Echocardiographic and clinical outcomes of patients undergoing septal myectomy plus anterior mitral leaflet extension for hypertrophic cardiomyopathy.

Septal myectomy is indicated in patients with obstructive hypertrophic cardiomyopathy (HCM) and intractable symptoms. Concomitant mitral valve (MV) surgery is performed for abnormalities contributing to systolic anterior motion (SAM), or for SAM-mediated mitral regurgitation (MR) with or without left ventricular outflow tract (LVOT) obstruction. One MV repair technique is anterior mitral leaflet extension (AMLE) utilizing bovine pericardium, stiffening the leaflet and enhancing coaptation posteriorly. Fifteen HCM patients who underwent combined myectomy-AMLE for LVOT obstruction or moderate-to-severe MR between 2009 and 2020 were analyzed using detailed echocardiography. The mean age was 56.6 years and 67% were female. The average peak systolic LVOT gradient and MR grade measured 73.4 mmHg and 2.3, respectively. Indications for myectomy-AMLE were LVOT obstruction and moderate-to-severe MR in 67%, MR only in 20%, and LVOT obstruction only in 13%. There was no mortality observed, and median follow-up was 1.2 years. Two patients had follow-up grade 1 mitral SAM, one of whom also had mild LVOT obstruction. No recurrent MR was observed in 93%, and mild MR in 7%. Compared with preoperative measures, there was a decrease in follow-up LV ejection fraction (68.2 vs 56.3%, p = 0.02) and maximal septal wall thickness (25.5 vs 21.3 mm, p < 0.001), and an increase in the end-diastolic diameter (21.9 vs 24.8 mm/m2, p = 0.04). There was no change in global longitudinal strain (-12.1 vs -11.6%, p = 0.73) and peak LV twist (7.4 vs 7.3°, p = 0.97). In conclusion, myectomy-AMLE is a viable treatment option for carefully selected symptomatic HCM patients with LVOT obstruction or moderate-to-severe MR.

Persistent left superior vena cava identified by transesophageal echocardiography.

A 70-year-old female with severe aortic stenosis presented for aortic valve replacement and underwent routine preoperative Swan-Ganz catheter placement. Transesophageal echocardiography demonstrated a dilated coronary sinus with a catheter present. A high suspicion of venous anomaly prompted an agitated saline study. Flow through the coronary sinus into the right atrium was observed, confirming the presence of a persistent left superior vena cava. Although the persistent left superior vena cava has a low prevalence in the general population, it is one of the most common thoracic venous anomalies. During central venous cannulation, the presence of venous anomalies increases procedural complication rates. Fortunately, our patient remained asymptomatic both before and after catheter insertion. Awareness of this anomaly could help clinicians avoid complications.

Quadricuspid aortic valve: Case series and review of literature.

A quadricuspid aortic valve is an uncommon valve lesion. Its physical manifestations vary, and it may be associated with other cardiac lesions. Echocardiography is the imaging modality of choice, with computerized tomography or cardiac magnetic resonance imaging being utilized as adjunctive imaging modalities in certain cases. Herein, we present a case series of three patients with this valvular lesion treated at our institution, as well as a contemporary review of the literature.

A Focused Review on the Pathophysiology, Diagnosis, and Management of Cardiac Amyloidosis.

Amyloidosis is a systemic disorder that results from abnormal protein metabolism, producing amyloid fibrils that are subsequently deposited within vital organs. Cardiac involvement is typically associated with the specific subtypes of immunoglobulin lightchain, transthyretin, secondary amyloidosis, and dialysis-related amyloidosis. The hallmark of cardiac amyloidosis is the development of restrictive cardiomyopathy and heart failure, usually with a preserved left ventricular ejection fraction. The diagnosis is based on the integration of clinical signs and symptoms, echocardiography, cardiac magnetic resonance imaging, nuclear scintigraphy, electrocardiography, and cardiac biomarkers. Traditionally, management of heart failure symptoms and prevention of heart failure exacerbations have been the cornerstones of therapy. However, various treatments are currently under investigation that aim to eliminate or neutralize the underlying amyloidogenic substrate. Herein, we provide a focused review and discussion of the cardiovascular manifestations, epidemiologic and clinical characteristics, diagnostic modalities, and treatment strategies of cardiac amyloidosis.

