Aortic closure signal length on doppler echocardiography differentiates aortic patient-prosthesis mismatch from prosthetic stenosis.

PURPOSE: The purpose of this study was to investigate the diagnostic potential of the aortic closure (A2) signal length on Doppler echocardiography in distinguishing aortic patient-prosthesis mismatch (PPM) from prosthetic stenosis among patients with elevated gradients over bioprosthetic valves. METHODS: The A2 signal length was retrospectively measured for 150 patients with bioprosthetic aortic valves (50 with PPM, 50 with prosthetic stenosis, and 50 with normally functioning valves) from transthoracic echocardiograms performed at NYU Langone Health between 01/01/2012 and 08/01/2018. RESULTS: Mean A2 signal length was shorter among patients with PPM (11.1 ms ± 5.2 ms), than among those with prosthetic stenosis (21.1 ms ± 6.0 ms), P < .001 and controls (21.7 ms ± 7.4 ms), P < .001. There was no difference in A2 signal length between prosthetic stenosis and controls. The A2 signal length yielded an AUC of 0.89 (95% CI 0.82-0.95) for predicting PPM over prosthetic stenosis. CONCLUSION: Among patients with bioprosthetic aortic valves, the length of the A2 signal on Doppler echocardiography is shorter in PPM than in prosthetic stenosis and normally functioning valves. The A2 signal length may represent a novel metric to distinguish PPM from prosthetic stenosis.

Average e' velocity on transthoracic echocardiogram is a novel predictor of left atrial appendage sludge or thrombus in patients with atrial fibrillation.

BACKGROUND: Studies have demonstrated the value of transthoracic echocardiogram (TTE) diastolic parameters in predicting left atrial appendage (LAA) thrombus; however, these studies have been small. We aim to clarify the relationship between TTE diastolic parameters, in particular average e', and LAA thrombus or sludge. METHODS: A case-control review was conducted of subjects with non-valvular atrial fibrillation (n = 2263) who had undergone TEE (transesophageal echocardiogram) and had a TTE within 1 year of TEE. Cases of LAA sludge or thrombus were matched to controls by age, sex, left ventricular ejection fraction (LVEF), and anticoagulation status. RESULTS: Forty-three subjects (mean age 73 ± 12, 65% male, LVEF 47%, 44% on anticoagulation) with LAA sludge or thrombus were identified. Compared to matched controls, average TTE e' (7.3 ± 2.1 cm/s vs 8.7 ± 2.1 cm/s, P < 0.001) and the E:e' ratio (15 ± 7 cm/s vs 12 ± 5 cm/s; P = 0.005) were significant predictors of LAA sludge or thrombus. Average TTE e' value of >11 cm/s had 100% sensitivity for ruling out LAA sludge or thrombus. CONCLUSION: In individuals with atrial fibrillation, average e' >11 cm/s on TTE is a promising independent predictor of the absence of LAA sludge or thrombus on TEE.

Knowledge Gaps in Cardiovascular Care of the Older Adult Population: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Geriatrics Society.

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.

An unusually accentuated diastolic anterior motion of the mitral valve in aortic insufficiency.

A 55-year-old woman was diagnosed with endocarditis involving the aortic valve and resulting in moderate aortic insufficiency. Transesophageal and transthoracic echocardiography demonstrated an unusually accentuated diastolic anterior motion of the anterior mitral valve leaflet toward the interventricular septum. The anterior leaflet remained within a few millimeters of the septum throughout diastole, with a narrow jet of aortic insufficiency separating the anterior leaflet from the septum. We hypothesize that the particularly long anterior mitral leaflet was drawn toward the septum during diastole due to the Venturi effect of the aortic insufficiency jet within a narrow ventricular outflow tract. This accentuated diastolic anterior motion may be a diastolic correlate of systolic anterior motion of the mitral valve.

