Worsening Renal Function during Index Hospitalization Does Not Predict Prognosis in Heart Failure with Preserved Ejection Fraction Patients.

INTRODUCTION: Worsening renal function (WRF) predicts poor prognosis in patients with left ventricular systolic dysfunction. The effect of WRF in heart failure with preserved ejection fraction (HFpEF) is unclear. OBJECTIVE: The objective of this study was to determine whether WRF during index hospitalization for HFpEF is associated with increased death or readmission for heart failure. METHODS: National Veterans Affairs electronic medical data recorded between January 1, 2002, and December 31, 2014, were screened to identify index hospitalizations for HFpEF using an iterative algorithm. Patients were divided into 3 groups based on changes in serum Cr (sCr) during this admission. WRF was defined as a rise in sCr ≥0.3 mg/dL. Group 1 had no evidence of WRF, group 2 had transient WRF, and group 3 had persistent WRF at the time of discharge. RESULTS: A total of 10,902 patients with index hospitalizations for HFpEF were identified (mean age 72, 97% male). Twenty-nine percent had WRF during this hospital admission, with 48% showing recovery of sCr and 52% with no recovery at discharge. The mortality rate over a mean follow-up duration of 3.26 years was 72%. Compared to group 1, groups 2 and 3 showed no significant difference in risk of death from any cause (hazard ratio [HR] = 0.95 [95% confidence interval [CI]: 0.87, 1.03] and 1.02 [95% CI: 0.93, 1.11], respectively), days hospitalized for any cause (incidence density ratio [IDR] = 1.01 [95% CI: 0.92, 1.11] and 1.01 [95% CI: 0.93, 1.11], respectively), or days hospitalized for heart failure (IDR = 0.94 [95% CI: 0.80, 1.10] and 0.94 [95% CI: 0.81, 1.09], respectively) in analyses adjusted for covariates affecting renal function and outcomes. CONCLUSIONS: While there is a high incidence of WRF during index hospitalizations for HFpEF, WRF is not associated with an increased risk of death or hospitalization. This suggests that WRF alone should not influence decisions regarding heart failure management.

Fungal prosthetic aortic valve endocarditis and endarteritis: An unusual cause of aortic root vegetations.

Fungal endocarditis is a relatively rare occurrence with high morbidity and mortality. Patients may have an indolent and non-specific course requiring a high index of suspicion to make a diagnosis. Here, we present the case of a 33-year-old patient who presented with fevers and acute lower limb ischemia requiring a 4-compartment fasciotomy caused by septic emboli from Candida albicans endocarditis. The patient had a large vegetation in the ascending aorta associated with a mycotic aneurysm, which is an exceedingly rare location for a vegetation. We also review the literature and summarize the typical echocardiographic appearance and vegetation locations in fungal endocarditis.

Left Ventricular Thrombus in the Setting of Normal Left Ventricular Function in Patients with Crohn's Disease.

Crohn's disease results in a hypercoagulable state increasing the risk of venous or arterial thromboembolism. Cardiac involvement has not been routinely identified. Two cases are presented to illustrate that patients with Crohn's disease may represent an exception to the rule that left ventricular apical thrombus should be associated with an underlying wall motion abnormality and reduction in left ventricular ejection fraction.

Patients with Diabetes and Significant Epicardial Coronary Artery Disease Have Increased Systolic Left Ventricular Apical Rotation and Rotation Rate at Rest.

OBJECTIVE: The purpose of this study was to determine whether resting myocardial deformation and rotation may be altered in diabetic patients with significant epicardial coronary artery disease (CAD) with normal left ventricular ejection fraction. DESIGN: A prospective observational study. SETTING: Diagnosis of epicardial CAD in patients with diabetes. PATIENTS AND METHODS: Eighty-four patients with diabetes suspected of epicardial CAD scheduled for cardiac catheterization had a resting echocardiogram performed prior to their procedure. Echocardiographic measurements were compared between patients with and without significant epicardial CAD as determined by cardiac catheterization. MAIN OUTCOME MEASURES: Measurement of longitudinal strain, strain rate, apical rotation, and rotation rate, using speckle tracking echocardiography. RESULTS: Eighty-four patients were studied, 39 (46.4%) of whom had significant epicardial CAD. Global peak systolic apical rotation was significantly increased (14.9 ± 5.1 vs. 11.0 ± 4.8 degrees, P < 0.001) in patients with epicardial CAD along with faster peak systolic apical rotation rate (90.4 ± 29 vs. 68.1 ± 22.2 degrees/sec, P < 0.001). These findings were further confirmed through multivariate logistic regression analysis (global peak systolic apical rotation OR = 1.17, P = 0.004 and peak systolic apical rotation rate OR = 1.05, P < 0.001). CONCLUSIONS: Patients with diabetes with significant epicardial CAD and normal LVEF exhibit an increase in peak systolic apical counterclockwise rotation and rotation rate detected by echocardiography, suggesting that significant epicardial CAD and its associated myocardial effects in patients with diabetes may be detected noninvasively at rest.