Bicuspid Aortic Valve and Aortic Root Morphology in Hispanic Patients.

BACKGROUND: The study aim was to evaluate the aortic valve and aortic root morphology in Hispanic patients with a bicuspid aortic valve (BAV). BAV disease is one of the most common congenital anomaly of the heart, and is associated with abnormalities of the aorta. Interracial differences have been described between Caucasian and African-American patients with BAV, which may have clinical and therapeutic implications. The clinical and anatomical spectrum of BAV disease in Hispanic patients has not been well established. METHODS: A retrospective review was conducted of all heart operations performed at the authors' institution between April 2008 and June 2013. Patients with BAV who underwent aortic valve replacement (AVR) were identified. All echocardiograms available were reviewed in order to compare cusp morphology, valvular function, and ascending aorta dimensions between Hispanic and non-Hispanic individuals. RESULTS: A total of 291 patients (159 Hispanic, 132 non-Hispanic) with a mean age of 62 ± 13 years were identified. The baseline characteristics were similar between the two groups. In both Hispanics and non-Hispanics, the most prevalent cusp morphology was fusion of the right and left coronary cusps (82% for both groups). The most common indication for surgery was aortic stenosis. Hispanic patients had a larger aortic annulus diameter (2.58 ± 0.32 cm versus 2.39 ± 0.39 cm, p = 0.04). However, this difference was not significant after adjusting for age, gender, body surface area, and the presence of moderate-to-severe aortic insufficiency. Ascending aortopathy was present in 42.7% of the total study population. Regardless of ethnicity, the most common pattern of aortopathy involved the tubular ascending aorta with mild to moderate root enlargement (type 1). CONCLUSIONS: Compared with other ethnic groups, Hispanics with BAVs have similar aortic valve morphology and function, as well as comparable aortopathy.

Left ventricular end-diastolic pressure as an independent predictor of outcome during balloon aortic valvuloplasty.

OBJECTIVES: In this study, we examined the predictive value of the left ventricular end-diastolic pressure (LVEDP) in patients undergoing balloon aortic valvuloplasty (BAV). BACKGROUND: The LVEDP is a useful indicator of hemodynamic status in patients with severe aortic stenosis. In BAV, decompensated heart failure is associated with worse outcomes. METHODS: We identified all consecutive patients with severe symptomatic aortic stenosis who underwent retrograde BAV at the Massachusetts General Hospital from 2004 to 2008. Patients were stratified and compared according to their baseline LVEDP into ≤15 mm Hg, 16-20 mm Hg, 21-25 mm Hg, and ≥26 mm Hg. Procedural and in-hospital outcomes and adverse events were compared. Multivariate logistic regression was used for the adjusted analysis. RESULTS: A total of 111 patients with a mean age of 83±11 years underwent BAV. Of these, the LVEDP was ≤15 mm Hg in 29 (26%), 16-20 mm Hg in 41 (37%), 21-25 mm Hg in 16 (14%), and ≥26 mm Hg in 25 (23%) patients. Baseline characteristics were similar among the four groups. Noticeably, patients with high LVEDP levels had significantly higher rates of the combined endpoint of in-hospital death, myocardial infarction (MI), cardiopulmonary arrest, and tamponade was P = 0.02. Periprocedural MI was more common among those with higher LVEDP (16% vs. 2.3%; P = 0.04). Multivariate analysis revealed LVEDP (OR 1.08, for each mm Hg increase in pressure, 95 % CI 1.02-1.14), small LV chamber size, and New York Heart Association class as independent predictors of adverse outcomes. CONCLUSIONS: The LVEDP is an important independent predictor of poor in-hospital outcome during BAV. In these patients, the immediate hemodynamic status may be more important than the baseline left ventricular systolic function. Hemodynamic optimization before or during BAV should be considered and may be beneficial.

