10.5%, P < .001). Intubated patients were less often full code (66.5% vs 82.2%, P < .001) during the pandemic. Although a lower portion of COVID-19 positive patients had a full code status compared with non-COVID patients (77.6% vs 92.4%, P<.001), there was no statistically significant difference in code status at death (38.3% vs 38.3%, P = .96). Conclusions: The proportion of full code patients was significantly lower during the pandemic. Age and COVID status were the key determinants of code status during the pandemic. There was a higher demand for palliative care services during the pandemic.
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THE WEEKEND EFFECT ON OUTCOMES IN PATIENTS PRESENTING WITH ACUTE AORTIC DISSECTION: A NATIONWIDE ANALYSIS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02733-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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WEEKEND EFFECT ON PATIENTS PRESENTING WITH CARDIAC ARREST: A NATIONWIDE ANALYSIS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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The Utility of Maternal Point of Care Ultrasound on Labor and Delivery Wards. J Cardiovasc Dev Dis 2022; 9:jcdd9010029. [PMID: 35050239 PMCID: PMC8777988 DOI: 10.3390/jcdd9010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 12/10/2022] Open
Abstract
Point-of-care ultrasonography (POCUS) refers to limited bedside ultrasound used to evaluate patients for conditions specific to the scope of their practice. Given the benefits of its application, interest in its use is increasing. We aimed to review the literature and assess the potential feasibility of using POCUS of the heart and lungs in the field of obstetrics. We aim to describe its relevance and value as an adjunctive tool for critically ill obstetric patients on labor and delivery wards.
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DNR Code Status Is Not Associated with Under-Utilization of Inpatient Transthoracic Echocardiograms. J Cardiovasc Dev Dis 2021; 8:jcdd8090112. [PMID: 34564130 PMCID: PMC8471040 DOI: 10.3390/jcdd8090112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/05/2021] [Accepted: 09/09/2021] [Indexed: 11/16/2022] Open
Abstract
In the strictest sense, do-not-resuscitate (DNR) status means that cardiopulmonary resuscitation should not be performed after death has occurred; all other medical interventions in line with a patient's goals of care should be implemented. The use of transthoracic echocardiography (TTE) in patients with DNR status is unknown. Therefore, we aim to evaluate the utilization of TTE among patients with DNR status using this retrospective data analysis. A total of 16,546 patient admissions were included in the final study. A total of 4370 (26.4%) of the patients had a TTE during hospitalization; among full code patients, 3976 (25.7%) underwent TTE, whereas TTEs were performed in 394 (37.4%) of DNR patients. On univariate logistic regression analysis, full code status had OR (95% confidence interval, CI) 0.57 (0.51-0.66), p < 0.01 compared with DNR status for the performance of inpatient TTE. In the final multivariate model adjusted for age, sex, race, and clinical comorbidities, the full code patients had OR (95% CI) 0.91 (0.79-1.05), p = 0.22 compared with DNR patients for the performance of inpatient TTE. DNR status is not associated with a decrease in inpatient transthoracic echocardiography performance.
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Incremental prognostic value of biventricular longitudinal strain and high-sensitivity troponin I in COVID-19 patients. Echocardiography 2021; 38:1272-1281. [PMID: 34184314 PMCID: PMC8444873 DOI: 10.1111/echo.15133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/10/2021] [Accepted: 05/31/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Whether the combination of ventricular strain with high-sensitivity troponin I (hs-TNI) has an incremental prognostic value in coronavirus disease 2019 (COVID-19) patients has not been evaluated. The study aimed to evaluate the prognostic value of biventricular longitudinal strain and its combination with hs-TNI in COVID-19 patients. METHODS A total of 160 COVID-19 patients who underwent both echocardiography and hs-TNI testing were enrolled in our study. COVID-19 patients were divided into two groups (critical and non-critical) according to severity-of-illness. The clinical characteristics, cardiac structure and function were compared between the two groups. The prognostic value of biventricular longitudinal strain and its combination with hs-TNI were evaluated by logistic regression analyses and receiver operating characteristic curves. Left ventricular longitudinal strain (LV LS) and right ventricular free wall longitudinal strain (RVFWLS) were determined by 2D speckle-tracking echocardiography. RESULTS The LV LS and RVFWLS both were significantly lower in critical patients than non-critical patients (LV LS: -16.6±2.4 vs -17.9±3.0, P = .003; RVFWLS :-18.8±3.6 vs -23.9±4.4, P<.001). During a median follow-up of 60 days, 23 (14.4%) patients died. The multivariant analysis revealed that LV LS and RVFWLS [Odd ratio (95% confidence interval): 1.533 (1.131-2.079), P = .006; 1.267 (1.036-1.551), P = .021, respectively] were the independent predictors of higher mortality. Further, receiver-operating characteristic analysis revealed that the accuracy for predicting death was greater for the combination of hs-TNI levels with LV LS than separate LV LS (AUC: .91 vs .77, P = .001), and the combination of hs-TNI levels with RVFWLS than RVFWLS alone (AUC: .89 vs .83, P = .041). CONCLUSIONS Our study highlights that the combination of ventricular longitudinal strain with hs-TNI can provide higher accuracy for predicting mortality in COVID-19 patients, which may enhance risk stratification in COVID-19 patients.
