Atypical Presentation of Takotsubo Cardiomyopathy in an Elderly Woman.

We describe an 83-year-old woman who presented to the emergency department with extreme thirst. Diagnostic testing revealed Takotsubo cardiomyopathy. Following symptomatic improvement and discharge, she returned to the emergency department with exudative pericardial effusion and elevated intrapericardial pressures. This case illustrates the importance of close follow-up of Takotsubo patients in whom complications such as pericardial effusion may lead to cardiac tamponade and hemodynamic instability if not managed properly.

Hemodynamic determinants of left atrial strain in patients with hypertrophic cardiomyopathy: A combined echocardiography and CMR study.

BACKGROUND: Left atrial (LA) strain is associated with symptomatic status and atrial fibrillation in patients with hypertrophic cardiomyopathy (HCM). However, hemodynamic determinants of LA reservoir (LARS), conduit, and pump strains have not been examined and data are needed on the relation of LA strain with exercise tolerance in HCM. METHODS: Fifty HCM patients with echocardiographic and CMR imaging within 30 days were included. Left ventricular (LV) volumes, mass, EF, scar extent, extracellular volume fraction (ECV), and LA maximum volume were measured by CMR. Echo studies were analyzed for mitral inflow, pulmonary vein flow, mitral annulus tissue Doppler velocities, LV global longitudinal strain, and LA strain. Twenty six patients able and willing to exercise underwent cardiopulmonary stress testing for peak oxygen consumption (MVO2), and VE/VCO2 slope. Patients were followed for clinical events. FINDINGS: LARS was significantly associated with indices of LA systolic function, LV GLS, and LV filling pressures (P<0.05). Conduit strain was significantly associated with mitral annulus early diastolic velocity and ECV, whereas LA pump strain was determined by LA systolic function and indices of LV end diastolic pressure (all P<0.05). LARS and conduit strain were significantly higher in patients who achieved ≥80% of MVO2. LARS, conduit, and pump strains were significantly associated with atrial fibrillation (P<0.05). CONCLUSIONS: LV structure, systolic and diastolic function, and LA systolic function determine the 3 components of LA strain. LA strain is associated with exercise tolerance and clinical events in patients with HCM.

Left ventricular function in patients with hypertrophic cardiomyopathy and its relation to myocardial fibrosis and exercise tolerance.

We sought to determine the relation between myocardial extracellular volume (ECV), left ventricular (LV) diastolic function, and exercise tolerance in patients with hypertrophic cardiomyopathy (HCM). Forty five HCM patients with an ejection fraction >50% and no previous septal reduction therapy underwent imaging by CMR and transthoracic echocardiography. CMR was used to quantify LV volumes, mass, EF, LA volumes, scar burden, pre and post contrast T1 relaxation times and ECV. Echocardiography was used to measure outflow tract gradients, mitral inflow and annular velocities, circumferential strain, systolic, early and late diastolic strain rates. Exercise duration and peak oxygen consumption were noted. HCM patients had increased native T1 relaxation time and ECV vs. controls [ECV controls: 24.7 (23.2-26.4) vs. HCM: 26.8 (24.6-31.3)%, P = 0.014]. Both parameters were significantly associated with LV diastolic dysfunction, circumferential strain, diastolic strain rate and peak oxygen consumption (r = -0.73, P < 0.001). Compared to controls, HCM patients have significantly longer native T1 relaxation time and higher ECV. These structural changes lead to worse LV global and segmental diastolic function and in turn reduced exercise tolerance.

Balancing hemostasis and thrombosis in interventional vascular medicine and surgery.

Antithrombotic therapy and revascularization are critical factors in managing patients presenting with acute coronary syndromes and are described in multiple guidelines documents. In addition to preventing intravascular thrombosis, they increase the risk of bleeding, which has been implicated as a risk factor in short- and long-term mortality. Randomized controlled trials provide useful aggregate information comparing the risks and benefits of various therapies. In this paper, we will use a case-based format to discuss optimal individualized antithrombotic treatments.

Alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy. A multicenter North American registry.

