Large-bore suction thrombectomy for sub-massive pulmonary embolism during second trimester of pregnancy: a case report.

Background: Pregnancy-associated pulmonary embolism (PAPE) remains a significant cause of maternal mortality. Anticoagulation remains the mainstay of therapy for most pulmonary embolism (PE)-related pregnancies. However, in patients with haemodynamic compromise or those refractory to anticoagulation, management is challenging. Systemic thrombolysis is associated with a substantial risk of maternal bleeding and fetal loss. In non-pregnant PE patients, large bore catheter-directed suction thrombectomy is a proven and important technique to manage intermediate or high-risk PE, allowing for normalization of pulmonary pressures, avoidance of haemodynamic deterioration, without the need for thrombolytics, major surgery, significant blood loss, or prolonged hospitalization. Case summary: A primigravid patient in her second trimester of pregnancy, initially diagnosed with a deep vein thrombosis refractory to heparin, presents with near-syncope due to sub-massive pulmonary embolism. The various management options including thrombolysis and surgical embolectomy etc. were discussed in detail by a multi-disciplinary PE team. She underwent large bore suction thrombectomy with complete thrombi removal, normalization of right heart strain, without the need for thrombolytics or surgery, minimal blood loss and was discharged after a short length of stay. She gave birth at term to a healthy infant. Conclusion: Suction thrombectomy is an important consideration for physicians managing high-risk PAPE and is likely to be associated with much a lower risk of maternal and fetal mortality compared to thrombolysis or surgery.

Genetic Studies of Hypertrophic Cardiomyopathy in Singaporeans Identify Variants in TNNI3 and TNNT2 That Are Common in Chinese Patients.

BACKGROUND: To assess the genetic architecture of hypertrophic cardiomyopathy (HCM) in patients of predominantly Chinese ancestry. METHODS: We sequenced HCM disease genes in Singaporean patients (n=224) and Singaporean controls (n=3634), compared findings with additional populations and White HCM cohorts (n=6179), and performed in vitro functional studies. RESULTS: Singaporean HCM patients had significantly fewer confidently interpreted HCM disease variants (pathogenic/likely pathogenic: 18%, P<0.0001) but an excess of variants of uncertain significance (24%, P<0.0001), as compared to Whites (pathogenic/likely pathogenic: 31%, excess of variants of uncertain significance: 7%). Two missense variants in thin filament encoding genes were commonly seen in Singaporean HCM (TNNI3:p.R79C, disease allele frequency [AF]=0.018; TNNT2:p.R286H, disease AF=0.022) and are enriched in Singaporean HCM when compared with Asian controls (TNNI3:p.R79C, Singaporean controls AF=0.0055, P=0.0057, genome aggregation database-East Asian AF=0.0062, P=0.0086; TNNT2:p.R286H, Singaporean controls AF=0.0017, P<0.0001, genome aggregation database-East Asian AF=0.0009, P<0.0001). Both these variants have conflicting annotations in ClinVar and are of low penetrance (TNNI3:p.R79C, 0.7%; TNNT2:p.R286H, 2.7%) but are predicted to be deleterious by computational tools. In population controls, TNNI3:p.R79C carriers had significantly thicker left ventricular walls compared with noncarriers while its etiological fraction is limited (0.70 [95% CI, 0.35-0.86]) and thus TNNI3:p.R79C is considered variant of uncertain significance. Mutant TNNT2:p.R286H iPSC-CMs (induced pluripotent stem cells derived cardiomyocytes) show hypercontractility, increased metabolic requirements, and cellular hypertrophy and the etiological fraction (0.93 [95% CI, 0.83-0.97]) support the likely pathogenicity of TNNT2:p.R286H. CONCLUSIONS: As compared with Whites, Chinese HCM patients commonly have low penetrance risk alleles in TNNT2 or TNNI3 but exhibit few clinically actionable HCM variants overall. This highlights the need for greater study of HCM genetics in non-White populations.

Multilayer Myocardial Mechanics in Genotype-Positive Left Ventricular Hypertrophy-Negative Patients With Hypertrophic Cardiomyopathy.

It is unknown whether the presence of a sarcomeric mutation alone is sufficient to result in abnormal myocardial force generation, or whether additional changes in myocardial architecture (hypertrophy, disarray, and fibrosis) are required to impair systolic function. Speckle tracking echocardiography allows quantification of global strain/strain rates, twist, and dyssynchrony. In the present study we sought to further elucidate early abnormalities of myocardial mechanics in sarcomeric mutation carriers without evidence of clinical disease. Sixty genotype-positive left ventricular hypertrophy-negative (G+left ventricular hypertrophy [LVH]-) patients and 60 normal controls were studied. Velocity vector imaging was applied retrospectively to echocardiographic images to quantify global longitudinal and circumferential strain/strain rate, and rotation parameters. The G+LVH- group demonstrated both smaller left ventricular diastolic cavity dimensions (4.5 ± 0.6 cm vs 4.8 ± 0.4 cm) and a higher LVEF (66 ± 6% vs 60 ± 5%) compared with controls. An increase in circumferential subendocardial systolic strain (-30 ± 5 vs -27 ± 3%) and both systolic and diastolic subendocardial strain rate was seen in the G+LVH- group. Peak rotation angles were higher at the base and apex, with an increase in total twist (9.0 ± 3.8 vs 6.9 ± 2.9). In the control group, global and average segmental strain were similar, suggesting no/minimal dyssynchrony (global mechanical synchrony index [GMSi] 0.97-0.98). In the G+LVH- group GMSi was significantly lower (subendocardial GMSi 0.95; subepicardial GMSi 0.60), suggesting increasing subendocardial to subepicardial dyssynchrony. In conclusion, utilizing multilayer strain analysis, we demonstrate that G+LVH- subjects have enhanced subendocardial systolic strain rate and twist, as well as mechanical dyssynchrony within the left ventricular myocardium. These results demonstrate that abnormalities in myocardial mechanics precede the development of clinical hypertrophy.