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Patent Ductus Arteriosus in Pregnancy: Cardio-Obstetrics Management in a Late Presentation. CASE 2021; 5:119-122. [PMID: 33912781 PMCID: PMC8071818 DOI: 10.1016/j.case.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Congenital heart disease may be first diagnosed during pregnancy. PDA with significant left-to-right shunting can cause peripartum cardiac decompensation. Multidisciplinary management of congenital heart disease in pregnancy is recommended.
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Saddle pulmonary embolism and thrombus-in-transit straddling the patent foramen ovale 28 days after COVID symptom onset. Echocardiography 2020; 37:1296-1299. [PMID: 32735050 DOI: 10.1111/echo.14796] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 01/22/2023] Open
Abstract
We present a late presentation of saddle pulmonary embolism and thrombus-in-transit straddle the patent foramen on patient who successfully recovered from severe acute respiratory syndrome coronavirus-2 (COVID-19) pneumonia. Seven days postdischarge (ie, 28 days after initial COVID-19 symptom onset), she was readmitted to hospital for severe dyspnea. Computer tomography angiogram and echocardiography confirmed the diagnosis. Severe pro-inflammatory and pro-thrombotic states with endothelial involvement have been reported associated with severe COVID-19 infection. However, the duration of hypercoagulable state has not yet known. This case highlights the risk of thromboembolic phenomena for prolonged periods of times after recovering from COVID-19 pneumonia.
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Abstract
A substantial proportion of patients with acute myocardial infarction develop clinical heart failure, which remains a common and major healthcare burden. It has been shown that in patients with chronic coronary artery disease, ischemic episodes lead to a global pattern of cardiomyocyte remodeling and dedifferentiation, hallmarked by myolysis, glycogen accumulation, and alteration of structural proteins. These changes, in conjunction with an impaired global coronary reserve, may eventually become irreversible and result in ischemic cardiomyopathy. Moreover, noninvasive imaging of myocardial scar and hibernation can inform the risk of sudden cardiac death. Therefore, it would be intuitive that imaging of myocardial viability is an essential tool for the proper use of invasive treatment strategies and patient prognostication. However, this notion has been challenged by large-scale clinical trials demonstrating that, in the modern era of improved guideline-directed medical therapies, imaging of myocardial viability failed to deliver effective guidance of coronary bypass surgery to a reduction of adverse cardiac outcomes. In addition, current available imaging technologies in this regard are numerous, and they target diverse surrogates of structural or tissue substrates of myocardial viability. In this document, we examine these issues in the current clinical context, collect current evidence of imaging technology by modality, and inform future directions.
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A self-resolving, post-traumatic aortopulmonary shunt. Echocardiography 2020; 37:781-783. [PMID: 32277495 DOI: 10.1111/echo.14654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/29/2022] Open
Abstract
A 34-year-old Hispanic man sustained a stab wound to his chest complicated with hemopericardium and pericardial tamponade. He underwent emergent clamshell thoracotomy as well as repair to the pulmonary artery. A transthoracic echocardiogram showed no evidence of intracardiac shunt. Two months later, a new murmur was noted, with a transthoracic echocardiogram revealing high-velocity flow between the left coronary sinus and the main pulmonary artery, with which a coronary computed tomography angiogram concurred. A transesophageal echocardiogram was performed which revealed an aortopulmonic fistula from the left coronary sinus of Valsalva, approximately 1cm anterior to the ostium of the left main coronary artery, to the main pulmonary artery just distal to the pulmonic valve. Pulmonary insufficiency was minimal. The main pulmonary artery was dilated, measuring 3.2 cm by coronary computed tomography angiogram. Right ventricular systolic function was normal. Right and left heart catheterizations were performed to further assess hemodynamics and coronary anatomy; pulmonary artery pressures were 16/8 mm Hg. Aortopulmonary fistula was seen on aortogram. Surgery was deferred in view of lack of symptoms and uncertainty in its natural history in the setting of traumatic etiology. A repeat transthoracic echocardiogram at six-month follow-up showed spontaneous closure of the fistula.
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Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Coronary Artery Bypass Grafting: Trends in Utilization and Propensity-Matched Analysis of In-Hospital Outcomes. Circ Cardiovasc Interv 2019; 11:e006179. [PMID: 29643130 DOI: 10.1161/circinterventions.117.006179] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 02/19/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited. METHODS AND RESULTS We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 (Ptrend<0.001). There were 3880 records in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% versus 2.4%; P=0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; P<0.001), stroke (1.4% versus 2.7%; P<0.001), bleeding complications (10.6% versus 24.6%; P<0.001), and acute kidney injury (16.2% versus 19.3%; P<0.001). Requirement for prior permanent pacemaker was higher in the TAVR cohort, whereas the incidence of vascular complications and acute kidney injury requiring dialysis was similar in the 2 groups. Average length of stay was shorter in patients undergoing TAVR. CONCLUSIONS TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients.
