Echocardiographic parameters associated with recovery in heart failure with reduced ejection fraction.

OBJECTIVE: The study aims to determine the clinical and echocardiographic parameters of patients with recovered heart failure (HFrecEF). METHODOLOGY: Sixty-seven patients (cases) were identified as heart failure with recovered ejection fraction (HFrecEF), defined as improvement in EF ≥ 10%. Sixty-nine patients (controls) were randomly selected by convenience sampling with no or <10% improvement in EF (HFrEF non-recovered). RESULTS: The mean interval between baseline and follow-up echocardiography was 10.5 months in cases and 11.2 months in the control group. HFrecEF showed a 22.7% improvement in mean ejection fraction, and HFrEF non-recovered group also showed a minor increment of 5.5%. HFrecEF patients were significantly younger (49.51 vs 57.54 years, P .001) with non-ischemic cardiomyopathy (86.6% vs 52.2%). Patients with HFrecEF had significantly less left ventricular end-diastolic and end-systolic volumes (LVEDV: 162.51 mL vs 208.54 mL, P < .001; LVESV: 119.81 mL vs 157.13 mL, P < .001) and index left atrial volume (37.66 mL vs 47.09 mL, P < .001) than patients with non-recovered EF. The right ventricle (RV) and inferior vena cava were significantly dilated with higher mean tricuspid annular plane systolic excursion (TAPSE) among patients with HFrecEF than HFrEF non-recovered. CONCLUSION: Based on univariate analysis, younger age, non-ischemic etiology, LVEDV, LVESV, deceleration time, better TAPSE, dilated right ventricle, dilated IVC, and smaller left atrial volumes were found significant, but on multivariate logistic regression model only left ventricle end-diastolic volume, left atrial volume, and TAPSE were linked to the recovery of ejection fraction.

Cardiopulmonary Exercise Testing, Impedance Cardiography, and Reclassification of Risk in Patients Referred for Heart Failure Evaluation.

BACKGROUND: An impaired cardiac output response to exercise is a hallmark of chronic heart failure (HF). We determined the extent to which impedance cardiography (ICG) during exercise in combination with cardiopulmonary exercise test (CPX) responses reclassified risk for adverse events in patients with HF. METHODS AND RESULTS: CPX and ICG were performed in 1236 consecutive patients (48±15 years) evaluated for HF. Clinical, ICG and CPX variables were acquired at baseline and subjects were followed for the composite outcome of cardiac-related death, hospitalization for worsening HF, cardiac transplantation, and left ventricular assist device implantation. Cox proportional hazards analyses including clinical, noninvasive hemodynamic, and CPX variables were performed to determine their association with the composite endpoint. Net reclassification improvement (NRI) was calculated to quantify the impact of adding hemodynamic responses to a model including established CPX risk markers on reclassifying risk. There were 422 events. Among CPX variables, peak VO2 and indices of ventilatory inefficiency (VE/VCO2 slope, oxygen uptake efficiency slope) were significant predictors of risk for adverse events. Among hemodynamic variables, change in cardiac index, peak cardiac time interval, and peak left cardiac work index were the strongest predictors of risk. Having 5 impaired CPX and ICG responses to exercise yielded a sevenfold higher risk for adverse events compared with having no abnormal responses. Combining ICG responses to CPX resulted in NRIs ranging between 0.34 and 0.89, attributable to better reclassification of events. CONCLUSION: Cardiac hemodynamics determined by ICG complement established CPX measures in reclassifying risk among patients with HF.

Restoration of normal left ventricular geometry after percutaneous mitral annuloplasty: case report and review of literature.

