Percutaneous atrial septal defect closure in Ebstein's anomaly.

We report a patient with Ebstein's anomaly, on chronic milrinone therapy for right ventricular failure, who underwent palliative percutaneous closure of her atrial septal defect (ASD) due to recurring strokes. Repeated evaluation of right-sided pressures was performed prior to ASD closure to determine if our patient could tolerate the intervention. Definitive ASD closure was performed under fluoroscopic and transesophageal echocardiogram guidance.

Advanced heart failure with reduced ejection fraction.

Patients suffering advanced heart failure with reduced ejection fraction (HFrEF) account for a large portion of patients admitted to hospitals worldwide. Mortality and 30-day readmission rates for HFrEF are now a focus of value-based payment models, making management of this disease a priority for hospitals, physicians, and payers alike. Angiotensin-converting enzyme inhibitors have been the cornerstone of therapy for decades. However, with treatment, the prognosis for patients with advanced HFrEF remains poor. Fortunately, advances in medical therapy and mechanical support offer some patients improvement in both survival and quality of life. We review advances in short- and long-term mechanical support and explore changes to organ allocation for cardiac transplantation. In addition, we provide a guide to facilitate appropriate referral to an advanced heart failure team.

Echocardiographic profile of rheumatic heart disease at a tertiary cardiac centre.

BACKGROUND: Rheumatic Heart Disease (RHD) continues to be a major public health problem in developing countries like Pakistan. Objective of this cross sectional-analytical study was to analyze the severity of valvular lesions on echocardiography in patients pre-diagnosed with RHD. METHODS: The transthoracic echocardiographic records of RHD patients from 2004 to 2008 were retrospectively reviewed for type and degree of valvular involvement according to AHA/ACC guidelines. RESULTS: A total of 13,414 patients [7,219 Males (53.8%), 6,195 Females (46.2%)] ranging from 11 to 90 years with a mean age of 42.33 +/- 18.976 were studied. On echocardiography, 7,500 (56%) had mitral regurgitation (8.8% severe MR), 6,449 (48.2%) had tricuspid regurgitation (7.1% severe TR) and 5,550 (41.4%) had aortic regurgitation (4.8% severe AR). MS was detected in 2,729 (20.3%) patients (15.3% severe MS), AS in 102 (0.8%) and TS in 31 (0.2%) patients. Mixed mitral valve disease was seen in 3,185 (23.7%), mixed aortic valve disease in 222 (1.7%) and mixed tricuspid valve disease in 47 (0.4%) patients. All three valves were involved in 2,826 (21.06%) patients, combination of mitral and aortic valves in 3,103 (23.13%), mitral and tricuspid in 3,784 (28.2%), and mitral only in 3,701 (27.59%) patients. There was some mitral valve abnormality in all patients. CONCLUSION: Mitral valve was most commonly affected, while regurgitant lesions were more common than stenotic lesions, and most severe in younger patients. All valvular lesions had almost an equal distribution among the sexes, except aortic regurgitation, which was more common in females. Therefore, echocardiography should be done routinely for patients with RHD, focusing on younger population, to facilitate diagnosis and definitive treatment before complications set in.

Use of Remote Pulmonary Artery Pressure Monitoring (CardioMEMS System) in Total Artificial Heart to Assess Pulmonary Hemodynamics for Heart Transplantation.

The temporary total artificial heart (TAH-t) has been valuable as a bridge to transplantation in patients with biventricular failure. However, the challenges of accurately assessing pulmonary vascular resistance after TAH-t implantation can preclude these patients from heart transplantation, especially those with pre-existing pulmonary hypertension. The CardioMEMS Heart Failure System (St. Jude's Medical, Little Canada, MN) comprises a wireless pressure sensor that is implanted percutaneously in the pulmonary artery and transmits real-time measurements of pulmonary artery pressures. Systolic and diastolic pulmonary artery (PA) pressures measurements have been well correlated between the CardioMEMS PA Sensor and traditional Swan-Ganz catheter and between the CardioMEMS PA Sensor and standard echocardiography. Here, we report the use of the CardioMEMS device in a patient with severe pulmonary hypertension supported with a SynCardia TAH-t (Tucson, AZ) during assessment for candidacy for transplantation.

