Outcomes and survival with aortic valve replacement compared with medical therapy in patients with low-, moderate-, and severe-gradient severe aortic stenosis and normal left ventricular ejection fraction.

BACKGROUND: This study determined outcomes and survival with aortic valve replacement (AVR) versus medical therapy in patients with normal left ventricular ejection fraction (LVEF) with severely reduced aortic valve areas (AVA) but nonsevere mean gradients. METHODS: We identified 248 aortic stenosis (AS) patients with LVEF ≥ 50% and echocardiographic AVA < 1.0 cm(2). Group 1 had low-gradient: <30 mmHg mean gradient; group 2 (moderate: 30 to 40 mm Hg); and group 3 (severe: >40 mm). RESULTS: There were 94, 87, and 67 patients in groups 1, 2, and 3. Incidence of death in groups 1, 2, and 3 were 55%, 39%, and 39% (P not significant). Incidence of AVR in groups 1, 2, and 3 were 23%, 53%, and 49% (P < 0.0001 for group 1 vs. 2; P = 0.0003 for group 1 vs. group 3). Incidence of AVR or death was 71%, 77%, and 76% (P not significant). AVR (hazard ratio = 0.30; 95% CI, 0.18, 0.51; P < 0.0001) and mitral annular calcification (hazard ratio = 2.33; 95% CI, 1.40, 3.88; P = 0.001) were independently associated with time to mortality. Kaplan-Meier curves for time to death did not differ significantly among the three groups. Kaplan-Meier survival curves for patients with and without AVR showed patients in all three groups who underwent AVR had significantly greater survival. CONCLUSION: Among patients with normal LVEF and AVA < 1.0 cm(2), overall survival does not differ among those with low-, moderate-, or severe-aortic valve gradients. Survival is significantly improved with AVR, regardless of gradient.

A novel two-dimensional echocardiographic finding in cardiac amyloidosis.

BACKGROUND: A number of echocardiographic findings characteristic of cardiac amyloidosis (CA) have been described, each with limitations. METHODS: A distinctive wall motion pattern of preserved myocardial thickening at left ventricular apex with hypokinesis in basal and midsegments was observed in two patients with biopsy proven CA. Following this observation, endomyocaradial biopsy files beginning in 2007 were reviewed. Seven consecutive patients with documented CA were identified. Two-dimensional (2D) echocardiograms for each were reviewed in consensus by two experienced echocardiographers. Clinical and electrocardiographic data were obtained from chart review. RESULTS: All patients were men with class II-IV heart failure. Six had light chain CA, 1 senile CA. Six patients had coronary angiography. One had a 60% left anterior descending coronary artery stenosis. Five had nonobstructive disease. Echocardiograms for all seven patients demonstrated the distinctive pattern of preserved myocardial thickening at apex with hypokinesis in basal and midsegments. Reduced ejection fraction was present in six and increased wall thickness and myocardial echogenicity in seven. Other echo signs of amyloid were variably present. Three had low voltage on electrocardiogram. CONCLUSION: A distinctive 2D echocardiographic pattern of preserved segmental wall motion at left ventricular apex with hypokinesis in basal to midsegments was consistently identified in seven consecutive patients with endomyocardial biopsy-proven CA.

Comparison of sensitivity, specificity, positive predictive value, and negative predictive value of stress testing versus 64-multislice coronary computed tomography angiography in predicting obstructive coronary artery disease diagnosed by coronary angiography.

Sixty-four-multislice coronary computed tomographic angiography (CTA) and coronary angiography were performed in 145 patients (mean age 67 +/- 10 years), and stress testing was performed in 47 of these patients to determine the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA and of stress testing in diagnosing obstructive coronary artery disease (CAD) in patients with suspected CAD. In 145 patients, coronary CTA had 98% sensitivity, 74% specificity, 90% positive predictive value, and 94% negative predictive value in diagnosing obstructive CAD. In 47 patients, stress testing had 69% sensitivity, 36% specificity, 78% positive predictive value, and 27% negative predictive value for diagnosing obstructive CAD, whereas coronary CTA had 100% sensitivity, 73% specificity, 92% positive predictive value, and 100% negative predictive value for diagnosing obstructive CAD. In conclusion, coronary CTA has better sensitivity, specificity, positive predictive value, and negative predictive value than stress testing in diagnosing obstructive CAD.