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Racial differences of heart failure with midrange ejection fraction (HFmrEF): a large urban centre-based retrospective cohort study in the USA. BMJ Open 2019; 9:e026479. [PMID: 31048442 PMCID: PMC6501992 DOI: 10.1136/bmjopen-2018-026479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES We aimed to study the racial differences in clinical presentations, survival outcomes and outcome predictors among patients with heart failure (HF) with midrange ejection fraction (HFmrEF, EF 40%-49%). DESIGN This is a retrospective study. SETTING Adults with HF diagnosis at Montefiore Medical Center, Bronx, New York between 2008 and 2012, with an inpatient echocardiogram showing left ventricular ejection fraction of 40%-49% were included as HFmrEF population. PARTICIPANTS 1,852 HFmrEF patients are included in the study (56% male, mean age 67 years). There were 493 (26.5%) non-Hispanic whites, 541 (29.2%) non-Hispanic black, 489 (26.4%) Hispanics and 329 (17.8%) other racial populations. OUTCOME MEASURES Cumulative probabilities of all-cause mortality among different racial groups were estimated and multivariable adjusted Cox proportional regressions were performed to assess predictors of mortality. RESULTS Among the HFmrEF patients, white patients were older and were less likely to be on guideline-directed medications. Blacks had a lower prevalence of prior myocardial infarction comparing to other groups. Hispanics had more chronic diseases and yet better survival comparing to whites and blacks after adjustment for age, sex and comorbidities. Distinct sets of survival predictors were revealed in individual racial groups. Baseline use of mineralocorticoid receptor antagonist (MRA) was associated with lower mortality among HFmrEF patients in general (HR 0.61, 95% CI 0.37 to 0.99). CONCLUSIONS There are significant racial/ethnic differences in clinical phenotypes, survival outcomes and mortality predictors of HFmrEF. Furthermore, the use of MRA predicted a reduced mortality in HFmrEF patients.
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A risk score for predicting atrial fibrillation in individuals with preclinical diastolic dysfunction: a retrospective study in a single large urban center in the United States. BMC Cardiovasc Disord 2019; 19:47. [PMID: 30813895 PMCID: PMC6391831 DOI: 10.1186/s12872-019-1024-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/15/2019] [Indexed: 01/12/2023] Open
Abstract
Background Left ventricular diastolic dysfunction has been shown to associate with increased risk of atrial fibrillation (AF). We aimed to examine the predictors of AF in individuals with preclinical diastolic dysfunction (PDD) - diastolic dysfunction without clinical heart failure – and develop a risk score in this population. Methods Patients underwent echocardiogram from December 2009 to December 2015 showing left ventricular ejection fraction (LVEF) ≥ 50% and grade 1 diastolic dysfunction, without clinical heart failure, valvular heart disease or AF were included. Outcome was defined as new onset AF. Cumulative probabilities were estimated and multivariable adjusted competing-risks regression analysis was performed to examine predictors of incident AF. A predictive score model was constructed. Results A total of 9591 PDD patients (mean age 66, 41% men) of racial/ethnical diversity were included in the study. During a median follow-up of 54 months, 455 (4.7%) patients developed AF. Independent predictors of AF included advanced age, male sex, race, hypertension, diabetes, and peripheral artery disease. A risk score including these factors showed a Wolber’s concordance index of 0.65 (0.63–0.68, p < 0.001), suggesting a good discrimination. Conclusions Our study revealed a set of predictors of AF in PDD patients. A simple risk score predicting AF in PDD was developed and internally validated. The scoring system could help clinical risk stratification, which may lead to prevention and early treatment strategies. Electronic supplementary material The online version of this article (10.1186/s12872-019-1024-4) contains supplementary material, which is available to authorized users.
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Addressing maternal mortality: the pregnant cardiac patient. Am J Obstet Gynecol 2019; 220:167.e1-167.e8. [PMID: 30278179 DOI: 10.1016/j.ajog.2018.09.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/07/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
Cardiac disease in pregnancy is the number one indirect cause of maternal mortality in the United States. We propose a triad solution that includes universal screening for cardiovascular disease in pregnancy and postpartum women, patient education, and institution of a multidisciplinary cardiac team. Additionally, we emphasize essential elements to maximize care for the pregnant cardiac patient based on our experience at our institution in Bronx, NY.
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Fibrin sheath infections can be safely and successfully treated with percutaneous vacuum-assisted thrombectomy. J Hosp Infect 2018; 101:112-113. [PMID: 30316836 DOI: 10.1016/j.jhin.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 10/05/2018] [Indexed: 11/30/2022]
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ACC/AATS/AHA/ASE/EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for the Treatment of Patients With Severe Aortic Stenosis: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Soc Echocardiogr 2017; 31:117-147. [PMID: 29254695 DOI: 10.1016/j.echo.2017.10.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The American College of Cardiology collaborated with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This is the first AUC to address the topic of AS and its treatment options, including surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). A number of common patient scenarios experienced in daily practice were developed along with assumptions and definitions for those scenarios, which were all created using guidelines, clinical trial data, and expert opinion in the field of AS. The 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(1) and its 2017 focused update paper (2) were used as the primary guiding references in developing these indications. The writing group identified 95 clinical scenarios based on patient symptoms and clinical presentation, and up to 6 potential treatment options for those patients. A separate, independent rating panel was asked to score each indication from 1 to 9, with 1-3 categorized as "Rarely Appropriate," 4-6 as "May Be Appropriate," and 7-9 as "Appropriate." After considering factors such as symptom status, left ventricular (LV) function, surgical risk, and the presence of concomitant coronary or other valve disease, the rating panel determined that either SAVR or TAVR is Appropriate in most patients with symptomatic AS at intermediate or high surgical risk; however, situations commonly arise in clinical practice in which the indications for SAVR or TAVR are less clear, including situations in which 1 form of valve replacement would appear reasonable when the other is less so, as do other circumstances in which neither intervention is the suitable treatment option. The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present. This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.
