Computerized Cognitive Training and 24-Month Mortality in Heart Failure.

BACKGROUND: Cognitive dysfunction predicts mortality in heart failure (HF). Computerized cognitive training (CCT) has shown preliminary efficacy in improving cognitive function. However, the relationship between CCT and mortality is unclear. Aims were to evaluate (1) long-term efficacy of CCT in reducing 24-month mortality and (2) age, HF severity, global cognition, memory, working memory, depressive symptoms, and health-related quality of life as predictors of 24-month mortality among patients with HF. METHODS: In this prospective longitudinal study, 142 patients enrolled in a 3-arm randomized controlled trial were followed for 24 months. Logistic regression was used to achieve the aims. RESULTS: Across 24 months, 16 patients died (CCT, 8.3%; control groups, 12.8%). Computerized cognitive training did not predict 24-month mortality (odds ratio [OR], 0.65). Older age (OR, 1.08), worse global cognition (OR, 0.73), memory (OR, 0.81), and depressive symptoms (OR, 1.10) at baseline predicted 24-month mortality. CONCLUSIONS: Efficacious interventions are needed to improve global cognition, memory, and depressive symptoms and reduce mortality in HF.

Atrial Fibrillation and Older Age Predict Serum Brain-Derived Neurotrophic Factor Levels Among Patients With Heart Failure.

BACKGROUND: Predictors have not been determined of serum brain-derived neurotrophic factor (BDNF) levels among patients with heart failure (HF). OBJECTIVE: The primary purpose was to evaluate history of atrial fibrillation, age, gender, and left ventricular ejection fraction as predictors of serum BDNF levels at baseline, 10 weeks, and 4 and 8 months after baseline among patients with HF. METHODS: This study was a retrospective cohort analyses of 241 patients with HF. Data were retrieved from the patients' health records (coded history of atrial fibrillation, left ventricular ejection fraction), self-report (age, gender), and serum BDNF. Linear multiple regression analyses were conducted. RESULTS: One hundred three patients (42.7%) had a history of atrial fibrillation. History of atrial fibrillation was a significant predictor of serum BDNF levels at baseline (ß = -0.16, P = .016), 4 months (ß = -0.21, P = .005), and 8 months (ß = -0.19, P = .015). Older age was a significant predictor at 10 weeks (ß = -0.17, P = .017) and 4 months (ß = -0.15, P = .046). CONCLUSIONS: Prospective studies are needed to validate these results. Clinicians need to assess patients with HF for atrial fibrillation and include treatment of it in management plans.

Randomized Controlled Trial of a Cognitive Intervention to Improve Memory in Heart Failure.

BACKGROUND: The objective of this 3-arm randomized controlled trial was to evaluate the efficacy of computerized cognitive training (CCT) in improving primary outcomes of delayed-recall memory and serum brain-derived neurotrophic factor (BDNF) levels; and the secondary outcomes were working memory, instrumental activities of daily living (IADLs) and health-related quality of life (HRQL) in patients with heart failure (HF). METHODS AND RESULTS: Patients (n = 256) were randomly assigned to 8 weeks of CCT using BrainHQ, computerized crossword puzzles active control intervention, and usual care. All patients received weekly nurse-enhancement interventions. Data were collected at enrollment and baseline visits and at 10 weeks and 4 and 8 months. In mixed effects models, there were no statistically significant group or group-by-time differences in outcomes. There were statistically significant differences over time in all outcomes in all groups. Patients improved over time on measures of delayed-recall memory, working memory, IADLs, and HRQL and had decreased serum BDNF. CONCLUSIONS: CCT did not improve outcomes compared with the active control intervention and usual care. Nurse-enhancement interventions may have led to improved outcomes over time. Future studies are needed to test nurse-enhancement interventions in combination with other cognitive interventions to improve memory in persons with HF.