OBJECTIVES: The purpose of the study is to identify the predictors of clinical outcome (mortality and survival without repeat septal reduction procedures) of alcohol septal ablation for the treatment of patients with hypertrophic obstructive cardiomyopathy. BACKGROUND: Alcohol septal ablation is used for treatment of medically refractory hypertrophic obstructive cardiomyopathy patients with severe outflow tract obstruction. The existing literature is limited to single-center results, and predictors of clinical outcome after ablation have not been determined. Registry results can add important data. METHODS: Hypertrophic obstructive cardiomyopathy patients (N = 874) who underwent alcohol septal ablation were enrolled. The majority (64%) had severe obstruction at rest, and the remaining had provocable obstruction. Before ablation, patients had severe dyspnea (New York Heart Association [NYHA] functional class III or IV: 78%) and/or severe angina (Canadian Cardiovascular Society angina class III or IV: 43%). RESULTS: Significant improvement (p < 0.01) occurred after ablation (~5% in NYHA functional classes III and IV, and 8 patients in Canadian Cardiovascular Society angina class III). There were 81 deaths, and survival estimates at 1, 5, and 9 years were 97%, 86%, and 74%, respectively. Left anterior descending artery dissections occurred in 8 patients and arrhythmias in 133 patients. A lower ejection fraction at baseline, a smaller number of septal arteries injected with ethanol, a larger number of ablation procedures per patient, a higher septal thickness post-ablation, and the use beta-blockers post-ablation predicted mortality. CONCLUSIONS: Variables that predict mortality after ablation, include baseline ejection fraction and NYHA functional class, the number of septal arteries injected with ethanol, post-ablation septal thickness, beta-blocker use, and the number of ablation procedures.

Impact of computerized dosing on eptifibatide-associated bleeding and mortality.

OBJECTIVE: The study aimed to determine the impact on eptifibatide-associated bleeding by implementing a computerized dosing algorithm in the cardiac catheterization suite. BACKGROUND: Excessive dosing of eptifibatide is associated with increased bleeding rates and hospital mortality. Although dosing adjustments based on renal function has been recommended, its implementation and clinical impact have not been assessed in daily practice. METHODS: A computerized algorithm was implemented in January 2006 to calculate appropriate eptifibatide infusion dose (1 microg kg(-1) min(-1) for creatinine clearance <50 mL/min or 2 microg kg(-1) min(-1) for creatinine clearance >or=50 mL/min) using the Cockroft-Gault formula. All patients had hemoglobin measured before and the day after the procedure. Bleeding within 24 hours and mortality during hospitalization were compared in consecutive patients before and after implementation of the algorithm. RESULTS: A total of 334 patients qualified for inclusion (pre-algorithm n = 91, post-algorithm n = 243). There was an increase in the proportion of patients receiving recommended doses of eptifibatide dosing (74.7% pre-algorithm vs 97.5% post-algorithm, P

Delayed untwisting: the mechanistic link between dynamic obstruction and exercise tolerance in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: We sought to determine the mechanisms linking dynamic obstruction and exercise tolerance in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: Patients with HOCM have reduced exercise tolerance. However, the association between dynamic obstruction and peak oxygen consumption (VO2max) is weak. METHODS: We enrolled 25 patients with HOCM, 20 with hypertrophic cardiomyopathy (HCM), and 20 normal control patients. Two-dimensional, Doppler, strain, and left ventricular (LV) twist mechanics by speckle tracking echocardiography were obtained. The 25 HOCM patients had left heart catheterization, and 16 were re-examined after septal reduction. RESULTS: Deformation measurements were the lowest in HOCM patients and increased (p<0.05) after septal reduction. Twist and untwisting rate were not different between patients with HCM and control patients, but untwisting was significantly delayed in HCM patients and longest in HOCM patients. The delay related well with LV end-diastolic pressure (r=0.76) and volume (r=-0.73), and VO2max (r=-0.75, all p<0.01). After septal reduction, untwisting occurred earlier and accounted for the increase in end-diastolic volume (r=0.65), and VO2max (r=0.74, both p<0.05). CONCLUSIONS: Dynamic obstruction leads to delayed untwisting in HOCM, which accounts well for the increased LV filling pressures, the reduced LV volumes, and VO2max. After septal reduction, untwisting occurs earlier and leads to an improvement in LV filling and exercise tolerance.

Initial experience with alcohol septal ablation using a novel magnetic navigation system.

OBJECTIVES: We compared the use of magnetically assisted intervention (MAI) with conventional guidewire techniques to perform alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: Treatment of symptomatic patients with HOCM using ASA has been established as an effective therapy. However, in many cases cannulaton of the septal artery can be technically challenging. Recently, a magnetically directed guidewire system has been developed to assist in navigation in difficult percutaneous interventions. By directing the guidewire to the septal branch, this system has potential to shorten the procedure time and increase success and safety of ASA in patients with HOCM. METHODS: From October 2004 through October 2006, 44 consecutive patients underwent ASA using MAI with the Niobe system (Stereotaxis, Inc., St. Louis, MO). We compared these patients to 29 age- and gradient-matched cases using conventional techniques performed by an operator with >100 prior cases. RESULTS: All procedures were successful. Both the MAI and conventional groups had improved symptoms, exercise times, and reduced gradients compared with baseline. One dissection occurred in the conventional group. Although there were no aggregate differences in acute or 3-month clinical outcomes, the time required for guidewire cannulation of the septal branch decreased progressively with increasing experience (third tertile vs first tertile (3 [1.25-4.75 vs 10.5 [6-17] minutes, P = 0.004) compared with the conventional group (6 [2-10.25] minutes, P = 0.075 vs third tertile), suggesting a learning curve for MAI. CONCLUSIONS: MAI has the potential to improve wiring time and outcomes of HOCM patients undergoing ASA.

