Incidence, management, and prognosis of post-ischaemic ventricular septal defect: Insights from a 12-year tertiary centre experience.

Background: Among mechanical complications of acute myocardial infarction, ventricular septal defect (VSD) is uncommon but still serious. The evolution of emergency coronary revascularisation paradoxically decreased our knowledge of this disease, making it even rarer. Aim: To describe ischaemic VSD incidence, management, and associated in-hospital and 1-year outcomes over a 12-years period. Methods: A retrospective single-centre register of patients managed for ischaemic VSD between January 2009 and December 2020. Results: Ninety-seven patients were included representing 8 patients/ years and an incidence of 0.44% of ACS managed. The majority of the patients were 73-years-old males (n = 54, 56%) with STEMI presentation (n = 75, 79%) and already presented with Q necrosis on ECG (n = 70, 74%). Forty-nine (51%) patients underwent PCI, 60 (62%) inotrope/vasopressors infusion, and 70 (72%) acute mechanical circulatory support (IABP 62%, ECMO 13%, and Impella® 3%). VSD surgical repair was performed for 44 patients (45%) and 1 patient was transplanted. In-hospital mortality was 71%, and 86% at 1 year, without significant improvement over the decade. Surgery appears to be a protective factor [0.51 (0.28-0.94) p = 0.003], whereas age [1.06 (1.03-1.09), p < 0.001] and lactate [1.16 (1.09-1.23), p < 0.001] were linked to higher 1-year mortality. None of the patients that were managed medically survived 1 year. Conclusion: Post-ischaemic VSD is a rare but serious complication still associated with high mortality. Corrective surgery is associated with better survival, however, timing, patient selection, and a place for mechanical circulatory support need to be defined.

Prevalence, management, and outcomes of haemorrhagic events in left ventricular assist device recipients.

AIMS: Left ventricular assist devices (LVADs) have reduced the mortality of patients with advanced heart failure both as bridge-to-transplant and as destination therapy. However, LVADs are associated with various complications, including bleedings, which affect the prognosis. The aim of the study was to explore the prevalence, management, and outcomes of haemorrhagic adverse events in LVAD recipients. METHODS AND RESULTS: We conducted a retrospective, single-centre, cohort study including all patients who received an LVAD from January 2008 to December 2019 in our tertiary centre (Rangueil University Hospital, Toulouse, France). Bleeding events, death, and heart transplantation were collected from electronic medical files. Eighty-eight patients were included, and 43 (49%) presented at least one bleeding event. Gastrointestinal (GI) bleeding was the most frequent (n = 21, 24%), followed by epistaxis (n = 12, 14%) and intracranial haemorrhage (n = 9, 10%). Bleeding events were associated with increased mortality [hazard ratio (HR) 3.8, 95% confidence interval (CI) 1.5-9.3, P < 0.01], particularly in case of intracranial haemorrhage (HR 14.6, 95% CI 4.2-51.1, P < 0.0001). GI bleedings were associated with a trend towards increased mortality (HR 3.0, 95% CI 0.9-9.3, P = 0.05). Each bleeding episode multiplied the risk of death by 1.8 (95% CI 1.2-2.7, P < 0.01). Finally, only early bleedings (<9 months post-implantation) had an impact on mortality (HR 4.2, 95% CI 1.6-11.1, P < 0.01). Therapeutic management was mainly based on temporary interruption of anticoagulation and permanent interruption of antiplatelet therapy. Invasive management was rarely performed. CONCLUSIONS: Haemorrhagic events in LVAD recipients are frequent and associated with increased mortality. GI bleedings are the most frequent, and intracranial haemorrhages the most associated with mortality. Management remains empirical requiring more research.

Diaphragmatic speckle tracking imaging for 2D-strain assessment in mechanical ventilation weaning test.

Ultrasound (US) is recognized as a useful tool for detecting lung physiology and pathology. Lung US is compared with standard techniques for evaluating lung structure and function such as computed tomography and pulmonary function tests. At present, markers of normal physiology and pathology are detected using expected image patterns. Detecting the latter depends on the experience of the operator. Diaphragmatic dysfunction is a particularly frequent problem in intensive care. Diaphragmatic dysfunction is easily assessed using lung US. Speckle tracking analysis, a known method for assessing tissue displacement and deformation in cardiology, is proposed to be utilized in lung US for detecting and quantifying lung sliding. Using speckle tracking analysis to diaphragmatic deformation quantification could be an informative and new tool for weaning from mechanical ventilation.

Quantitative assessment of tricuspid regurgitation using right and left ventricular stroke volumes obtained from tomographic equilibrium radionuclide ventriculography.

