Impact of stroke volume assessment by three-dimensional transesophageal echocardiography on the classification of low-gradient aortic stenosis.

BACKGROUND: Accurate assessment of flow status is crucial in low-gradient aortic stenosis (AS). However, the clinical implication of three-dimensional transesophageal echocardiography (3DTEE) on flow status evaluation remains unclear. This study aimed to investigate the assessment of flow status using 3D TEE in low-gradient AS patients. METHODS: We retrospectively reviewed patients diagnosed with low-gradient AS and preserved ejection fraction at our institution between 2019 and 2022. Patients were categorized into low-flow/low-gradient (LF-LG) AS or normal-flow/low-gradient (NF-LG) AS based on two-dimensional transthoracic echocardiography (2DTTE). We compared the left ventricular outflow tract (LVOT) geometry between the two groups and reclassified them using stroke volume index (SVi) obtained by 3DTEE. RESULTS: Among 173 patients (105 with LF-LG AS and 68 with NF-LG AS), 54 propensity-matched pairs of patients were analyzed. 3DTEE-derived ellipticity index of LVOT was significantly higher in LF-LG AS patients compared to NF-LG AS patients (p = 0.012). We assessed the discordance in flow status classification between SVi2DTTE and SVi3DTEE in both groups using a cutoff value of 35 ml/m2. The LF-LG AS group exhibited a significantly higher discordance rate compared to the NF-LG AS group, with rates of 50% and 2%, respectively. The optimal cutoff values of SVi3DTEE for identifying low flow status, based on 2DTTE-derived cutoff values, were determined to be 43 ml/m2. CONCLUSIONS: LVOT ellipticity in low-gradient AS patients varies depending on flow status, and this difference contributes to discrepancies between SVi3DTEE and SVi2DTTE, particularly in LF-LG AS patients. Utilizing SVi3DTEE is valuable for accurately assessing flow status.

Risk Factors for Major Bleeding during Prolonged Anticoagulation Therapy in Patients with Venous Thromboembolism: From the COMMAND VTE Registry.

BACKGROUND: There are limited data assessing the risk for bleeding on anticoagulation therapy beyond the acute phase in patients with venous thromboembolism (VTE). The present study aimed to identify risk factors for major bleeding during prolonged anticoagulation therapy in VTE patients. PATIENTS AND METHODS: The COMMAND VTE Registry is a multicenter registry enrolling 3,027 consecutive patients with acute symptomatic VTE. The current study population consisted of 2,728 patients who received anticoagulation therapy beyond the acute phase, after excluding those patients with major bleeding events (n = 48), death (n = 66), or loss to follow-up (n = 32) during the initial parenteral anticoagulation period within 10 days after diagnosis, and those without anticoagulation therapy beyond 10 days after diagnosis (n = 153). RESULTS: During the median follow-up period of 555 days, major bleeding occurred in 189 patients (70 patients within 3 months; 119 patients beyond 3 months) with fatal bleeding in 24 patients (13%). The cumulative incidence of major bleeding was 2.7% at 3 months, 5.2% at 1 year, and 11.8% at 5 years. Active cancer (hazard ratio [HR], 3.06, 95% confidence interval [CI], 2.23-4.18), previous major bleeding (HR, 2.38, 95% CI, 1.51-3.59), anemia (HR, 1.75, 95% CI, 1.27-2.43), thrombocytopenia (HR, 2.11, 95% CI, 1.27-3.33), and age ≥75 years (HR, 1.64, 95% CI, 1.22-2.20) were independently associated with an increased risk for major bleeding by the multivariable Cox regression model. CONCLUSION: Major bleeding events were not uncommon during prolonged anticoagulation therapy in real-world VTE patients. Active cancer, previous major bleeding, anemia, thrombocytopenia, and old age were the independent risk factors for major bleeding.

Associations of residual left ventricular and left atrial remodeling with clinical outcomes in patients after aortic valve replacement for severe aortic stenosis.

