The effect of catheter ablation for ventricular arrhythmias originating from the left ventricular papillary muscles on mitral valve function.

BACKGROUND: Ablation of ventricular arrhythmias (VA) originating from the left ventricular (LV) papillary muscles (PM) has the potential to damage the mitral valve apparatus resulting in mitral regurgitation (MR). This study sought to evaluate the effect of radiofrequency (RF) ablation of a PM on MR severity. METHODS: Patients with pre- and postablation transthoracic echocardiograms who underwent PM ablation for treatment of VA were retrospectively identified and compared to similar patients who underwent VA ablation at non-PM sites. MR severity was evaluated pre- and postablation in both groups and graded as none/trace (Grade 0); mild/mild-to-moderate (Grade 1); moderate (Grade 2); moderate-to-severe/severe (Grade 3). RESULTS: A total of 45 and 49 patients were included in the PM and non-PM groups, respectively. There were no significant baseline demographic differences. The PM group had longer RF ablation times (22.3 vs. 13.3 min, p < .01) compared to the non-PM group. Most patients had low-grade MR in both groups at baseline. Change in pre- versus postablation MR within the PM group was not statistically significant by Wilcoxon rank-sum test (Figure 2, p = .46). MR severity following ablation was also evaluated using logistic regression models. The odds ratio for worsening MR in the PM group compared to non-PM was 0.19 (95% confidence interval: 0.008-4.18, p = .29) after adjusting for comorbidities, LV ejection fraction, and LV internal end-diastolic diameter. CONCLUSION: RF ablation of VA originating from PM under intracardiac echocardiography guidance did not result in clinically or statistically significant worsening of MR.

Interactions Among Vitamin D, Atrial Fibrillation, and the Renin-Angiotensin-Aldosterone System.

Blockade of the renin-angiotensin-aldosterone system (RAAS) with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARB) has been shown to decrease incident atrial fibrillation (AF). Vitamin D deficiency has been implicated but associations between vitamin D and AF are inconsistent. However, vitamin D deficiency results in renin and angiotensin upregulation. This study seeks to determine the relation between vitamin D deficiency and incident AF and characterize this relation in the setting of RAAS inhibition. A total of 47,062 patients with 25-hydroxyvitamin D [25(OH)D] laboratory testing were retrospectively identified. Clinical information was extracted from the medical record. The primary outcome was incidence of AF. Given significant patient variation, propensity score matching was used to select comparable groups of those who initiated ACEI/ARB ("AI") versus those who did not ("NAI"). Odds ratios (ORs) for incident AF associated with ACEI/ARB initiation and 25(OH)D level were estimated using generalized linear mixed models. AI patients had less incident AF than NAI patients (OR 0.36, 95% confidence interval [CI] 0.32 to 0.39) consistent with previous studies, but 25(OH)D deficiency was not associated with incident AF (OR 1.08, 95% CI 0.95 to 1.22). When stratified by 25(OH)D, there was a statistically significant decreased rate of AF in AI patients. Interestingly, this benefit was attenuated in 25(OH)D deficiency (deficient: OR 0.48, 95% CI 0.38 to 0.60 vs normal: OR 0.34, 95% CI 0.30 to 0.37). In conclusion, 25(OH)D deficiency was not associated with incident AF, and the benefit of ACE/ARB use was attenuated in 25(OH)D deficiency; this suggests that 25(OH)D may act as a cofactor in the mitigation of AF by RAAS inhibition.

Statin therapy across the lifespan: evidence in major age groups.

This review provides needed perspective on statin efficacy and safety in individuals under 40, 40-75, and > 75 years of age. Starting with the 2013 ACC-AHA cholesterol guidelines extensive evidence base on randomized controlled trials (RCTs) we added references in the past 5 years that discussed statin efficacy and safety over the life span. In those under 40, statins are primarily used for treatment of severe hypercholesterolemia, often familial, and they are well tolerated. In middle-aged adults, statins have strong evidence for benefit in primary and secondary prevention trials; however, in primary prevention, a clinician-patient risk discussion should precede statin prescription in order to determine appropriate treatment. In those over 75, issues of statin intensity and net benefit loom large as associated comorbidity, polypharmacy, and potential for adverse effects impact the decision to use statins with RCT data strongest in support of use in secondary prevention. Statin drugs have been studied by RCTs in a large number of individuals. In those groups shown to benefit, statins have reduced the risk of atherosclerotic cardiovascular disease with few side effects as compared to controls. This review has detailed considerations that should occur when statins are given to individuals in different age groups.

