Pleural Effusions Following Liver Transplantation: A Single-Center Experience.

INTRODUCTION: This was a single-center retrospective study to evaluate incidence, prognosis, and risk factors in patients with postoperative pleural effusions, a common pulmonary complication following liver transplantation. METHODS: A retrospective review was performed on 374 liver transplantation cases through a database within the timeframe of January 1, 2009 through December 31, 2015. Demographics, pulmonary and cardiac function testing, laboratory studies, intraoperative transfusion/infusion volumes, postoperative management, and outcomes were analyzed. RESULTS: In the immediate postoperative period, 189 (50.5%) developed pleural effusions following liver transplantation of which 145 (76.7%) resolved within 3 months. Those who developed pleural effusions demonstrated a lower fibrinogen (149.6 ± 66.3 mg/dL vs 178.4 ± 87.3 mg/dL; P = .009), total protein (5.8 ± 1.0 mg/dL vs 6.1 ± 1.2 mg/dL; P = .04), and hemoglobin (9.8 ± 1.8 mg/dL vs 10.3 ± 1.9 mg/dL; P = .004). There was not a statistically significant difference in 1-year all-cause mortality and in-hospital mortality between liver transplant recipients with and without pleural effusions. Liver transplant recipients who developed pleural effusions had a longer hospital length of stay (16.4 ± 10.9 days vs 14.0 ± 16.5 days; P = .1), but the differences were not statistically significant. However, there was a significant difference in tracheostomy rates (11.6% vs 5.4%; P = .03) in recipients who developed pleural effusions compared to recipients who did not. CONCLUSIONS: In summary, pleural effusions are common after liver transplantation and are associated with increased morbidity. Pre- and intraoperative risk factors can offer both predictive and prognostic value for post-transplantation pleural effusions. Further prospective studies will be needed to further evaluate the relevance of these findings to limit instances of postoperative pleural effusions.

Serial echocardiography for valve dysfunction and aortic dilation in bicuspid aortic valves.

BACKGROUND AND AIMS: Complications of bicuspid aortic valve commonly include aortic stenosis, aortic regurgitation, and ascending aortic dilation. The progression of these lesions is not well described. MATERIALS AND METHODS: We reviewed 249 bicuspid aortic valve patients with at least two echocardiograms from 2006 to 2016. Valve morphology (right-left or right-noncoronary cusp fusion) was confirmed by visual inspection, and aortic stenosis and regurgitation were quantified according to current guidelines; the ascending aorta was measured at end-systole 2-3 cm above the sinotubular junction. Annualized progression of stenosis, regurgitation, and aortic dilation from first to most recent echocardiogram were compared between right-left and right-nonfused valves using multivariable logistic regression to adjust for baseline differences in groups. RESULTS: Among 249 bicuspid aortic valve patients (mean age 47.6 ± 13.5 years, 66.3% male), 75.9% had right-left cusp fusion. At baseline, aortic stenosis was absent or mild in 80.3%; aortic regurgitation was absent or mild in 80.7%; and aortic diameters were 35.0 ± 5.7 mm (sinuses of Valsalva) and 37.4 ± 6.2 mm (ascending). Mean annualized decrease in aortic valve area was 0.07 cm2 /year, with 30% of bicuspid aortic valve patients progressing ≥0.1 cm2 /year. Aortic regurgitation progressed ≥1 grade in 37 patients. Mean annualized increase in ascending aorta diameter was 0.36 mm/year in right-left and 0.65 mm/year in right-nonbicuspid valves. CONCLUSIONS: In this serial echocardiographic study of bicuspid aortic valve patients, cusp orientation was not associated with progression of valve dysfunction. Right-noncoronary cusp fusion was associated with ascending aortic diameter progression.

Evaluating a decision tool for diagnosing diastolic dysfunction and estimation of left ventricular filling pressures in the presence of mitral annular calcium.

