Reliability and reproducibility of the venous excess ultrasound (VExUS) score, a multi-site prospective study: validating a novel ultrasound technique for comprehensive assessment of venous congestion.

Though the novel venous excess ultrasound (VExUS) score is increasingly used as a noninvasive means of venous congestion measurement, the inter-rater reliability (IRR), inter-user reproducibility (IUR), and utility of concurrent ECG have not been evaluated. We conducted a multicenter study of the IRR, IUR, and utility of ECG for VExUS interpretation between four attending physicians of diverse specialties, reporting the Kappa statistic (KS) and Intraclass Correlation Coefficient (ICC) for IRR and IUR for scans with and without ECG. Eighty-four paired VExUS exams from 42 patients, 60 of which had a concurrent ECG tracing, were interpreted. They showed substantial IRR, with a KS of 0.71 and ICC of 0.83 for the overall VExUS grade (p < 0.001), and IUR, with a KS 0.63 and ICC of 0.8. There was greater agreement among images with an ECG tracing. These results suggest that ECG-augmented VExUS may be a reliable and reproducible measure interpretable by clinicians with diverse backgrounds.

A focused update to the 2019 NLA scientific statement on use of lipoprotein(a) in clinical practice.

Since the 2019 National Lipid Association (NLA) Scientific Statement on Use of Lipoprotein(a) in Clinical Practice was issued, accumulating epidemiological data have clarified the relationship between lipoprotein(a) [Lp(a)] level and cardiovascular disease risk and risk reduction. Therefore, the NLA developed this focused update to guide clinicians in applying this emerging evidence in clinical practice. We now have sufficient evidence to support the recommendation to measure Lp(a) levels at least once in every adult for risk stratification. Individuals with Lp(a) levels <75 nmol/L (30 mg/dL) are considered low risk, individuals with Lp(a) levels ≥125 nmol/L (50 mg/dL) are considered high risk, and individuals with Lp(a) levels between 75 and 125 nmol/L (30-50 mg/dL) are at intermediate risk. Cascade screening of first-degree relatives of patients with elevated Lp(a) can identify additional individuals at risk who require intervention. Patients with elevated Lp(a) should receive early, more-intensive risk factor management, including lifestyle modification and lipid-lowering drug therapy in high-risk individuals, primarily to reduce low-density lipoprotein cholesterol (LDL-C) levels. The U.S. Food and Drug Administration approved an indication for lipoprotein apheresis (which reduces both Lp(a) and LDL-C) in high-risk patients with familial hypercholesterolemia and documented coronary or peripheral artery disease whose Lp(a) level remains ≥60 mg/dL [∼150 nmol/L)] and LDL-C ≥ 100 mg/dL on maximally tolerated lipid-lowering therapy. Although Lp(a) is an established independent causal risk factor for cardiovascular disease, and despite the high prevalence of Lp(a) elevation (∼1 of 5 individuals), measurement rates are low, warranting improved screening strategies for cardiovascular disease prevention.

Mortality Associated With Proportionality of Secondary Mitral Regurgitation After Transcatheter Mitral Valve Repair: North American Mitraclip for Functional Mitral Regurgitation Registry.

The association, if any, between the effective regurgitant orifice area (EROA) to left ventricular end-diastolic volume (LVEDV) ratio and 1-year mortality is controversial in patients who undergo mitral transcatheter edge-to-edge repair (m-TEER) with the MitraClip system (Abbott Vascular, Santa Clara, CA). This study's objective was to determine the association between EROA/LVEDV and 1-year mortality in patients who undergo m-TEER with MitraClip. In patients with severe secondary (functional) mitral regurgitation (MR), we analyzed registry data from 11 centers using generalized linear models with the generalized estimating equations approach. We studied 525 patients with secondary MR who underwent m-TEER. Most patients were male (63%) and were New York Heart Association class III (61%) or IV (21%). Mitral regurgitation was caused by ischemic cardiomyopathy in 51% of patients. EROA/LVEDV values varied widely, with median = 0.19 mm2/ml, interquartile range [0.12,0.28] mm2/ml, and 187 patients (36%) had values <0.15 mm2/ml. Postprocedural mitral regurgitation severity was substantially alleviated, being 1+ or less in 74%, 2+ in 20%, 3+ in 4%, and 4+ in 2%; 1-year mortality was 22%. After adjustment for confounders, the logarithmic transformation (Ln) of EROA/LVEDV was associated with 1-year mortality (odds ratio 0.600, 95% confidence interval 0.386 to 0.933, p = 0.023). A higher Society of Thoracic Surgeons risk score was also associated with increased mortality. In conclusion, lower values of Ln(EROA/LVEDV) were associated with increased 1-year mortality in this multicenter registry. The slope of the association is steep at low values but gradually flattens as Ln(EROA/LVEDV) increases.