BACKGROUND: Quantitative assessment of valve regurgitation using volumetric method by comparing right and left ventricular stroke volumes is still under investigations. AIMS: To investigate the accuracy of tomographic equilibrium radionuclide ventriculography (t-ERV) for the quantification of tricuspid regurgitation (TR). METHODS AND RESULTS: Sixty-one patients (44 men; mean age 59 ± 12 years) who underwent both t-ERV and transthoracic echocardiography (TTE) studies within 2 weeks for right ventricular systolic function assessment were eligible for inclusion. A sub-group of 22 patients underwent both t-ERV and CMR. Patients with mitral/aortic regurgitation by TTE were excluded of the study. TR regurgitant volume (RVol) was calculated using the proximal isovelocity surface area (PISA) method from TTE and the volumetric method (right ventricular stroke volume minus left ventricular stroke volume) from t-ERV. There was a significant correlation between RVol as assess by ERV and by TTE (R = 0.95, P < 0.0001). Intraclass correlation coefficient between TTE and ERV for TR quantification was 0.95 (P < 0.0001). Among patients who underwent CMR, the correlation between RVol obtained by TTE and by t-ERV and CMR were R = 0.81 and R = 0.75, respectively (all P < 0.0001). CONCLUSION: TR assessment using the t-ERV correlates well with PISA from TTE in patients referred for right ventricular systolic function assessment.

Feasibility and accuracy of gated blood pool SPECT equilibrium radionuclide ventriculography for the assessment of left and right ventricular volumes and function in patients with left ventricular assist devices.

BACKGROUND: Left ventricular assist devices (LVADs) require serial assessment of right and left ventricular (RV & LV) volumes and function. Because the RV is not assisted, its function is a critical determinant of the hemodynamic and contributes significantly to postoperative morbidity and mortality. We evaluated the feasibility and the accuracy of tomographic-equilibrium radionuclide ventriculography (t-ERV) for the assessment of patients with LVADs. METHODS: Twenty-four patients with LVAD underwent t-ERV. Because of the limited acoustic window, transthoracic echocardiography (TTE) was only feasible in 19 patients. Functional evaluation including six-minute walk test (6MWT) and peak oxygen consumption (POC) was performed in 18 patients. Nine patients underwent a cardiac multidetector computed tomography (MDCT). Eight patients underwent a second evaluation by ERV 4.3 ± 1.4 months later. RESULTS: Reliability between t-ERV and MDCT for LV end-diastolic volume, LV end-systolic volume, LV ejection fraction, RV end-diastolic volume, RV end-systolic volume, and RV ejection fraction (RVEF) was 0.900 (P = .001), 0.911 (P = .001), 0.765 (P = .021), 0.728 (P = .042), 0.875 (P = .004), and 0.781 (P = .023), respectively. There was no correlation between t-ERV and RV systolic parameters assessed by TTE. RVEF was correlated with POC (R = 0.521; P = .027). A cut-off value of 40% for RVEF measured by t-ERV could discriminate patients with poor functional status (P = .048 for NYHA stage; P = .016 for 6MWT and P = .007 for POC). CONCLUSION: t-ERV is a simple, reproducible, and an accurate technique for the assessment of RV function in patients with LVADs and warrants consideration in the evaluation and monitoring of symptomatic patients.

Left Ventricular Function Assessment Using 2 Different Cadmium-Zinc-Telluride Cameras Compared with a γ-Camera with Cardiofocal Collimators: Dynamic Cardiac Phantom Study and Clinical Validation.

UNLABELLED: This study compared two SPECT cameras with cadmium-zinc-telluride (CZT) detectors to a conventional Anger camera with cardiofocal collimators for the assessment of left ventricular (LV) function in a phantom and patients. METHODS: A gated dynamic cardiac phantom was used. Eighteen acquisitions were processed on each CZT camera and the conventional camera. The total number of counts within a myocardial volume of interest varied from 0.25 kcts to 1.5 Mcts. Ejection fraction was set to 33%, 45%, or 60%. Volume, LV ejection fraction (LVEF), regional wall thickening, and motion (17-segment model) were assessed. One hundred twenty patients with a low pretest likelihood of coronary artery disease and normal findings on stress perfusion SPECT were retrospectively analyzed to provide the reference limits for end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction, and regional function for each camera model. RESULTS: In the phantom study, for each ejection fraction value, volume was higher for the CZT cameras than for the conventional camera, resulting in a decreased but more accurate LVEF (all P < 0.001). In clinical data, body-surface-indexed EDV and ESV (mL/m(2)) were higher for one of the CZT cameras (Discovery NM 530c) than for the other (D-SPECT) or the conventional camera (respectively, 40.5 ± 9.2, 37 ± 7.9, and 35.8 ± 6.8 for EDV [P < 0.001] and 12.5 ± 5.3, 9.4 ± 4.2, and 8.3 ± 4.4 for ESV [P < 0.001]), resulting in a significantly decreased LVEF: 70.3% ± 9.1% vs. 75.2% ± 8.1% vs. 77.8% ± 9.3%, respectively (P < 0.001). CONCLUSION: The new CZT cameras yielded global LV function results different from those yielded by the conventional camera. LV volume was higher for the Discovery NM 530c than for the D-SPECT or the conventional camera, leading to decreased LVEF in healthy subjects. These differences should be considered in clinical practice and warrant the collection of a specific reference database.