OBJECTIVES: This study sought to evaluate a decision algorithm for the estimation of left ventricular filling pressure (LVFP) in patients with mitral annular calcification (MAC). BACKGROUND: In a single center study, Abudiab et al evaluated echocardiographic parameters to estimate LVFP in patients with MAC against invasive hemodynamic measurements and developed a decision algorithm which demonstrated high predictive accuracy. METHODS: Retrospectively, 55 patients (mean age 68.5 ± 11.5) with MAC and a left heart catheterization within 24 hours of an echocardiogram were identified. The decision algorithm was applied using echo data to classify patients as having normal or elevated LVFP which was then compared with the invasively obtained LVFP. RESULTS: The algorithm performed poorly at predicting pre-A LVFP as normal or high (P = .182). Accuracy for the algorithm was 0.59 [0.46, 0.72] (mean [95% CI]), sensitivity was 0.45 [0.28, 0.62], specificity was 0.73 [0.54, 0.86], false positive rate was 0.27 [0.14, 0.46], and false negative rate was 0.55 [0.38, 0.72]. E/A ratio, IVRT, and E/e'ratio showed no significant relationship to actual patient LVFP. CONCLUSIONS: The Abudiab et al algorithm failed to demonstrate comparable sensitivity, specificity, and accuracy in our sample. Additional study is necessary to refine this tool prior to more widespread use in clinical practice.

Association of Left Atrial Function Index With Late Atrial Fibrillation Recurrence after Catheter Ablation.

INTRODUCTION: Although catheter ablation (CA) for atrial fibrillation (AF) is commonly used to improve symptoms, AF recurrence is common and new tools are needed to better inform patient selection for CA. Left atrial function index (LAFI), an echocardiographic measure of atrial mechanical function, has shown promise as a noninvasive predictor of AF. We hypothesized that LAFI would relate to AF recurrence after CA. METHODS AND RESULTS: All AF patients undergoing index CA were enrolled in a prospective institutional AF Treatment Registry between 2011 and 2014. LAFI was measured post hoc from pre-ablation clinical echocardiographic images in 168 participants. Participants were mostly male (33% female), middle-aged (60 ± 10 years), obese and had paroxysmal AF (64%). Mean LAFI was 25.9 ± 17.6. Over 12 months of follow-up, 78 participants (46%) experienced a late AF recurrence. In logistic regression analyses adjusting for factors known to be associated with AF, lower LAFI remained associated with AF recurrence after CA [OR 0.04 (0.01-0.67), P = 0.02]. LAFI discriminated AF recurrence after CA slightly better than CHADS2 (C-statistic 0.60 LAFI, 0.57 CHADS2). For participants with persistent AF, LAFI performed significantly better than CHADS2 score (C statistic = 0.79 LAFI, 0.56 CHADS2, P = 0.02). CONCLUSION: LAFI, an echocardiographic measure of atrial function, is associated with AF recurrence after CA and has improved ability to discriminate AF recurrence as compared to the CHADS-2 score, especially among persistent AF patients. Since LAFI can be calculated using standard 2D echocardiographic images, it may be a helpful tool for predicting AF recurrence.

Body mass index predicts major bleeding risks in patients on warfarin.

Despite the lack of an optimum dosing strategy in obese patients, warfarin remains the most commonly used anticoagulant. Body mass index (BMI) >30 has been linked to increased time to obtain a therapeutic international normalized ratio on initiation of warfarin as well as higher maintenance dose. Despite higher dosage requirements, few studies have examined the relationship between warfarin and bleeding events in obese individuals. We examined the performance of BMI in predicting the incidence of bleeding at an anticoagulation clinic (ACC) over a 1 year period. Eight hundred and sixty-three patients followed in the ACC over a 1 year period were evaluated for bleeds in relation to BMI [defined as weight (kg)/height (m(2))]. Seventy-one of the 863 patients had a bleeding event (8.2 %); mean age 69.5 years and 44 % females. BMI categories were normal weight (21 %), overweight (38 %), obese class I (21 %), II (9 %), and III (11.3 %), respectively. Prevalence of major and minor bleeding events were 4.4 and 3.8 %, respectively. In univariate analyses, hazard ratio (HR) for major bleeding risks increases with higher obesity categories (HR 1.3, 1.85, and 1.93 for classes I, II, III, respectively). In multivariable adjusted model obesity classes II and III significantly increased the risk of major bleeds (HR 1.84, p < 0.001). Bleeding risk is higher in obese compared to normal weight individuals who are on warfarin. These results suggests that BMI plays a role in bleeding events in patients on warfarin.

