A case report of percutaneous MitraClip implantation in an adult with a double-outlet right ventricle.

Background: Atrioventricular valve regurgitation (AVVR) is present in up to 75% of Fontan patients, and it is associated with an increased risk of Fontan circulation failure, morbidity, and mortality. Traditional treatment options include surgical repair vs. surgical replacement. We present, to the best of our knowledge, one of the first cases of successful trans-catheter repair of severe common AVVR using the MitraClip device. Case summary: A 20-year-old male with a history of double-outlet right ventricle (DORV) with unbalanced common atrioventricular canal to the right ventricle, severely hypoplastic left ventricle, and total anomalous pulmonary venous return status post-Fontan procedure presented with progressively worsening dyspnoea on exertion. Transoesophageal echocardiogram demonstrated severe common AVVR. After discussion of the case during the adult congenital heart disease multidisciplinary conference, patient underwent successful placement of two MitraClip devices, reducing the regurgitation from torrential to moderate. Discussion: MitraClip therapy can be used to alleviate symptoms in patients deemed as high risk for surgery. However, careful attention must be paid to haemodynamics before and after clip placement, which may predict short-term clinical outcomes.

Novel technique for high-risk coronary protection during implantation of transcatheter aortic valve implants.

Transcatheter aortic valve replacement (TAVR) has become increasingly common as the indications expanded to include valve-in-valve (ViV) applications and a wider patient population with lower surgical risk. Intra-operative coronary arterial occlusion remains a significant source of morbidity, particularly in ViV applications or cases with high-risk anatomy. We present a novel technique for coronary artery protection utilizing a guide extension catheter to secure coronary access during valve deployment and a ViV case demonstration in a patient with prior surgical aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure that has become an alternative to major cardiac surgery for replacing the aortic valve. A potential serious complication during this procedure is obstruction of the major coronary blood vessels supplying the heart itself. This may occur during deployment of the prosthetic aortic valve, a process which can inadvertently lead to blockage of the opening of the arteries of the heart. We present a novel method for protecting the opening of these arteries during TAVR to reduce the risk of this complication.

Giant Aneurysm of Left Main Coronary Artery in a Patient With Prior Operation for 4-Valve Endocarditis.

Left main coronary artery aneurysm is an unusual complication of infective endocarditis. Although this type of aneurysm is often asymptomatic, rupture and thrombus formation that result in myocardial infarction are known complications; therefore, prompt recognition and surgical intervention are warranted. This report describes a patient who presented with a giant left main coronary artery aneurysm 3.5 years after being treated for 4-valve endocarditis. The management and technical aspects of this challenging case are discussed here.

An artificial intelligence-based noninvasive solution to estimate pulmonary artery pressure.

Aims: Design to develop an artificial intelligence (AI) algorithm to accurately predict the pulmonary artery pressure (PAP) waveform using non-invasive signal inputs. Methods and results: We randomly sampled training, validation, and testing datasets from a waveform database containing 180 patients with pulmonary atrial catheters (PACs) placed for PAP waves collection. The waveform database consisted of six hemodynamic parameters from bedside monitoring machines, including PAP, artery blood pressure (ABP), central venous pressure (CVP), respiration waveform (RESP), photoplethysmogram (PPG), and electrocardiogram (ECG). We trained a Residual Convolutional Network using a training dataset containing 144 (80%) patients, tuned learning parameters using a validation set including 18 (10%) patients, and tested the performance of the method using 18 (10%) patients, respectively. After comparing all multi-stage algorithms on the testing cohort, the combination of the residual neural network model and wavelet scattering transform data preprocessing method attained the highest coefficient of determination R 2 of 90.78% as well as the following other performance metrics and corresponding 95% confidence intervals (CIs): mean square error of 11.55 (10.22-13.5), mean absolute error of 2.42 (2.06-2.85), mean absolute percentage error of 0.91 (0.76-1.13), and explained variance score of 90.87 (85.32-93.31). Conclusion: The proposed analytical approach that combines data preprocessing, sampling method, and AI algorithm can precisely predict PAP waveform using three input signals obtained by noninvasive approaches.

