ABSTRACT
This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document1 addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.
Subject(s)
Cardiology/standards , Heart Diseases/diagnostic imaging , Multimodal Imaging/standards , Advisory Committees , Humans , Societies, Medical , United StatesABSTRACT
Septostomy reduces right ventricular (RV) workload at the expense of hypoxemia in patients with advanced pulmonary hypertension (PH). A patent foramen ovale (PFO) may serve as a "natural" septostomy, but the incidence and impact of a PFO in PH remains uncertain. We prospectively examined echocardiograms in 404 PH patients referred for initial hemodynamic assessment. Patients included had saline bubble injection and if negative repeatinjection after Valsalva maneuver. Echocardiographic and hemodynamic data were examined. Survival was modeled using Kaplan-Meier method. Eisenmenger syndrome or known atrial shunts other than PFO were excluded: 292 patients met entry criteria. A PFO was identified in 16.8% of the entire cohort, 22.9% of pulmonary arterial hypertension (PAH) patients, and 8.6% of Dana Point group 2 PH patients. Right atrial to pulmonary capillary wedge pressure difference was lowest in the latter group (-7.9 ± 7.1 vs -1.7 ± 5.5 mm Hg for all others, p <0.01). Patients with a PFO were younger (53.9 vs 58.6 years, pâ¯=â¯0.02). A PFO was more often present with moderately or severely dilated (pâ¯=â¯0.01) or dysfunctional (pâ¯=â¯0.03) RVs. Six year survival was unchanged by PFO presence for all patients, including those with PAH. Proportional hazards analysis found only age and functional class independently predicted survival (p <0.01). A PFO is identified less often in Dana Point group 2 PH, likely due to inability of Valsalva maneuver to overcome right atrial to pulmonary capillary wedge pressure difference. In conclusion, the incidence of a PFO in the PH population increases with more dilated and dysfunctional RVs, suggesting that the PFO may be stretched open rather than congenital. The presence of a PFO does not impact survival in PH or PAH.
Subject(s)
Foramen Ovale, Patent/complications , Heart Ventricles/physiopathology , Hypertension, Pulmonary/etiology , Pulmonary Wedge Pressure/physiology , Adolescent , Adult , Aged , Aged, 80 and over , Cardiac Surgical Procedures/methods , Echocardiography, Transesophageal , Female , Follow-Up Studies , Foramen Ovale, Patent/diagnosis , Foramen Ovale, Patent/surgery , Heart Ventricles/diagnostic imaging , Humans , Hypertension, Pulmonary/mortality , Hypertension, Pulmonary/physiopathology , Male , Middle Aged , Prognosis , Prospective Studies , Survival Rate/trends , United States/epidemiology , Valsalva Maneuver , Young AdultABSTRACT
This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.
Subject(s)
American Heart Association , Cardiology , Heart Valve Diseases/diagnosis , Multimodal Imaging/standards , Societies, Medical , Thoracic Surgery , Angiography/standards , Echocardiography/standards , Heart Valve Diseases/surgery , Humans , Magnetic Resonance Imaging, Cine/standards , Tomography, X-Ray Computed/standards , United StatesABSTRACT
OBJECTIVES: Pulmonary hypertension portends a poorer prognosis for blacks versus white populations, but the underlying reasons are poorly understood. We investigated associations of disease characteristics, insurance status, and race with clinical outcomes. STUDY DESIGN: Retrospective cohort study of patients presenting for initial pulmonary hypertension evaluation at 2 academic referral centers. METHODS: We recorded insurance status (Medicare, Medicaid, private, self-pay), echocardiographic, and hemodynamics data from 261 patients (79% whites, 17% blacks) with a new diagnosis of pulmonary hypertension. Subjects were followed for 2.3 years for survival. Adjustment for covariates was performed with Cox proportional hazards modeling. RESULTS: Compared with white patients, blacks were younger (50 ± 15 vs 53 ± 12 years; P = .04), with females representing a majority of patients in both groups (80% vs 66%; P = .08) and similar functional class distribution (class 2/3/4: 30%/52%/16% blacks vs 33%/48%/14% whites; P = .69). Blacks diagnosed with incident pulmonary hypertension were more frequently covered by Medicaid (12.5% vs 0.7%) and had less private insurance (50% vs 61%; P = .007) than whites. At presentation, blacks had more right ventricular dysfunction (P = .04), but similar mean pulmonary arterial pressure (46 vs 45 mm Hg, respectively; P = .66). After adjusting for age and functional class, blacks had greater mortality risk (hazard ratio [HR], 2.06; 95% confidence interval [CI], 1.18-3.44), which did not differ by race after additional adjustment for insurance status (HR, 1.74; 95% CI, 0.84-3.32; P =.13). CONCLUSIONS: In a large cohort of patients with incident pulmonary hypertension, black patients had poorer right-side heart function and survival rates than white patients. However, adjustment for insurance status in our cohort removed differences in survival by race.