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Regional Variation in Utilization, In-hospital Mortality, and Health-Care Resource Use of Transcatheter Aortic Valve Implantation in the United States. Am J Cardiol 2017; 120:1869-1876. [PMID: 28865889 DOI: 10.1016/j.amjcard.2017.07.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 07/17/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
Abstract
We queried the National Inpatient Sample database from 2012 to 2014 to identify all patients aged ≥18 years undergoing transcatheter aortic valve implantation (TAVI) in the United States. Regional differences in TAVI utilization, in-hospital mortality, and health-care resource use were analyzed. Of 41,025 TAVI procedures in the United States between 2012 and 2014, 10,390 were performed in the Northeast, 9,090 in the Midwest, 14,095 in the South, and 7,450 in the West. Overall, the number of TAVI implants per million adults increased from 24.8 in 2012 to 63.2 in 2014. The utilization of TAVI increased during the study period in all 4 geographic regions, with the number of implants per million adults being highest in the Northeast, followed by the Midwest, South, and West, respectively. Overall in-hospital mortality was 4.2%. Compared with the Northeast, risk-adjusted in-hospital mortality was higher in the Midwest (adjusted odds ratio [aOR] 1.26 [1.07 to 1.48]) and the South (aOR 1.61 [1.40 to 1.85]) and similar in the West (aOR 1.00 [0.84 to 1.18]). Average length of stay was shorter in all other regions compared with the Northeast. Among patients surviving to discharge, disposition to a skilled nursing facility or home health care was most common in the Northeast, whereas home discharge was most common in the West. Average hospital costs were highest in the West. In conclusion, we observed significant regional differences in TAVI utilization, in-hospital mortality, and health-care resource use in the United States. The findings of our study may have important policy implications and should provide an impetus to understand the source of this regional variation.
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Circumferential strain acquired by CMR early after acute myocardial infarction adds incremental predictive value to late gadolinium enhancement imaging to predict late myocardial remodeling and subsequent risk of sudden cardiac death. J Interv Card Electrophysiol 2017; 50:211-218. [PMID: 29143170 DOI: 10.1007/s10840-017-0296-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/30/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Late adverse myocardial remodeling after acute myocardial infarction (AMI) is strongly associated with sudden cardiac death (SCD). Cardiac magnetic resonance (CMR) performed early after AMI can predict late remodeling and SCD risk with moderate accuracy. This study assessed the ability of CMR-measured circumferential strain (CS) to add incremental predictive information to late gadolinium enhancement (LGE). METHODS Patients with an AMI and LVEF < 50% were screened for inclusion. A total of 27 patients, totaling 432 myocardial segments, prospectively underwent CMR 7 ± 5 days after percutaneous coronary intervention (PCI). LGE, microvascular obstruction (MVO), and myocardial CS were measured for each segment. The primary endpoint was late segmental adverse remodeling defined as segmental wall motion score (WMS) > 1 measured by echocardiography 3 months after PCI. RESULTS A total of 141 segments experienced the primary endpoint at 3 months. The mean LGE volume was higher in these segments, but LGE was also present in many segments with normal WMS (40 ± 28 versus 20 ± 26%, p < 0.01). Segments that met the primary endpoint also showed greater impairment of CS. Segments with both LGE > 17% and impaired CS >- 7.2% on CMR were more likely to experience late adverse remodeling (73%) as compared to segments with neither (9%, p < 0.001) or one abnormal parameter (36%, p < 0.001). CS >- 7.2% also added incremental accuracy to LGE > 17% for predicting late adverse remodeling (AUC 0.81 from 0.70, p < 0.001). CONCLUSIONS When performed early after AMI, LGE is a moderate predictor of late remodeling and CS is a powerful predictor of late myocardial remodeling. When combined, they can predict late remodeling, a surrogate of SCD, with high accuracy.