Transcatheter Systemic AV Valve-in-Valve Implantation in a Patient With LTGA and Ebstein Anomaly.

We present the first in-human transcatheter systemic atrioventricular valve-in-valve implantation in a 37-year-old patient with Ebstein anomaly, levo-transposition of the great arteries, and prior systemic valve replacement. She had severe bioprosthetic valve regurgitation and reduced systolic function. She had high surgical risk and was planned for transcatheter intervention. (Level of Difficulty: Advanced.).

Glycemic status, non-traditional risk and left ventricular structure and function in the Jackson Heart Study.

BACKGROUND: Left ventricular structure and function abnormalities may be an early marker of cardiomyopathy among African Americans with diabetes (DM) even in the absence of coronary artery disease (CAD), arrhythmia, valvular heart disease and end-stage renal disease (ESRD). This study examined the association of prediabetes (PDM), DM and HbA1c with left ventricular structure and function among Jackson Heart Study (JHS) participants without traditional risk factors. METHODS: Retrospective cross-sectional analyses of the association of PDM, DM and HbA1c with, left ventricular ejection fraction (LV EF), fractional shortening (LV FS), stroke volume index (SVI), cardiac index (CI), left ventricular end diastolic volume index (LVEDVI), left ventricular end systolic volume index (LVESVI), relative wall thickness (RWT), myocardial contraction fraction (MCF) and left ventricular mass index (LVMI). The study was conducted in 2234 adult JHS participants without preexisting CAD, arrhythmia, valvular heart disease or ESRD. Statistical analyses included descriptive, univariate and covariate adjusted linear regression analyses. Sensitivity analyses to explore the impact of hypertension on study outcomes were also carried out. RESULTS: DM compared with no DM was associated with lower, SVI (- 0.96 ml/m2, p = 0.029), LVEDVI (- 1.44 ml/m2 p = 0.015), and MCF (- 1.90% p = 0.007) but higher CI (0.14 L/min/m2, p < 0.001), RWT (0.01 cm, p = 0.002) and LVMI (2.29 g/m2, p = 0.009). After further control for DM duration, only CI remaining significantly higher for DM compared with no DM participants (0.12 L/min/m2, p = 0.009). PDM compared with no PDM was associated with lower, SVI (- 0.87 ml/m2, P = 0.024), LVEDVI (- 1.15 ml/m2 p = 0.003) and LVESVI (- 0.62 ml/m2 p = 0.025). HbA1c ≥ 8.0% compared with HbA1c < 5.7% was associated with lower SVI (- 2.09 ml/m2, p = 0.004), LVEDVI (- 2.11 ml/m2 p = 0.032) and MCF (- 2.94% p = 0.011) but higher CI (0.11 L/min/m2, p = 0.043) and RWT (0.01 cm, p = 0.035). CONCLUSIONS: Glycemic status is associated with important left ventricular structure and function changes among African Americans without prior CAD, arrhythmia, valvular heart disease and ESRD. Longitudinal studies may further elucidate these relationships.

A High Precision Machine Learning-Enabled System for Predicting Idiopathic Ventricular Arrhythmia Origins.

Background: Radiofrequency catheter ablation (CA) is an efficient antiarrhythmic treatment with a class I indication for idiopathic ventricular arrhythmia (IVA), only when drugs are ineffective or have unacceptable side effects. The accurate prediction of the origins of IVA can significantly increase the operation success rate, reduce operation duration and decrease the risk of complications. The present work proposes an artificial intelligence-enabled ECG analysis algorithm to estimate possible origins of idiopathic ventricular arrhythmia at a clinical-grade level accuracy. Method: A total of 18,612 ECG recordings extracted from 545 patients who underwent successful CA to treat IVA were proportionally sampled into training, validation and testing cohorts. We designed four classification schemes responding to different hierarchical levels of the possible IVA origins. For every classification scheme, we compared 98 distinct machine learning models with optimized hyperparameter values obtained through extensive grid search and reported an optimal algorithm with the highest accuracy scores attained on the testing cohorts. Results: For classification scheme 4, our pioneering study designs and implements a machine learning-based ECG algorithm to predict 21 possible sites of IVA origin with an accuracy of 98.24% on a testing cohort. The accuracy and F1-score for the left three schemes surpassed 99%. Conclusion: In this work, we developed an algorithm that precisely predicts the correct origins of IVA (out of 21 possible sites) and outperforms the accuracy of all prior studies and human experts.