The clinical implications of myocardial perfusion abnormalities in patients with esophageal or lung cancer after chemoradiation therapy.

PURPOSE: This study aims to identify the clinical implications of myocardial perfusion defects after chemoradiation therapy (CRT) in patients with esophageal and lung cancer. METHODS: We retrospectively compared myocardial perfusion imaging (MPI) results before and after CRT in 16 patients with esophageal cancer and 24 patients with lung cancer. New MPI defects in the radiation therapy (RT) fields were considered related to RT. Follow-up to evaluate for cardiac complications and their relation with the results of MPI was performed. Statistical analysis identified predictors of cardiac morbidities. RESULTS: Eleven females and twenty nine males at a mean age of 66.7 years were included. Five patients (31%) with esophageal cancer and seven patients (29%) with lung cancer developed myocardial ischemia in the RT field at mean intervals of 7.0 and 8.4 months after RT. The patients were followed-up for mean intervals of 15 and 23 months in the esophageal and lung cancer groups, respectively. Seven patients in each of the esophageal (44%) and lung (29%) cancer patients (P = 0.5) developed cardiac complications of which one patient with esophageal cancer died of complete heart block. Six out of the fourteen patients (43%) with cardiac complication had new ischemia on MPI after CRT of which only one developed angina. The remaining eight patients with cardiac complications had normal MPI results. MPI result was not a statistically significant predictor of future cardiac complications after CRT. A history of congestive heart failure (CHF) (P = 0.003) or arrhythmia (P = 0.003) is a significant predictor of cardiac morbidity after CRT in univariate analysis but marginal predictors when multivariate analysis was performed (P = 0.06 and 0.06 for CHF and arrhythmia, respectively). CONCLUSIONS: Cardiac complications after CRT are more common in esophageal than lung cancer patients but the difference is not statistically significant. MPI abnormalities are frequently seen after CRT but are not predictive of future cardiac complications. A history of arrhythmia or CHF is significantly associated with cardiac complications after CRT.

Lung perfusion imaging can risk stratify lung cancer patients for the development of pulmonary complications after chemoradiation.

INTRODUCTION: We investigated the value of lung perfusion imaging in predicting the risk of developing pulmonary complications after chemoradiation (CRT) or radiation therapy (RT) for lung cancer. METHODS: Fifty patients who underwent lung perfusion imaging before RT for lung cancer were included. Planar and single photon emission computed tomography/computed tomography images of the lungs were obtained. Lung perfusion score (LPS) was developed to visually grade localized perfusion defect per lung on a scale of 0 to 4 and perfusion pattern in the remaining lungs on a scale of 1 to 4. The LPS is the sum of the score for the localized perfusion defect in each lung plus the score for the remaining lungs perfusion. LPSs were correlated with pulmonary function tests and the patients were followed for 8 months after therapy to determine the incidence of grade 2 to 5 symptomatic therapy related pulmonary complications according to the common terminology criteria for adverse events (CTCAE 3.0). RESULTS: Thirty-four patients underwent CRT and 16 underwent RT. The mean total radiation dose delivered was 56.1 +/- 10.4 Gy. Eighteen patients (36%) suffered from pulmonary complications at a mean interval of 3.4 months after therapy. Nine patients had grade 2, 7 had grade 3, 1 had grade 4, and 1 had grade 5 pulmonary complications. The mean LPS was 4.9 in patients who developed pulmonary complications versus 3.5 in patients who did not (p = 0.01). There were no significant difference between pulmonary function tests in the patients with pulmonary complications and the patient without. In addition, there were no significant differences between the mean lung radiation dose, the volume of lung irradiated or the percentage of lung receiving greater than 20 Gy between the two groups. CONCLUSIONS: LPS using lung perfusion imaging is useful for predicting possible pulmonary complications after CRT or RT in lung cancer patients.