911 Calls for Emergency Medical Services in Heart Failure: A Descriptive Qualitative Study.

BACKGROUND: Heart failure (HF) is a common condition leading to activation of emergency medical services (EMS). OBJECTIVE: The aim of this study was to describe reasons given by persons with HF, family members, or other caregivers for requesting EMS activation during 911 calls. METHODS: In this descriptive qualitative study, a content analysis was performed on transcribed audio files of 383 EMS requests involving 383 persons with HF in the community. RESULTS: One hundred forty-seven calls (38.4%) were placed by the family members, 75 (19.6%) were placed by the patients, 56 (14.6%) were placed by healthcare workers or personnel from living facilities, and the remaining calls (n = 105, 27.4%) were placed by others (eg, friends, neighbors, officers). Three broad categories of symptoms, signs, and events were identified as the reasons for an EMS request. Frequently reported symptoms were breathing problems (55.4%), chest pain (18.3%), and other pain (eg, head, extremities) (16.7%). Signs included decreased consciousness (15.4%), swelling (5.7%), and bleeding (5.0%). The reported events involved falls (8.1%), heart attack (6.3%), hypoxic episodes (6.0%), stroke (5.2%), and post-hospital-discharge complications (4.7%). In most calls (74.9%), multiple reasons were reported and a combination of symptoms, signs, and events were identified. Heart failure diagnosis was mentioned in fewer than 10% of the calls. CONCLUSIONS: Overall, symptoms and signs of HF exacerbation were common reasons to activate 911 calls. Falls were frequently reported. Under the duress of the emergent situations surrounding the 911 call, callers rarely mentioned the existence of HF. Interventions are needed to guide patients with HF and their family members to promote the management of HF to reduce EMS activation as well as to activate EMS quickly for acute changes in HF conditions.

Design and Rationale of the Cognitive Intervention to Improve Memory in Heart Failure Patients Study.

BACKGROUND: Memory loss is an independent predictor of mortality among heart failure patients. Twenty-three percent to 50% of heart failure patients have comorbid memory loss, but few interventions are available to treat the memory loss. The aims of this 3-arm randomized controlled trial were to (1) evaluate efficacy of computerized cognitive training intervention using BrainHQ to improve primary outcomes of memory and serum brain-derived neurotrophic factor levels and secondary outcomes of working memory, instrumental activities of daily living, and health-related quality of life among heart failure patients; (2) evaluate incremental cost-effectiveness of BrainHQ; and (3) examine depressive symptoms and genomic moderators of BrainHQ effect. METHODS: A sample of 264 heart failure patients within 4 equal-sized blocks (normal/low baseline cognitive function and gender) will be randomly assigned to (1) BrainHQ, (2) active control computer-based crossword puzzles, and (3) usual care control groups. BrainHQ is an 8-week, 40-hour program individualized to each patient's performance. Data collection will be completed at baseline and at 10 weeks and 4 and 8 months. Descriptive statistics, mixed model analyses, and cost-utility analysis using intent-to-treat approach will be computed. CONCLUSIONS: This research will provide new knowledge about the efficacy of BrainHQ to improve memory and increase serum brain-derived neurotrophic factor levels in heart failure. If efficacious, the intervention will provide a new therapeutic approach that is easy to disseminate to treat a serious comorbid condition of heart failure.

Pulse Oximeter Derived Blood Pressure Measurement in Patients With a Continuous Flow Left Ventricular Assist Device.

Currently, blood pressure (BP) measurement is obtained noninvasively in patients with continuous flow left ventricular assist device (LVAD) by placing a Doppler probe over the brachial or radial artery with inflation and deflation of a manual BP cuff. We hypothesized that replacing the Doppler probe with a finger-based pulse oximeter can yield BP measurements similar to the Doppler derived mean arterial pressure (MAP). We conducted a prospective study consisting of patients with contemporary continuous flow LVADs. In a small pilot phase I inpatient study, we compared direct arterial line measurements with an automated blood pressure (ABP) cuff, Doppler and pulse oximeter derived MAP. Our main phase II study included LVAD outpatients with a comparison between Doppler, ABP, and pulse oximeter derived MAP. A total of five phase I and 36 phase II patients were recruited during February-June 2014. In phase I, the average MAP measured by pulse oximeter was closer to arterial line MAP rather than Doppler (P = 0.06) or ABP (P < 0.01). In phase II, pulse oximeter MAP (96.6 mm Hg) was significantly closer to Doppler MAP (96.5 mm Hg) when compared to ABP (82.1 mm Hg) (P = 0.0001). Pulse oximeter derived blood pressure measurement may be as reliable as Doppler in patients with continuous flow LVADs.