Surgical mitral valve intervention is not considered suitable in patients with severe functional mitral regurgitation due to severe dilated cardiomyopathy and severe systolic dysfunction. In such patients percutaneous mitral valve intervention is the next best alternative. We are presenting case report of a patient who presented with severe dyspnea progressing to orthopnea and paroxysmal nocturnal dyspnea. He was found to have severe functional mitral regurgitation and severe left ventricle systolic dysfunction. Surgical mitral intervention was not considered suitable and percutaneous mitral annuloplasty was done. At one month follow-up significant improvement in symptoms were noted with improvement in severity of mitral regurgitation severity. At 6 months follow-up further improvement in symptoms were noted along with significant improvement in the severity of mitral regurgitation and normalization of left ventricle geometry. At 1 year follow-up his symptoms further improved, left ventricle geometry remained normal and mitral regurgitation severity remained mild to moderate. Our case demonstrate that in patient with severe LV systolic dysfunction, severe mitral regurgitation and left bundle branch block percutaneous mitral annuloplasty can obviate the need for CRT-D due to significant improvement in LV function and geometry along with regression in severity of mitral regurgitation. Improvement in mitral regurgitation severity and LV geometry started early and kept improving with excellent result at 6 and 12 months.

A New 12-Lead ECG Prognostic Score.

BACKGROUND: The Diagonal Line Rule (DLR) is an educational pattern recognition tool for the classification of 12-lead electrocardiograms (ECGs) as normal or abnormal. OBJECTIVE: To develop a score using the DLR for the risk stratification of abnormal ECGs. METHODS: Patients at the Palo Alto, VA, referred for a routine resting ECG between 1987 and 1999 were retrospectively considered. The initial ECGs of 43,798 patients were scored according to the DLR. The main outcome variable was cardiovascular mortality with 8 years of follow-up. RESULTS: ECG abnormalities identified by the DLR were combined with age, gender, and ST depression to develop an additive score. The score was validated and shown to stratify levels of cardiac risk with a 0.78 area under the receiver operating characteristic (ROC) curve for identifying those who had a cardiovascular death. CONCLUSION: The score effectively stratifies ECGs for prediction of risk of cardiovascular death.

The long-term prognostic value of the Q wave criteria for prior myocardial infarction recommended in the universal definition of myocardial infarction.

BACKGROUND: We sought to characterize the prognostic value of the third universal definition of myocardial infarction (UDMI) and ≥40msec Q wave criteria. METHODS: We evaluated hazard ratios (HR) with 95% confidence intervals (CI) for cardiovascular (CV) death for computerized Q wave measurements from the electrocardiograms of 43,661 patients collected from 1987 to 1999 at the Palo Alto VA. There were 3929 (9.0%) CV deaths over a mean follow-up of 7.6 (±3.8) years. RESULTS: The risk of CV death for Q waves ≥40msec in any two contiguous leads in any lead group was equivalent to or higher than that for contiguous UDMI Q waves, with HR 2.44 (95% CI 2.15-4.11) and HR 2.42 (95% CI (2.18-3.42), respectively. CONCLUSIONS: The UDMI Q wave criteria do not provide an advantage over ≥40msec Q waves at predicting CV death.

Examining QRS amplitude criteria for electrocardiographic left ventricular hypertrophy in recommendations for screening criteria in athletes.

BACKGROUND: Current guidelines for interpretation of the ECGs of athletes recommend that isolated R and S wave amplitudes that exceed traditional criteria for left ventricular hypertrophy be accepted as a physiological response to exercise training. This is based on training and echocardiographic studies but not on long term follow up. Demonstration of the prognostic characteristics of the amplitude criteria in a non-athletic population could support the current guidelines. OBJECTIVE: To evaluate the prognostic value of the R and S wave voltage criteria for electrocardiographic left ventricular hypertrophy (ECG-LVH) in an ambulatory clinical population. SUBJECTS AND METHODS: The target population consisted of 20,903 ambulatory subjects who had ECGs recorded between 1987 and 1999 and were followed for cardiovascular death until 2013. During the mean follow up of 17 years, there were 881 cardiovascular deaths. RESULTS: The mean age was 43 ± 10, 91% were male and 16% were African American. Of the 2482 (12%) subjects who met the Sokolow-Lyon criteria, 241 (1.2%) subjects with left ventricular (LV) strain had an HR of 5.4 (95% CI 4.1-7.2, p<0.001), while 2241 (11%) subjects without strain had an HR of 1.4 (95% CI 1.2-1.8, p<0.001). Of the 4836 (23%) subjects who met the Framingham voltage criteria, 350 (2%) subjects with LV strain had an HR of 5.1 (95% CI 4.0-6.5, p<0.001), while 4486 (22%) subjects without strain had an HR of 1.1 (95% CI 0.9-1.3, p=0.26). The individual components of the Romhilt-Estes had HRs ranging from 1.4 to 3.6, with only the voltage component not being significant (HR 1.1, 95% CI 0.9-1.5, p=0.35). CONCLUSIONS: This study demonstrates that the R and S wave voltage criteria components of most of the original classification schema for electrocardiographic left ventricular hypertrophy are not predictive of CV mortality. Our findings support the current guidelines for electrocardiographic screening of athletes.