Anatomy of the Tricuspid Valve and Pathophysiology of Tricuspid Regurgitation.

Transcatheter valve interventions have seen a significant increase in the past decade. The combination of improved techniques and available tools provides less invasive options supplementing surgical therapies. The tricuspid valve (TV) apparatus is a complex structure between the right atrium and the right ventricle; it generally consists of 3 leaflets (anterior, posterior, and septal) inserted in the fibrous tricuspid annulus and connected to the papillary muscle via the chordae tendinae. This article reviews TV anatomy, the pathophysiology of tricuspid regurgitation, and multimodality imaging to study TV, as well as provides an overview of transcatheter TV intervention.

Utility of Handheld Ultrasound Performed by Cardiology Fellows in Patients Presenting with Suspected ST-Elevation Myocardial Infarction.

Background: In academic hospitals, cardiology fellows may be the first point of contact for patients presenting with suspected ST-elevation myocardial infarction (STEMI) or acute coronary syndrome (ACS). In this study, we sought to determine the role of handheld ultrasound (HHU) in patients with suspected acute myocardial injury (AMI) when used by fellows in training, its association with the year of training in cardiology fellowship, and its influence on clinical care. Methods: This prospective study's sample population comprised patients who presented to the Loma Linda University Medical Center Emergency Department with suspected acute STEMI. On-call cardiology fellows performed bedside cardiac HHU at the time of AMI activation. All patients subsequently underwent standard transthoracic echocardiography (TTE). The impact of the detection of wall motion abnormalities (WMAs) on HHU in regard to clinical decision-making, including whether the patient would undergo urgent invasive angiography, was also evaluated. Results: Eighty-two patients (mean age: 65 years, 70% male) were included. The use of HHU by cardiology fellows resulted in a concordance correlation coefficient of 0.71 (95% confidence interval: 0.58-0.81) between HHU and TTE for left ventricular ejection fraction (LVEF), and a concordance correlation coefficient of 0.76 (0.65-0.84) for wall motion score index. Patients with WMA on HHU were more likely to undergo invasive angiogram during hospitalization (96% vs. 75%, P < 0.01). The time interval between the performance of HHU to initiation of cardiac catheterization (time-to-cath) was shorter in patients with abnormal versus normal HHU examinations (58 ± 32 min vs. 218 ± 388 min, P = 0.06). Finally, among patients who underwent angiography, those with WMA were more likely to undergo angiography within 90 min of presentation (96% vs. 66%, P < 0.001). Conclusion: HHU can be reliably used by cardiology fellows in training for measurement of LVEF and assessment of wall motion abnormalities, with good correlation to findings obtained via standard TTE. HHU-identified WMA at first contact was associated with higher rates of angiography as well as sooner angiography compared to patients without WMA.

Burnout and Well-Being Among Cardiology Fellowship Program Directors.