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Cardiovascular outcomes of pregnancy in Marfan's syndrome patients: A literature review. CONGENIT HEART DIS 2017; 13:203-209. [DOI: 10.1111/chd.12546] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 11/30/2022]
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Association of Chronic Kidney Disease With In-Hospital Outcomes of Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2017; 10:2050-2060. [PMID: 29050621 DOI: 10.1016/j.jcin.2017.07.044] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/21/2017] [Accepted: 07/19/2017] [Indexed: 11/15/2022]
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Comparison of Predictors of Heart Failure With Preserved Versus Reduced Ejection Fraction in a Multiracial Cohort of Preclinical Left Ventricular Diastolic Dysfunction. Am J Cardiol 2017; 119:1815-1820. [PMID: 28450040 DOI: 10.1016/j.amjcard.2017.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/01/2017] [Accepted: 03/01/2017] [Indexed: 01/13/2023]
Abstract
Preclinical diastolic dysfunction (PDD) is a well-known but poorly understood risk factor for heart failure. We aimed to investigate risk factors contributing to progression of PDD to heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). Patients with echocardiogram from 2003 to 2008 with left ventricular ejection fraction ≥50%, grade I diastolic dysfunction, and free of clinical heart failure were included. The end point was incident HFpEF or HFrEF. Cumulative probabilities were estimated and multivariable adjusted Cox proportional hazards regressions were performed to examine predictors of incident HFpEF and HFrEF. In total, 7,878 patients with PDD (79.2% nonwhite) were included. At the end of follow-up (median 5.9 years), 146 patients developed HFrEF, and 635 patients developed HFpEF. The 10-year cumulative probabilities of HFrEF and HFpEF were 3.1% and 12.6%, respectively. Incidence of HFrEF was significantly lower in non-Hispanic blacks (2.2%) compared with non-Hispanic whites (4.5%). Age, diabetes, myocardial infarction, and renal disease were independent predictors of both HFrEF and HFpEF. Male gender, cerebrovascular accident, and low baseline left ventricular ejection fraction were associated with HFrEF only; whereas pulmonary disease, blood urea nitrogen, and anemia were predictors of HFpEF only. In conclusion, our results revealed a distinct set of predictors of HFrEF and HFpEF in patients with PDD and underscored a differential approach of risk stratification, prevention, and early treatment based on heart failure subtypes.
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Dynamic left ventricular changes in patients with gestational diabetes: A speckle tracking echocardiography study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:20-27. [PMID: 27681654 DOI: 10.1002/jcu.22399] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 05/27/2016] [Accepted: 08/11/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE The left ventricle (LV) undergoes physiologic remodeling in adaptation to the hemodynamic changes that occur in pregnancy. Speckle tracking echocardiography (STE) is a novel and reliable tool to evaluate subtle myocardial alterations that have been utilized to assess myocardial changes in patients with diabetes mellitus (DM) but not in patients with gestational DM (GDM). We seek to evaluate changes in LV function using STE in patients with GDM compared with women with normal pregnancy. METHODS This was a single-center retrospective cohort study. A total of 312 pregnant patients that underwent transthoracic echocardiogram (TTE) between 2009 and 2014 were screened. After excluding patients with comorbidities or insufficient data, 90 women were included. TTE from the second and third trimester for each patient were then reviewed, and STE analysis was performed. RESULTS Of the 90 subjects, 72 had normal pregnancies and 18 developed GDM. There was no difference in LV end-diastolic diameter (4.73 ± 0.40 versus 4.60 ± 0.56, p = 0.25), LV end-systolic diameter (3.12 ± 0.35 versus 2.91 ± 0.61, p = 0.152), or ejection fraction (62.26 ± 4.12 versus 63.50 ± 5.24, p = 0.314) between the two groups. Global longitudinal strain was lower (-19.8 ± 3.34 versus -17.2 ± 2.18, p < 0.001) in patients with GDM, while time-to-peak strain was greater (0.43 ± 0.05 versus 0.50 ± 0.06, p < 0.001). Circumferential and radial strains were preserved in both groups. CONCLUSIONS Although conventional TTE variables show preserved LV size and function, LV longitudinal strain suggests subclinical myocardial dysfunction in patients with GDM. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:20-27, 2017.
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A meta-analysis and meta-regression of long-term outcomes of transcatheter versus surgical aortic valve replacement for severe aortic stenosis. Int J Cardiol 2016; 225:234-243. [DOI: 10.1016/j.ijcard.2016.10.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 08/04/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022]
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Iatrogenic Ventricular Septal Defect Following Transcatheter Aortic Valve Replacement: A Systematic Review. Heart Lung Circ 2016; 25:968-74. [DOI: 10.1016/j.hlc.2016.03.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 03/12/2016] [Indexed: 11/17/2022]
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Sapien 3 versus Sapien XT prosthetic valves in transcatheter aortic valve implantation: A meta-analysis. Int J Cardiol 2016; 220:472-8. [DOI: 10.1016/j.ijcard.2016.06.159] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022]
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Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown cause that can affect the heart. Cardiac sarcoidosis may be present in as many as 25% of patients with systemic sarcoidosis, and it is frequently underdiagnosed. The early and accurate diagnosis of myocardial involvement is challenging. Advanced imaging techniques play important roles in the diagnosis and management of patients with cardiac sarcoidosis.
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Impact of transcatheter aortic valve implantation on left atrial appendage flow velocities. JOURNAL OF CLINICAL ULTRASOUND : JCU 2016; 44:375-382. [PMID: 26875747 DOI: 10.1002/jcu.22347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/17/2015] [Accepted: 01/21/2016] [Indexed: 06/05/2023]
Abstract
PURPOSE Left atrial appendage (LAA) flow velocity has not been extensively studied in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the impact of TAVI on LAA flow velocity. METHODS Medical records of consecutive TAVI recipients were reviewed retrospectively. Patients with persistent atrial fibrillation were excluded. LAA velocities were measured before and after TAVI by transesophageal echocardiography. RESULTS Sixty-one patients were included. Mean LAA emptying (EV) and filling (FV) flow velocity before TAVI were 33 ± 16 cm/s and 31 ± 14 cm/s, respectively. They increased to 37 ± 20 (p = 0.0036) and 33 ± 13 cm/s (p = 0.047) after TAVI in the whole population sample, but not in patients with normal flow AS. In low-flow, low-gradient (LFLG) AS patients, EV and FV increased from 36 ± 22 to 47 ± 30 cm/s (p < 0.01), and from 29 ± 12 to 40 ± 15 cm/s (p < 0.01), respectively, after TAVI. There was no difference between normal flow and LFLG AS patients in the number of patients who achieved EV ≥ 40 cm/s post-TAVI (35% versus 47%, p = 0.54, respectively). CONCLUSIONS LAA EV and FV were low prior to TAVI and increased significantly after TAVI only in patients with LFLG AS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:375-382, 2016.