Competence, Compassion, and Care of the Self: Family Caregiving Needs and Concerns in Heart Failure.

BACKGROUND: Family caregivers are essential to the well-being of patients with chronic heart failure (HF) because they provide care in managing complex medication regimens, dietary sodium restrictions, and symptoms. OBJECTIVE: The purpose of this qualitative study was to gain a deeper understanding of the HF caregiving experience and describe the needs and concerns expressed by caregivers. METHODS: Qualitative descriptive methodology was conducted using data from responses to open-ended questions asked as part of a larger longitudinal study. The sample was 63 patients with HF and 63 family caregivers. RESULTS: Using basic content analysis, the 3 main themes of needs and concerns that emerged were competence concerns, compassion maintenance, and care of the self. Subthemes of competence concerns were doing things right, making a serious mistake, and uncertainty. CONCLUSIONS: Family caregivers of patients with HF had many needs and concerns about their competence in performing tasks, their compassion, and caring for themselves. Data can be used to design testable interventions to improve the HF caregiving experience for patients and caregivers.

B-Type Natriuretic Peptide Levels Predict Ventricular Arrhythmia Post Left Ventricular Assist Device Implantation.

B-type natriuretic peptide (BNP) levels have been shown to predict ventricular arrhythmia (VA) and sudden death in patients with heart failure. We sought to determine whether BNP levels before left ventricular assist device (LVAD) implantation can predict VA post LVAD implantation in advanced heart failure patients. We conducted a retrospective study consisting of patients who underwent LVAD implantation in our institution during the period of May 2009-March 2013. The study was limited to patients receiving a HeartMate II or HeartWare LVAD. Acute myocardial infarction patients were excluded. We compared between the patients who developed VA within 15 days post LVAD implantation to the patients without VA. A total of 85 patients underwent LVAD implantation during the study period. Eleven patients were excluded (five acute MI, four without BNP measurements, and two discharged earlier than 13 days post LVAD implantation). The incidence of VA was 31%, with 91% ventricular tachycardia (VT) and 9% ventricular fibrillation. BNP remained the single most powerful predictor of VA even after adjustment for other borderline significant factors in a multivariate logistic regression model (P < 0.05). BNP levels are a strong predictor of VA post LVAD implantation, surpassing previously described risk factors such as age and VT in the past.

Ventricular arrhythmias in patients with implanted ventricular assist devices: a contemporary review.

Ventricular arrhythmia (VA) is a significant factor in the clinical management of patients with congestive heart failure (CHF). Understanding the implications of VA in ventricular assist device-supported CHF patients is critical to appropriate clinical decision making in this special population. This article details research findings on this topic, and attempts to link them to practical patient management strategies.

Frequency, time course, and possible causes of right ventricular systolic dysfunction after cardiac transplantation: a single center experience.

BACKGROUND: The frequency and causes of right ventricular (RV) systolic dysfunction early after cardiac transplantation are not well defined. METHODS: We investigated the prevalence and causes of RV dysfunction in 27 heart transplant recipients, as measured by lateral tricuspid annular plane excursion (TAPSE) and fractional area change (FAC) at a mean of 15 ± 11 days after transplant. Tissue Doppler imaging was used to assess systolic time velocity integral (TVI) of the RV basal free wall. A subset of 22 patients had follow-up TAPSE measurement at 406 ± 121 days. RESULTS: RV systolic dysfunction, defined as TAPSE > 2 standard deviation (SD) below values in a control group, was present in 100% (27/27) of patients (P < 0.05). FAC was also significantly lower in patients compared with controls (P < 0.0001). TVI confirmed the presence of RV dysfunction in all 16 patients with both TAPSE and TVI (P < 0.05). Ischemic time (P = 0.017) and posttransplant tricuspid regurgitation (P = 0.024) were independent predictors of early RV dysfunction (r = 0.753). On follow-up, RV function improved in 15 of 22 patients but all patients remained with TAPSE > 2 SD below controls. CONCLUSION: This study showed that 100% of patients had reduced RV function early after transplant. Two thirds of patients had partial recovery of RV function during the first year. In all patients, however, RV function remained significantly lower than in controls.