OBJECTIVES: The third annual Cardiovascular Diseases (CV) Fellowship Program Directors (PDs) Survey sought to understand burnout and well-being among CV fellowship PDs. BACKGROUND: Physician burnout is a common phenomenon. Data on burnout among cardiologists, specifically CV PDs, remain limited. METHODS: The survey contained 8 questions examining satisfaction, stress, and burnout among CV fellowship PDs. Burnout was defined based on the self-reported presence of ≥1 symptom of burnout, constant feelings of burnout, or complete burnout. RESULTS: Survey response rate was 57%. Most respondents were men (78%) and 54% represented university-based programs. Eighty percent reported satisfaction with their current job as PD, and 96% identified interactions with fellows as a driver of their satisfaction. Forty-five percent reported feeling a great deal of stress from their job. Stress was higher among women PDs, early-career PDs, and PDs of larger and university-based programs. Twenty-one percent reported some symptoms of burnout, and only 36% reported enjoyment without stress or burnout. Rates of enjoyment without stress or burnout were higher among men and late-career PDs, PDs of smaller programs, and PDs of community-based programs. Seventeen percent of PDs reported a high likelihood of resigning in the next year, of which the most common reason was the tasks of PDs were becoming overwhelming. CONCLUSIONS: Most CV fellowship PDs are satisfied with their position, but stress and burnout remain common. Women PDs, early-career PDs, and PDs of larger, university-based programs demonstrate more adverse markers of well-being. Opportunities exist to support CV fellowship PDs in their critical role.

Comparison of Outcomes in Patients Undergoing Renal Transplantation With Impaired vs Normal Left Ventricular Ejection Fraction.

BACKGROUND: Renal transplantation improves long-term outcomes in patients with end-stage renal disease (ESRD); however, patients with impaired left ventricular ejection fraction (LVEF) are less likely to be selected for renal transplantation. We sought to evaluate the effect of renal transplantation in this population. METHODS: We retrospectively evaluated 181 patients who underwent renal transplantation between 2011 and 2016. For patients with pretransplant LVEF <50% (cohort 1) and ≥50% (cohort 2), we evaluated the effect of renal transplantation on LVEF, graft failure, and mortality. RESULTS: Cohort 1 comprised 24 patients (mean age, 47 years; pretransplant LVEF 38%). Cohort 2 comprised 157 patients (mean age, 53 years; pretransplant LVEF 64%). Forty-six percent of cohort 1 experienced significant improvement in LVEF posttransplant, with mean LVEF improvement from 38% to 66%. There was no significant association between pretransplant LVEF and graft failure (hazard ratio [HR] = 2.7; 95% confidence interval [CI], 0.6-11.4; P = .1) or mortality (HR = 1.02; 95% CI, 0.3-3.6; P = .9). Coronary artery disease predicted mortality (HR = 3.12; 95% CI, 1.2-8.4; P = .02). Older age trended toward higher mortality (HR = 1.04; 95% CI, 1.0-1.1; P = .05). Younger age predicted graft failure (HR = 0.96; 95% CI, 0.8-0.9; P = .02). CONCLUSIONS: In patients with ESRD undergoing renal transplantation, there was no significant association between pretransplant LVEF and mortality or graft failure, suggesting that patients with ESRD with impaired LVEF can experience positive posttransplant outcomes.

A High-Precision Machine Learning Algorithm to Classify Left and Right Outflow Tract Ventricular Tachycardia.

INTRODUCTION: Multiple algorithms based on 12-lead ECG measurements have been proposed to identify the right ventricular outflow tract (RVOT) and left ventricular outflow tract (LVOT) locations from which ventricular tachycardia (VT) and frequent premature ventricular complex (PVC) originate. However, a clinical-grade machine learning algorithm that automatically analyzes characteristics of 12-lead ECGs and predicts RVOT or LVOT origins of VT and PVC is not currently available. The effective ablation sites of RVOT and LVOT, confirmed by a successful ablation procedure, provide evidence to create RVOT and LVOT labels for the machine learning model. METHODS: We randomly sampled training, validation, and testing data sets from 420 patients who underwent successful catheter ablation (CA) to treat VT or PVC, containing 340 (81%), 38 (9%), and 42 (10%) patients, respectively. We iteratively trained a machine learning algorithm supplied with 1,600,800 features extracted via our proprietary algorithm from 12-lead ECGs of the patients in the training cohort. The area under the curve (AUC) of the receiver operating characteristic curve was calculated from the internal validation data set to choose an optimal discretization cutoff threshold. RESULTS: The proposed approach attained the following performance: accuracy (ACC) of 97.62 (87.44-99.99), weighted F1-score of 98.46 (90-100), AUC of 98.99 (96.89-100), sensitivity (SE) of 96.97 (82.54-99.89), and specificity (SP) of 100 (62.97-100). CONCLUSIONS: The proposed multistage diagnostic scheme attained clinical-grade precision of prediction for LVOT and RVOT locations of VT origin with fewer applicability restrictions than prior studies.