Congenital heart disease in adults: Quantitative and qualitative evaluation of IR FLASH and IR SSFP MRA techniques using a blood pool contrast agent in the steady state and comparison to first pass MRA.

OBJECTIVES: To evaluate magnetic resonance angiography sequences during the contrast steady-state (SS-MRA) using inversion recovery (IR) with fast low-angle shot (IR-FLASH) or steady-state free precession (IR-SSFP) read-outs, following the injection of a blood-pool contrast agent, and compare them to first-pass MR angiography (FP-MRA) in adults with congenital heart disease (CHD). MATERIALS AND METHODS: Twenty-three adult patients with CHD who underwent both SS-MRA and FP-MRA using a 1.5-T scanner were retrospectively identified. Signal-to-noise and contrast-to-noise ratios were obtained at eight locations within the aorta and pulmonary vessels.. Image quality and the presence of artifacts were subjectively assessed by two radiologists. The presence of pathology was noted and given a confidence score. RESULTS: There was no difference in vessel dimensions among the sequences. IR-SSFP showed better image quality and fewer artifacts than IR-FLASH and FP-MRA. Confidence scores were significantly higher for SS-MRA compared to FP-MRA. Seven cases (30.4%) had findings detected at SS-MRA that were not detected at FP-MRA, and 2 cases (8.7%) had findings detected by IR-SSFP only. CONCLUSION: SS-MRA of the thoracic vasculature using a blood pool contrast agent offers superior image quality and reveals more abnormalities compared to standard FP-MRA in adults with CHD, and it is best achieved with an IR-SSFP sequence. These sequences could lead to increased detection rates of abnormalities and provide a simpler protocol image acquisition.

Statins and Nonadherence: Should We RELATE Better?

Statin nonadherence is a major challenge to optimal management. Patients nonadherent to statin therapy do not receive the expected benefit relative to the degree of low-density lipoprotein cholesterol (LDL-C) lowering obtained. This is important because new evidence guidelines recommend statins as the first-line therapy for those in high-risk groups (secondary prevention, patients with diabetes 40-75 years of age, and LDL-C ≥ 190 mg/dL) and in selected primary prevention patients. Statin assignment in the latter group occurs only in those with an estimated ≥7.5% 10-year atherosclerotic cardiovascular disease risk after shared decision making in a clinician-patient risk discussion. However, in numerous studies, statin nonadherence shows little or no benefit in reducing cardiovascular events or mortality compared to placebo, effectively negating the risk reduction expected from statin use and concomitantly increasing the total cost of health care. The causes and solutions for nonadherence are multifactorial and include patient, clinician, and health system factors. We believe that a clinician-patient partnership that facilitates patients' understanding of the potential for optimal benefit with the least adverse effects is an important first step toward improving adherence. A transtheoretical model of stages of behavior change helps clinicians address many of the common factors limiting adherence to statins. We conclude with a teaching tool emphasizing a structured approach to statin therapy with patient-centered risk discussions.

Association between leaflet fusion pattern and thoracic aorta morphology in patients with bicuspid aortic valve.

PURPOSE: To determine if patients with certain bicuspid aortic valve (BAV) phenotypes are predisposed to particular morphological abnormalities of the thoracic aorta. MATERIALS AND METHODS: One hundred ninety-two patients with BAV who underwent magnetic resonance angiography between January 2007 and July 2010 were retrospectively identified. Aortic morphology was examined through measurements of aortic size index at nine levels along the thoracic aorta, three-dimensional volume of the ascending aorta, vessel asymmetry, and assessment of aortic root morphology. RESULTS: We found 140 patients (73%) with right and left coronary cusps (R-L) fusion, 46 patients (24%) with R-N fusion, and 6 patients (3%) with left and noncoronary cusps (L-N) fusion. Mean aortic volume in the proximal ascending aorta was significantly greater in R-L patients (0.93 versus 0.60 cm(3)/m(2); P < 0.01). R-N patients possessed greater aortic size index at the distal ascending aorta and proximal aortic arch, and were also significantly more likely to have Type 2 patterns of aortic dilatation. CONCLUSION: Our results suggest that BAV with R-L fusion is associated with increased dimensions of the aortic root, while BAV with R-N fusion is associated with increased dimensions of the distal ascending aorta and proximal arch. Our findings illustrate the morphological heterogeneity that exists among BAV phenotypes.