Videoscope-assisted transaortic myectomy in patients with hypertrophic cardiomyopathy with complex left ventricular anatomy.

BACKGROUND: The transaortic approach is the most common method of septal myectomy. However, difficulties arise due to a limited view of the surgical field. Here, we report our experience with videoscope-assisted transaortic myectomy. METHODS: We reviewed myectomy operations that were performed between July 2015 and June 2019 at Chung-Ang University Hospital, Seoul, South Korea. Patients who previously had cardiac surgery, alcohol septal ablation, or concomitant disease which required combined surgery, were excluded. Among the 21 patients included, 10 patients underwent videoscope-assisted transaortic myectomy (VA group), and 11 patients underwent myectomy in a conventional manner (CO group). The preoperative data, echocardiographic images, operative records, and postoperative outcomes of these patients were reviewed. RESULTS: There were no differences in baseline characteristics between groups VA and CO. The main indications for videoscope-assisted transaortic myectomy in group VA were midventricular septal muscle resection (70%), abnormal papillary muscle resection (40%), and abnormal chordal connection resection (30%). Eight (80%) patients had multiple indications for videoscope-assisted transaortic myectomy. There was no surgical mortality in either group. Postoperative patients showed less than moderate mitral regurgitation and a New York Heart Association class either III or IV. There were no differences in hospital days (9.5 vs. 12.0 days; p = .383), nor postoperative pressure gradient (14 vs. 15 mmHg; p > .99). CONCLUSIONS: Videoscope-assisted transaortic myectomy is an effective surgical technique in selective hypertrophic cardiomyopathy patients with complex intraventricular anatomy, diffuse hypertrophy, and midventricular obstruction.

Disparities in Mortality and Cardiovascular Events by Income and Blood Pressure Levels Among Patients With Hypertension in South Korea.

Background Socioeconomic status is associated with differences in risk factors of cardiovascular disease and increased risks of cardiovascular disease and mortality. However, it is unclear whether an association exists between cardiovascular disease and income, a common measure of socioeconomic status, among patients with hypertension. Methods and Results This population-based longitudinal study comprised 479 359 patients aged ≥19 years diagnosed with essential hypertension. Participants were categorized by income and blood pressure levels. Primary end point was all-cause and cardiovascular mortality and secondary end points were cardiovascular events, a composite of cardiovascular death, myocardial infarction, and stroke. Low income was significantly associated with high all-cause (hazard ratio [HR], 1.26; 95% CI, 1.23-1.29, lowest versus highest income) and cardiovascular mortality (HR, 1.31; 95% CI, 1.25-1.38) as well as cardiovascular events (HR, 1.07; 95% CI, 1.05-1.10) in patients with hypertension after adjusting for age, sex, systolic blood pressure, body mass index, smoking status, alcohol consumption, physical activity, fasting glucose, total cholesterol, and the use of aspirin or statins. In each blood pressure category, low-income levels were associated with high all-cause and cardiovascular mortality and cardiovascular events. The excess risks of all-cause and cardiovascular mortality and cardiovascular events associated with uncontrolled blood pressure were more prominent in the lowest income group. Conclusions Low income and uncontrolled blood pressure are associated with increased all-cause and cardiovascular mortality and cardiovascular events in patients with hypertension. These findings suggest that income is an important aspect of social determinants of health that has an impact on cardiovascular outcomes in the care of hypertension.

Antihypertensive Drugs and the Risk of Cancer: A Nationwide Cohort Study.

We sought to assess the association between common antihypertensive drugs and the risk of incident cancer in treated hypertensive patients. Using the Korean National Health Insurance Service database, the risk of cancer incidence was analyzed in patients with hypertension who were initially free of cancer and used the following antihypertensive drug classes: Angiotensin-converting enzyme inhibitors (ACEIs); angiotensin receptor blockers (ARBs); beta blockers (BBs); calcium channel blockers (CCBs); and diuretics. During a median follow-up of 8.6 years, there were 4513 (6.4%) overall cancer incidences from an initial 70,549 individuals taking antihypertensive drugs. ARB use was associated with a decreased risk for overall cancer in a crude model (hazard ratio (HR): 0.744, 95% confidence interval (CI): 0.696-0.794) and a fully adjusted model (HR: 0.833, 95% CI: 0.775-0.896) compared with individuals not taking ARBs. Other antihypertensive drugs, including ACEIs, CCBs, BBs, and diuretics, did not show significant associations with incident cancer overall. The long-term use of ARBs was significantly associated with a reduced risk of incident cancer over time. The users of common antihypertensive medications were not associated with an increased risk of cancer overall compared to users of other classes of antihypertensive drugs. ARB use was independently associated with a decreased risk of cancer overall compared to other antihypertensive drugs.

Effect of angiotensin receptor blockers on the development of cancer: A nationwide cohort study in korea.