Timing of Antihypertensive Drug Therapy: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

BACKGROUND: The timing of antihypertensive drugs administration is controversial. The aim was to compare the efficacy of dosing of antihypertensive drugs in the morning versus evening. METHODS: A PubMed, EMBASE, and clinicaltrials.gov databases search for randomized clinical trials of antihypertensive therapies where patients were randomized to morning versus evening dosing. The outcomes were ambulatory blood pressure (BP) parameters (day-time, night-time, and 24/48-hour systolic blood pressure [SBP] and diastolic blood pressure [DBP]) and cardiovascular outcomes. RESULTS: Of 72 randomized controlled trials included, evening dosing significantly reduced ambulatory BP parameters: 24/48-hour SBP (mean difference [MD]=1.41 mm Hg; [95% CI, 0.48-2.34]), DBP (MD=0.60 mm Hg [95% CI, 0.12-1.08]), night-time SBP (MD=4.09 mm Hg [95% CI, 3.01-5.16]), DBP (MD, 2.57 mm Hg [95% CI, 1.92-3.22]), with a smaller reduction in day-time SBP (MD=0.94 mm Hg [95% CI, 0.01-1.87]), and DBP (MD=0.87 mm Hg [95% CI, 0.10-1.63]), and numerically lower cardiovascular events compared with morning dosing. However, when controversial data by Hermida (23 trials, 25 734 patients) were omitted (Pheterogeneity<0.05 for most outcomes), the above effect of evening dosing attenuated with no significant effect on 24/48-hour ambulatory blood pressure, day-time BP, and major adverse cardiac event and smaller reduction in night-time ambulatory SBP and DBP. CONCLUSIONS: Evening dosing of antihypertensive drugs significantly reduced ambulatory BP parameters and lowered cardiovascular events but the effect was mainly driven by trials by Hermida group. Unless the intention is to specifically lower night-time BP, antihypertensive drugs should be taken at a time of day that is convenient, optimizes adherence, and minimizes undesirable effects.

Amyloid deposition in an explanted bioprosthetic aortic valve: case report and review of the literature.

Herein we present a case of an 80-year-old gentleman who presented with exertional dyspnea status post aortic valve replacement with #23 Trifecta pericardial St. Jude aortic bioprosthetic valve (BV) 12 years prior. He subsequently underwent valve re-replacement due cusp calcification. Histologically, the surgically explanted BV revealed Congophilic deposits with birefringence under cross-polarized light. Extensive work-up identified no systemic source of amyloid in this patient. Liquid chromatography-tandem mass spectrometry-based (LC-MS/MS) proteomics showed the amyloid was composed of human-origin amyloid signature proteins (apolipoprotein A4, apolipoprotein E, serum amyloid P) and human-origin mu heavy chains. Background bovine collagen was also present. Transmission electron microscopy (TEM) showed collections of 7.5-10 nm nonbranching fibrils, consistent with amyloid. Using these techniques, we classified the amyloid as Mu heavy chain, deposition of which is highly unusual in BV. Finally, we provide a review of the literature regarding isolated amyloid deposition in BV.

Isolated left atrial appendage ostial stenosis.

A patient with atrial tachycardia presented with dyspnoea on exertion. Transoesophageal echocardiography revealed idiopathic left atrial appendage stenosis. The mouth of the atrial appendage was narrowed, and there was a high velocity to and fro jet between the left atrial body and the left atrial appendage. The study, therefore, suggested isolated left atrial appendage orifice stenosis.

Fibrinous material in a pericardial effusion mimicking intraatrial thrombus.

A 74-year-old woman presented with an acute cerebrovascular infarct involving multiple vascular territories, suggestive of an embolic event. The initial transesophageal images create the impression of an echogenic mass in the left atrial appendage. A small pericardial effusion was also seen surrounding the left atrial appendage. After further views were obtained, the echogenic mass appeared to be in this fluid-filled space rather than in the appendage itself. To confirm this finding, echo contrast (Definity) was administered. After contrast injection, the left atrial appendage was opacified, while the effusion around the appendage and the echodensity within this space were not opacified. Our case highlights the utility of contrast-enhanced echocardiography in clearly delineating the boundaries of the endocardium in cases, when a pericardial effusion surrounds the left atrial appendage.