Family caregivers of patients with heart failure: a longitudinal study.

BACKGROUND: The family caregivers of patients with heart failure (HF) report burden and poor quality of life, but little is known about changes in their perceptions over time. OBJECTIVES: The aims of this study were (1) to evaluate changes in caregiver burden (perceived time spent and difficulty with caregiving tasks), perceived control, depressive symptoms, anxiety, perceived life changes, and physical and emotional health-related quality of life; (2) to determine differences in perceptions between caregivers of patients with low HF symptoms (New York Heart Association class I and II) and caregivers of patients with high HF symptoms (New York Heart Association class III and IV); and (3) to the estimate time spent performing caregiving tasks. METHODS: Sixty-three HF patients and 63 family caregivers were enrolled; 53 caregivers completed the longitudinal study. Data were collected from medical records and interviews conducted by advanced practice nurses at baseline and 4 and 8 months later. RESULTS: Caregivers who completed the study had significant improvements in perceived time spent on and difficulty of caregiving tasks from baseline to 4 and 8 months, and depressive symptoms decreased from baseline to 8 months. Perceived life changes resulting from caregiving became more positive from baseline to 4 and 8 months. Perceived control, anxiety, and health-related quality of life did not change. Compared with caregivers of patients with low symptoms, caregivers of patients with high symptoms perceived that they spent more time on tasks and that tasks were more difficult, had higher anxiety, and had poorer physical health-related quality of life. Estimated time in hours spent providing care was high. CONCLUSIONS: In this sample, perceptions of the caregiving experience improved over 8 months. Health-related quality of life was moderately poor over the 8 months. Caregivers of patients with more severe HF symptoms may be particularly in need of interventions to reduce time and difficulty of caregiving tasks and improve physical health-related quality of life.

Evaluating depressive symptoms, BDNF Val66Met, and APOE-ε4 as moderators of response to computerized cognitive training in heart failure.

BACKGROUND: Depressive symptoms, brain-derived neurotrophic factor (BDNF) Val66Met, and apolipoprotein (APOE)-ε4 may moderate response to computerized cognitive training (CCT) interventions among patients with heart failure (HF). OBJECTIVES: The purpose of this study was to examine moderators of intervention response to CCT over 8 months among patients with HF enrolled in a 3-arm randomized controlled trial. Outcomes were memory, serum BDNF, working memory, instrumental activities of daily living (IADLs), and health-related quality of life (HRQL). METHODS: 256 patients with HF were randomized to CCT, computerized crossword puzzles active control, and usual care control groups for 8 weeks. Data were collected at enrollment, baseline, 10 weeks, and 4 and 8 months. Mixed effects models were computed to evaluate moderators. RESULTS: As previously reported, there were no statistically significant group by time effects in outcomes among the 3 groups over 8 months. Tests of moderation indicated that depressive symptoms and presence of BDNF Val66Met and APOE-ε4 were not statistically significant moderators of intervention response in outcomes of delayed recall memory, serum BDNF, working memory, IADLs, and HRQL. In post hoc analysis evaluating baseline global cognitive function, gender, age, and HF severity as moderators, no significant effects were found. HF severity was imbalanced among groups (P = .049) which may have influenced results. CONCLUSIONS: Studies are needed to elucidate biological mechanisms of cognitive dysfunction in HF and test novel interventions to improve memory, serum BDNF, working memory, IADLs and HRQL. Patients may need to be stratified or randomized by HF severity within intervention trials.

Pulmonary hypertension in an adult with unilateral absence of left pulmonary artery.