The potential cancer risk associated with long-term exposure to angiotensin receptor blockers (ARBs) is still unclear. We assessed the risk of incident cancer among hypertensive patients who were treated with ARBs compared with patients exposed to angiotensin-converting enzyme inhibitors (ACEIs), which are known to have a neutral effect on cancer development. Using the Korean National Health Insurance Service database, we analyzed the data of patients diagnosed with essential hypertension from January 2005 to December 2012 who were aged ≥40 years, initially free of cancer, and were prescribed either ACEI or ARB (n = 293,962). Cox proportional hazard model adjusted for covariates was used to evaluate the risk of incident cancer. During a mean follow-up of 10 years, 24,610 incident cancers were observed. ARB use was associated with a decreased risk of overall cancer compared with ACEI use (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.72-0.80). Similar results were obtained for lung (HR 0.73, 95% CI 0.64-0.82), hepatic (HR 0.56, 95% CI 0.48-0.65), and gastric cancers (HR 0.74, 95% CI 0.66-0.83). Regardless of the subgroup, greater reduction of cancer risk was seen among patients treated with ARB than that among patients treated with ACEIs. Particularly, the decreased risk of cancer among ARB users was more prominent among males and heavy drinkers (interaction P < .005). Dose-response analyses demonstrated a gradual decrease in risk with prolonged ARB therapy than that with ACEI use. In conclusion, ARB use was associated with a decreased risk of overall cancer and several site-specific cancers.

Pittsburgh B Compound Positron Emission Tomography in Patients With AL Cardiac Amyloidosis.

BACKGROUND: It remains unknown whether the noninvasive evaluation of the degree of amyloid deposition in the myocardium can predict the prognosis of patients with light chain (AL) cardiac amyloidosis. OBJECTIVES: The purpose of this study was to demonstrate that 11C-Pittsburgh B compound positron emission tomography (11C-PiB PET) is useful for prognostication of AL cardiac amyloidosis by noninvasively imaging the myocardial AL amyloid deposition. METHODS: This study consecutively enrolled 41 chemotherapy-naïve AL cardiac amyloidosis patients. The amyloid deposit was quantitatively assessed with amyloid P immunohistochemistry in endomyocardial biopsy specimens and was compared with the degree of myocardial 11C-PiB uptake on PET. The primary endpoint was a composite of all-cause death, heart transplantation, and acute decompensated heart failure. RESULTS: The degree of myocardial 11C-PiB PET uptake was significantly higher in the cardiac amyloidosis patients compared with normal subjects and correlated well with the degree of amyloid deposit on histology (R2 = 0.343, p < 0.001). During follow-up (median: 423 days, interquartile range: 93 to 1,222 days), 24 patients experienced the primary endpoint. When the cardiac amyloidosis patients were divided into tertiles by the degree of myocardial 11C-PiB PET uptake, patients with the highest PiB uptake experienced the worst clinical event-free survival (log-rank p = 0.014). The degree of myocardial PiB PET uptake was a significant predictor of clinical outcome on multivariate Cox regression analysis (adjusted hazard ratio: 1.185; 95% confidence interval: 1.054 to 1.332; p = 0.005). CONCLUSIONS: These proof-of-concept results show that noninvasive evaluation of myocardial amyloid load by 11C-PiB PET reflects the degree of amyloid deposit and is an independent predictor of clinical outcome in AL cardiac amyloidosis patients.

Prevalence of Positive 99 mTc-DPD Scintigraphy as an Indicator of the Prevalence of Wild-type Transthyretin Amyloidosis in the Elderly.

Senile or wild-type transthyretin (wtTTR) amyloidosis is an age-related disease caused by the deposition of wtTTR amyloid protein. In contrast to light chain amyloidosis, 99 mTc-DPD scintigraphy (DPD scan) is a useful diagnostic modality for wtTTR amyloidosis.We retrospectively analyzed patients older than 30 years who underwent DPD scanning for non-cardiac reasons at our hospital between June 2014 and March 2017 (n = 9,581). Transthoracic echocardiography was used to assess left ventricular hypertrophy (LVH), as well as systolic and diastolic function.A positive DPD scan was observed in only six patients (0.06%). All six of these patients were older than 70 years, and they constitute only 0.4% of patients in this age group (6/1652). Among the patients with a positive DPD scan, four showed concentric LVH and two showed a normal wall thickness. With respect to the severity of diastolic dysfunction and pulmonary artery pressure, patients with a positive DPD scan showed the expected E' and pulmonary artery systolic pressure for their age.Even considering the limited sensitivity of a positive DPD scan detecting wtTTR amyloidosis, the incidence of a positive DPD scan in non-cardiac patients indicated that wtTTR amyloid deposition does not seem to be a major cause for age-related diastolic dysfunction, nor does appear to have a high incidence in patients with heart failure with preserved EF in the elderly.