Prognostic Value of Left Ventricular Global Strain Analysis by Two-Dimensional Speckle-Tracking Echocardiography in Non-Hemodynamically Significant Intermediate Coronary Lesions.

Intermediate coronary lesions represent a major challenge for the invasive and noninvasive cardiologist. Left ventricular strain calculation by speckle tracking echocardiography has the capacity to analyze the motion of the cardiac tissue. This study aimed to evaluate its usefulness and prognostic significance in nonhemodynamically significant intermediate coronary lesions. We studied 247 patients who underwent a clinically indicated coronary angiogram. Each of the patients had a single nonrevascularized nonhemodynamically significant intermediate severity coronary lesion (ISCL) with a fractional flow reserve greater than 0.80. The left ventricular global longitudinal strain (GLS) was calculated using speckle-tracking echocardiography with TomTec 2D Cardiac Performance Analysis (Unterschleissheim, Germany). An abnormal GLS was defined as less than -20%. The primary endpoints were revascularization of the target lesion, admissions for major adverse cardiac events (MACE), and cardiac-related mortality, all within 2 years. On multivariate logistic regression data analysis, we found that patients with an ISCL and abnormal GLS had an increased risk for admissions due to MACE (odds ratio [OR] 1.06, P < 0.05, confidence interval [CI] 95%, 1.005-1.120], and an increased risk of cardiac-related death (OR 1.12, P < 0.05, CI 95% 1.012-1.275). There was no difference in the need for target lesion revascularization among individuals with normal and abnormal GLS (1.00, P 0.88, CI 95% .950-1.061). Left ventricular strain analysis by speckle-tracking echocardiography showed an independent prognostic value in patients with nonrevascularized nonhemodynamically significant coronary lesions.

Location of death among patients presenting with cardiovascular disease to the emergency department in the United states.

BACKGROUND: In-hospital deaths are an important outcome and little is known about deaths in the emergency department (ED). Among patients who died of cardiovascular diseases (CVD), we assessed causes of death, temporal trends and the relative distribution of deaths in the ED versus hospital. METHODS: Using the United States Nationwide Emergency Department Sample, we conducted a retrospective study of patients presenting to the ED with a primary diagnosis of CVD between 2006 and 2014. We used descriptive statistics to describe causes of deaths, temporal trends and location of death. RESULTS: During the study period, there were 27 144 508 visits to the ED with CVD diagnoses (~2% of all ED visits,). The most common CVD diagnoses were heart failure (n = 8 571 598), acute myocardial infarction (n = 4 827 518) and atrial fibrillation/flutter (n = 4 713 241). There were a total of 2.2 million deaths caused by the CVD, with the majority (57.6%) occurring in the ED. Cardiac arrest was the most common cause of in-hospital death (n = 1 225 095, 55.3%), followed by acute myocardial infarction (n = 279 310, 12.6%), heart failure (n = 217 367, 9.8%), intracranial hemorrhage (n = 168 009, 7.6%) and ischemic stroke (n = 151 615, 6.8%). The proportion of deaths in the ED for these causes were 91.9% cardiac arrest (n = 1 173 471), 3.6% acute myocardial infarction (n = 46 909), 1.0% heart failure (n = 12 599) and 1.1% intracranial hemorrhage (n = 13 579). There was a decrease in death for most CVDs over time. CONCLUSIONS: Inpatient CVD admissions and their associated death may not be a robust measure of the national burden of CVD since ED death-which are common for some conditions-are not captured.