Subject(s)
Black or African American/statistics & numerical data , Hypertension, Pulmonary/ethnology , Hypertension, Pulmonary/therapy , Insurance Coverage/statistics & numerical data , Insurance, Health/statistics & numerical data , Academic Medical Centers , Adult , Age Factors , Aged , Comorbidity , Female , Healthcare Disparities/ethnology , Humans , Hypertension, Pulmonary/mortality , Hypertension, Pulmonary/physiopathology , Male , Middle Aged , Proportional Hazards Models , Retrospective Studies , Severity of Illness Index , Sex Factors , Socioeconomic FactorsSubject(s)
Elephants , Heart Defects, Congenital/epidemiology , Animals , Emotions , Humans , United StatesABSTRACT
Diabetes complicates management in a number of disease states and adversely impacts survival; how diabetes affects patients with pulmonary hypertension (PH) has not been well characterized. With insulin resistance having recently been demonstrated in PH, we sought to examine the impact of diabetes in these patients. Demographic characteristics, echo data, and invasive hemodynamic data were prospectively collected for 261 patients with PH referred for initial hemodynamic assessment. Diabetes was defined as documented insulin resistance or treatment with antidiabetic medications. Fifty-five patients (21%) had diabetes, and compared with nondiabetic patients, they were older (mean years ± SD, 61 ± 13 vs. 56 ± 16; [Formula: see text]), more likely to be black (29% vs. 14%; [Formula: see text]) and hypertensive (71% vs. 30%; [Formula: see text]), and had higher mean (±SD) serum creatinine levels (1.1 ± 0.5 vs. 1.0 ± 0.4; [Formula: see text]). Diabetic patients had similar World Health Organization functional class at presentation but were more likely to have pulmonary venous etiology of PH (24% vs. 10%; [Formula: see text]). Echo findings, including biventricular function, tricuspid regurgitation, and pressure estimates were similar. Invasive pulmonary pressures and cardiac output were similar, but right atrial pressure was appreciably higher (14 ± 8 mmHg vs. 10 ± 5 mmHg; [Formula: see text]). Despite similar management, survival was markedly worse and remained so after statistical adjustment. In summary, diabetic patients referred for assessment of PH were more likely to have pulmonary venous disease than nondiabetic patients with PH, with hemodynamics suggesting greater right-sided diastolic dysfunction. The markedly worse survival in these patients merits further study.
Subject(s)
Heart Arrest/therapy , Heart Failure/therapy , Heart-Assist Devices , Shock, Cardiogenic/therapy , Transposition of Great Vessels/surgery , Ventricular Function, Left , Ventricular Function, Right , Aged , Fatal Outcome , Female , Heart Arrest/diagnosis , Heart Arrest/etiology , Heart Arrest/physiopathology , Heart Failure/diagnosis , Heart Failure/etiology , Heart Failure/physiopathology , Heart Transplantation , Humans , Male , Middle Aged , Prosthesis Design , Recovery of Function , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/etiology , Shock, Cardiogenic/physiopathology , Time Factors , Transposition of Great Vessels/complications , Transposition of Great Vessels/diagnosis , Transposition of Great Vessels/physiopathology , Treatment OutcomeABSTRACT
A 75-year old woman with a history of coronary disease status post 3-vessel coronary artery bypass grafting (CABG) 8 years ago and a repeat one-vessel CABG 2 years ago in the setting of aortic valve replacement with a #19 mm St. Jude bileaflet mechanical valve for severe aortic stenosis presented with two to three weeks of progressive dyspnea and increasing substernal chest discomfort. Echocardiography revealed a gradient to 31 mmHg across her aortic valve, increased from a baseline of 13 mmHg five months previously. Fluoroscopy revealed thrombosis of her mechanical aortic valve. She was not a candidate for surgery given her multiple comorbidities, and fibrinolysis was contraindicated given a recent subdural hematoma 1 year prior to presentation. She was treated with heparin and eptifibatide and subsequently demonstrated resolution of her aortic valve thrombosis. We report the first described successful use of eptifibatide in addition to unfractionated heparin for the management of subacute valve thrombosis in a patient at high risk for repeat surgery or fibrinolysis.