Unilateral absence of pulmonary artery is a rare congenital abnormality that occurs due to malformation of the sixth aortic arch during embryonic development. The clinical presentation of unilateral absence of pulmonary artery can vary based on age of diagnosis; however, in the adult population, it can present with a variety of manifestations including hemoptysis, recurrent pneumonia, and pulmonary hypertension or as an incidental finding. Diagnosis and management of unilateral absence of pulmonary artery remain a challenge. Here, we describe a case of a 37-year-old female with no known past medical history who presented with progressively worsening dyspnea and fatigue. She was incidentally found to have unilateral absence of pulmonary artery on computerized tomography angiography of the chest. Her imaging and physical exam demonstrated signs of volume overload and severe pulmonary hypertension. She received diuretics with good response and was discharged with referral to pulmonary hypertension clinic and eventual follow-up with right heart catheterization. In summary, we describe a rare congenital condition and highlight its diagnostic and therapeutic challenges.

Cardiodiagnostic sex-specific differences of the female athlete in sports cardiology.

The cardiovascular care of highly active individuals and competitive athletes has developed into an important focus within the field of sports medicine. An evolving understanding of exercise-induced cardiovascular remodeling in athletes has led to a more robust characterization of physiologic adaptation versus pathological dysfunction, but this distinction is often challenging due to diagnostic commonalities. Current data reflects sporting-focused analyses of mainly male athletes, which may not be easily applicable to the female athletic heart. Increasingly female-specific cardiac dimensional and physiologic data are starting to emerge from comparative studies that may be utilized to address this growing need, and further guide individualized care. Here, we review current literature evaluating female-specific cardiovascular adaptations of the athletic heart, and formulate a discussion on cardiac remodeling, cardiodiagnostic findings, etiologic mechanisms, limitations of currently available data, and direction for future research in the cardiovascular care of female athletes.

Virtual reality cognitive intervention for heart failure: CORE study protocol.

Introduction: Heart failure (HF) is a prevalent, serious chronic illness that affects 6.5 million adults in the United States. Among patients with HF, the prevalence of attention impairment is reported to range from 15% to 27%. Although attention is fundamental to human activities including HF self-care, cognitive interventions for patients with HF that target improvement in attention are scarce. The COgnitive intervention to Restore attention using nature Environment (CORE) study aims to test the preliminary efficacy of the newly developed Nature-VR, a virtual reality-based cognitive intervention that is based on the restorative effects of nature. Nature-VR development was guided by Attention Restoration Theory. The target outcomes are attention, HF self-care, and health-related quality of life (HRQoL). Our exploratory aims examine the associations between attention and several putative/established HF biomarkers (eg, oxygen saturation, brain-derived neurotrophic factor, apolipoprotein E, dopamine receptor, and dopamine transporter genes) as well as the effect of Nature-VR on cognitive performance in other domains (ie, global cognition, memory, visuospatial, executive function, and language), cardiac and neurological events, and mortality. Methods: This single-blinded, two-group randomized-controlled pilot study will enroll 74 participants with HF. The Nature-VR intervention group will view three-dimensional nature pictures using a virtual reality headset for 10 minutes per day, 5 days per week for 4 weeks (a total of 200 minutes). The active comparison group, Urban-VR, will view three-dimensional urban pictures using a virtual reality headset to match the Nature-VR intervention in intervention dose and delivery mode, but not in content. After baseline interviews, four follow-up interviews will be conducted to assess sustained effects of Nature-VR at 4, 8, 26, and 52 weeks. Discussion: The importance and novelty of this study consists of using a first-of-its kind, immersive virtual reality technology to target attention and in investigating the health outcomes of the Nature-VR cognitive intervention among patients with HF.

Effect of improvement in left ventricular ejection fraction on long-term survival in revascularized patients with ischaemic left ventricular systolic dysfunction.

