Association of Left Atrial Hemodynamics by Magnetic Resonance Imaging With Long-Term Outcomes in Patients With Cardiac Amyloidosis.

BACKGROUND: Left atrial (LA) function and strain patterns by magnetic resonance imaging (MRI) have been investigated as markers of several cardiovascular pathologies, including cardiac amyloidosis (CA). However, associations with clinical outcomes have not been investigated. PURPOSE: To compare LA function and strain by MRI in CA patients to a matched cohort of patients without cardiovascular disease (CVD) and evaluate the association with long-term clinical outcomes in CA patients. STUDY TYPE: Retrospective case control. POPULATION: A total of 51 patients with CA and 51 age-, gender-, and race-matched controls without CVD who underwent MRI in sinus rhythm. FIELD STRENGTH/SEQUENCE: ECG-gated balanced steady-state free precession sequence at 1.5 T. ASSESSMENT: All measurements were completed by one investigator (M.M.B.). LA function and strain parameters were measured including LA indexed minimum and maximum volumes, LA reservoir (R), contractile (CT), and conduit (CD) strain. We compared groups after adjusting for age, hypertension, New York Heart Association class, modified staging system (troponin-I, BNP, estimated GFR) and left ventricular ejection fraction (LVEF) for an endpoint of all-cause mortality and a composite endpoint of heart failure hospitalization (HFH) or death. STATISTICAL TESTS: Differences between groups were evaluated with t tests for continuous variables or χ2 tests for categorical variables. A multivariable regression model was used to assess the associations of the P values-two-sided tests-<0.05 were considered statistically significant. RESULTS: CA patients with median follow up of 4.9 (8.5) months had significantly lower LA strain and higher LA volumes in comparison to the matched cohort. In the multivariable analysis, only LVEF was significantly associated with death while ƐCT (OR 0.6, CI: 0.41-0.89), indexed minimum LA volume (OR 1.06, CI: 1.02-1.13) and indexed maximum LA volume (OR 1.08, CI: 1.01-1.15) were significantly associated with the composite outcome of death or HFH. CONCLUSION: In this retrospective study of CA patients, ƐCT and indexed minimum and maximum LA volumes were significantly associated with the composite outcome of death or HFH. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 3.

Association of left atrial strain by cardiovascular magnetic resonance with recurrence of atrial fibrillation following catheter ablation.

BACKGROUND: Atrial fibrillation (AF) is a progressive condition, which is characterized by inflammation/fibrosis of left atrial (LA) wall, an increase in the LA size/volumes, and decrease in LA function. We sought to investigate the relationship of anatomical and functional parameters obtained by cardiovascular magnetic resonance (CMR), with AF recurrence in paroxysmal AF (pAF) patients after catheter ablation. METHODS: We studied 80 consecutive pAF patients referred for ablation, between January 2014 and December 2019, who underwent pre- and post-ablation CMR while in sinus rhythm. LA volumes were measured using the area-length method and included maximum, minimum, and pre-atrial-contraction volumes. CMR-derived LA reservoir strain (ℇR), conduit strain (ℇCD), and contractile strain (ℇCT) were measured by computer assisted manual planimetry. We used a multivariate logistical regression to estimate the independent predictors of AF recurrence after ablation. RESULTS: Mean age was 58.6 ± 9.4 years, 75% men, mean CHA2DS2-VASc score was 1.7, 36% had prior cardioversion and 51% were taking antiarrhythmic drugs. Patients were followed for a median of 4 years (Q1-Q3 = 2.5-6.2 years). Of the 80 patients, 21 (26.3%) patients had AF recurrence after ablation. There were no significant differences between AF recurrence vs. no recurrence groups in age, gender, CHA2DS2-VASc score, or baseline comorbidities. At baseline, patients with AF recurrence compared to without recurrence had lower LV end systolic volume index (32 ± 7 vs 37 ± 11 mL/m2; p = 0.045) and lower ℇCT (7.1 ± 4.6 vs 9.1 ± 3.7; p = 0.05). Post-ablation, patients with AF recurrence had higher LA minimum volume (68 ± 32 vs 55 ± 23; p = 0.05), right atrial volume index (62 ± 20 vs 52 ± 19 mL/m2; p = 0.04) and lower LA active ejection fraction (24 ± 8 vs 29 ± 11; p = 0.05), LA total ejection fraction (39 ± 14 vs 46 ± 12; p = 0.02), LA expansion index (73.6 ± 37.5 vs 94.7 ± 37.1; p = 0.03) and ℇCT (6.2 ± 2.9 vs 7.3 ± 1.7; p = 0.04). Adjusting for clinical variables in the multivariate logistic regression model, post-ablation minimum LA volume (OR 1.09; CI 1.02-1.16), LA expansion index (OR 0.98; CI 0.96-0.99), and baseline ℇR (OR 0.92; CI 0.85-0.99) were independently associated with AF recurrence. CONCLUSION: Significant changes in LA volumes and strain parameters occur after AF ablation. CMR derived baseline ℇR, post-ablation minimum LAV, and expansion index are independently associated with AF recurrence.