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Spontaneous Echocardiographic Contrast in the Left Atrium During Transcatheter Aortic Valve Replacement is Associated With Worse Outcomes. THE JOURNAL OF INVASIVE CARDIOLOGY 2016; 28:152-157. [PMID: 27031937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Patients undergoing transcatheter aortic valve replacement (TAVR) often have spontaneous echocardiographic contrast (SEC) observed in the left atrium (LA). Mid-term prognosis of patients with SEC following TAVR is not well studied. We assessed the impact of SEC on outcomes after TAVR. METHODS Medical records of 93 consecutive patients who underwent TAVR at a single center were reviewed retrospectively. The primary endpoint was defined as the composite of a cardioembolic event, death from any cause, and admission for decompensated heart failure within 3 months of TAVR. RESULTS After excluding 3 patients who had procedural complications, 90 patients were included in the study. The mean age was 81 ± 8 years old and 50% were male. There were 12 patients with SEC in the LA (group 1) and 78 patients without SEC in the LA (group 2) during the TAVR procedure. Atrial fibrillation was more common in group 1 (50% vs 13%, respectively; P=.01) and diabetes was more common in group 2 (17% vs 53%, respectively; P=.03). The primary endpoint occurred in 22 patients (24%) and occurred more in group 1 (58% vs 19%, respectively; P<.01). On regression analysis, after adjusting for sex and STS score, SEC had a hazard ratio (HR) of 5.02 (95% confidence interval [CI], 1.96-12.9; P<.001) and STS ≥15 had an HR of 6.37 (95% CI, 2.02-20.1; P=.01). On survival analysis, group 1 had lower event-free survival compared with group 2 (log-rank P=.01). CONCLUSION SEC during TAVR procedure is a negative prognostic marker for death, cardioembolic events, or admission for decompensated heart failure in the first 3 months post procedure.
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Ventricular septal rupture complicating acute myocardial infarction in the modern era with mechanical circulatory support: a single center observational study. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2016; 6:10-16. [PMID: 27073732 PMCID: PMC4788724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 09/28/2015] [Indexed: 06/05/2023]
Abstract
Ventricular septal rupture (VSR) is a rare but devastating complication after acute myocardial infarction (AMI). While the incidence has decreased, the mortality rate from VSR has remained extremely high. The use of mechanical circulatory support with intra-aortic balloon pump (IABP) and extracorporal membrane oxygenation (ECMO) may be useful in providing hemodynamic stability and time for myocardial scarring. However, the optimal timing for surgical repair remains an enigma. Retrospective analysis of 14 consecutive patients diagnosed with VSR after AMI at Montefiore Medical Center between January 2009 and June 2015. A chart review was performed with analysis of baseline characteristics, hemodynamics, imaging, percutaneous interventions, surgical timing, and outcomes. The survival group had a higher systolic BP (145 vs 98, p<0.01), higher MAP (96 vs 76, p=0.03), and lower HR (75 vs 104, p=0.05). Overall surgical timing was 6.5 ± 3.7 days after indexed myocardial infarction with a significant difference between survivors and non-survivors (9.8 vs 4.3, p=0.01). The number of pre-operative days using IABP was longer in survivors (6.5 vs 3.2, p=0.36) as was post-operative ECMO use (4.5 vs 2 days, p=0.35). The overall 30-day mortality was 71.4% with a 60% surgical mortality rate. Hemodynamics at the time of presentation and a delayed surgical approach of at least 9 days showed significant association with improved survival. Percutaneous coronary intervention (PCI) was more common in non-survivors. The use of IABP in the pre-operative period and post-operative ECMO use likely provide a survival benefit.