Left ventricular strain and myocardial work in apical hypertrophic cardiomyopathy.

Background: Apical hypertrophic cardiomyopathy (ApHCM) is recognized for its associated cardiovascular morbidity. Herein we describe left ventricular (LV) function and mechanics over long-term follow-up in ApHCM. Methods: A retrospective study of 98 consecutive ApHCM patients was performed (mean age: 64±15 years, 46% female) using 2D and speckle-tracking echocardiography. LV function and mechanics were characterized by global longitudinal strain (GLS), segmental strain, and myocardial work indices. Myocardial work was calculated by integrating longitudinal strain and blood pressure as estimated by the brachial artery cuff pressure, to generate an LV pressure-strain loop with adjusted ejection and isovolumetric periods. Composite complications were defined as all-cause mortality, sudden death, myocardial infarction, and/or stroke. Results: Mean LV ejection fraction measured 67%±11% and GLS was -11.7%±3.9%. Global work index (GWI) was 1,073±349 mmHg%, constructive work was 1,379±449 mmHg%, wasted work was 233±164 mmHg%, and work efficiency was 82%±8%. In 72 patients with follow-up echocardiography, at a median of 3.9 years there was progressive impairment in GLS (-11.9% vs. -10.7%; P=0.006), GWI (1,105 vs. 989 mmHg%; P=0.02), and global constructive work (1,432 vs. 1,312 mmHg%; P=0.03), without change in wasted work or work efficiency. Atrial fibrillation (ß=0.37; P<0.001), mitral annular e' velocity (ß=-0.32; P=0.001), and glomerular filtration rate (ß=-0.2; P=0.03) were independently associated with follow-up GLS; atrial fibrillation (ß=-0.27; P=0.01) and glomerular filtration rate (ß=0.23; P=0.04) were also associated with follow-up GWI. Global wasted work >186 mmHg% was predictive of composite complications (AUC =0.7, 95% CI: 0.53-0.82, sensitivity 93%, specificity 41%). Conclusions: ApHCM is associated with preserved LV ejection fraction but abnormal LV GLS and work indices, with progressive impairment. Important clinical and echocardiographic measures are independently predictive of long-term follow-up LV GLS, GWI and adverse events.

Cardiac geometry, function and mechanics in left ventricular non-compaction cardiomyopathy with preserved ejection fraction.

BACKGROUND: Left ventricular non-compaction (LVNC) cardiomyopathy in adults has primarily been studied with a phenotypic expression of low ejection fraction (EF) and dilated cardiomyopathy; however, data on LVNC with preserved EF is scarce. The present study aimed to evaluate cardiac geometry and mechanics in LVNC patients with preserved EF. METHODS: A retrospective cohort study of patients diagnosed with LVNC and a preserved EF between 2008 and 2019 was performed. LVNC was defined according to the presence of established transthoracic 2D echocardiographic (TTE) criteria as follows: (1) prominent LV trabeculations with deep recesses; (2) bi-layered myocardial appearance; and, (3) systolic non-compacted:compacted ratio≥ 2. Subjects were matched 1:1 to controls without LVNC referred for routine TTE. Geometric, functional and mechanics parameters were analyzed in the two cohorts using 2D and speckle-tracking TTE. RESULTS: Seventeen patients with LVNC and preserved EF were identified. Compared with controls, patients with LVNC had similar LV systolic function and chamber dimensions, but a larger mass and relative wall thickness, and more abnormal LV geometry (76% vs. 18%, p = 0.002), LA remodeling, and pulmonary hypertension. Global longitudinal strain was significantly decreased (-15.4 ± 3.2 vs. -18.9 ± 2.8%, p = < 0.01) and the prevalence of rigid body rotation was significantly increased (57% vs. 14%, p = 0.05) in the LVNC population. The peak twist values were comparable in both cohorts. CONCLUSIONS: Impaired LV geometry and longitudinal mechanics, as well as increased myocardial stiffness as expressed by rigid body rotation, characterize LVNC with preserved EF when compared with controls.

