Mid- and long-term risk of atrial fibrillation among breast cancer surgery survivors.

BACKGROUND: The risk of incident atrial fibrillation (AF) among breast cancer survivors, especially for younger women, and cancer treatment effects on the association remain unclear. This study aimed to investigate the risk of AF among breast cancer survivors and evaluate the association by age group, length of follow-up, and cancer treatment. METHODS: Using data from the Korean Health Insurance Service database (2010-2017), 113,232 women newly diagnosed with breast cancer (aged ≥ 18 years) without prior AF history who underwent breast cancer surgery were individually matched 1:5 by birth year to a sample female population without cancer (n = 566,160) (mean[SD] follow-up, 5.1[2.1] years). Sub-distribution hazard ratios (sHRs) and 95% confidence intervals (CIs) considering death as a competing risk were estimated, adjusting for sociodemographic factors and cardiovascular/non-cardiovascular comorbidities. RESULTS: BCS had a slightly increased AF risk compared to their cancer-free counterparts (sHR 1.06; 95% CI 1.00-1.13), but the association disappeared over time. Younger BCS (age < 40 years) had more than a 2-fold increase in AF risk (sHR 2.79; 95% CI 1.98-3.94), with the association remaining similar over 5 years of follow-up. The increased risk was not observed among older BCS, especially those aged > 65 years. Use of anthracyclines was associated with increased AF risk among BCS (sHR 1.57; 95% CI 1.28-1.92), which was more robust in younger BCS (sHR 1.94; 95% CI 1.40-2.69 in those aged ≤ 50 years). CONCLUSIONS: Our findings suggest that younger BCS had an elevated risk of incident AF, regardless of the length of follow-up. Use of anthracyclines may be associated with increased mid-to-long-term AF risk among BCS.

3-D transesophageal echocardiography aids in assessment of embolic stroke due to aortic atherosclerotic plaque: A case series.

Atherosclerosis is the most common cause of heart disease and stroke. Plaque thickness ≥4 mm in the ascending aorta or aortic arch is strongly correlated with cerebral embolic events and ischemic stroke. However, despite imaging workup, the cause of embolic stroke remains unidentified in many patients. Transesophageal echocardiography (TEE) is the preferred echocardiographic method for the evaluation of cardiac source of emboli. 2D TEE imaging evaluates aortic root and aortic arch in a single plane or two planes with biplane imaging. However, 2D TEE often fails to detect mobile or complex components in the ascending aorta and aortic arch plaques. The routine availability of 3D TEE in current ultrasound systems may significantly improve the assessment of aortic plaques as a potential embolic source. In this case series, we present four consecutive patients with stroke who underwent TEE by a single cardiologist for possible cardioembolic source. Some of these patients may have been labelled as "cryptogenic stroke" or "embolic stroke of undetermined source" (ESUS) due to the presence of insignificant or nonmobile ascending aortic or aortic arch plaques on 2D TEE imaging. In our four consecutive patients with ESUS who underwent TEE by a single operator, 3D TEE showed complex aortic arch plaques with ulceration with mobile components and established these plaques as the likely source of embolic stroke.

Post-cardioversion atrial stunning - Not to be forgotten.

We present a case of a 60-year-old male who was found to be in atrial fibrillation during routine evaluation. Anticoagulation was initiated for 36 h and he was referred for TEE-guided electrical cardioversion. There was no thrombus identified in the left atrial appendage, however, the appendage was large and had a tongue-like accessory lobe along with spontaneous contrast in the left atrium and its appendage. TEE probe was not withdrawn, patient underwent successful cardioversion with 200 joules and developed a marked increase in left atrial and left atrial appendage spontaneous contrast along with the development of tear drop shaped thrombus in the left atrial appendage immediately after cardioversion, which rapidly became more dense. There was an associated marked decrease in appendage velocities. Patient was hospitalized to initiate low molecular weight heparin. This case highlights the need for vigilance in patients with an unknown duration of atrial fibrillation, who have received a short duration of anticoagulant therapy and who have adverse appendage anatomy as thrombus may develop immediately after cardioversion despite anticoagulation.

Impact of physician performed point of care ultrasound (POCUS) during first outpatient cardiology consultation on patient management and downstream testing.