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Inferolateral ST-segment Elevation in Boerhaave Syndrome. Am J Med 2016; 129:e27-8. [PMID: 26597672 PMCID: PMC4799847 DOI: 10.1016/j.amjmed.2015.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/01/2015] [Accepted: 09/01/2015] [Indexed: 11/24/2022]
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The Impact of Race on the Prognosis of Preclinical Diastolic Dysfunction: A Large Multiracial Urban Population Study. Am J Med 2016; 129:222.e1-10. [PMID: 26475254 DOI: 10.1016/j.amjmed.2015.08.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/05/2015] [Accepted: 08/25/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study was performed to assess the impact of race on the incidence of heart failure and survival in patients with preclinical diastolic dysfunction. METHODS All adults during a 5-year period with grade 1 diastolic dysfunction on echocardiogram, left ventricular ejection fraction ≥ 50%, and no diagnosis of heart failure were included in this study. Clinical endpoints were new diagnosis of heart failure (International Classification of Diseases-Ninth Revision code 428.0) and all-cause mortality. A total of 7878 patients: 20.8% non-Hispanic White, 35.8% non-Hispanic Black, and 31.0% Hispanic individuals (mean age was 68 ± 12 years, 37% men) were included in the study. Non-Hispanic Whites were older, more frequently male, and had a higher mean socioeconomic status and more antecedent myocardial infarction. RESULTS Non-Hispanic Blacks and Hispanics had more hypertension, diabetes, renal disease, and cerebrovascular disease. After a median follow-up time of 6 years, 1356 patients developed heart failure and 2078 patients died. The 10-year cumulative probabilities of heart failure and all-cause mortality were 23.9% and 32.6%, respectively. Time to incident heart failure was similar among the 3 racial groups. However, non-Hispanic Blacks (hazard ratio 0.80, P = .002) and Hispanics (hazard ratio 0.67, P < .001) experienced lower mortality compared with non-Hispanic Whites, which was confirmed on a propensity-scored sensitivity analysis. CONCLUSIONS Time to heart failure was similar among the 3 racial groups, however, non-Hispanic Whites experienced worse survival compared with non-Hispanic Blacks and Hispanics, despite their higher burden of risk factors. The reasons for worse survival in the non-Hispanic white population need to be further explored.
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Abstract
Determination of ventricular arrhythmic risk is crucial for guiding management of cardiac disease. Although for patients at increased risk an implantable cardioverter-defibrillator is recommended, it is widely acknowledged that current criteria for device use based predominantly on left ventricular ejection fraction are deficient. Genesis of ventricular arrhythmias involves a complex interaction of myocardial substrate abnormalities, precipitating triggers, and modulating factors. There are much data showing that by more directly assessing these factors, noninvasive imaging using echocardiography, radionuclide imaging, and cardiac magnetic resonance enhances arrhythmic risk stratification beyond ejection fraction and commonly used electrocardiographic and serum biomarkers. It is anticipated that further technological advancements studied in well-designed clinical trials will provide both more precise determination of risk and guide therapies to enhanced survival and patient well-being.
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Mechanical valve obstruction: Review of diagnostic and treatment strategies. World J Cardiol 2015; 7:875-881. [PMID: 26730292 PMCID: PMC4691813 DOI: 10.4330/wjc.v7.i12.875] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/22/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
Prosthetic valve obstruction (PVO) is a rare but feared complication of mechanical valve replacement. Diagnostic evaluation should focus on differentiating prosthetic valve thrombosis (PVT) from pannus formation, as their treatment options differ. History of sub-optimal anti-coagulation and post-op time course to development of PVO are useful clinical characteristics in differentiating thrombus from pannus formation. Treatment of PVT is influenced by the patient’s symptoms, valve location, degree of obstruction and thrombus size and may include thrombolysis or surgical intervention. Alternatively, pannus formation requires surgical intervention. The purpose of this article is to review the pathophysiology, epidemiology, diagnostic approach and treatment options for aortic and mitral valve PVO.
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Aortocavitary fistula as a complication of infective endocarditis and subsequent complete heart block in a patient with severe anemia. J Community Hosp Intern Med Perspect 2015; 5:29446. [PMID: 26653694 PMCID: PMC4677595 DOI: 10.3402/jchimp.v5.29446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 09/28/2015] [Accepted: 10/02/2015] [Indexed: 01/16/2023] Open
Abstract
Infective endocarditis has different presentations depending on the involvement of valvular and perivalvular structures, and it is associated with high morbidity and mortality. Aortocavitary fistula is a rare complication. We introduce the case of a 48-year-old female with native valve endocarditis, complicated by aortocavitary fistula to the right atrium, and consequently presented with syncope.
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The Reply. Am J Med 2015; 128:e39. [PMID: 26592317 DOI: 10.1016/j.amjmed.2015.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 07/29/2015] [Indexed: 11/24/2022]
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Paradoxical low-flow aortic stenosis is defined by increased ventricular hydraulic load and reduced longitudinal strain. J Cardiovasc Med (Hagerstown) 2015; 18:87-95. [PMID: 26556444 DOI: 10.2459/jcm.0000000000000324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology. METHODS One hundred and twenty patients (age 79 ± 12 years, 37% men) with an indexed aortic valve area (AVAi) of 0.6 cm/m or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi ≤ 35 ml/m, N = 46; normal-flow aortic stenosis, SVi > 35 ml/m, N = 74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography. RESULTS Patients with PLF-AS were found to have more valvular load (lower AVAi, P = 0.028; lower energy loss coefficient, P = 0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both P < 0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), P < 0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (P < 0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR) = 1.34, P = 0.043; OR = 1.31, P = 0.004; OR = 1.34, P = 0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (OR = 1.38, P = 0.015; OR = 1.33, P < 0.001 for both, respectively) were associated with PLF-AS. CONCLUSION Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.