BACKGROUND: Aortic valve replacement (AVR) is currently the standard therapy for severe aortic stenosis (AS), and regression of left ventricular (LV) hypertrophy after AVR has been reported. However, data regarding a temporal relation between LV mass and left atrial (LA) volume are limited, and their prognostic impacts have not been fully elucidated. We aimed to clarify the temporal patterns of LA and LV reverse remodeling and their associations with clinical outcomes. METHODS: We retrospectively reviewed 198 consecutive patients who underwent AVR for severe AS. After excluding patients with prior cardiac surgery, atrial fibrillation, concomitant moderate to severe aortic regurgitation, or concurrent mitral valve surgery, 83 patients with echocardiographic LV mass index (LVMI) and LA volume index (LAVI) data before and 1 year after AVR were eligible for the outcome analysis and 29 patients with these 2 measures before surgery, 1 month, 1 year, and 3 years after surgery were eligible for the analysis of time-dependent change of LVMI and LAVI. RESULTS: Significant reductions in LVMI and LAVI (both p<0.001) after surgery were observed over time. LA dilatation improved and reached a plateau 1 month after surgery, whereas LV hypertrophy improved more gradually and reached a plateau at 1 year. The presence of both LV hypertrophy and LA dilatation 1 year after surgery was associated with significantly higher mortality (patients with both conditions vs. patients with neither or one condition=22.6% vs. 7.3% at 3 years; p=0.031) and major adverse cardiac and cerebrovascular events (38.9% vs. 12.6% at 3 years; p=0.021). CONCLUSIONS: LA reverse remodeling occurred rapidly after AVR for severe AS, and regression of LV hypertrophy was more gradual. The presence of both residual LV hypertrophy and LA dilatation 1 year after AVR was associated with poor long-term outcomes.

Trends in the clinical and pathological characteristics of cardiac rupture in patients with acute myocardial infarction over 35 years.

BACKGROUND: There is little known about whether the clinical and pathological characteristics and incidence of cardiac rupture (CR) in patients with acute myocardial infarction (AMI) have changed over the years. METHODS AND RESULTS: The incidence and clinical characteristics of CR were investigated in patients with AMI, who were divided into 3 cohorts: 1977-1989, 1990-2000, and 2001-2011. Of a total of 5699 patients, 144 were diagnosed with CR and 45 survived. Over the years, the incidence of CR decreased (1977-1989, 3.3%; 1990-2000, 2.8%; 2001-2011, 1.7%; P=0.002) in association with the widespread adoption of reperfusion therapy. The mortality rate of CR decreased (1977-1989, 90%; 1990-2000, 56%; 2001-2011, 50%; P=0.002) in association with an increase in the rate of emergent surgery. In multivariable analysis, first myocardial infarction, anterior infarct, female sex, hypertension, and age >70 years were significant risk factors for CR, whereas impact of hypertension on CR was weaker from 2001 to 2011. Primary percutaneous coronary intervention (PPCI) was a significant protective factor against CR. In 64 autopsy cases with CR, myocardial hemorrhage occurred more frequently in those who underwent PPCI or fibrinolysis than those who did not receive reperfusion therapy (no reperfusion therapy, 18.0%; fibrinolysis, 71.4%; PPCI, 83.3%; P=0.001). CONCLUSIONS: With the development of medical treatment, the incidence and mortality rate of CR have decreased. However, first myocardial infarction, anterior infarct, female sex, and old age remain important risk factors for CR. Adjunctive cardioprotection against reperfusion-induced myocardial hemorrhage is emerging in the current PPCI era.

Left coronary artery occlusion caused by a large thrombus on the left coronary cusp in a patient with a continuous-flow ventricular assist device.

Despite continual improvements in ventricular assist device (VAD) therapy, various clinical issues are emerging. Importantly, various types of thromboembolic complications have been reported to date. Recently, we encountered a rare continuous-flow VAD-related thromboembolic event that resulted in acute myocardial infarction. A 26-year-old female who just underwent HeartMate II(®) VAD implantation suddenly developed widespread anterolateral myocardial infarction on postoperative day 16. Echocardiography and aortography revealed a large thrombus on the left coronary cusp of the aortic valve that almost completely occluded the left coronary ostium. After VAD implantation, her aortic valve did not open, even at relatively low pump speeds; this was thought to be one of the causes for thrombus formation. Continuous suction of blood from the left ventricle and non-pulsatile flow into the ascending aorta resulted in a continuously closed aortic valve and stagnation of blood in the coronary cusp. Furthermore, both small body size (body surface area <1.3 m(2)) and postoperative right ventricular failure may have exacerbated blood stagnation and thrombus formation in this patient. We should have adjusted the anticoagulation and antiplatelet therapy protocols based on the patient's condition. She underwent off-pump coronary artery bypass surgery and remained in clinically stable condition afterwards.

A rare connection by newly formed conduit vessels between the left internal mammalian artery and radial artery bypass grafts after failure of grafts.

Neovascularization such as formation of collateral vessels following total occlusion of native coronary artery is common in coronary artery disease. This is a case report of a very rare connection by newly formed conduit vessels between the left internal mammalian artery and the radial artery establishing bypass, which occurred after failure of bypass grafts.