Vaccination-Associated Myocarditis and Myocardial Injury.

SARS-CoV-2 vaccine-associated myocarditis/myocardial injury should be evaluated in the contexts of COVID-19 infection, other types of viral myocarditis, and other vaccine-associated cardiac disorders. COVID-19 vaccine-associated myocardial injury can be caused by an inflammatory immune cell infiltrate, but other etiologies such as microvascular thrombosis are also possible. The clinical diagnosis is typically based on symptoms and cardiac magnetic resonance imaging. Endomyocardial biopsy is confirmatory for myocarditis, but may not show an inflammatory infiltrate because of rapid resolution or a non-inflammatory etiology. Myocarditis associated with SARS-COVID-19 vaccines occurs primarily with mRNA platform vaccines, which are also the most effective. In persons aged >16 or >12 years the myocarditis estimated crude incidences after the first 2 doses of BNT162b2 and mRNA-1273 are approximately 1.9 and 3.5 per 100 000 individuals, respectively. These rates equate to excess incidences above control populations of approximately 1.2 (BNT162b2) and 1.9 (mRNA-1273) per 100 000 persons, which are lower than the myocarditis rate for smallpox but higher than that for influenza vaccines. In the studies that have included mRNA vaccine and SARS-COVID-19 myocarditis measured by the same methodology, the incidence rate was increased by 3.5-fold over control in COVID-19 compared with 1.5-fold for BNT162b2 and 6.2-fold for mRNA-1273. However, mortality and major morbidity are less and recovery is faster with mRNA vaccine-associated myocarditis compared to COVID-19 infection. The reasons for this include vaccine-associated myocarditis having a higher incidence in young adults and adolescents, typically no involvement of other organs in vaccine-associated myocarditis, and based on comparisons to non-COVID viral myocarditis an inherently more benign clinical course.

Myocardial Injury and Altered Gene Expression Associated With SARS-CoV-2 Infection or mRNA Vaccination.

SARS CoV-2 enters host cells via its Spike protein moiety binding to the essential cardiac enzyme angiotensin-converting enzyme (ACE) 2, followed by internalization. COVID-19 mRNA vaccines are RNA sequences that are translated into Spike protein, which follows the same ACE2-binding route as the intact virion. In model systems, isolated Spike protein can produce cell damage and altered gene expression, and myocardial injury or myocarditis can occur during COVID-19 or after mRNA vaccination. We investigated 7 COVID-19 and 6 post-mRNA vaccination patients with myocardial injury and found nearly identical alterations in gene expression that would predispose to inflammation, coagulopathy, and myocardial dysfunction.

Esophago-Pericardial Fistula as a Rare and Life-Threatening Complication of Epicardial Ventricular Tachycardia Ablation.

We describe a rare complication of esophago-pericardial fistula after epicardial ventricular tachycardia ablation. Echocardiogram revealed evidence of pneumopericardium and additional imaging studies confirmed esophageal leak with evidence of fistula formation requiring prompt surgical repair. (Level of Difficulty: Intermediate.).

Pulmonary valve assessment by three-dimensional echocardiography.

The pulmonary valve (PV) has historically been ignored by imaging studies. Disorders of the PV encountered in adult cardiac patients are increasingly encountered due to advanced care of patients with congenital heart disease and associated PV diseases. Despite advances in PV imaging, multiple challenges remain when it comes to obtaining high quality PV images. While 2D TTE is the usual initial imaging tool for PV, excellent views of the PV annulus and its one or two leaflets are obtained in less than half of patients. The 3D echocardiography en face view allows all three leaflets to be evaluated concurrently, as well as assessments of the RV outflow tract and main pulmonary artery, which has improved quantitative assessment of PV diseases. Increasing image quality and experience with live/real time 3D TEE amplifies its utility in accurate evaluation and helps guide and monitor successful percutaneous PV interventions. 2D TTE remains the first line diagnostic tool; however, 3D TTE and 3D TEE provide better image quality which increases diagnostic accuracy and guidance to therapy. In this review article, we stress improvement in 3D echocardiography and its role in diagnostic and therapeutic options for PV diseases.