Myocardial Strain in Prediction of Outcomes After Surgery for Severe Mitral Regurgitation.

OBJECTIVES: We investigated whether global longitudinal strain (GLS) is a better predictor of clinical events after surgery for mitral regurgitation (MR) than conventional parameters. BACKGROUND: The optimal timing for surgery is guided by left ventricular (LV) dimension or left ventricular ejection fraction (LVEF), even though normal LVEF can mask depressed LV systolic function in severe mitral MR. METHODS: From 2006 to 2016, 506 patients (age 58.5 ± 13.7 years, 54.3% male) with severe primary MR who underwent mitral valve surgery were included. We measured GLS and global circumferential strain. Cardiac events included admission for worsening heart failure (HF), reoperation for failure of MV surgery, and cardiac death. RESULTS: During a median follow-up period of 3.5 years, 56 (11.1%) patients died, 41 (8.1%) were hospitalized for HF, and 10 (2.0%) underwent reoperation. In univariate analysis, LVEF, atrial fibrillation, left atrial dimension, age, previous ischemia, concomitant coronary artery bypass graft, and both GLS and global circumferential strain were predictive of cardiac events. On multivariate Cox models, age (hazard ratio [HR]: 1.429, 95% confidence interval [CI]: 1.116 to 1.831; p = 0.005), left atrial dimension (HR: 1.034, 95% CI: 1.006 to 1.063; p = 0.019) and GLS (HR: 1.229, 95% CI: 1.135 to 1.331; p < 0.001) were independent predictors of cardiac events. In subgroup analysis, LV GLS was a significant predictor of cardiac outcome, regardless of the presence of LV dysfunction, the presence of atrial fibrillation, and the type of surgery. Impaired GLS was associated with all-cause mortality (HR: 1.068, 95% CI: 1.003 to 1.136; p = 0.040). CONCLUSIONS: GLS appears to be a better predictor of cardiac events all-cause death than conventional parameters. Measuring preoperative GLS is helpful to predict post-operative outcome and determine optimal timing for surgery in patients with severe primary MR.

Statin therapy is associated with lower all-cause mortality in patients with non-obstructive coronary artery disease.

OBJECTIVE: Non-obstructive coronary artery disease (CAD) is a frequent clinical condition and is associated with an increase in cardiovascular events. However, appropriate medical therapy for this population is not known. We investigated the association between statin use and risk of all-cause mortality and coronary revascularization in patients with non-obstructive CAD. METHODS: From 2007 to 2011, we identified 8372 consecutive patients with non-obstructive CAD (1-49% stenosis) documented by coronary computed tomography angiography (CCTA) from 3 medical centers. Patients with statins or aspirin use before CCTA, and a history of revascularization before initial CCTA were excluded. All-cause mortality and a composite of mortality and late coronary revascularization (>90 days after CCTA) were analyzed according to the use of statins. RESULTS: Mean age of the study population was 61.4 ± 10.9 years and 70.3% were male. Statins were prescribed to 1983 (23.7%) patients. During 828 days of follow-up (IQR 385-1342), 221 (2.6%) cases of all-cause mortality and 295 (3.5%) cases of the composite endpoint were observed. Statin therapy was associated with lower risks of all-cause mortality (adjusted HR 0.397; 95% CI 0.262-0.602; p < 0.0001) and composite endpoint (adjusted HR 0.430; 95% CI 0.310-0.597; p < 0.0001). Association between statin therapy and better clinical outcomes was regardless of age, sex, presence of hypertension or diabetes, coronary artery calcium score, low-density lipoprotein cholesterol levels, high-sensitivity C-reactive protein levels, or glomerular filtration rate. CONCLUSIONS: Statin therapy was associated with a lower risk of all-cause mortality in patients with non-obstructive CAD documented by CCTA, regardless of combined clinical risk factors.

Nonbacterial Thrombotic Endocarditis in a Patient with Bowel Infarction due to Mesenteric Vein Thrombosis.

Ante mortem cases of venous thrombosis in patients with nonbacterial thrombotic endocarditis (NBTE) have not yet been reported. We describe a rare case of NBTE in a patient with mesenteric vein thrombosis. A healthy 37-year-old man with abdominal pain and fever underwent emergency small bowel resection due to bowel ischemia resulting from mesenteric vein thrombosis. Transthoracic echocardiography revealed multiple mobile masses attached to the anterior leaflet of the mitral valves and their chordae tendineae. On suspicion of infective endocarditis, the cardiac masses were excised through open-heart surgery. However, pathologic reviews were compatible with NBTE. The patient was stable after the cardiac surgery and was treated with warfarin. Laboratory and imaging findings regarding his hypercoagulable condition were all negative.