Index Admission and Thirty-Day Readmission Outcomes of Patients With Cancer Presenting With STEMI.

BACKGROUND: National-level data of cancer patients' readmissions after ST-segment elevation myocardial infarction (STEMI) are lacking. OBJECTIVES: The primary aim of this study was to compare the rates and causes of 30-day readmissions in patients with and without cancer. METHODS: Among patients admitted with STEMI in the United States National Readmission Database (NRD) from October 2015-December 2017, we identified patients with the diagnosis of active breast, colorectal, lung, or prostate cancer. The primary endpoint was the 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of patients with and without cancer. RESULTS: A total of 385,522 patients were included in the analysis: 5956 with cancer and 379,566 without cancer. After propensity score matching, 23,880 patients were compared (Cancer = 5949, No Cancer = 17,931). Patients with cancer had higher 30-day readmission rates (19% vs. 14%, p < 0.01). The most common causes for readmission among patients with cancer were cardiac (31%), infectious (21%), oncologic (17%), respiratory (4%), stroke (4%), and renal (3%). During the first readmission, patients with cancer had higher adjusted rates of in-hospital mortality (15% vs. 7%; p < 0.01) and bleeding complications (31% vs. 21%; p < 0.01), compared to the non-cancer group. In addition, cancer (OR 1.5, 95% CI 1.2-1.6, p < 0.01) was an independent predictor for 30-day readmission. CONCLUSIONS: About one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cardiac causes predominated the reason for 30-day readmissions in patients with cancer.

Depression and anxiety in patients with heart disease and/or cancer based on the National Health Interview Survey.

Depression and anxiety in patients with heart disease and/or cancer have been shown to affect quality of life, adherence with medical management, and prognosis. We investigated the association of the diagnoses of cancer, heart disease, or both with self-reported symptoms consistent with serious mental illness (SMI). We used the K6 score to identify self-reported symptoms consistent with SMI from patients' responses to the 2017 National Health Interview Survey. Our final cohort included 24,777 individual surveys. Of those respondents, 1509 reported cancer, 2639 reported heart disease, and 534 reported both. About 96% of patients reported a K6 score <13, and 4% reported a K6 score ≥13, which is suggestive of SMI. Logistic regression identified significant associations between SMI and an inability to afford mental care/counseling, an inability to afford prescribed medications, and unemployed status, with odds ratios of 6.97, 2.94, and 3.49, respectively. Having both heart disease and cancer was independently associated with SMI (odds ratio = 2.57; 95% confidence interval, 1.53-4.31; P < 0.001). In conclusion, in a nationally representative self-reported questionnaire, patients with a combined diagnosis of cancer and heart disease were significantly more likely to report SMI than those with either diagnosis alone.

Safety and long-term efficacy of thoracoscopic Epicardial ablation in patients with paroxysmal atrial fibrillation: a retrospective study.

BACKGROUND: The aim of this study is to report the long-term efficacy and safety of thoracoscopic epicardial left atrial ablation (TELA) in patients with paroxysmal atrial fibrillation (AF). METHODS: This was a retrospective review of medical records. We included all patients diagnosed with paroxysmal AF who underwent TELA at our institution between 04/2011 and 06/2017. TELA included pulmonary vein isolation, LA dome lesions and LA appendage exclusion. All (n = 55) patients received an implantable loop recorder (ILR), 30 days post-operatively. Antiarrhythmic and anticoagulation therapy were discontinued at 90 and 180 days postoperatively, respectively, if patients were free of AF recurrence. Failure was defined as ≥two minutes of continuous AF, or atrial tachycardia. RESULTS: Fifty-five patients (78% males, mean age = 61.6 years) qualified for the study. The average duration in AF was 3.64 +/- 3.4 years, mean CHA2DS2-VASc Score was 2.0 +/- 1.6. The procedure was attempted in 57 patients and completed successfully in 55 (96.5%). Two patients experienced a minor pulmonary vein bleed that was managed conservatively. Post procedure, one patient experienced pulmonary edema, another experienced a pneumothorax requiring a chest tube and another experienced acute respiratory distress syndrome resulting in longer hospitalization. Otherwise, there were no major procedural complications. Success rates were 89.1% (n = 49/55), 85.5% (n = 47/55) and 76.9% (n = 40/52) at 6, 12 and 24 months, respectively. In the multivariate cox-proportional hazard model, survival at the mean of covariates was 86 and 74% at 12 and 24 months, respectively. CONCLUSION: In this single center experience, TELA was a safe and efficacious procedure for patients with paroxysmal AF.