Transesophageal echocardiography simulation: A review of current technology.

Transesophageal echocardiography (TEE) has experienced tremendous increase in interest and demand alongside the rapid growth of transcatheter structural cardiac interventions. TEE instruction prolongs the procedure, increasing the risk of probe malfunction from overheating and patient complications from prolonged sedation. Echocardiographic simulation programs have been developed to hone the procedural skills of novice operators in a time-unrestricted, low-pressure environment before they perform TEEs on real patients. Simulators likely benefit training in interventional TEE for the same reasons. We searched PubMed, basic Google, and Google Scholar for currently marketed TEE simulators, including foreign as well as US companies. We queried the vendors regarding features of the simulators that pertain to effective instructional design for diagnostic TEE. We also queried regarding the simulators' applicability to training in interventional TEE. The vendors' responses are reported here. In addition, we discuss the specific training needs for structural heart interventions, for which echocardiographic simulation could be a powerful educational tool. Lastly, we discuss the role of simulation for formative and summative assessment, and the advances required to improve training in complex procedures within the field of interventional echocardiography.

The National Lipid Association scientific statement on coronary artery calcium scoring to guide preventive strategies for ASCVD risk reduction.

An Expert Panel of the National Lipid Association reviewed the evidence related to the use of coronary artery calcium (CAC) scoring in clinical practice for adults seen for primary prevention of atherosclerotic cardiovascular disease. Recommendations for optimal use of this test in adults of various races/ethnicities, ages and multiple domains of primary prevention, including those with a 10-year ASCVD risk <20%, those with diabetes or the metabolic syndrome, and those with severe hypercholesterolemia were provided. Recommendations were also made on optimal timing for repeat calcium scoring after an initial test, use of CAC scoring in those taking statins, and its role in informing the clinician patient discussion on the benefit of aspirin and anti-hypertensive drug therapy. Finally, a vision is provided for the future of coronary calcium scoring.

Enhancing the value of PCSK9 monoclonal antibodies by identifying patients most likely to benefit. A consensus statement from the National Lipid Association.

Acquisition costs and cost-effectiveness have limited access and recommendations to use proprotein convertase subtilisin/kexin type 9 (PCSK9)-inhibiting monoclonal antibodies (mAbs). Recently, prices were reduced by 60% for alirocumab and evolocumab. This statement systematically reviewed subgroup analyses from statin and PCSK9 mAb trials to identify higher risk groups for which PCSK9 mAbs at the new price could be considered a reasonable (

Feasibility of pulmonary valve imaging using transesophageal echocardiography upper esophageal view.

BACKGROUND: The present study designed to evaluate feasibility of transesophageal echocardiographic (TEE) imaging of the pulmonary valve (PV) at the transaortic upper esophageal (TAUE) window. We hypothesized that patients with larger aorta would be more likely to have visualization of the PV from this TAUE window. METHODS: 2D TEE images of the PV were prospectively acquired by one operator at the TAUE window looking through the aortic arch. Patients were divided into four groups based on image quality of PV (group 1, not visualized; group 2, barely visualized; group 3, sufficient visualization; group 4, excellent visualization). Clinical, echocardiographic, and radiologic parameters were collected. RESULTS: A total of 212 consecutive patients (54 ± 14 years, 63.7% male) were enrolled. Group distribution was as follows: group 1, n = 60 (28.3%); group 2 n = 39 (18.4%); group 3, n = 27 (12.7%); group 4, n = 86 (40.6%). There were no differences between groups' baseline clinical characteristics. There was a weak although statistically negative correlation between PV image quality and aortic arch dimension (r = -0.17 P = 0.01). There was a stronger positive correlation between PV thickness (r = 0.38 P < 0.001) and PV image quality. Retrospective subgroup analysis of 76 patients with recent chest CT showed similar, but not significant trends as by TEE. CONCLUSION: The use of 2D TEE TAUE results in diagnostic image quality of the PV in the majority of patients and outstanding image quality in a subset of patients. PV image quality is negatively affected by increasing aorta diameter and positively affected by PV thickness.

The acute effects of edge-to-edge percutaneous mitral valve repair on the shape and size of the mitral annulus and its relation to mitral regurgitation.