Improved differential diagnosis of intracardiac and extracardiac shunts using acoustic intensity mapping of saline contrast studies.

AIMS: The aim of this study was to test the hypothesis that temporal patterns of saline contrast entry into, and exit from the left heart are significantly different in intra- and extra-cardiac shunts and can be used to differentiate the shunt mechanism when Valsalva manoeuvre cannot be performed, or is of uncertain quality. We propose a novel approach of mapping the temporal changes in acoustic intensity (AI) within the left and right heart to identify and define these unique patterns. METHODS AND RESULTS: We screened cases of right to left shunting on resting agitated saline contrast echocardiograms with clinical criteria that identified the origin of shunting as either a patent foramen ovale or pulmonary arteriovenous malformation. Acoustic time-intensity curves were generated from the right and left heart chambers that reflected the change in saline contrast density over time. Several novel pre-specified parameters were measured from these curves, in addition to the standard heartbeat counting method, to characterize the entrance (wash-in) and exit (wash-out) patterns of saline contrast in the left heart. Statistical analysis showed that AI mapping provided superior differentiation of the two populations than did the traditional beat counting method. CONCLUSION: Diagnosis of shunt mechanism from saline contrast studies can be improved over current methods through the use of AI mapping to define the rapidity that peak contrast effect develops, the speed that the contrast effect decays, and the contrast intensity late in the recording.

Slope of the anterior mitral valve leaflet: a new measurement of left ventricular unloading for left ventricular assist devices and systolic dysfunction.

Left ventricular assist device (LVAD)-supported patients are evaluated routinely with use of transthoracic echocardiography. Values of left ventricular unloading in this unique patient population are needed to evaluate LVAD function and assist in patient follow-up. We introduce a new M-mode measurement, the slope of the anterior mitral valve leaflet (SLAM), and compare its efficacy with that of other standard echocardiographically evaluated values for left ventricular loading, including E/e' and pulmonary artery systolic pressures. Average SLAM values were determined retrospectively for cohorts of random, non-LVAD patients with moderately to severely impaired left ventricular ejection fraction (LVEF) (<0.35, n=60). In addition, pre- and post-LVAD implantation echocardiographic images of 81 patients were reviewed. The average SLAM in patients with an LVEF <0.35 was 11.6 cm/s (95% confidence interval, 10.4-12.8); SLAM had a moderately strong correlation with E/e' in these patients. Implantation of LVADs significantly increased the SLAM from 7.3 ± 2.44 to 14.7 ± 5.01 cm/s (n=42, P <0.0001). The LVAD-supported patients readmitted for exacerbation of congestive heart failure exhibited decreased SLAM from 12 ± 3.93 to 7.3 ± 3.5 cm/s (n=6, P=0.041). In addition, a cutpoint of 10 cm/s distinguished random patients with LVEF <0.35 from those in end-stage congestive heart failure (pre-LVAD) with an 88% sensitivity and a 55% specificity. Evaluating ventricular unloading in LVAD patients remains challenging. Our novel M-mode value correlates with echocardiographic values of left ventricular filling in patients with moderate-to-severe systolic function and dynamically improves with the ventricular unloading of an LVAD.

Transthoracic echocardiographic assessment of continuous-flow left ventricular assist devices.

An increasing number of patients are implanted with continuous-flow left ventricular assist devices (LVAD) for the treatment of severe congestive heart failure. In parallel with this growing experience has been an increase in knowledge of how these devices alter cardiac physiology and the important implications this has for cardiac function. Echocardiography offers the ability to provide serial noninvasive evaluation before and after LVAD implantation to document these changes, guide management decisions, and identify LVAD dysfunction. The authors detail a comprehensive assessment of LVAD function by transthoracic echocardiography.