Left ventricular remodeling after mitral valve repair and papillary muscle approximation.

BACKGROUND: Mitral valve repair with papillary muscle approximation (MVr-PMA) for severe secondary mitral regurgitation (MR) decreases MR recurrence compared with MVr alone. This study assessed the effects of MVr-PMA on left ventricular (LV) remodeling and shape, systolic function and strain mechanics. METHODS: Forty-eight patients who underwent MVr-PMA for severe secondary MR and had follow-up echocardiograms available for review were identified. Student's t-test, linear regression modeling, and receiver-operating characteristic curves were used in the statistical analyses. RESULTS: Median follow-up time was 14.9 months. MVr-PMA was associated with significant LV reverse remodeling with a smaller LV end-diastolic diameter, Systolic Sphericity Index, and interpapillary muscle distance at follow-up. Nine patients (18.8%) experienced moderate recurrent MR. When compared to recurrent MR patients at follow-up, those with durable MVr-PMA had a greater LV ejection fraction (32.8 vs. 22.0%, P=0.03), a smaller end-diastolic diameter (59.6 vs. 67.3 mm, P=0.03), Systolic Sphericity Index (0.35 vs. 0.47, P=0.03), and end-systolic interpapillary muscle distance (16.3 vs. 21.1 mm, P=0.03). A durable MVr-PMA also resulted in stable global longitudinal strain when compared with pre-operative values, while the recurrent MR group experienced a further decline (no recurrent MR: -8.4 vs. -7.5%; recurrent MR: -8.2 vs. -5.4%; P<0.05). A pre-operative LV end-diastolic diameter ≥ 64 mm was a discriminative predictor of MR recurrence (sensitivity=100%, specificity=51%, AUC=0.756, P=0.02). CONCLUSIONS: A durable MVr-PMA confers improved LV geometry and function, and stable LV mechanics. The extent of baseline LV remodeling identifies patients at risk for recurrent MR.

Incidentally found guidewire during bacterial endocarditis workup.

A 67-year-old female with recent hospitalization for pneumonia was transferred to our facility for high fevers and positive blood cultures for staph aureus. During her treatment for pneumonia, central venous catheter was placed. A systolic murmur was found in conjunction with fever and notable premature ventricular contractions on telemetry monitoring. Chest x-ray and transesophageal echocardiography were then performed, and a free guidewire was identified which was later successfully removed under interventional radiology.

The Role of False Tendons in Left Ventricular Remodeling and Secondary Mitral Regurgitation After Acute Myocardial Infarction.

BACKGROUND: Left ventricular false tendons (LVFT) are common structures visualized on transthoracic echocardiography (TTE). The present study tested the hypothesis that LVFT, via a possible 'constraint' mechanism, attenuate left ventricular (LV) remodeling and secondary mitral regurgitation after acute myocardial infarction. METHODS: Seventy-one patients admitted to the Coronary Care Unit following an ST-elevation (n = 63) or non-ST-elevation (n = 8) myocardial infarction were analyzed; 29 (41%) had LVFT, and 42 (59%) did not (no-LVFT). All had a TTE and at least 1 follow-up study after revascularization. The χ² analysis, Student's t-test, and Mann Whitney U test were used for the statistical analyses. RESULTS: The mean age (64 vs. 66 years), left ventricular ejection fraction (LVEF) (41% vs. 39%), left ventricular end-diastolic diameter (LVEDd) index (23 mm/m² for both), and prevalence of ≥ moderate secondary/functional mitral regurgitation (MR) (17% vs. 14%) were similar between the LVFT and no-LVFT groups. At 1-year follow-up, there was no significant difference in chamber remodeling amongst the LVFT versus no-LVFT group when assessed by: 1) ≥ 10% decrease in the relative LVEF (24% vs. 26%; p = 0.83); 2) ≥ 10% increase in the LVEDd index (41% vs. 38%, p = 0.98); and, 3) ≥ 10% increase in the LV mass index (48% vs. 41%, p = 0.68). There was no difference in the prevalence of ≥ moderate secondary/functional MR (17% vs. 12%, p = 0.77). Outcomes remained similar when stratifying by LVFT morphology or ischemic territory. CONCLUSIONS: In patients with mild to moderate LV dysfunction and normal chamber size, LVFT do not affect the development of LV remodeling or secondary/functional MR post-myocardial infarction.