BACKGROUND: The effects of edge-to-edge percutaneous mitral valve repair on the shape and size of the mitral annulus and its relation to mitral regurgitation (MR) have not been well characterized. We evaluated acute changes in mitral annular shape and dimensions, and their effect on MR severity, in patients with functional and degenerative MR following MitraClip® . METHODS: Patients that underwent MitraClip® between January 2013 and May 2016 at our institution were retrospectively reviewed. EXCLUSIONS: inadequate images, prior mitral valve repair, and rapid atrial fibrillation. Intra-procedure TEE 3D images acquired prior to and after implantation of MitraClip® were analyzed using software to model the mitral valve apparatus. RESULTS: Of seventy-eight patients that underwent MitraClip® procedure, 60 were eligible. Mean age was 78.3 ± 11 years. Severe MR (4+) was present in 37 patients, moderately/severe MR (3+) in 23. All patients achieved MR reduction to ≤2. 3D annular circumference, bicommissural diameter, and anteroposterior diameter had a significant size reduction after MitraClip® . None of the mitral annular measures had significantly different mean change between the large and small MR change groups at the 0.05 significance level. CONCLUSIONS: In patients with functional or degenerative MR, the MitraClip® significantly affect mitral annular dimensions; however, these changes do not correlate with the immediate MR reduction.

JCL roundtable: Coronary artery calcium scoring and other vascular imaging for risk assessment.

Computed tomographic (CT) coronary calcium scoring has been established by large prospective, population-based studies as the single best noninvasive predictor of atherosclerotic cardiovascular risk available today. The calcium score correlates highly with the total burden of coronary atherosclerosis demonstrated at autopsy. It adds significantly to traditional risk calculators such as the Framingham Risk Calculator or the Pooled Cohort Equations. The 2018 U.S. Cholesterol Guidelines endorse the use of CT coronary calcium scoring to refine risk estimates in the intermediate range of 7.5%-20% over 10 years. Most, but not all, adults with calcium scores of zero can reasonably elect to avoid or defer statin therapy, but repeating the calcium score should be considered in 5 to 10 years. Discussants at this roundtable urge that coronary calcium scoring be offered to many more adults than currently receiving this test, including those with borderline 10-year risk in the range of 5%-7.5%. CT coronary angiography is a procedure based on intravenous contrast injection, mostly used in low-risk patients with chest pain. In British guidelines, CT angiography is preferred over stress testing for initial assessment of suspected coronary symptoms. Carotid ultrasound evaluating both the carotid intima-media thickness and presence of plague is less predictive than coronary calcium scoring for overall atherosclerotic risk but more predictive for stroke risk.

Structural and Functional Phenotyping of the Failing Heart: Is the Left Ventricular Ejection Fraction Obsolete?

Diagnosis, prognosis, treatment, and development of new therapies for diseases or syndromes depend on a reliable means of identifying phenotypes associated with distinct predictive probabilities for these various objectives. Left ventricular ejection fraction (LVEF) provides the current basis for combined functional and structural phenotyping in heart failure by classifying patients as those with heart failure with reduced ejection fraction (HFrEF) and those with heart failure with preserved ejection fraction (HFpEF). Recently the utility of LVEF as the major phenotypic determinant of heart failure has been challenged based on its load dependency and measurement variability. We review the history of the development and adoption of LVEF as a critical measurement of LV function and structure and demonstrate that, in chronic heart failure, load dependency is not an important practical issue, and we provide hemodynamic and molecular biomarker evidence that LVEF is superior or equal to more unwieldy methods of identifying phenotypes of ventricular remodeling. We conclude that, because it reliably measures both left ventricular function and structure, LVEF remains the best current method of assessing pathologic remodeling in heart failure in both individual clinical and multicenter group settings. Because of the present and future importance of left ventricular phenotyping in heart failure, LVEF should be measured by using the most accurate technology and methodologic refinements available, and improved characterization methods should continue to be sought.

Women's Health Considerations for Lipid Management.

Understanding opportunities to reduce dyslipidemia before, during, and after pregnancy has major implications for cardiovascular disease risk prevention for the entire population. The best time to screen for dyslipidemia is before pregnancy or in the early antenatal period. The differential diagnosis of hypertriglyceridemia in pregnancy is the same as in nonpregnant women except that clinical lipidologists need to be aware of the potential obstetric complications associated with hypertriglyceridemia. Dyslipidemia discovered during pregnancy should be treated with diet and exercise intervention, as well as glycemic control if indicated. A complete lipid profile assessment during each trimester of pregnancy is recommended.