AIMS: The importance of improvement in the ejection fraction to the prognosis of revascularized patients with ischaemic left ventricular (LV) dysfunction is uncertain. METHODS AND RESULTS: Eighty-seven patients with ischaemic LV dysfunction (mean ejection fraction 29 ± 8% by biplane Simpson's) had dobutamine echocardiography before revascularization (coronary bypass graft surgery-81, percutaneous intervention-6). Follow-up echocardiograms were performed a mean of 4.8 ± 6.2 months after revascularization. An 8% increase in the ejection fraction was considered significant (two times the inter-observer difference of 3.7%). Patients were followed for cardiac death. During a mean follow-up of 5.2 ± 3.9 years, there were 20 (23%) cardiac deaths. Class 3/4 heart failure, increasing low-dose wall motion score, increasing % non-viable myocardium, and digoxin use in follow-up were univariate predictors of death. Beta-blocker use, ejection fraction improvement, angina, aspirin use, and increasing fractional shortening were univariate predictors of survival. Ejection fraction improvement [P= 0.02, hazard ratio (HR) = 0.26], digoxin use in follow-up (P= 0.006, HR = 5.85), and low-dose wall motion score (P= 0.017, HR = 4.78) were independent predictors of outcome. In step-wise analysis, low-dose wall motion score added incremental prognostic value to ejection fraction improvement (P= 0.003), and digoxin use in follow-up (P= 0.003) added incremental value to a low-dose score and ejection fraction improvement. CONCLUSION: Ejection fraction improvement is an independent predictor of long-term outcome in revascularized patients but viability (low-dose wall motion score) and digoxin use in follow-up are also independent predictors and add incremental prognostic value to ejection fraction improvement.

Incremental prognostic value of echocardiography in patients with prior mitral valve surgery.

BACKGROUND AND AIM OF THE STUDY: Patients with prior mitral valve surgery are at increased risk for events late after surgery. The study aim was to investigate the value of assessing clinical variables, and left and right heart anatomy and function, to predict outcome in these patients. METHODS: Two-dimensional echocardiography, Doppler echocardiography and tissue Doppler imaging (TDI) were performed in 84 patients at a mean of 7.3 +/- 7.1 years after mitral valve surgery. The left ventricular ejection fraction (LVEF) was 50 +/- 15%, and 30% of patients were in NYHA class III/IV (congestive heart failure; CHF). Follow up was obtained for events that included repeat mitral or tricuspid valve surgery, and death. RESULTS: During a follow up period of 4.3 +/- 2.0 years, 28 patients suffered events, the univariate clinical predictors of which were NYHA class, calcium antagonist therapy, hyperlipidemia, and tobacco smoking. Left heart predictors included the mean mitral valve gradient (MMVG), left atrial volume index, and lateral wall TDI systolic velocity. Right heart predictors were atrial and right ventricular (RV) dimensions, RV systolic pressure, tricuspid regurgitation (TR) severity, RV free wall TDI E-velocity and E/e' ratio. Multivariate analysis showed that NYHA class (p = 0.02; RR 1.8 (1.1-2.9)), MMVG (p < 0.001; RR 1.16 (1.08-1.24)) and RV dimensions (p = 0.001; RR = 3.2 (1.7-6.2)) were independent predictors of events. A step-wise analysis of independent predictors showed that MMVG added an incremental value to NYHA class (p = 0.003), while RV size added additional value (p = 0.007) to the combination of NYHA class and MMVG. CONCLUSION: Echocardiographic assessments of the left and right heart can add significant prognostic value to the clinical assessment of patients after mitral valve surgery.

Memory dysfunction, psychomotor slowing, and decreased executive function predict mortality in patients with heart failure and low ejection fraction.

BACKGROUND: The purpose of this study was to evaluate whether dysfunction of specific cognitive abilities is a predictor of impending mortality in adults with systolic heart failure (HF). METHODS: A total of 166 stable outpatients with HF completed cognitive function evaluation in language, working memory, memory, visuospatial ability, psychomotor speed, and executive function using a neuropsychological test battery. Demographic and clinical variables, comorbidity, depressive symptoms, and health-related quality of life were also measured. Patients were followed for 12 months to determine all-cause mortality. RESULTS: There were 145 survivors and 21 deaths. In logistic regression analyses, significant predictors of mortality were lower left ventricular ejection fraction (LVEF) and poorer scores on measures of global congnitive function Mini-Mental State Examination [MMSE], working memory, memory, psychomotor speed, and executive function. Memory loss was the most predictive cognitive function variable (overall chi(2) = 17.97, df = 2, P < .001; Nagelkerke R(2) = 0.20). Gender was a significant covariate in 2 models, with men more likely to die. Age, comorbidity, depressive symptoms, and health-related quality of life were not significant predictors. In further analyses, significant predictors of mortality were lower systolic blood pressure and poorer global cognitive function, working memory, memory, psychomotor speed, and executive function, with memory being the most predictive. CONCLUSIONS: As hypothesized, lower LVEF and memory dysfunction predicted mortality. Poorer global cognitive score as determined by the MMSE, working memory, psychomotor speed, and executive function were also significant predictors. LVEF or systolic blood pressure had similar predictive values. Interventions are urgently needed to prevent and manage memory loss in HF.