The Pleiotropic Effects of Statins in Endocrine Disorders.

BACKGROUND: The 3-Hydroxy-3-MethylGlutaryl-CoA reductase inhibitors, better known as statins, are used extensively in the treatment of dyslipidemia and cardiovascular risk reduction. They have also demonstrated a variety of non-lipid lowering, or pleiotropic effects. Pertaining to the endocrine system the benefits of statins can extend to patients with the polycystic ovarian syndrome and thyroid disease. However, there is also increasing evidence that statin use can lead to deleterious effects in different organs, including worsening glycemia and the development of diabetes mellitus. OBJECTIVE: The aim of this review is to describe the most relevant and updated evidence regarding the pleiotropic effects of statins in endocrine disorders. METHODS: We did a systematic review of scientific articles published in PubMed regarding the effects of statins on the different aspects of the endocrine system up until June 5th of 2018. RESULTS: We identified preliminarily 61 publications, of which 4 were excluded due to having abstract format only, and 5 were excluded for not containing pertinent information to the study. CONCLUSION: Several aspects of the endocrine system have been shown to be influenced by the pleiotropic effects that statins exert, however, the benefits of statins on cardiovascular morbidity and mortality largely outweigh this deleterious effect, and statin therapy should continue to be recommended.

The effects of physical activity on cancer prevention, treatment and prognosis: A review of the literature.

INTRODUCTION: The World Health Organization has reported that approximately 35% of cancer-related deaths are attributed to modifiable risk factors. Among the most important risk factors amenable to modification are obesity and lack of physical activity. The purpose of this article is to review the current evidence of the benefits of physical activity in various types of cancer. METHODS: A PubMed search for the key words "physical activity and cancer" as well as "exercise and cancer" was used to identify all indexed publications on this topic for potential utilization in this review. One MET was defined as the amount of oxygen consumed while a person is sitting quietly and is about 3.5 mL O2/kg body weight/min. MET represents the ratio of the working metabolic rate to the resting metabolic rate. RESULTS: Routine physical activity was found to be associated with a reduced incidence of several of the most common malignancies, including colon, breast, lung, and endometrial cancer as well as many others. Physical activity also appears to reduce all-cause mortality and cancer-related mortality among patients with breast and colon cancer, and may improve the functional status and quality of life for these patients during cancer therapy. CONCLUSIONS: The benefits of physical activity in the prevention and progression of cancer patients are multiple. However, the strength of the available evidence is limited by the observational nature of most studies. Given the probable improvement in prevention, mortality, and quality of life with structured physical activity in different malignancies, it is important that healthcare providers discuss physical activity programs with their cancer patients. Larger randomized trials are recommended.

Transthyretin Cardiac Amyloidosis as Diagnosed by 99mTc-PYP Scanning in Patients with Acute Heart Failure and Preserved Ejection Fraction.