Statins and the Liver.

Lipid lowering, particularly with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors ("statins"), reduces the risk of cardiovascular disease. Patients with chronic liver disease present challenges to the use of lipid medications. In the case of most liver disorders, the concern has been one of safety. There is evidence that most lipid-lowering medications can be used safely in many situations, although large outcomes trials are lacking. This review examines lipid physiology and cardiovascular risk in specific liver diseases and reviews the evidence for lipid lowering and the use of statins in chronic liver disease.

Incidence and Risk Factors for Postcontrast Acute Kidney Injury in Survivors of Sudden Cardiac Arrest.

STUDY OBJECTIVE: Survivors of sudden cardiac arrest may be exposed to iodinated contrast from invasive coronary angiography or contrast-enhanced computed tomography, although the effects on incident acute kidney injury are unknown. The study objective was to determine whether contrast administration within the first 24 hours was associated with acute kidney injury in survivors of sudden cardiac arrest. METHODS: This cohort study, derived from a prospective clinical trial, included patients with sudden cardiac arrest who survived for 48 hours, had no history of end-stage renal disease, and had at least 2 serum creatinine measurements during hospitalization. The contrast group included patients with exposure to iodinated contrast within 24 hours of sudden cardiac arrest. Incident acute kidney injury and first-time dialysis were compared between contrast and no contrast groups and then controlled for known acute kidney injury risk factors. RESULTS: Of the 199 survivors of sudden cardiac arrest, 94 received iodinated contrast. Mean baseline serum creatinine level was 1.3 mg/dL (95% confidence interval [CI] 1.4 to 1.5 mg/dL) for the contrast group and 1.6 mg/dL (95% CI 1.4 to 1.7 mg/dL) for the no contrast group. Incident acute kidney injury was lower in the contrast group (12.8%) than the no contrast group (17.1%; difference 4.4%; 95% CI -9.2% to 17.5%). Contrast administration was not associated with significant increases in incident acute kidney injury within quartiles of baseline serum creatinine level or after controlling for age, sex, race, congestive heart failure, diabetes, and admission serum creatinine level by regression analysis. Older age was independently associated with acute kidney injury. CONCLUSION: Despite elevated baseline serum creatinine level in most survivors of sudden cardiac arrest, iodinated contrast administration was not associated with incident acute kidney injury even when other acute kidney injury risk factors were controlled for. Thus, although acute kidney injury is not uncommon among survivors of sudden cardiac arrest, early (<24 hours) contrast administration from imaging procedures did not confer an increased risk for acute kidney injury.

Percutaneous Repair of Aortic Pseudoaneurysms: A Case Series.

BACKGROUND: Aortic pseudoaneurysms (APSAs) are an uncommon but serious complication of aortic surgery with potentially fatal complications if left untreated. Operative repair is associated with significant morbidity and mortality. Percutaneous APSA repair may reduce the risk of these complications and represents an alternative option for patients. We report our experience with percutaneous intervention for the treatment of APSAs. METHODS AND RESULTS: We retrospectively reviewed all patients at our institution who underwent percutaneous APSA repair with Amplatzer septal occluders and vascular plugs between January 2004 and September 2014. Ten patients are included in this study, representing our first cases of percutaneous APSA repair. Follow-up was performed with serial computed tomographic angiography. The primary outcome was the success rate of device deployment. Secondary outcomes included success rate of complete APSA exclusion, postprocedural symptoms, and periprocedural and postprocedural complications. Mean clinical follow-up time was 12 months (range, 5-30 months) and mean imaging follow-up time was 29 months (range, 14-52 months). Device deployment was successful in all patients, although 2 patients required reintervention due to device malposition and the discovery of additional defects on postprocedure CT angiography. There were no periprocedural or postprocedure complications. Long-term follow-up imaging was available for 7 patients and revealed complete APSA exclusion in 4 patients. One out of the remaining 3 patients ultimately required operative intervention. CONCLUSIONS: Percutaneous APSA repair can be performed safely with a good procedural success, albeit with variable long-term results. This procedure may be considered as an alternative to surgical repair in select patients.