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Increased apical rotation in severe aortic stenosis is associated with reduced survival: a speckle-tracking study. J Am Soc Echocardiogr 2015; 28:1294-301. [PMID: 26341121 DOI: 10.1016/j.echo.2015.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with severe aortic stenosis (AS) are known to have increased left ventricular apical rotation (ApRot) during systole, but its clinical relevance is unknown. The aim of this study was to assess the association of ApRot with patient symptoms and total mortality. METHODS A retrospective analysis was performed on 82 patients (mean age, 77 ± 14 years; 40% men) with newly diagnosed severe AS with indexed aortic valve areas ≤ 0.6 cm(2)/m(2) and left ventricular ejection fractions ≥ 50%. Sixty-three percent of patients were symptomatic. ApRot was calculated using speckle-tracking echocardiography. Patients were divided into two groups on the basis of ApRot: high ApRot (>4.0°, n = 41) and low ApRot (≤4.0°, n = 41). RESULTS There were 33 deaths and 30 aortic valve replacement procedures after 33 ± 17 months of follow-up. Patients in the high-ApRot group had smaller indexed aortic valve areas (P = .021) and increased valvuloarterial impedance (P = .014). There was no difference in overall symptoms, but the low-ApRot group experienced more syncope (P = .020). Patients in the high-ApRot group had reduced survival with medical therapy (log-rank P = .018) after aortic valve replacement (log-rank P = .039) and overall (log-rank P = .009). Asymptomatic patients with low ApRot had the best survival, while asymptomatic patients with high ApRot had similar survival to that of symptomatic patients (log-rank P = .008). On adjusted Cox regression, ApRot ≥ 6.0° was independently associated with death (hazard ratio, 3.06; P = .003). On receiver operating characteristic curve analysis, ApRot added incremental prognostic value to indexed aortic valve area, symptom status, and aortic valve replacement status. CONCLUSION Increased ApRot is independently associated with poor survival and may represent a compensatory mechanism to preserve cardiac output against severe obstruction to flow and high systolic load.
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Physiological adaptation of the left ventricle during the second and third trimesters of a healthy pregnancy: a speckle tracking echocardiography study. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2015; 5:119-126. [PMID: 26309775 PMCID: PMC4539098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/15/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND During a healthy pregnancy women experience cardiovascular and hemodynamic changes and normal ranges of left ventricular (LV) function on two-dimensional speckle tracking echocardiography (STE) are not well defined. The aim of this study was to describe the cardiovascular changes that occur during the second and third trimesters of a healthy pregnancy using STE. METHODS Pregnant subjects were enrolled retrospectively if they underwent a transthoracic echocardiography (TTE) between 2011-2014. Subjects with abnormal TTE findings, hypertension, diabetes, preeclampsia, prior cardiac surgery, poor imaging quality or in the 1st trimester were excluded. A total of 74 pregnant subjects were categorized into the 2nd or 3rd trimesters. Twenty-one healthy age-matched females were selected as a control group. RESULTS The heart undergoes extensive remodeling during pregnancy with increased LV septal thickness, posterior wall thickness, cavity size and mass (p=0.045, p=0.002, p<0.001, p=0.018, respectively). However, myocardial mechanical function measured by: global longitudinal strain, radial strain, circumferential strain, systolic and diastolic global longitudinal strain rate (GLSR), global radial strain rate (GRSR) and global circumferential strain rate, remains preserved. Only time to peak strain rate corrected for heart rate for diastolic GRSR and diastolic GLSR were significantly increased in the third trimester (p=0.016 for both). CONCLUSION Despite extensive heart remodeling, many STE derived parameters of LV function in healthy pregnant women remain unchanged and valid for women in the 2nd and 3rd trimester. Future studies investigating early detection of pregnancy related heart disease can refer to these parameters as reference ranges.
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Does the transapical approach impair early recovery of systolic strain following transcatheter aortic valve replacement? AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2015; 5:110-118. [PMID: 26309774 PMCID: PMC4539097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 07/14/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND In transcatheter aortic valve replacement (TAVR) the trans-apical approach (TA) is associated with apical myocardial injury but it is unknown if this injury impacts myocardial function. This study was performed to assess the impact of TA on apical longitudinal strain (ALS) and global longitudinal strain (GLS) after TAVR. METHODS 44 consecutive patients (age 81 ± 7 years, 48% male) underwent TAVR via trans-femoral (TF) (n=27) or TA (n=17) approach. Speckle-tracking analysis of left ventricular longitudinal strain was performed on images from peri-procedure transesophageal echocardiograms immediately before and after valve implantation. The primary endpoint was a GLS improvement of at least 25% post-TAVR. RESULTS GLS improved significantly above baseline after valve implantation in both TF (p<0.001) and TA (p=0.027) groups. The absolute magnitudes of ALS and GLS improvement were similar between TF and TA patients (ALS: p=0.282; GLS: p=0.248). Peak ALS and GLS achieved post-TAVR were similar between TF and TA patients (ALS: p=0.933; GLS: p=0.365). 47% of patients achieved a GLS improvement of >25%; 16 of which improved their GLS to <-15%. The severity of pre-TAVR GLS impairment was a strong independent predictor of GLS improvement (OR=1.61, p=0.003). A pre-TAVR GLS ≥-13.7% was 82% sensitive and 82% specific for TAVR to confer a GLS improvement >25%. CONCLUSION Equal improvement in myocardial strain was observed in the TF and TA patients. Pre-TAVR GLS impairment was an independent predictor of post-TAVR GLS recovery, highlighting how it is the patient's baseline GLS dysfunction, not the method of approach, that dictates post-TAVR functional recovery.
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