Transthyretin amyloid deposition is present in 17% of autopsies of patients with heart failure and a preserved ejection fraction (HFpEF). Technetium-pyrophosphate scintigraphy (Tc-PYP) is sensitive and specific to diagnose cardiac transthyretin amyloid deposition (ATTR). The prevalence of ATTR by Tc-PYP was evaluated along with echocardiographic parameters in patients with HFpEF. One-hundred consecutive patients with HFpEF, who had Tc-PYP, were retrospectively evaluated. Echocardiographic variables were analyzed to compare patients with positive versus negative ATTR infiltration. Myocardial ATTR was present in 19% of patients. Individuals with ATTR were older with a mean age of 82 ± 7 versus 75 ± 13 years (P = 0.03), had increased left ventricular hypertrophy with the interventricular septum measuring 1.6 (IQR, 1.4-2.0) versus 1.4 (IQR, 1.3-1.6) cm (P = 0.002), had a greater mean left ventricular mass index of 160 ± 50 g/m versus 131 ± 44 g/m (P = 0.01), and a reduced global longitudinal strain measuring -11% (IQR, -9 to -12) versus -12% (IQR, -10 to -16), P = 0.04. The prevalence of ATTR myocardial deposition demonstrated by Tc-PYP in patients with HFpEF is comparable to that of autopsy studies. It is more common in older patients, with increased left ventricular hypertrophy and reduced global longitudinal strain.

Bi-Atrial Compression Due to Ascending and Descending Aortic Aneurysms.

Aortic aneurysms compressing an atrium causing symptoms are uncommon. We describe a case of bi-atrial compression due to ascending and descending aneurysms leading to dyspnea.

Percutaneous Closure of Two Acquired Aorto-Right Ventricular Fistulae Following Right Ventricular Outflow Tract Surgery.

The present case illustrates the successful transcatheter closure of an unusual double aortic root-to-right ventricular outflow tract fistula utilizing two Amplatzer duct occluders II.

Anterior Mitral Leaflet Augmentation for Ischemic Mitral Regurgitation Performed Via a Right Thoracotomy Approach.

Ischemic mitral regurgitation (MR) after myocardial infarction is associated with poor long-term survival, and the optimal treatment strategy remains debated. The most common repair technique used is a restrictive annuloplasty. However, up to 15% to 30% of patients experience recurrent MR owing to progressive left ventricular remodeling and geometric distortion of the mitral valve apparatus. Anterior mitral leaflet augmentation using a pericardial patch, in combination with a true-sized mitral annuloplasty, has been proposed as an adjunctive technique to increase the durability of valve repair for ischemic MR. Herein, we describe 2 cases of anterior mitral leaflet augmentation with annuloplasty repair for severe ischemic MR via a minimally invasive right thoracotomy, and review the literature regarding patient selection and clinical outcomes of this technique.

Outcome of patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention during on- versus off-hours (a Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] trial substudy).

Patients with ST-segment elevation myocardial infarction (STEMI) admitted during nonregular working hours (off-hours) have been reported to have greater mortality than those admitted during regular working hours (on-hours), perhaps because of the lower availability of catheterization laboratory services and longer door-to-balloon times. This might not be the case, however, for hospital centers in which primary percutaneous coronary intervention (PCI) is invariably performed. We conducted a substudy using the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction study data to determine whether the STEMI arrival time was associated with differing clinical outcomes. We identified all patients with STEMI admitted to a PCI-capable hospital who underwent primary PCI. Patients presenting during on-hours were compared to those presenting during off-hours. The primary outcome of death, major adverse cardiovascular events, and net adverse clinical events was examined. We identified 2,440 patients (1,205 [49%] on-hours and 1,235 [51%] off-hours). Similar baseline characteristics were observed. The off-hour patients had a significantly longer door-to-balloon time (92 vs 75 minutes; p <0.0001) and total ischemic time (209 vs 194 minutes; p <0.0001). Despite these differences, the risk-adjusted all-cause mortality, major adverse cardiovascular events, and net adverse clinical events rates were similar for both groups during the in-hospital, 1-year, and 3-year follow-up. In conclusion, patients with STEMI presenting to primary PCI hospitals during off-hours might have slightly longer delays to revascularization; however, they experienced similar short- and long-term survival and clinical outcomes as those arriving during on-hours.