Feasibility of using real time "Live 3D" echocardiography to visualize the stenotic aortic valve.

BACKGROUND: Aortic stenosis valve area (AS AVA) using the continuity equation (CE AVA) has limitations. Thus anatomic assessment of AS AVA would be useful. METHOD: AS AVA was measured using "live three-dimensional (3D)" echocardiography that is a two-dimensional (2D) display of a three-dimensionally acquired 2-3 cm thick pyramidal image. In 52 aortic stenosis patients with CE AVA measurements, attempts were made at measuring AS AVA using 2D echocardiography (2D AVA) and real time, Live 3D echocardiography (3D AVA). 3D AVA and 2D AVA were compared to each other and to CE AVA. RESULTS: 2D AVA could be obtained in 30 patients (58%) and 3D AVA in 50 patients (96%). Of the 30 patients in whom 3D AVA and 2D AVA were both measured, the correlation was 0.831 (P < 0.001). 3D AVA was smaller in 19 patients. In 17 of these patients, 3D AVA was closer to CE AVA. In two patients, 2D AVA was smaller than 3D AVA and in both patients 3D AVA was closer to CE AVA. The correlations between 2D AVA and CE AVA and 3D AVA and CE AVA were 0.581 and 0.673, respectively (all P < 0.001). CONCLUSION: A simplified 3D technique that is a "thick slice" 2D examination, can obtain AS AVA more often than a "thin slice" 2D echocardiogram. This 3D AVA correlates well with 2D AVA but is smaller and correlates better with CE AVA suggesting that the effective AS orifice is not planar but is more of a "tunnel" than a "flat ring."

Cognitive deficits in chronic heart failure.

BACKGROUND: Patients with heart failure (HF) have been found to have cognitive deficits, but it remains unclear whether these deficits are associated with HF or with aging or comorbid conditions common in HF. OBJECTIVES: : The purpose of this study was (a) to determine the types, the frequency, and the severity of cognitive deficits among patients with chronic HF compared with age- and education-matched healthy participants and participants with major medical conditions other than HF, and (b) to evaluate the relationships between HF severity, age, and comorbidities and cognitive deficits. METHODS: A sample of 414 participants completed the study (249 HF patients, 63 healthy and 102 medical participants). The HF patients completed measures of HF severity, comorbidity (multiple comorbidity, depressive symptoms), and neuropsychological functioning. Blood pressure and oxygen saturation were assessed at interview; clinical variables were abstracted from records. Participants in the comparison groups completed the same measures as the HF patients except those specific to HF. RESULTS: Compared with the healthy and medical participants, HF patients had poorer memory, psychomotor speed, and executive function. Significantly more HF patients (24%) had deficits in three or more domains. Higher (worse) HF severity was associated with more cognitive deficits; HF severity interacted with age to explain deficits in executive function. Surprisingly, men with HF had poorer memory, psychomotor speed, and visuospatial recall ability than women. Multiple comorbidity, hypertension, depressive symptoms, and medications were not associated with cognitive deficits in this sample. DISCUSSION: HF results in losses in memory, psychomotor speed, and executive function in almost one fourth of patients. Patients with more severe HF are at risk for cognitive deficits. Older patients with more severe HF may have more problems in executive function, and men with HF may be at increased risk for cognitive deficits. Studies are urgently needed to identify the mechanisms for the cognitive deficits in HF and to test innovative interventions to prevent cognitive loss and decline.