Prevalence of an increased ascending thoracic aorta diameter diagnosed by two-dimensional echocardiography versus 64-multislice cardiac computed tomography.

The prevalence of an enlarged ascending thoracic aortic diameter (AAD) diagnosed by 2-dimensional echocardiography compared with 64-slice cardiac computed tomography (MSCT) was investigated in 97 women and 117 men (mean age 65 +/- 12 years). Enlarged AADs were diagnosed in 42 of 214 patients (20%) by echocardiography and in 45 of 214 patients (21%) by MSCT (p = NS). The sensitivity, specificity, positive predictive value, and negative predictive value of echocardiography in diagnosing an enlarged AAD using MSCT were 69%, 93%, 74%, and 92%, respectively. A Bland-Altman plot showed that the agreement for AAD measured by echocardiography and MSCT was 95% inside the 2-SD limits. In conclusion, the sensitivity, specificity, positive predictive value, and negative predictive value of 2-dimensional echocardiography in diagnosing enlarged AAD using MSCT were 69%, 93%, 74%, and 92%, respectively.

Pseudoaneurysm with thrombus and left ventricular inflow obstruction after left circumflex stenting.

A 61-year-old woman had stenting of the left circumflex coronary artery. She had a repeat coronary angiogram the day after stenting because of hypotension and orthopnea. The left circumflex stent was patent. A transesophageal echocardiogram showed a 2.5 cm x 3.0-cm mass in the atrioventricular groove compressing the left atrium. A pseudoaneurysm with thrombus and left ventricular inflow obstruction was diagnosed. The patient was observed for 48 hours to allow the pseudoaneurysm to seal and coagulate. She then had surgical evacuation of the thrombus, which had caused her hypotension and orthopnea by compression of the left atrium.

Prevalence of an increased ascending and descending thoracic aorta diameter diagnosed by multislice cardiac computed tomography in men versus women and in persons aged 23 to 50 years, 51 to 65 years, 66 to 80 years, and 81 to 88 years.

The prevalence of increased ascending thoracic aortic diameter (AAD) and increased descending thoracic aortic diameter (DAD) diagnosed using multislice cardiac computed tomography was investigated in 624 consecutive patients at an academic cardiology practice in 2006. Increased AAD (>3.7 cm) was present in 71 of 361 men (20%) and in 23 of 263 women (9%) (p <0.001). Increased DAD (>3.0 cm) was present in 26 of 339 men (8%) and in 8 of 258 women (3%) (p <0.02). Increased AAD was present in (1) 7 of 96 patients (7%) aged 23 to 50 years, (2) 22 of 234 patients (9%) aged 51 to 65 years, (3) 53 of 263 patients (20%) aged 66 to 80 years, and (4) 12 of 31 patients (39%) aged 81 to 88 years (p <0.005 comparing groups 3 and 1; p <0.001 comparing groups 4 and 1, groups 4 and 2, and groups 3 and 2; p <0.02 comparing groups 4 and 3). Increased DAD was present in (1) 0 of 96 patients (0%) aged 23 to 50 years, (2) 5 of 227 patients (2%) aged 51 to 65 years, (3) 21 of 244 patients (9%) aged 66 to 80 years, and (4) 8 of 30 patients (27%) aged 81 to 88 years (p <0.005 comparing groups 3 and 1, groups 3 and 2, and groups 4 and 3; p <0.001 comparing groups 4 and 1 and groups 4 and 2). In conclusion, men have a higher prevalence of increased AAD and DAD than women, and increasing age increases the prevalence of increased AAD and DAD.