BACKGROUND: Goal directed point of care ultrasound (POCUS) is a bedside tool to assist with clinical diagnosis. We examined the impact of POCUS performed by consulting cardiologist (CC) during initial cardiology consult on clinical management and downstream testing. METHODS: Sixty-nine study patients (pts) seen in a general cardiology outpatient clinic of a tertiary center by an expert imaging CC were compared to a control group of 65 pts seen by three different CCs without POCUS during the same time-period, in whom the first standard echo (SE) was performed after the initial visit. RESULTS: Baseline characteristics were similar between the two groups for age, cardiac risk factors, and referral diagnoses. Echo findings on POCUS and by SE (mean delay of 17.2 days after visit) in the control group were comparable for RV size and function and for valvular heart disease. More patients with lower LVEF, higher LV filling pressures, new regional wall motion abnormalities, and increased aortic root size were present among POCUS group resulting in greater yield of echo abnormalities. There were more cardiovascular medication changes at the first visit (15.3% vs. 5.7%, p < .01), less referral for noninvasive stress testing (10% vs. 29%, p < .01), more advanced cardiac testing and subspecialty referrals (29% vs. 18% pts, p = .06), in the study compared to the control group after cardiology visit. CONCLUSION: POCUS at time of consultation detects more abnormal echo findings, results in more medication adjustments, less referral for noninvasive stress testing, earlier referral for advanced cardiac diagnostic imaging, and subspecialty cardiac referrals.

Echocardiography in the Assessment of Valve Regurgitation- Incremental Role of Three Dimensional Echocardiography.

Echocardiography (Echo) has a primary role in the evaluation of cardiac valve regurgitation. Echo valve regurgitation assessment includes multiple qualitative and quantitative methods which require adequate image quality, comprehensive echocardiographic images and precise measurements to obtain accurate assessment. For patient management, it is also important to investigate the mechanism of valve regurgitation. Severity and mechanism of valve regurgitation determine whether continued medical follow up is optimal or surgical or percutaneous valve repair, or replacement option should be necessary. Transthoracic Echo (TTE) is the gold standard most commonly used for the assessment of valve leaflet anatomy, valve motion and regurgitation severity to determine primary versus secondary causes of valve regurgitation, however transesophageal echo (TEE) provides high resolution imaging of valve leaflets and supporting apparatus and oftentimes determines mechanism of valve regurgitation particularly for mitral and tricuspid valves when TTE is unable to determine the mechanism. By providing surgical type views in a moving heart under normal hemodynamic conditions, 3D TEE has greatly improved assessment of mechanism and etiology of valve regurgitation. Besides, TEE also allows quantitation of valve regurgitation severity by Doppler methods as well as direct 3D planimetry of valve area and regurgitant orifice area. Doppler methods are pre and afterload dependent whereas direct 3D planimetry allows assessment of location and severity of valve regurgitation irrespective of ventricular loading conditions. Pre or intraoperative 3D TEE assessment can provide valuable information for surgical planning of valve repair or replacement. This review discusses various valvular pathologies causing regurgitation and the role of TTE and TEE in improving this assessment as shown by several case examples.

Reversible Takotsubo cardiomyopathy with non-revascularized concomitant severe coronary artery disease.

Takotsubo cardiomyopathy is a transient cardiac condition commonly triggered by a stressor, presenting with clinical features mimicking acute coronary syndromes. We report an unusual case of Takotsubo cardiomyopathy in a man with severe three-vessel coronary artery disease awaiting coronary bypass surgery who developed rapid spontaneous recovery of cardiac function before revascularization.

New pathological illuminations on 3D transillumination transesophageal echocardiography imaging.

The use of 3D technology has significantly improved the diagnostic accuracy of echocardiography by overcoming the limitation of 2D echocardiography. Transillumination 3D image post processing technique enhances shadows and contrast of cardiac structures with a movable virtual light source improving further the clarity and detail provided by conventional 3D imaging. In this report, we present 3 cases, one of mobile atherosclerotic aortic root plaque, another of small thrombi on ICD lead, and a third case of bicuspid aortic valve perforation due to infective endocarditis in whom TEE 3D transillumination further improved the diagnostic quality of conventional 3D imaging and lead to accurate clinical diagnosis.

Is there a silver lining for US health care from COVID-19 pandemic?