The Stanford/PAVA data collection form for coding J waves on routine screening 10second ECGs.

The study of J waves and slurs and their association with cardiovascular death is clouded by the lack of a standardized coding or classification methodology. Over the past three years of studying these ECG patterns, we have evolved a Data Entry Form that is designed to resolve some of the key issues. These issues include the effect of other ECG findings, whether the QRS-ST junction occurs before or after the J waves, if contiguous leads are required and rules to distinguish J waves from fragmented QRS complexes. This form is now being used to code the ECGs of 44,000 VA patients and the follow up is being extended to 15years to resolve these issues.

Targeting essential genes in Salmonella enterica serovar typhimurium with antisense peptide nucleic acid.

We investigated the capability of antisense peptide nucleic acids (PNAs) conjugated to the (KFF)(3)K cell-penetrating peptide to target possible essential genes (ligA, rpoA, rpoD, engA, tsf, and kdtA) in Salmonella enterica serovar Typhimurium and inhibit bacterial growth in vitro and in cell culture. All targeted PNA-based gene inhibition has shown great potency in gene expression inhibition in a sequence-specific and dose-dependent manner at micromolar concentrations. Among tested PNAs, the anti-rpoA and -rpoD PNAs showed the greatest potency.

Covid-19 Infection During Pregnancy With Acute Heart Failure, Venous Thrombosis And Pneumonia.

The COVID-19 infection has spread rampantly, attaining pandemic status within three months of its first appearance. It has been classically associated with respiratory signs and symptoms. However, unusual presentations have also been reported in multiple literatures. We are reporting a case of acute heart failure in a pregnant patient diagnosed with Covid-19 infection. Her hospital course has been complicated by pneumonia and venous thrombosis during the postpartum period. Her laboratory investigations showed evidence of myocardial injury, acute heart failure, and COVID-19 infection in second PCR sample taken during postpartum period. Echocardiography exhibited features of severe left ventricle systolic dysfunction. She had successful delivery through caesarean-section, nevertheless, her postpartum period was complicated by pneumonia and right femoral venous thrombosis. CT scan of the chest and pulmonary arteries revealed infiltrations in the left lower lobe and right middle lobe, suggestive of consolidation, with no evidence of pulmonary embolism. Cardiac MRI displayed severe global LV and RV systolic dysfunction, but no evidence of myocardial infarction, myocardial infiltration, or abnormal myocardial delayed enhancement. Her condition improved and she was discharged on heart failure medications. During follow-up at the heart failure clinic, her symptoms continued to ameliorate, except the LV and RV systolic dysfunction which persisted. Multiple unusual presentations of Covid-19 infection have been reported in various literatures and screening of the COVID-19 infection should be practiced on regular basis especially among high-risk patients. Prompt identification of COVID-19 infection will lead to proper isolation and mitigation of infection spread among hospitalized patients and health care workers. Covid-19 PCR should be repeated in cases having clinical indication and negative first sample. A proper history and cardiac MRI can differentiate between different aetiologies of heart failure during pregnancy and peripartum COVID-19 infection. Adequate anticoagulation should be considered in COVID-19 patients due to the high risk of thromboembolism. Among patients with COVID-19 infection, CT chest helps demonstrate the extent of pulmonary involvement.