Differences of lateral and septal mitral annulus velocity by tissue Doppler imaging in the evaluation of left ventricular diastolic function.

Left ventricular diastolic dysfunction (LVDD) was investigated in 276 outpatients at a university cardiology practice by tissue Doppler imaging of mitral valve annular velocity. The well-investigated parameters of mitral inflow were used as the standard. Using septal E/Ea ratios, 62 patients (22%) had no LVDD, 44 patients (16%) had mild LVDD, 126 patients (46%) had moderate LVDD, 25 patients (9%) had severe LVDD, and 19 patients (7%) had indeterminate LVDD. Using lateral E/Ea ratios, 131 patients (48%) had no LVDD, 40 patients (14%) had mild LVDD, 62 patients (22%) had moderate LVDD, 9 patients (3%) had severe LVDD, and 12 patients (13%) had indeterminate LVDD. In conclusion, the use of septal tissue Doppler imaging tends to overestimate the severity of LVDD compared with the use of lateral tissue Doppler imaging.

Increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium in patients with chronic renal insufficiency.

Cardiovascular morbidity and mortality is high in patients with chronic renal insufficiency. Patients with chronic renal insufficiency have an increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium than patients with normal renal function. These risk factors for cardiovascular morbidity and mortality contribute to the increased incidence of cardiovascular morbidity and mortality seen in patients with chronic renal insufficiency.

Prevalence and prognosis of intrapulmonary shunts in patients with hepatic cirrhosis.

We investigated the prevalence of intrapulmonary shunts in 82 patients with hepatic cirrhosis referred for echocardiography as part of liver transplantation evaluation. Intrapulmonary shunts were present in 49 of 82 patients (60%). Baseline characteristics were similar in patients with and without intrapulmonary shunts. Mean follow up was 41 +/- 15 months in patients with intrapulmonary shunts and 42 +/- 15 months in patients without intrapulmonary shunts (P not significant). At follow up, 8 of 49 patients (16%) with intrapulmonary shunts and 4 of 33 patients (12%) without intrapulmonary shunts had died (P not significant).

Relation of decreased ankle-brachial index to prevalence of atherosclerotic risk factors, coronary artery disease, aortic valve calcium, and mitral annular calcium.

Coronary artery disease was present in 89 of 118 patients (75%) with a decreased ankle-brachial index (ABI) and in 34 of 118 age- and gender-matched patients (29%) with a normal ABI (p <0.001). Aortic valve calcium or mitral annular calcium was present in 81 of 118 patients (69%) with a decreased ABI and in 43 of 118 patients (36%) with a normal ABI (p <0.001).

Prevalence of left ventricular diastolic dysfunction in obese persons with and without diabetes mellitus.

Forty obese diabetic patients (mean age 48 +/- 9 years) and 93 obese nondiabetic patients (mean age 43 +/- 9 years) underwent Doppler and tissue Doppler echocardiographic evaluation of left ventricular diastolic function before gastric bypass surgery. Moderate or severe left ventricular diastolic dysfunction was present in 24 of 40 obese diabetics (60%) and in 21 of 93 obese nondiabetics (23%) (p <0.001).

Association of right ventricular dysfunction with in-hospital mortality in patients with acute pulmonary embolism and reduction in mortality in patients with right ventricular dysfunction by pulmonary embolectomy.

Twenty-one of 64 patients (33%) with pulmonary embolisms with right ventricular (RV) dilation and 6 of 126 patients (5%) with pulmonary embolisms without RV dilation died during hospitalization (p <0.001). In the 64 patients with RV dilation, in-hospital mortality occurred in 2 of 18 hemodynamically unstable patients (11%) who underwent pulmonary embolectomy, in 2 of 6 hemodynamically stable patients (33%) treated with thrombolytic therapy plus intravenous heparin, and in 17 of 40 hemodynamically stable patients (43%) treated with intravenous heparin (p <0.025 comparing pulmonary embolectomy with no pulmonary embolectomy).