The COVID-19 pandemic has had an impact on economy and health care system of every nation. United States has been the hardest hit country both with incidence and absolute mortality from COVID-19. In some of its states the health care system have been stretched to their limits. This has led to a rapid change in the health care practice due to newly approved emergency legislative bills, new state government laws, measures taken by institutions and practices as well as the changing consumer behavior. Some of these adaptations - in particular, the transition of patient care to virtual visits are revolutionary. Increased vigilance by health care organization and workers to minimize the spread of infection to others as well for personal protection may result in lasting behavioral change that will prevent hospital acquired or transmitted infections and may lead to reduced morbidity and mortality from the regular "flu". The recycling of personal protective equipment and the emerging research showing it a safe practice will reduce health care expenditure. It is quite possible that this pandemic may be the silver lining that will save the US health care from its unsustainable consumption of US gross domestic product.

Detection of LV apical thrombus by three-dimensional transesophageal echocardiography.

INTRODUCTION: Patients with apical myocardial infarction are at higher risk of developing left ventricular (LV) thrombi. Standard transesophageal echocardiography (TEE) is commonly used in assessing cardiac source of embolic cerebrovascular accident (CVA). Contrast-enhanced transthoracic echocardiography (TTE) improves sensitivity for thrombus detection compared with noncontrast TTE, and however for LV apical thrombi, contrast-enhanced magnetic resonance imaging (MRI) and/or contrast-enhanced computed tomography (CT) outperform both TTE and TEE in some studies. CASE: A 67-year-old man with history of prior myocardial infarction (MI), four-vessel coronary artery bypass surgery, congestive heart failure with LV ejection fraction of 30%, and diabetes mellitus presented to our facility with acute right occipital-parietal stroke and recent history of left lower extremity ischemia. Head and neck MRI and MR angiography found multiple posterior circulation infarcts suggestive of cardio-embolic etiology. TTE image quality was suboptimal even after contrast use to evaluate for LV thrombus, and due to renal insufficiency, MRI or CT was precluded and 3DTEE identified large LV apical thrombus with mobile components. CONCLUSION: 3DTEE may increase the detection of LV apical thrombi as well as evaluating its characteristics by live imaging as well as by offline reconstruction. TEE may be a useful diagnostic modality, especially in patients with decreased renal function, where iodinated contrast for cardiac CT or Gadolinium for MRI may be contraindicated. Multimodality imaging studies may further prove the utility of 3D echocardiographic imaging in the detection of LV apical thrombus.

Reversible cardiac dysfunction in severe COVID-19 infection, mechanisms and case report.

A previously healthy 49-year-old male patient presented with COVID-19 infection and required mechanical ventilation and extracorporeal membrane oxygenation due to severe hypoxemia. Echocardiography showed cardiac dysfunction with an apical sparing strain pattern, which rapidly normalized within a week. Apical sparing myocardial strain in patients with COVID-19 infection may suggest reverse-type stress cardiomyopathy.

Echocardiography in transcatheter aortic (Core)Valve implantation: Part 2-Transesophageal echocardiography.

Transesophageal echocardiography (TEE) plays a significant role during transcatheter aortic valve implantation (TAVR). 2DTEE allows assessment of anatomy of the aortic valve, aortic root, left ventricular (LV) outflow tract, severity of the aortic valve stenosis (AS), and the presence and severity of other valve stenosis and regurgitation. Left and right ventricular size and global function as well as cardiac hemodynamics pre and post TAVR and LV regional wall motion can be assessed. Three-dimensional (3D) imaging adds significantly via accurate measurement of aortic annulus that helps select the appropriate valve size. Biplane imaging allows simultaneous assessment of target cardiac structure in two orthogonal views and provides a rapid assessment during and immediately post valve deployment by evaluating stent height, leaflet motion, and the presence and severity of paravalvular leak (PVL). 2DTEE and 3DTEE allow evaluation of mechanism of PVL that helps guide the decision regarding need for balloon post dilation of the implanted valve or valve in valve implantation.

Echocardiography in transcatheter aortic valve implantation-Part 1-Transthoracic echocardiography.

Transcatheter aortic valve replacement (TAVR) has been a revolutionary technique in the treatment of degenerative aortic valve stenosis. Selection of appropriate patients and appropriate valve size is crucial for improved patient outcome. Echocardiographic imaging is a critical component for patient selection and plays an important role in the selection of valve size, procedural guidance, and patient follow-up. This review discusses role of echocardiography in patient selection, device implantation, and postimplant follow-up for the first-generation CoreValve as used in pivotal trial. Same TTE imaging principles apply to the second- and third-generation self-expandable valves as well as the balloon-expandable valves. Multiple case examples are used to illustrate imaging principles pre- and post-TAVR. In addition, case examples to demonstrate complications post-TAVR are shown.