Cutaneous T-cell Lymphoma Predisposing to Recurrent Infective Endocarditis by Methicillin-resistant Staphylococcus Aureus (MRSA) in a Patient with Intracardiac Defibrillator (ICD).

Cutaneous T-cell lymphoma (CTCL) is a rare group of extra-nodal non-Hodgkin's lymphomas resulting in infiltration of the skin by the malignant cells. Sézary syndrome (SS) and mycosis fungoides (MF) are the most common subtypes, and infectious complications are the major cause of death in such patients. The presence of implantable cardiac devices (ICD) and CTCL make the patient more vulnerable to the device-related infective endocarditis (IE) caused by methicillin-resistant staphylococcus aureus (MRSA). The need for reimplantation of ICD should be assessed in detail and non-cardiac conditions should be considered while making such decisions. Herein, we report a unique case of non-ischemic cardiomyopathy with an implantable cardiac defibrillator (ICD), who later developed CTCL, complicated by the recurrent right-sided IE which is caused by MRSA. Key Words: Cutaneous T-cell lymphoma, Methicillin-resistant staphylococcus aureus (MRSA), Infective endocarditis.

Durable Left Ventricular Assist Device with Mechanical Mitral and Aortic Valves.

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Human Laterality Disorders: Pathogenesis, Clinical Manifestations, Diagnosis, and Management.

Human laterality disorders comprise a group of diseases characterized by abnormal location (situs) and orientation of thoraco-abdominal organs and vessels across the left-right axis. Situs inversus totalis is mirror image reversal of thoraco-abdominal organs/great vessels. Situs ambiguus, better known as heterotaxy, is abnormal arrangement of thoraco-abdominal organs across the left-right axis excluding situs inversus totalis. Heterotaxy, also referred to as atrial or atrial appendage isomerism, is characterized by abnormal location of left-sided or right-sided organs with loss of asymmetry of normally paired asymmetric organs. It is associated with a variety of anomalies involving the heart, great vessels, lungs and intra-abdominal organs. Right and left atrial isomerism are associated with multiple complex congenital cardiac and vascular anomalies, many of which are lethal when untreated. Isomerism may also affect the lungs, spleen, liver, gall bladder, and intestines. Innovative surgical therapy of heterotaxy/isomerism has reduced early mortality and markedly improved long-term prognosis.

Sensitivity and Specificity of Pulmonary Artery Pressure Measurement in Echocardiography and Correlation with Right Heart Catheterization.

OBJECTIVE: Echocardiography is helpful in assessment of pulmonary hemodynamic, however its correlation with Right heart catheterization (RHC) is conflicting. We conducted a study to evaluate sensitivity and specificity of pulmonary hemodynamic parameters measured in echocardiography. Furthermore its correlation with the values measured in RHC was assessed. METHOD: Retrospective, cross-sectional study conducted at King Fahad medical City, Riyadh, Saudi Arabia. 95 adult patients referred for right heart catheterization were enrolled in the study. All the patients had echocardiography and RHC within one week of each other. RESULT: Diabetes mellitus, hypertension and dyslipidemia were present among 55%, 66% and 41% of patients respectively. 85% of the study participants were diagnosed to have pulmonary hypertension and 79% of the study participants had postcapillary pulmonary hypertension. Sensitivity of pulmonary artery systolic pressure (PAPs), mean pulmonary artery pressure (PAPm) using PAPs and pulmonary artery acceleration velocity (PAcT) were 86%, 93% and 89% respectively. Correlation of PAPs, PAPm using PAPs and PAcT on echo with invasive hemodynamic in RHC were 0.56, 0.43 and 0.24 respectively. Among patients with moderate to severe Tricuspid Regurgitation (TR) and tricuspid annular plane systolic excursion (TAPSE) <1.5cm correlation of PAPs, PAPm using PAPs and PAcT on echocardiography with right heart catheterization were 0.31, 0.24 and 0.42 respectively. CONCLUSION: Echocardiographic assessment of PAPs and PAPm has high sensitivity and weak to moderate correlation with hemodynamic data in RHC. PAPs measurement on echocardiogram has best correlation with invasive measurement followed by PAPm measurement using PAPs. Among patients with moderate to severe TR and TAPSE <1.5cm PAPm measurement using PAcT has better correlation than using PAPs.