Prevalence of valve calcium and association of valve calcium with coronary artery disease, atherosclerotic vascular disease, and all-cause mortality in 137 patients undergoing hemodialysis for chronic renal failure.

Of 137 patients (mean age 63 years) who underwent hemodialysis for chronic renal failure, 65 (47%) had mitral valve calcium, mitral annular calcium, or aortic valve calcium. Thirty-eight of 65 patients (59%) who had valve calcium died at 3.5-year follow-up versus 21 of 72 patients (29%) who did not have valve calcium and who died at 4.3-year follow-up (p = 0.0005).

Association of reduced carbon monoxide diffusing capacity with moderate or severe left ventricular diastolic dysfunction in obese persons.

STUDY OBJECTIVES: To determine the association of reduced diffusing capacity of the lung for carbon monoxide (D(LCO)) with moderate or severe left ventricular diastolic dysfunction (LVDD) in obese persons. DESIGN: We investigated the association of D(LCO) with LVDD in 105 patients with a mean +/- SD body mass index of 49 +/- 5 kg/m2. An abnormal D(LCO) was < 80%. LVDD was investigated by Doppler and by tissue Doppler echocardiography. The Doppler echocardiographic data were analyzed blindly without knowledge of the clinical characteristics or whether the D(LCO) was normal or abnormal. SETTING: A university hospital. PATIENTS: The 105 patients included 19 men and 86 women (mean age, 45 +/- 9 years). RESULTS: An abnormal D(LCO) was present in 62 of 105 patients (59%). Moderate or severe LVDD was present in 35 of 105 patients (33%). Moderate or severe LVDD was present in 25 of 62 patients (40%) with an abnormal D(LCO) and in 10 of 43 patients (23%) with a normal D(LCO) (p < 0.05). CONCLUSION: Obese patients with a decreased D(LCO) have an increased prevalence of moderate or severe LVDD.

Comparison of outcomes in patients with active infective endocarditis and a paravalvular abscess on a prosthetic valve versus a native valve.

We investigated in-hospital and long-term mortality in 16 patients with infective endocarditis and paravalvular abscess on a prosthetic valve (6 of whom underwent surgery) and in 12 patients with infective endocarditis and paravalvular abscess on a native valve (8 of whom underwent surgery). The only significant risk factor for in-hospital mortality in patients with prosthetic or native value paravalvular abscess was age (P < 0.001). In-hospital mortality was 33% in patients with prosthetic valve paravalvular abscess undergoing surgery and 33% in patients treated medically (P = not significant). In-hospital mortality was 25% in patients with native valve paravalvular abscess undergoing surgery and 25% in patients treated medically (P = not significant). At 4.8-year follow up, survival of patients with prosthetic valve paravalvular abscess was 67% for patients treated surgically versus 40% for patients treated medically (P = not significant). At 4.8-year follow up, survival of patients with native valve paravalvular abscess was 75% for patients treated surgically versus 50% for patients treated medically (P = not significant).

Importance of echocardiography in patients with severe nonischemic heart failure: the second Prospective Randomized Amlodipine Survival Evaluation (PRAISE-2) echocardiographic study.

BACKGROUND: Echocardiography is used commonly in clinical practice when caring for patients with heart failure. It is unknown whether the presence of certain findings provides an incremental ability to predict survival beyond the use of baseline clinical findings alone. The second PRAISE-2 echocardiographic study was prospectively designed to identify echocardiographic predictors of survival among patients with nonischemic cardiomyopathy and heart failure and to determine if components of the echocardiographic examination add prognostic information to baseline demographic and clinical information. METHODS: One hundred patients participated in the second Prospective Randomized Amlodipine Survival Evaluation Study (PRAISE-2) echocardiographic study; of these, 93 had full and interpretable echocardiographic examinations. Cox proportional hazards modeling was used to assess the relation between various characteristics and survival as well as to assess the incremental prognostic information gained by echocardiography beyond the clinical examination. RESULTS: Seven of 10 routine echocardiographic measures were significantly associated with death. These included mitral regurgitation (hazard ratio [HR], 2.31; 95% CI, 1.02, 5.27), left ventricular ejection fraction <20% (HR, 2.59; 95% CI, 1.14, 5.88), restrictive left ventricular filling pattern (HR, 2.37; 95% CI, 1.05, 5.32), and peak D velocity (HR, 1.62; 95% CI, 0.38, 0.87). The only statistically significant clinical predictor of survival was dyspnea at rest. The addition any of several echocardiographic parameters to baseline clinical information significantly improved the ability to predict survival. CONCLUSIONS: Several readily available echocardiographic parameters are predictive of death and when added to clinical examination findings significantly improve the ability to determine prognosis among patients with nonischemic cardiomyopathy and heart failure.