The effectiveness of psychological interventions on self-care, psychological and health outcomes in patients with chronic heart failure-A systematic review and meta-analysis.

OBJECTIVE: To review the evidence to determine the effects of psychological interventions on self-care and psychological and health outcomes in patients with chronic heart failure (CHF). METHODS: We evaluated the effectiveness of randomized controlled trials using psychological methods or theory on self-care behaviors, anxiety and depression levels, HRQoL, and physical function. Studies published in English, from January 2006 to December 2016, were considered. We searched published and unpublished studies in the following electronic databases: CINAHL, Cochrane Library, EMBASE, PubMed, PsycINFO, Scopus, Web of Science, and ProQuest Dissertations and Theses. Risk of bias was assessed using a standard procedure based on the Cochrane Collaboration tool described in the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: A total of 29 articles, consisting of 25 studies with 3837 participants, were included in this systematic review. Findings showed that despite heterogeneity between studies, psychological interventions tend to improve self-care in CHF patients without clinical depression and cognitive impairment. Pooled results also revealed that the intervention effect on short-term HRQoL, as measured by the Minnesota Living with Heart Failure Questionnaire (MLHFQ), was in favor of the intervention group (combined MD -7.53, 95% CI -12.83 to -2.23); however, such effect disappeared as the length of time from the intervention increased. The intervention effects on the participants' anxiety level, as measured by HADS, and physical function, as measured by 6MWT, were not statistically significant. DISCUSSION: Efforts aimed at promoting self-care were the cornerstone of HF disease management. Nurses play an important role in patient education and secondary prevention. Compared to other professionals, nurses have more patient contact opportunities and are more holistic in all aspects of disease management; therefore, more nurses can be trained to incorporate the brief psychological techniques (such as motivational interviews and cognitive behavior therapy) to maximize intervention effectiveness. The main limitation of the review is the moderate to high level of heterogeneity among the included studies, which may partially undermine the reliability and reproducibility of the results. Because of the heterogeneity among the studies, a conclusion on the optimal format and forms of the intervention could not be drawn. Replication of the studies will be required in the future to isolate the active intervention component and to identify the ideal intervention format and dosage.

Transitional Care to Reduce Heart Failure Readmission Rates in South East Asia.

Heart failure (HF) is an emerging public health problem due to increasing hospitalisations, readmissions and direct healthcare costs. Transitional care (TC) aims to improve multidisciplinary care coordination in HF and provides a streamlined strategy to ensure discharge success. This article reviews the different TC models and interventions in HF, and compares their strengths, weaknesses and efficacies. Notably, a nurse-led TC model under the direct administration of a dedicated multidisciplinary team appears to be the superior model of care. The emerging use of remote technology to track patient progress adds value, as human resources are scarce. Several knowledge gaps are highlighted in this article. The authors share their local institutional TC experience and discuss its early impact on HF care.

Who needs a transplant and when?

PURPOSE OF REVIEW: Heart transplantation remains the treatment of choice for patients with advanced heart failure. We review the current definition of optimal therapy, prediction of prognosis and revisit contraindications for transplant. RECENT FINDINGS: Clinical trials of eplerenone and ivabradine were associated with improved prognosis, whereas others (nesiritide) were disappointing. Advances in cardiac resynchronization therapy and ventricular assist devices (VAD) have resulted in an expansion of their indications. Advances in catheter ablation for ventricular tachycardia have made this an uncommon indication for heart transplantation. Surgical ventricular reconstruction and mitral valve intervention have not resulted in survival benefit. Bypass surgery was associated with a lower mortality from cardiovascular causes. Prognostic risk scores have been developed in heart failure patients; however, ongoing refinements are needed. Selected patients with diabetes, HIV and pretransplant malignancy, now have favourable outcomes after heart transplantation. VAD as bridge to candidacy is an option in heart failure patients with 'fixed' pulmonary hypertension. Alternate listing strategies have also been studied to provide high-risk patients with an opportunity for heart transplantation. SUMMARY: Heart failure patients should be on current optimal medical and device therapy with a poor prognosis before consideration for heart transplantation. An individualized approach to heart transplantation assessment is recommended.