Spontaneous Coronary Artery Dissection in Relation to Physical and Emotional Stress: A Retrospective Study in 4 Arab Gulf Countries.

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome and sudden cardiac death. The triggers for SCAD often do not include traditional atherosclerotic risk factors. The most commonly reported triggers are extreme physical or emotional stress. The current study compared in-hospital and follow-up events in patients with SCAD with and without reported stress. Data from 83 patients with a confirmed diagnosis of SCAD were collected retrospectively from 30 centers in 4 Arab Gulf countries (KSA, UAE, Kuwait, and Bahrain) from January 2011 to December 2017. In-hospital myocardial infarction (MI), percutaneous coronary intervention (PCI), ventricular tachycardia/ventricular fibrillation, cardiogenic shock, death, ICD placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) events were compared between those with and without reported stress. Emotional and physical stress was defined as new or unusually intense stress, within 1 week of their initial hospitalization. The median age of patients in the study was 44 (37-55) years. Foty-two (51%) were women. Stress (emotional, physical, and combined) was reported in 49 (59%) of all patients. Sixty-two percent of women with SCAD reported stress, and 51 % of men with SCAD reported stress. Men more commonly reported physical and combined stress. Women more commonly reported emotional stress (P < 0.001). The presence or absence of reported stress did not impact on overall adverse cardiovascular events (P = 0.8). In-hospital and follow-up events were comparable in patients with SCAD in the presence or absence of reported stress as a trigger.

STEMI and COVID-19 Pandemic in Saudi Arabia.

The COVID-19 pandemic had significant impact on health care worldwide which has led to a reduction in all elective admissions and management of patients through virtual care. The purpose of this study is to assess changes in STEMI volumes, door to reperfusion, and the time from the onset of symptoms until reperfusion therapy, and in-hospital events between the pre-COVID-19 (PC) and after COVID-19 (AC) period. All acute ST-segment elevation myocardial infarction (STEMI) cases were retrospectively identified from 16 centers in the Kingdom of Saudi Arabia during the COVID-19 period from January 01 to April 30, 2020. These cases were compared to a pre-COVID period from January 01 to April 30, 2018 and 2019. One thousand seven hundred and eighty-five patients with a mean age 56.3 (SD ± 12.4) years, 88.3% were male. During COVID-19 Pandemic the total STEMI volumes was reduced (28%, n = 500), STEMI volumes for those treated with reperfusion therapy was reduced too (27.6%, n= 450). Door to balloon time < 90 minutes was achieved in (73.1%, no = 307) during 2020. Timing from the onset of symptoms to the balloon of more than 12 hours was higher during 2020 comparing to pre-COVID 19 years (17.2% vs <3%, respectively). There were no differences between the AC and PC period with respect to in-hospital events and the length of hospital stay. There was a reduction in the STEMI volumes during 2020. Our data reflected the standard of care for STEMI patients continued during the COVID-19 pandemic while demonstrating patients delayed presenting to the hospital.

Impact of a Social Support Program Supervised by a Multidisciplinary Team on Psychosocial Distress and Knowledge About Heart Failure Among Heart Failure Patients.