Subject(s)
Aortic Valve , Fibrinolytic Agents/administration & dosage , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis/adverse effects , Heparin/administration & dosage , Peptides/administration & dosage , Platelet Aggregation Inhibitors/administration & dosage , Thrombosis/drug therapy , Aged , Eptifibatide , Female , Fibrinolysis/drug effects , Humans , Thrombosis/etiologySubject(s)
Advisory Committees/standards , American Heart Association , Cardiology/standards , Clinical Competence/standards , Percutaneous Coronary Intervention/standards , Physicians/standards , Cardiology/methods , Coronary Artery Disease/diagnosis , Coronary Artery Disease/therapy , Foundations/standards , Humans , Percutaneous Coronary Intervention/methods , Research Report/standards , United StatesSubject(s)
Angioplasty, Balloon, Coronary/standards , Cardiac Catheterization/standards , Clinical Competence/standards , Coronary Artery Disease/therapy , Education, Medical, Graduate/standards , Percutaneous Coronary Intervention/standards , Angioplasty, Balloon, Coronary/adverse effects , Angioplasty, Balloon, Coronary/education , Cardiac Catheterization/adverse effects , Consensus , Coronary Artery Disease/diagnosis , Humans , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/education , Quality Improvement/standards , Quality Indicators, Health Care/standards , Risk Factors , Treatment OutcomeSubject(s)
Cardiac Catheterization , Fractional Flow Reserve, Myocardial , Percutaneous Coronary Intervention , Terminology as Topic , Ultrasonography, Interventional , Cardiac Catheterization/classification , Clinical Competence , Curriculum , Education, Medical, Graduate , Humans , Learning Curve , Percutaneous Coronary Intervention/classification , Percutaneous Coronary Intervention/education , Predictive Value of Tests , Ultrasonography, Interventional/classificationABSTRACT
Therapeutic ionizing radiation, such as that used in the treatment of Hodgkin's lymphoma, can cause cardiac valvular damage that may take several years to manifest as radiation-associated valvular heart disease. Treatment can be complicated by comorbid radiation injury to other cardiac and mediastinal structures that lead to traditional surgical valve replacement or repair becoming high-risk. A representative case is presented that demonstrates the complexity of radiation-associated valvular heart disease and its successful treatment with percutaneous transcatheter valve replacement. The prevalence and pathophysiologic mechanism of radiation-associated valvular injury are reviewed. Anthracycline adjuvant therapy appears to increase the risk of valvular fibrosis. Left-sided heart valves are more commonly affected than right-sided heart valves. A particular pattern of calcification has been noted in some patients, and experimental data suggest that radiation induction of an osteogenic phenotype may be responsible. A renewed appreciation of the cardiac valvular effects of therapeutic ionizing radiation for mediastinal malignancies is important, and the treatment of such patients may be assisted by the development of novel, less-invasive approaches.
Subject(s)
Aortic Valve Insufficiency/etiology , Aortic Valve Stenosis/etiology , Aortic Valve/pathology , Aortic Valve/radiation effects , Calcinosis/etiology , Hodgkin Disease/radiotherapy , Radiation Injuries/etiology , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Aortic Valve Insufficiency/diagnosis , Aortic Valve Insufficiency/physiopathology , Aortic Valve Insufficiency/therapy , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/physiopathology , Aortic Valve Stenosis/therapy , Calcinosis/diagnosis , Calcinosis/physiopathology , Calcinosis/therapy , Cardiac Catheterization , Echocardiography, Doppler, Color , Echocardiography, Transesophageal , Electrocardiography , Heart Valve Prosthesis Implantation/methods , Humans , Male , Middle Aged , Radiation Injuries/diagnosis , Radiation Injuries/physiopathology , Radiation Injuries/therapy , Radiotherapy/adverse effects , Treatment OutcomeABSTRACT
Infective endocarditis (IE) is an infection of a heart valve or other cardiac structure at a site of endothelial damage. The definition has been also expanded to include infected cardiac devices. A variety of organ systems may be adversely affected in patients with IE. Although advances have improved the diagnostic accuracy for IE, morbidity and mortality remain remarkably high. This article reviews the pathophysiology, complications, diagnosis, and management of IE with recent updates to the literature and the major cardiovascular society guidelines. The increasingly prevalent clinical problem of intracardiac device-related IE is addressed, along with the recent changes to the IE prophylaxis guidelines.