Quadricuspid Aortic Valve: Characteristics, Associated Structural Cardiovascular Abnormalities, and Clinical Outcomes.

BACKGROUND: Quadricuspid aortic valve (QAV) is a rare congenital cardiac defect. This study sought to determine QAV frequency in a large echocardiography database, to characterize associated cardiovascular abnormalities, and to describe long-term outcomes. METHODS AND RESULTS: Fifty patients (mean ± SD age, 43.5 ± 21.8 years at the time of the index diagnosis; female sex, 52%) received a diagnosis of QAV between January 1, 1975, and March 14, 2014 (frequency, 0.006%). The QAV was type A in 32% and type B in 32% (Hurwitz and Roberts classification). Aortic dilatation was present in 29% of the patients, and 26% had moderate or severe aortic valve regurgitation at the index diagnosis. Stenosis affected only 8% of the valves and was mild. Other findings, including abnormalities of other cardiac valves, septal defects, persistent left superior vena cava, and patent ductus arteriosus, were present in 32% of patients. During a mean ± SD follow-up of 4.8 ± 5.6 years, 8 patients underwent aortic valve surgery, with severe aortic valve regurgitation being the surgical indication in 7 patients. One patient with mild to moderate aortic valve regurgitation underwent aortic valve repair for obstruction of the left coronary ostium by the accessory cusp of QAV. No infective endocarditis or aortic dissection was found. Overall survival was 91.5% and 87.7% at 5 and 10 years. CONCLUSIONS: Aortic dilatation and other structural cardiac abnormalities were relatively common among patients with QAV. Aortic valve regurgitation was the predominant hemodynamic abnormality and the indication for aortic valve surgery in most patients who received surgery. Long-term survival was excellent.

Quantitation of valve regurgitation severity by three-dimensional vena contracta area is superior to flow convergence method of quantitation on transesophageal echocardiography.

BACKGROUND: Quantitation of regurgitation severity using the proximal isovelocity acceleration (PISA) method to calculate effective regurgitant orifice (ERO) area has limitations. Measurement of three-dimensional (3D) vena contracta area (VCA) accurately grades mitral regurgitation (MR) severity on transthoracic echocardiography (TTE). METHODS: We evaluated 3D VCA quantitation of regurgitant jet severity using 3D transesophageal echocardiography (TEE) in 110 native mitral, aortic, and tricuspid valves and six prosthetic valves in patients with at least mild valvular regurgitation. The ASE-recommended integrative method comprising semiquantitative and quantitative assessment of valvular regurgitation was used as a reference method, including ERO area by 2D PISA for assigning severity of regurgitation grade. RESULTS: Mean age was 62.2±14.4 years; 3D VCA quantitation was feasible in 91% regurgitant valves compared to 78% by the PISA method. When both methods were feasible and in the presence of a single regurgitant jet, 3D VCA and 2D PISA were similar in differentiating assigned severity (ANOVAP<.001). In valves with multiple jets, however, 3D VCA had a better correlation to assigned severity (ANOVAP<.0001). The agreement of 2D PISA and 3D VCA with the integrative method was 47% and 58% for moderate and 65% and 88% for severe regurgitation, respectively. CONCLUSION: Measurement of 3D VCA by TEE is superior to the 2D PISA method in determination of regurgitation severity in multiple native and prosthetic valves.

Impaired Left and Right Ventricular Systolic and Diastolic Function in Response to Exercise in Patients with Diastolic Dysfunction.