Angled Microcatheter Assisted Antegrade Dissection Re-Entry Technique for Tortuous Totally Occluded Coronary Arteries.

BACKGROUND: Subacute total occlusion in the setting of a tortuous vessel can be a therapeutic challenge. we demonstrate a safe and successful approach to deploy drug eluting stent of this complex lesion by using angled microcatheter. CASE PRESENTATION: A 61-year-old male with multiple atherosclerotic risk factors diagnosed with NSTEMI secondary to subacute total occlusion of the mid right coronary artery (RCA) with collaterals filling from septal perforators arising from mid left anterior descending artery. Due to severe tortuosity of RCA, the wire inside of Corsair microcatheter kept directing away from the lumen. Therefore, Corsair was exchanged for 90-degree SuperCross™ angled microcatheter that was rotated to direct its opening towards the lumen. A Confianza pro 12 wire was used to puncture into the lumen from the subinitimal position. SuperCross™ microcatheter was advanced over the wire into the lumen and eventually drug eluting stents were deployed successfully. CONCLUSION: While facing subacute total occlusion with proximal end in a tortuous artery, SuperCross™ microcatheter assisted dissection reentry could be attempted after failure of antegrade wire escalation technique. LEARNING OBJECTIVE: Facilitate the use of SuperCross™ microcatheter assisted dissection reentry as a successful approach for subacute total occlusion in tortuous vessels.

Bilateral vas deferens calcification in a patient with multi-vessel coronary artery disease and severe aortic stenosis: linking infertility with cardiovascular disease.

Vas deferens calcification is a chronic arterio-sclerotic process that develops over many years and is strongly associated with infertility. Incidental findings on imaging are the most common means of diagnosing this condition. We report a case of a 56-year man who likely has male factor infertility and was found to have bilateral vas deferens calcification on CT imaging. This was performed during pre-procedural workup for transcatheter aortic valve replacement (TAVR) for management of severe aortic stenosis (AS). The patient was also had severe calcific multi-vessel coronary artery disease requiring percutaneous coronary intervention with atherectomy. This case highlights a novel clinical association linking infertility with coronary and valvular heart disease. It is possible that this association exists in larger numbers than previously recognized. Closer monitoring of pelvic imaging for TAVR access planning in patients with severe AS may bring more cases to light.

Post-Myocardial Infarction Complications During the COVID-19 Pandemic - A Case Series.

We report 4 cases of post myocardial infarction complications due to the delay in presentation during COVID-19 era. We highlighted the need for auscultating the chest for early diagnosis. Through this case series, we urge to raise awareness among cardiac patients to access healthcare despite the fear of COVID-19.

Meta-analysis of minimalist versus standard care approach for transcatheter aortic valve replacement.

BACKGROUND: The change in practice of transcatheter aortic valve replacement (TAVR) to a minimalist approach is a debate. METHODS: Online database search for studies that compared the minimalist approach with the standard approach for TAVR were searched from inception through September 2020. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the fixed or random-effects model. RESULTS: A total of 9 studies with 2,880 TAVR patients (minimalist TAVR;1066 and standard TAVR; 1,814) were included. Compared to standard approach, there were no significant differences in in-hospital mortality, 30-day mortality, or hospital readmissions. However, there was a reduced risk of acute kidney injury (OR0.49;95%CI0.27-0.89), major bleeding (OR0.21;95%CI0.12-0.38) and major vascular complications (OR0.60,95%CI0.39-0.91) associated with the minimalist TAVR group. There was comparatively shorter hospital length of stay (mean difference -2.41;95%CI-2.99,-1.83) days, procedural time (mean difference -43.99;95%CI-67.25,-20.75) minutes, fluoroscopy time (mean difference -2.69;95%CI-3.44,-1.94) minutes and contrast volume (mean difference -26.98;95%CI-42.18,-11.79) ml in the minimalist TAVR group. CONCLUSIONS: This meta-analysis demonstrated potential benefits of the minimalist TAVR approach over the standard approach regarding some adverse clinical outcomes as well as procedural outcomes without significant differences in mortality or readmission rates.