BACKGROUND: Heart failure drains significant financial resources with morbidity and mortality higher than cancer. Social support is defined as the care provided by the family members, friends and health care workers to the patients. Absence of social support and poor perceived social support will create stress, anxiety, depression and anger which further deteriorate the underlying disease and worsen quality of life. Discussion in group creates better understanding of the disease which helps the patients improving their skills in managing their condition. OBJECTIVE: To evaluate the impact of multidisciplinary team supervised social support program on components of psychosocial distress and knowledge about heart failure among heart failure patients. METHODS: Adult patients with heart failure attending King Fahad Medical City as inpatient or outpatient were enrolled in this prospective cohort study. Patients were given questionnaire to assess their perception of social support they have at their disposal, quality of life, knowledge regarding heart failure and self-care behavior. They then had interactive education in groups supervised by multidisciplinary team members about the pathogenesis of their disease with management strategies, dietary restriction, importance of exercise and healthy life style pattern. Patients shared their experiences in the group and had opportunity to learn from each other. Patients were assessed regarding their perceived social support, quality of life, knowledge regarding heart failure and self-care behavior immediately after the session and at 1 month interval. RESULTS: There were total 500 patients participated in the study. Among the study participants 62% were male and majority was living with the family. Components of psychosocial distress were present in up to 40% of study participants and only 36% considered knowledgeable regarding heart failure. After the interactive social support group meeting components of psychosocial distress were significantly reduced with significant improvement in knowledge about heart failure. At 1 month follow up participants reported persistent improvement in quality of life, improvement in self-care behavior, perceived social support and wanted to continue in social group program. CONCLUSION: Social support program supervised by multidisciplinary team providing education and social support improved knowledge, self-care behavior, perceived social support and quality of life among heart failure patients.

Percutaneous coronary intervention for acute coronary syndrome in dextrocardia and situs inversus.

A 55-year-old male presented with Non-ST Elevated Myocardial Infarction (NSTEMI). He was a known case of dextrocardia. His standard ECG showed finding consistent with dextrocardia. Coronary angiogram was performed after due manipulation and then successful Percutaneous Coronary Intervention (PCI) of right coronary artery was done.

Cardiorespiratory Fitness and Reclassification of Risk for Incidence of Heart Failure: The Veterans Exercise Testing Study.

BACKGROUND: It is well established that cardiorespiratory fitness (CRF) is inversely associated with cardiovascular and all-cause mortality. However, little is known regarding the association between CRF and incidence of heart failure (HF). METHODS AND RESULTS: Between 1987 and 2014, we assessed CRF in 21 080 HF-free subjects (58.3±11 years) at the Veterans Affairs Medical Centers in Washington, DC, and Palo Alto, CA. Subjects were classified by age-specific quintiles of CRF. Multivariable Cox models were used to determine the association between HF incidence and clinical and exercise test variables. Reclassification characteristics of fitness relative to standard clinical risk factors were determined using the category-free net reclassification improvement and integrated discrimination improvement indices. During the follow-up (mean 12.3±7.4 years), 1902 subjects developed HF (9.0%; average annual incidence rate, 7.4 events per 1000 person-years). When CRF was considered as a binary variable (unfit/fit), low fitness was the strongest predictor of risk for HF among clinical and exercise test variables (hazard ratio, 1.91; 95% confidence interval, 1.74-2.09; P<0.001). In a fully adjusted model with the least-fit group as the reference, there was a graded and progressive reduction in risk for HF as fitness level was higher. Risks for developing HF were 36%, 41%, 67%, and 76% lower among increasing quintiles of fitness compared with the least-fit subjects (P<0.001). Adding CRF to standard risk factors resulted in a net reclassification improvement of 0.37 (P<0.001). CONCLUSIONS: CRF is strongly, inversely, and independently associated with the incidence of HF in veterans referred for exercise testing.

Longest follow-up of in situ working Bjork Shiley valve: 42-year follow-up.

The Bjork Shiley valve (BSV) is considered as the pioneer among modern disc valves, and eventually evolved into a reliable prosthesis after considerable research and multiple modifications. Various case reports have been published with follow-up of different types of BSV. We are reporting the longest follow-up ever published of a plano-convex type of BSV. Our patient's valve was implanted in 1973 due to a congenital bicuspid aortic valve with concomitant severe, symptomatic aortic stenosis, discovered at the age of 27. She presented with exertional dyspnoea, syncope and chest pain; however, her cardiovascular status remained stable and these symptoms abated after successful valve replacement at the age of 34. She is now 77 years old with no limitations in her activities and is able to walk a few miles most days of the week. Her echocardiograms throughout the decades have shown acceptable gradients across the aortic prosthesis without evidence of haemolysis. Our case report includes a summary of the patient with a discussion of the evidence that supports the durability of the original plano-convex BSV.