Diuretic resistance predicts mortality in patients with advanced heart failure.

BACKGROUND: In patients with chronic heart failure (CHF), diuretic requirements increase as the disease progresses. Because diuretic resistance can be overcome with escalating doses, the evaluation of CHF severity and prognosis may be incomplete without considering the intensity of therapy. METHODS: The prognostic importance of diuretic resistance (as evidenced by a high-dose requirement) was retrospectively evaluated in 1153 patients with advanced CHF who were enrolled in the Prospective Randomized Amlodipine Survival Evaluation (PRAISE). The relation of loop diuretic and angiotensin-converting enzyme inhibitor doses (defined by their median values) and other baseline characteristics to total and cause-specific mortality was determined by proportion hazards regression. RESULTS: High diuretic doses were independently associated with mortality, sudden death, and pump failure death (adjusted hazard ratios [HRs] 1.37 [P =.004], 1.39 [P =.042], and 1.51 [P =.034], respectively). Use of metolazone was an independent predictor of total mortality (adjusted HR = 1.37, P =.016) but not of cause-specific mortality. Low angiotensin-converting enzyme inhibitor dose was an independent predictor of pump failure death (adjusted HR = 2.21, P =.0005). Unadjusted mortality risks of congestion and its treatment were additive and comparable to those of established risk factors. CONCLUSIONS: The independent association of high diuretic doses with mortality suggests that diuretic resistance should be considered an indicator of prognosis in patients with chronic CHF. These retrospective observations do not establish harm or rule out a long-term benefit of diuretics in CHF, because selection bias may entirely explain the relation of prescribed therapy to death.

Comparison of frequency of left ventricular thrombi in patients with anterior wall versus non-anterior wall acute myocardial infarction treated with antithrombotic and antiplatelet therapy with or without coronary revascularization.

Of 200 patients with ST-segment elevation acute myocardial infarction (AMI), all received antiplatelet and antithrombotic therapy, and 186 patients (93%) underwent coronary revascularization. Left ventricular thrombi were diagnosed by 2-dimensional echocardiography

Comparison of outcomes in patients with active infective endocarditis with versus without paravalvular abscess and with and without valve replacement.

In 82 patients with infective endocarditis, including 11 with a perivalvular abscess detected by transesophageal echocardiography, age was a significant predictor of in-hospital mortality (p <0.001). At 3.8-year follow-up, 5 of 7 patients with an abscess who had valve replacement and 2 of 4 patients with an abscess who did not have surgery survived (p = NS); 13 of 22 patients (59%) with no abscess who had valve replacement and 20 of 49 patients (41%) with no abscess who did not have surgery survived (p = NS).

Comparison of two-dimensional echocardiographic tissue harmonic imaging and gated sestamibi single-photon emission computed tomographic left ventricular ejection fraction measurements.

There was good correlation between left ventricular ejection fraction (EF) measurements employing 2-dimensional echocardiography with tissue harmonic imaging and single-photon emission computed tomography using quantitative gated scintigraphy, although in most patients, echocardiographic EF was lower. There was a high degree of agreement between these 2 techniques in assignment of EF to the categories of normal, mildly, moderately, or severely decreased. However, when EF categories did differ, echocardiography always resulted in assignment to a lower category.