Assessment of valvular surfaces in children with a congenital bicuspid aortic valve: preliminary three-dimensional echocardiographic study.

BACKGROUND: Congenital bicuspid aortic valve (BAV) is the most common congenital heart defect and may be responsible for aortic stenosis early in life. However, its pathogenesis remains unclear. A relationship between the severity of aortic stenosis and valvular surfaces has not been reported in the paediatric population. AIMS: To assess the feasibility of three-dimensional transthoracic echocardiographic planimetry in congenital BAV in children and to evaluate the influence of valvular asymmetry and aortic valve area (AVA) on stenosis severity. METHODS: Seventy consecutive children with BAV were included in this prospective single-centre study. Using the multiplanar review mode, surfaces were measured by planimetry (in systole for AVA and diastole for cusp surfaces). The degree of stenosis was assessed by instantaneous aortic Doppler. Results are expressed as medians and first and third quartiles. RESULTS: Median age was 5.6 years (2.2-11.5). Feasibility was 97%. Intra- and interobserver concordances were excellent for the measurement of cusp surfaces and AVA. Among the 70 children, 25 had aortic stenosis. The small/large cusp ratio was strongly associated with aortic stenosis (P<0.001). The area under the receiver operating characteristic curve was 0.89 (95% confidence interval 0.82-0.97). The best cut-off value for differentiating stenotic from non-stenotic valve was 0.75, with 84% sensitivity and 83% specificity. When indexed for body surface area, AVA was significantly smaller (P=0.031) in case of stenotic BAV (1.51cm(2) [0.99-2.28]) compared with non-stenotic BAV (1.99cm(2) [1.57-2.52]). CONCLUSIONS: Three-dimensional echocardiographic planimetry is a feasible and reproducible method for assessing aortic surfaces in congenital BAV. Aortic stenosis seems to strongly depend on the asymmetry of the valve.

Gender disparity in 48-hour mortality is limited to emergency percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Previous studies indicate that mortality from acute coronary syndromes is higher in women than in men, especially in case of interventional strategy. AIM: To assess whether the in-hospital mortality rate differs between genders during the first 48h after emergency percutaneous coronary intervention for ST-elevation myocardial infarction (emergency PCI-STEMI) or after non-emergency PCI. METHODS: All patients treated with PCI between January 2005 and June 2008 were included. The primary endpoint was frequency of death within 48h after the PCI procedure; secondary endpoints included frequency of recurrent myocardial infarction, new PCI or coronary artery bypass graft surgery, stroke, and major vascular or renal complications. Data were analysed via logistic regression with and without propensity-score matching. RESULTS: More than 9000 patients underwent PCI. In the emergency PCI-STEMI group (n=1753), 48-hour mortality occurred in 2.2% of men and 4.9% of women (p=0.004). However, gender disparity occurred only in elderly patients; the rate was significantly (p=0.02) higher in women (8.1%) than in men (3.3%) aged > or =75 years. There was no evidence of gender disparity in the non-emergency PCI group (n=7336) or in secondary endpoints for either PCI group. Similar results were obtained in pair analyses of men and women with matching propensity scores. CONCLUSIONS: Elderly women have a disproportionately high in-hospital mortality rate during the first 48h after emergency PCI for treatment of STEMI; however, there is no gender discrepancy in younger patients or patients of any age who receive non-emergency procedures.

Risk of neurological decompression sickness in the diver with a right-to-left shunt: literature review and meta-analysis.

OBJECTIVE: Literature review and meta-analysis to review the evidence of relationship between the presence of right-to-left shunts (RLSs) and the occurrence of neurological decompression sickness (DCS) in divers. DATA SOURCES: MEDLINE, Google Scholar, and Health Technology Assessment databases. STUDY SELECTION: Five case-control studies in which the prevalence of a RLS in a group of divers with neurological DCS was compared with that of a group of divers with no history of DCS, 3 cross-transversal studies in which the prevalence of RLS was measured in divers with neurological DCS, and 4 cross-transversal studies in which the prevalence of RLS was measured in divers with no history of DCS were reviewed. DATA EXTRACTION: Only case-control studies were retained for meta-analysis. DATA SYNTHESIS: This meta-analysis gathers 5 studies and 654 divers. The combined odds ratio of neurological DCS in divers with RLS was 4.23 (3.05-5.87). The meta-analysis including only large RLS found a combined odds ratio of 6.49 (4.34-9.71). CONCLUSIONS: Because of a low incidence of neurological DCS, increase in absolute risk of neurological DCS due to RLS is probably small. Thus, in recreational diving, the systematic screening of RLS seems unnecessary. In professional divers, because of a chronic exposition and unknown consequences of cerebral asymptomatic lesions, these results raise again the benefit of the transcranial Doppler in the screening and quantification of the RLS, independently of their location.