Outcome of surgical myectomy after unsuccessful alcohol septal ablation for the treatment of patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: We sought to determine the outcome of myectomy after unsuccessful alcohol ablation. BACKGROUND: Alcohol septal ablation results in symptomatic improvement and a reduction in dynamic obstruction in most hypertrophic obstructive cardiomyopathy patients. However, a few patients remain with severe symptoms and obstruction and need surgery. The outcome of these cases is not well known. METHODS: The medical records of 375 patients who underwent alcohol ablation at our institution were reviewed. Twenty patients (5.3%, mean age 53 +/- 18 years, 17 women) subsequently needed surgical myectomy. The New York Heart Association (NYHA) functional class, angina class, exercise duration, left ventricular outflow tract (LVOT) gradient, ejection fraction, and septal thickness were tabulated. The anatomy and distribution of the septal perforator arteries were examined. RESULTS: After ablation, NYHA functional class (3 to 2.5; p < 0.05) and LVOT gradient (93 +/- 23 mm Hg to 71 +/- 26 mm Hg; p < 0.05) were slightly improved, without a change in exercise duration (171 +/- 124 s to 168 +/- 148 s; p > 0.5). Myectomy was performed at 19 +/- 15 months after ablation. There was no operative mortality, but permanent pacing was needed in 2 patients after surgery, and 3 other cases needed pacing before, or as a complication of, alcohol ablation. A significant improvement was noted, with the NYHA functional class decreasing to 1, exercise duration increasing to 423 +/- 171 s, and LVOT gradient decreasing to 6 +/- 11 mm Hg (all p < 0.05 versus post-alcohol ablation). CONCLUSIONS: Myectomy can be successfully performed after failed alcohol ablation, but with a higher incidence of heart block than in cases where only surgery is performed. Otherwise, alcohol ablation does not appear to adversely affect surgical outcome.

Effectiveness of percutaneous intervention for patients with obstructive hypertrophic cardiomyopathy and coronary artery disease.

Seven patients with obstructive hypertrophic cardiomyopathy and single-vessel coronary artery disease underwent percutaneous revascularization of the coronary lesion in addition to alcohol septal ablation therapy for dynamic outflow tract obstruction. One year later, there was a significant reduction of dynamic left ventricular outflow tract obstruction and no clinical evidence of restenosis.

Effects of SolCD39, a novel inhibitor of Platelet Aggregation, on Platelet Deposition and Aggregation after PTCA in a Porcine Model.

INTRODUCTION: This study evaluated CD39 in a porcine model of balloon angioplasty and in plasma of patients undergoing percutaneous intervention. CD39 (E-NTPDase1), is the endothelial ecto-ADPase inhibiting platelet function via hydrolysis of released platelet ADP. METHODS AND RESULTS: A recombinant soluble form of CD39 (solCD39) given intravenously to pigs had an elimination half life of 5--7 days, increased the bleeding time to an extent similar to aspirin, and inhibits platelet aggregation by>90%. Platelet counts and clot retraction remained normal following solCD39 administration. In a pig model of acute coronary balloon injury, solCD39 resulted in non-statistically significant decreases in platelet (7.7+/-1.4 versus 11.7+/- 3.4) and fibrin (3.5+/- 0.4 versus 4.2+/- 0.7) deposition ratios. Adding ex vivo to human platelet rich plasma (PRP) solCD39 produced nearly 100% inhibition of ADP-induced platelet aggregation. A dose-response effect of solCD39 on platelet aggregation induced by collagen or a thrombin receptor activating peptide (TRAP(SFLLRN)) was noted in PRP obtained from volunteers and patients receiving aspirin, clopidogrel or ticlopidine. SolCD39 also provided additional and complete inhibition of TRAP-induced platelet aggregation in PRP from patients who had received abciximab, aspirin and clopidogrel. CONCLUSIONS: SolCD39, a novel inhibitor of platelet activation and recruitment with a relatively long half-life appears to be well tolerated and is a potent inhibitor of ADP-, collagen-, or TRAP-induced platelet activation. Its potential use in percutaneous coronary intervention requires further study. ABBREVIATED ABSTRACT: E-NTPDase1/CD39 is the endothelial ecto-ADPase responsible for inhibition of platelet function. A recombinant soluble form (solCD39) had an elimination half life of 5-7 days in pigs, elevated bleeding times similar to aspirin, did not affect clot retraction, and inhibited platelet aggregation by > 90%. When combined with standard heparin therapy in a pig model of acute coronary balloon injury, solCD39 resulted in a trend toward a decrease in platelet and fibrin deposition. SolCD39 added ex vivo to human platelet rich plasma yielded nearly 100% inhibition of ADP-induced platelet aggregation and provided further inhibition when combined with standard therapy.