Diffuse coronary artery vasospasm in a patient with subarachnoid hemorrhage: A case report.

BACKGROUND: Coronary artery vasospasm (CAV) is a reversible, transient form of vasoconstriction with clinical manifestations ranging from stable angina to acute coronary syndromes (ACS). Vasospasm of epicardial coronary arteries or associated micro-vasculature can lead to total or subtotal occlusion and has been demonstrated in nearly 50% of patients undergoing angiography for suspected ACS. The mechanism for CAV has been described in literature, but in a subgroup of patients presenting with intracranial hemorrhage, it appears to be multifactorial. These patients tend to have electrocardiographic changes, elevation of cardiac biomarkers of injury and neurogenic stress cardiomyopathy. CASE SUMMARY: A 44-year-old woman presented with severe headaches and tonic-clonic seizures. She was found to have diffuse subarachnoid hemorrhage (SAH) requiring ventricular drain placement, coil embolization and induced hypertension. She subsequently developed chest pain with ST elevations in anterior precordial leads, elevated cardiac enzymes and apical ballooning with left ventricular ejection fraction of 35% on transthoracic echocardiogram. Coronary angiogram revealed severe diffuse triple vessel stenoses secondary to CAV seen distally. Subsequent cardiac MRI notable for apical non-viability and scar formation. CONCLUSION: This case highlights a unique etiology of acute myocardial infarction in a patient with SAH leading to ST elevations, diffuse triple vessel CAV and apical scar.

Program Directors Survey on Diversity in Cardiovascular Training Programs.

BACKGROUND: Women and minorities are under-represented in cardiovascular disease (CVD) specialties. It remains unknown how characteristics of the CVD learning environment affect diversity and how program directors (PDs) approach these critical issues. OBJECTIVES: The second annual Cardiovascular PD Survey aimed to investigate characteristics of the CVD learning environment that may affect diversity and strategies PDs use to approach these issues. METHODS: The survey contained 20 questions examining U.S.-based CVD PD perceptions of diversity in CVD and related characteristics of the CVD fellowship learning environment. RESULTS: In total, 58% of PDs completed the survey. Responding programs demonstrated geographic diversity. The majority were university-based or -affiliated. A total of 86% of PDs felt diversity in CVD as a field needs to increase, and 70% agreed that training programs could play a significant role in this. In total, 89% of PDs have attempted to increase diversity in fellowship recruitment. The specific strategies used were associated with PD sex and the presence of under-represented minority trainees in the program. PDs identified lack of qualified candidates and overall culture of cardiology as the 2 most significant barriers to augmenting diversity. A majority of programs have support systems in place for minority fellows or specific gender groups, including procedures to report issues of harassment or an unsafe learning environment. PDs identified shared best practices for recruitment and implicit bias training, among others, as important resources in their efforts to support diversity in CVD training. CONCLUSIONS: Diversity is important to CVD PDs. They are striving to increase it in their programs through recruitment and strategies directed toward the fellowship learning environment. The CVD community has opportunities to standardize strategies and provide national resources to support PDs in these critical efforts.

Amiodarone: A Comprehensive Guide for Clinicians.

Amiodarone is an effective antiarrhythmic medication frequently used in practice for both ventricular and atrial arrhythmias. Though classified as a class III antiarrhythmic, it affects all phases of the cardiac action potential. However, the drug has several side effects, including thyroid abnormalities, pulmonary fibrosis, and transaminitis, for which routine monitoring is recommended. It also interacts with several medications, such as warfarin, simvastatin, and atorvastatin, and many HIV antiretroviral medications. Given the common use of this medication in medical practice, it is vital that clinicians understand the indications, contraindications, dosing, side effects, and interactions of this medication. A thorough understanding of these topics is essential for clinicians to ensure safe and effective use of amiodarone.