Improving Care Using a Bidirectional Geriatric Cardiology Consultative Conference.

More than 13 million persons in the United States aged 65 and older have cardiovascular disease (CVD), and this population is expected to increase exponentially over the next several decades. In the absence of clinical studies that would inform how best to manage this population, there is an urgent need for collaborative, thoughtful approaches to their care. Although cardiologists are traditionally regarded as leaders in the care of older adults with CVD, these individuals have multiple comorbidities, physiological differences, and distinct goals of care than younger patients that require a specialized geriatric lens. Thus, collaboration is needed between geriatricians, cardiologists, and other specialists to address the unique needs of this growing population. Accordingly, clinicians at New York University Langone Health and School of Medicine established a monthly Geriatric Cardiology Conference to foster an integrative approach to the care of older adults with CVD by uniting specialists across disciplines to collaborate on treatment strategies. At each conference, an active case is discussed and analyzed in detail, and a consensus is reached among participants regarding optimal treatment strategies. The conference attracts faculty and trainees at multiple levels from geriatrics, cardiology, and cardiothoracic surgery. The model may serve as a paradigm for other institutions moving towards geriatric-informed care of older adults with CVD.

Positional Right Ventricular Obstruction in Pectus Excavatum.

Pectus excavatum is one of the most common congenital chest wall deformities. The degree of sternal depression, which may result in compression of the right heart by the chest wall, is variable. While typically asymptomatic, there are various symptoms that can result from severe pectus excavatum. We report on a patient with severe pectus excavatum leading to dynamic obstruction of the right ventricular outflow tract in the seated position.

Arthroscopic débridement for osteoarthritis of the knee.

BACKGROUND: The role of arthroscopic débridement in the treatment of osteoarthritis of the knee remains to be defined, and few clinical and radiographic characteristics have been quantitatively associated with the outcome. The hypothesis of this study was that the outcome of arthroscopic débridement for osteoarthritis of the knee is associated with preoperative clinical and radiographic features and intraoperative characteristics and that there are subsets of patients who are more and less likely to respond favorably to the treatment. METHODS: We performed a cross-sectional study of a consecutive cohort of 122 patients who underwent arthroscopic débridement for the treatment of osteoarthritis of the knee that had been unresponsive to anti-inflammatory therapy. One hundred and ten patients were followed for a mean of thirty-four months. Pain was assessed with the pain domain of the Knee Society scoring system. Radiographs were scored with the Kellgren-Lawrence method, and limb alignment and the widths of the medial and lateral joint spaces were measured. The severity of cartilage lesions was scored intraoperatively with a modified Noyes grading system. Specific methods of data collection and analysis were incorporated to minimize bias. RESULTS: Fifty-two (90%) of fifty-eight knees with mild arthritis, normal alignment, and a joint space width of > or = 3 mm were improved after arthroscopic débridement. Conversely, only five (25%) of twenty knees with severe arthritis, limb malalignment, and a joint space width of < 2 mm had substantial relief of symptoms. Of seventy-two patients who had improvement, forty-four (61%) had it within six months after the arthroscopy. The severity of the lesion was highly predictive of the clinical outcome both in patients with mild arthritis and in those with severe arthritis. CONCLUSIONS: The severity of the arthritis, as assessed preoperatively with radiography and intraoperatively by rating the severity of cartilage lesions, influences the clinical outcome of arthroscopic débridement of an osteoarthritic knee. Knees with severe arthritis fare poorly, whereas those with mild arthritis fare well. We could not predict the outcome for knees with moderate arthritis. We believe that these observations are relevant for establishing indications for arthroscopy in patients with osteoarthritis of the knee and may be useful for designing studies with a more rigorous experimental design.

