Pulmonary Hypertension: A Contraindication for Lung Volume Reduction Surgery?

BACKGROUND: Historically, pulmonary hypertension (PH) has been considered as one of the contraindications for lung volume reduction surgery (LVRS). Newer studies have shown that LVRS is successful in select emphysema patients with PH. METHODS: In-hospital and 1-year functional and quality of life (QOL) outcomes were studied in patients with PH post-LVRS. PH was defined as pulmonary artery pressure (PAP) exceeding 35 mm Hg by right heart catheterization (RHC), where available, or else exceeding 35 mm Hg by echocardiogram. RESULTS: Of 124 patients who underwent LVRS, 56 (45%) had PH (mean PAP, 41 mm Hg) with 48 mild to moderate and 8 severe PH. In-hospital outcomes were similar between patients with and without PH: hours of artificial ventilation (1.8 vs 0.06, P = .882), days in intensive care (4 vs 6, P = .263), prolonged air leak (12% vs 19%, P = .402), and days of hospital stay (13 vs 16, P = .072). Lung function improved significantly at the 1-year follow-up in patients with PH: forced expiratory volume in 1 second % predicted (26 vs 38, P = .001), forced vital capacity % (62 vs 90, P = .001), residual volume % predicted (224 vs 174, P = .001), diffusion capacity of the lung for carbon monoxide % predicted (36 vs 43, P = .001), 6-minute walk distance test (1104 vs 1232 feet, P = .001), and QOL utility scores (0.67 vs 0.77, P = .001). There were no differences in in-hospital, baseline, and follow-up functional and QOL outcomes between patients with and without PH. CONCLUSIONS: In this small, single-institution cohort, outcomes of patients undergoing LVRS for emphysema with PH were similar to those of patients without PH. LVRS may be a potential option for select emphysema patients with PH.

Transcatheter Mitral Valve Therapy With Novel Supra-Annular AltaValve: First Experience in the United States.

This case demonstrates the feasibility and procedural success of a novel supra-annular transcatheter mitral valve, the AltaValve via transapical approach in a patient with severe symptomatic mitral regurgitation who was a prohibitive surgical risk candidate. (Level of Difficulty: Advanced.).

Stress cardiomyopathy: clinical and ventriculographic characteristics in 107 North American subjects.

BACKGROUND: Stress cardiomyopathy (SCM) is a newly described reversible cardiomyopathy of largely unclear etiology. We studied SCM in a large cohort to gain further insights. METHODS: We retrospectively identified 114 cases of SCM from among 12,150 consecutive North American patients diagnosed as Troponin-positive acute coronary syndrome, from January 2000 through December 2007, at two 24-h coronary angioplasty-capable centers. Left ventriculographic wall contractility was analyzed and scored in 107 patients on the right anterior oblique view. RESULTS: In 107 patients (66+/-14 years, 99 females), variable regional contractility or "ballooning" was observed including: postero-basal, 1%; basal+mid-ventricular, 1%; diaphragmatic, 2%; localized apical, 2%; antero-lateral, 11%; complete mid-ventricular, 29%; and classical variant, 54%. The localized and complete mid-ventricular variants (n=45, 40 females) had a younger median age at presentation (64 vs. 71 years, p=0.008) and higher median LV ejection fraction (45% vs. 35%, p=0.006) than the classical or tako-tsubo variants (n=58, 55 females) with similar baseline exposure to stressors, risk factor and in-hospital complications. Frequency of involvement and mean contractile score (dysfunction) of the antero-lateral segment was significantly (p<0.05) greater in the order, antero-lateral>diaphragmatic>apical>basal. CONCLUSION: From a single large cohort of SCM, evidence on significant individual variation in clinical and morphological pattern was confirmed. Frequency and vulnerability to transient dysfunction differs within segments with antero-lateral involvement significantly greater than diaphragmatic, apical, basal-anterior and basal-posterior LV segments. Further studies in phenotype should be undertaken for proper identification, classification and pathophysiological implications.

Left atrial appendage filling defects on 64-slice multidetector computed tomography in patients undergoing pulmonary vein isolation: predictors and comparison to transesophageal echocardiography.

OBJECTIVES: To evaluate predictor variables and accuracy of left atrial appendage (LAA) filling defects seen on multidetector computed tomographic (MDCT) scan in predicting LAA thrombus in patients undergoing pulmonary vein (PV) isolation procedure. METHODS: Electrocardiogram-gated 64-slice MDCT and transesophageal echocardiography (TEE) were undertaken in 51 consecutive patients with nonvalvular atrial fibrillation who were referred for circumferential antral pulmonary vein isolation. RESULTS: In 51 patients (37 men; mean age, 64 years), left atrium (LA) diameter emerged as the predictor of LAA filling defects (odds ratio, 4.9; 95% confidence interval, 1.19-20.25). Left atrial appendage filling defects had sensitivity of 100%, specificity of 95.92%, positive predictive value of 0.5, and negative predictive value of 1, for thrombi seen on TEE image. A mean LAA/ascending aorta Hounsfield unit ratio of 0.78 or less was identified as a sensitive predictor of thrombus on TEE (sensitivity, 100%; specificity, 87.8%; positive predictive value, 0.25; and negative predictive value, 1). CONCLUSIONS: A larger LA predisposes to LAA filling defects on MDCT scan. Pending prospective validation, absence of LAA filling defects on 64-slice MDCT may reliably exclude LAA thrombi in patients with nonvalvular atrial fibrillation obviating the need for TEE.