BACKGROUND: Diastolic dysfunction (DD) is associated with exercise intolerance. To evaluate mechanisms of exercise intolerance in patients with DD, we performed bicycle stress echocardiography. METHOD AND RESULTS: Doppler measurements were performed at baseline, during exercise and recovery in 26 patients (58 ± 11 years) with DD and normal left ventricular ejection fraction and 6 normal controls (53 ± 5 years). Compared to controls, patients achieved similar target heart rates but lower METs (5.5 ± 2 vs. 9.8 ± 3, P < 0.01) and a higher peak pulmonary artery pressure (PAP) at peak exercise (50 ± 13 vs. 32 ± 7 mmHg, P < 0.01) despite similar PAP at rest and similar mean blood pressure at peak exercise (110.4 ± 18.0 vs. 106.9 ± 11.4 mmHg, P = NS). In patients versus controls, mitral E/E' was similar at baseline (10 ± 3 vs. 8 ± 1.3, P = NS) but higher at recovery (11 ± 2 vs. 7 ± 2, P < 0.05), % mitral filling time was shorter at baseline, onset, and peak exercise, whereas % LV and RV ejection time was similar to controls throughout exercise. Compared to controls, lateral mitral annular S' (11.8 ± 2.5 cm/sec vs. 14.9 ± 1.9 cm/sec, P < 0.02) and tricuspid annular S' (14.8 ± 4.1 cm/sec vs. 19.4 ± 4.0 cm/sec, P < 0.05) were lower at peak exercise in patients. CONCLUSION: Diastolic filling time is reduced at rest and stress while LV ejection time increases normally during exercise in DD. There is a reduced systolic reserve in LV and RV during exercise in DD. These mechanisms contribute to exercise intolerance and elevation of left atrial and PAP in patients with DD.

Temporal Trends of Cardiac Chambers Function with Trastuzumab in Human Epidermal Growth Factor Receptor II-Positive Breast Cancer Patients.

BACKGROUND: Trastuzumab has substantially improved overall survival and reduced the risk of disease recurrence in patients with human epidermal growth factor receptor type II (HER-II)-positive breast cancer. However, this benefit may be at the increased risk of cardiotoxicity. We aimed to explore the early subclinical left and right ventricular as well as atrial dysfunction, in trastuzumab-treated patients with HER-II-positive breast cancer, using velocity vector imaging. METHODS: Echocardiography images were acquired in 50 patients with HER-II-positive breast cancer undergoing trastuzumab therapy. All patients had baseline and 3-6 months and 12-15 months of follow-up echocardiograms after initiation of trastuzumab therapy. Subendocardial borders of all the cardiac chambers were traced from the apical views to obtain volumetric and deformation indices. RESULTS: Mean age was 60 ± 13 years. Left ventricular (LV) ejection fraction as well as conventional indices of right ventricular (RV) function did not change with trastuzumab. The RV peak systolic global longitudinal strain (GLε) significantly decreased (-24.53 ± 6.03 vs. -21.28 ± 5.11 vs. -21.84 ± 5.15, baseline vs. first and second follow-ups, P = 0.01). LV peak systolic GLε was reduced by 1.19 at early follow-up (P < 0.05). Left atrial reservoir and booster pump functions as well as right atrial reservoir function were reduced through follow-up as well. CONCLUSIONS: The RV exhibited greater change in strain after trastuzumab treatment when compared to the LV. Atria function was reduced by trastuzumab as well. The repercussion of these findings and their potential implication will warrant further study.

Echocardiography in Pregnancy: Part 2.

The prevalence of pregnant women with cardiovascular heart disease is increasing. Transthoracic echocardiography is safe during pregnancy, and it is an important diagnostic tool in pregnant women with established heart disease in order to monitor ventricular and valvular anatomy and function. In addition, it can be used to delineate cardiac anatomy in complex congenital heart disease and help stratify maternal risk during pregnancy. This review will focus on the use of echocardiography in the diagnosis and management of pregnant women with common congenital lesions and with prosthetic valves.

Echocardiography in Pregnancy: Part 1.

Cardiovascular disease (CVD) remains the leading cause of maternal mortality, and clinical diagnosis of CVD in women during pregnancy is challenging. Pregnant women with known heart disease require careful multidisciplinary management by obstetric and medical teams to assess for maternal and fetal risk. Echocardiography is a safe and effective diagnostic tool indicated in pregnant women with cardiac symptoms or women with known cardiac disease for appropriate selection of women who require close monitoring of cardiac condition and valvular function. Echocardiography is the single most important clinical tool to diagnose and manage heart disease during pregnancy. Echocardiography is able to characterize cardiac structural abnormalities and corresponding hemodynamic changes, identifies heart diseases that are poorly tolerated in pregnancy, and helps select patients who may require a cesarean delivery because of hemodynamic instability. An understanding of the physiologic alterations including increased heart rate, blood volume, and cardiac output as well as the decreased vascular resistance is important for early recognition and monitoring of the consequences of cardiac disease in pregnancy. This review will focus on common acquired cardiac lesions encountered during pregnancy and the role of echocardiography in the diagnosis and management of these diseases.