Ischemic and functional mitral regurgitation in heart failure: natural history and treatment.

Functional mitral regurgitation (FMR) occurs when normal or nearly normal mitral leaflets are prevented from proper coaptation by underlying left ventricular (LV) dysfunction, mitral annular dilation, or both. FMR is associated with an adverse prognosis in nonischemic or ischemic LV dysfunction. Multiple studies have confirmed that even mild FMR portends a worse prognosis, and that the risk of FMR is independent of LV volumes and other clinical risk factors. FMR can be difficult to quantitate echocardiographically because it is load dependent and can vary considerably from exam to exam. There is a systematic tendency to underestimate FMR severity by echocardiography because the regurgitant orifice in FMR is typically elliptical, but the formula for calculating regurgitant orifice area assumes circular geometry. Treatment of FMR begins with guideline-directed medical therapy (GDMT) for LV dysfunction and heart failure, including cardiac resynchronization, if indicated. Revascularization should be considered for ischemic FMR, when indicated. Finally, mitral valve surgery should be considered in patients undergoing CABG in whom moderate or greater FMR is present, and also when severe symptomatic FMR persists despite optimal GDMT and revascularization. Percutaneous options for treatment of FMR are in development but are not currently approved in the US.

A comparison of outcomes between OKT3 and antithymocyte globulin for treatment of steroid-resistant rejection in hepatitis C liver transplant recipients.

BACKGROUND: The treatment of steroid-resistant rejection (SRR) is associated with severe recurrent hepatitis C virus (HCV) infection after liver transplantation (LTx). After OKT3 was recently withdrawn from the market, thymoglobulin (TG) became the principal treatment for SRR. METHODS: A retrospective analysis of 32 HCV patients who were treated for SRR with OKT3 (n=15) or TG (n=17) using yearly protocol liver biopsies. Mean follow-up was 4.3 years (OKT3) and 3.2 years (TG). We compared both groups for patient survival, graft loss, and severity of HCV recurrence, manifested as the mean stage of fibrosis (MSF). RESULTS: Patient survival at 1, 2, and 5 years after LTx was 80%, 73%, and 67% in the OKT3 group and 82%, 77%, and 64% in the TG group, respectively. At 2 years after LTx, the graft losses were 3 versus 4 in the OKT3 and TG groups, respectively. At years 1 and 2, the MSF in the OKT3 group was 1.9 and 2.3 versus 2.4 and 2.8 in the TG group, respectively. None of the differences between both groups was statistically significant. CONCLUSION: There was no significant difference in patient survival, graft loss, or severity of recurrent HCV, measured as MSF, between both groups.

Matrix metalloproteinase inhibitors as investigative tools in the pathogenesis and management of vascular disease.

Matrix metalloproteinases (MMPs) are proteolytic enzymes that degrade various components of the extracellular matrix (ECM). MMPs could also regulate the activity of several non-ECM bioactive substrates and consequently affect different cellular functions. Members of the MMPs family include collagenases, gelatinases, stromelysins, matrilysins, membrane-type MMPs, and others. Pro-MMPs are cleaved into active MMPs, which in turn act on various substrates in the ECM and on the cell surface. MMPs play an important role in the regulation of numerous physiological processes including vascular remodeling and angiogenesis. MMPs may also be involved in vascular diseases such as hypertension, atherosclerosis, aortic aneurysm, and varicose veins. MMPs also play a role in the hemodynamic and vascular changes associated with pregnancy and preeclampsia. The role of MMPs is commonly assessed by measuring their gene expression, protein amount, and proteolytic activity using gel zymography. Because there are no specific activators of MMPs, MMP inhibitors are often used to investigate the role of MMPs in different physiologic processes and in the pathogenesis of specific diseases. MMP inhibitors include endogenous tissue inhibitors (TIMPs) and pharmacological inhibitors such as zinc chelators, doxycycline, and marimastat. MMP inhibitors have been evaluated as diagnostic and therapeutic tools in cancer, autoimmune disease, and cardiovascular disease. Although several MMP inhibitors have been synthesized and tested both experimentally and clinically, only one MMP inhibitor, i.e., doxycycline, is currently approved by the Food and Drug Administration. This is mainly due to the undesirable side effects of MMP inhibitors especially on the musculoskeletal system. While most experimental and clinical trials of MMP inhibitors have not demonstrated significant benefits, some trials still showed promising results. With the advent of new genetic and pharmacological tools, disease-specific MMP inhibitors with fewer undesirable effects are being developed and could be useful in the management of vascular disease.