Coronary Artery Disease and Reticular Macular Disease, a Subphenotype of Early Age-Related Macular Degeneration.

PURPOSE: Reticular macular disease (RMD) is the highest risk form of early age-related macular degeneration and also specifically confers decreased longevity. However, because RMD requires advanced retinal imaging for adequate detection of its characteristic subretinal drusenoid deposits (SDD), it has not yet been completely studied with respect to coronary artery disease (CAD), the leading cause of death in the developed world. Because CAD appears in middle age, our purpose was to screen patients aged 45-80 years, documented either with or without CAD, to determine if CAD is associated with RMD. DESIGN: A prospective cohort study of patients with documented CAD status and no known retinal disease in a clinical practice setting at one institution. Subjects and Controls: A number of 76 eyes from 38 consecutive patients (23 with documented CAD, 15 controls documented without CAD; 47.4% female; mean age 66.7 years). METHODS: Patients were imaged with near-infrared reflectance/spectral domain optical coherence tomography and assessed in masked fashion by two graders for the presence of SDD lesions of RMD and soft drusen. MAIN OUTCOME MEASURES: Presence or absence of RMD/SDD and soft drusen. RESULTS: RMD was more frequent in patients with CAD versus those without (Relative Risk [RR] = 2.1, CI = 1.08-3.95, P = 0.03). There was no association of CAD with soft drusen. CONCLUSIONS: A specific relationship between CAD and RMD suggests common systemic causes for both and warrants further study.

Dyspnea and Chest Pain in a Young Woman Caused by a Giant Pericardial Lymphohemangioma: Diagnosis and Treatment.

We describe a 21-year-old woman who presented with chest pain and dyspnea on exertion and who was found to have a large pericardial mass. Multimodality imaging was instrumental in narrowing the differential diagnosis and planning surgical treatment, which included coronary artery bypass and right-sided heart reconstruction. The final pathologic diagnosis was lymphohemangioma; to our knowledge, this was the largest cardiac/pericardial vascular tumor ever to be reported in the literature.

Knowledge Gaps in Cardiovascular Care of the Older Adult Population: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Geriatrics Society.

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.

Knowledge Gaps in Cardiovascular Care of Older Adults: A Scientific Statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: Executive Summary.

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease (CVD) is the leading cause of death and major disability in adults aged 75 and older. Despite the effect of CVD on quality of life, morbidity, and mortality in older adults, individuals aged 75 and older have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older adults with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in nursing homes and assisted living facilities. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older adults typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision-making, and recommend future research to close existing knowledge gaps. To achieve these objectives, a detailed review was conducted of current American College of Cardiology/American Heart Association (ACC/AHA) and American Stroke Association (ASA) guidelines to identify content and recommendations that explicitly targeted older adults. A pervasive lack of evidence to guide clinical decision-making in older adults with CVD was found, as well as a paucity of data on the effect of diagnostic and therapeutic interventions on outcomes that are particularly important to older adults, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older adults representative of those seen in clinical practice and that incorporate relevant outcomes important to older adults in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older adults and enhance person-centered care of older individuals with CVD in the United States and around the world.

Embolic myocardial infarction in a patient with a Fontan circulation.

Coronary artery embolism is an uncommon cause of acute myocardial infarction (MI). We present a patient with pulmonary atresia and severe right heart hypoplasia who underwent a lateral tunnel Fontan procedure in childhood and presented with an acute ST-segment elevation MI at 19 years of age. In addition to the known risk of thrombotic complications associated with a Fontan circulation, potential predisposing factors to thromboembolism in this patient included a right ventricle to left anterior descending coronary connection and a Fontan baffle leak. The patient was treated with device closure of the baffle leak and anticoagulation. This is one of the first reports of an embolic MI in a patient with a Fontan circulation. The optimal method of reducing thromboembolic risk in this patient, and those with a Fontan circulation in general, is complicated and no consensus exists.