Usefulness of the American Heart Association's Life Simple 7 to Predict the Risk of Atrial Fibrillation (from the REasons for Geographic And Racial Differences in Stroke [REGARDS] Study).

The American Heart Association has identified metrics of ideal cardiovascular (CV) health known as Life's Simple 7 (LS7). We determined the prospective relationship between the LS7 and the incident atrial fibrillation (AF) in a biracial cohort. The REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled non-Hispanic black and white adults 45 years or older. This analysis included 9,576 REGARDS participants (mean age 63 ± 8.4 years; 57% women; 30% black) who were free of AF at baseline and completed a follow-up examination 9.4 years later. An overall LS7 score was calculated at baseline as the sum of the LS7 component scores and classified as inadequate (0 to 4), average (5 to 9), or optimal (10 to 14) CV health. The primary outcome was incident AF, identified at follow-up by either electrocardiogram or a self-reported medical history of a physician diagnosis. A total of 725 incident AF cases were detected. Compared with the inadequate category (n = 534), participants in the optimal category (n = 1,953) had a 32% lower odds of developing AF (odds ratio 0.68; 95% confidence interval 0.47, 0.99) in a logistic regression model adjusted for demographic characteristics, alcohol use, left ventricular hypertrophy, coronary heart disease, and stroke. A 1-point higher LS7 score was associated with a 5% lower odds of incident AF (odds ratio = 0.95; 95% confidence interval 0.91, 0.99). In conclusion, better CV health, as defined by the LS7 score, is associated with a reduction in development of AF.

Clinical and Echocardiographic Correlates of Left Atrial Function Index: The Framingham Offspring Study.

BACKGROUND: Left atrial (LA) remodeling is a predictor of cardiovascular disease (CVD). We performed measurement of the LA function index (LAFI), a composite measure of LA structure and function, in a community-based cohort and here report the distribution and cross-sectional correlates of LAFI. METHODS: In 1,719 Framingham Offspring Study participants (54% women, mean age 66 ± 9 years), we derived LAFI from the LA emptying fraction, left ventricular (LV) outflow tract velocity time integral, and indexed maximal LA volume. We used multivariable linear regression to assess the clinical and echocardiographic correlates of LAFI adjusting for age, sex, anthropometric measurements, and CVD risk factors. RESULTS: The average LAFI was 35.2 ± 12.1. Overall, LAFI declined with advancing age (ß = -0.27, P < .001). LAFI was significantly higher (37.5 ± 11.6) in a subgroup of participants free of CVD and CVD risk factors compared with those with either of these conditions (34.5 ± 12.2). In multivariable models, LAFI was inversely related to antihypertensive use (ß = -1.26, P = .038), prevalent atrial fibrillation (ß = -4.46, P = .001), heart failure (ß = -5.86, P = .008), and coronary artery disease (ß = -2.01, P = .046). In models adjusting for echocardiographic variables, LAFI was directly related to LV ejection fraction (ß = 14.84, P < .001) and inversely related to LV volume (ß = -7.03, P < .001). CONCLUSIONS: LAFI was inversely associated with antihypertensive use and prevalent CVD and was related to established echocardiographic traits of LV remodeling. Our results offer normative ranges for LAFI in a white community-based sample and suggest that LAFI represents a marker of pathological atrial remodeling.

Atrial Fibrillation and Hypertension: Mechanistic, Epidemiologic, and Treatment Parallels.

Atrial fibrillation (AF) is an increasingly prevalent condition and the most common sustained arrhythmia encountered in ambulatory and hospital practice. Several clinical risk factors for AF include age, sex, valvular heart disease, obesity, sleep apnea, heart failure, and hypertension (HTN). Of all the risk factors, HTN is the most commonly encountered condition in patients with incident AF. Hypertension is associated with a 1.8-fold increase in the risk of developing new-onset AF and a 1.5-fold increase in the risk of progression to permanent AF. Hypertension predisposes to cardiac structural changes that influence the development of AF such as atrial remodeling. The renin angiotensin aldosterone system has been demonstrated to be a common mechanistic link in the pathogenesis of HTN and AF. Importantly, HTN is one of the few modifiable AF risk factors, and guideline-directed management of HTN may reduce the incidence of AF.