Early and mid‐term results with the growth stent—A possible concept for transcatheter treatment of aortic coarctation from infancy to adulthood by stent implantation?

Aims : Evaluation of the Growth Stent—a stent consisting of two stent halves connected by reabsorbable sutures—for the treatment of aortic coarctation in infants. Methods and Results : Surveillance study of 13 Growth Stents implanted in 12 patients aged 1–15 months (median 5 months). Body weight ranged from 3.4–12.8 kg (median 5.4 kg). Eight patients suffered from aortic (re‐)coarctation, four of them from stenosis of the aortic anastomosis after a Norwood I procedure. The follow‐up period was 24 months (11–51 months). Pressure gradients immediately after stent implantation decreased from 30 mm Hg (range 20–50 mm Hg) to 8 mm Hg (range 0–15 mm Hg). Five patients had one (3 pts) or two (2 pts) balloon dilations 3–28 months (median 12 months) after Growth Stent implantation. The median pressure gradient decreased from 25 mm Hg (range 15–30 mm Hg) to 15 mm Hg (range 5–25 mm Hg). Six patients received a large stent after 19–34 months. Median body weight was 11.8 kg (9.4–15 kg). Conclusions : The Growth Stent is suitable for the acute treatment of aortic coarctation in infants and can be overstented later on—if necessary—with a larger stent without causing restriction. © 2008 Wiley‐Liss, Inc.     

Complications of low‐dose,echo‐guided alcohol septal ablation

Background : Alcohol septal ablation (ASA) is a catheter‐based intervention that has been used as an alternative to surgical myectomy in highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods : This retrospective study was designed to evaluate the incidence of major complications in the mid‐term follow‐up of low‐dose (1–2.5 ml of ethanol), echo‐guided alcohol septal ablation. Results : A total of 101 consecutive patients (56 ± 15 years) with highly symptomatic HOCM were enrolled. At 6 months, there was a significant decrease in resting outflow gradient accompanied by reduction in basal septal diameter and improvement in symptoms (P < 0.01). Two patients (2%) experienced procedural ventricular tachycardias terminated by electrical cardioversion. A total of 87 patients (86%) underwent an uneventful postprocedural hospital stay. The postprocedural complete heart block occurred in 10 patients (10%), and subsequent permanent pacemaker was implanted in four cases (4%). Sustained ventricular arrhythmias requiring electrical cardioversion occurred in four patients (4%) within postprocedural hospital stay. Subsequently, ICD was not implanted in any of these cases. The patients were repeatedly examined by Holter ECG monitoring, and in the mid‐term follow‐up (6–50 months), they stayed asymptomatic and without any ventricular arrhythmias. Conclusion : This study demonstrates the same early incidence of complete heart block requiring permanent pacemaker implantation (4%) and sustained ventricular arrhythmias following low‐dose, echo‐guided ASA. © 2009 Wiley‐Liss, Inc.     

Noninvasive Estimation of Diastolic Pulmonary Artery Pressure by Doppler Analysis of Tricuspid Regurgitation Velocity in Pediatric Patients

Purpose. Diastolic pulmonary artery pressure (dPAP) is equal to right ventricular pressure at the time of pulmonary valve opening. We studied the accuracy of dPAP estimated from Doppler profile of tricuspid regurgitation (TR) jet in pediatric patients. Methods. Echocardiograms were prospectively performed on consecutive pediatric heart transplant recipients undergoing right‐heart catheterization and endomyocardial biopsy. An estimate of dPAP was obtained by superimposing the pulmonary valve opening time, indexed to the electrocardiogram, onto the TR Doppler tracing. Echocardiographic estimates of dPAP from end‐diastolic pulmonary regurgitation (PR) were obtained for comparison. Catheter‐derived right atrial pressure was added to the Doppler gradient in both groups. Doppler estimates and catheter‐derived measurements of dPAP were compared using Lin correlation and Bland–Altman analysis. Results. Sixty‐five catheterization studies were performed on 35 patients (20 males): median age at enrollment: 12.1 years (4 months to 18 years); median time: since transplant of 1.2 years (21 days to 16.1 years). Adequate TR signal was obtained in a significantly higher proportion of patients than an adequate PR signal (65% vs. 43%, respectively, P= .007). Median catheter‐derived dPAP was 12 mm Hg (6–30 mm Hg) and right atrial pressure was 6 mm Hg (1–17 mm Hg). Median estimated dPAP from TR was 15 mm Hg (range: 7–29 mm Hg), with the Lin correlation coefficient of 0.74 (95% confidence interval [CI]: 0.6–0.87). Median estimate for dPAP from PR was 10 mm Hg (range: 2–25 mm Hg), with the Lin correlation coefficient of 0.74 (95% CI: 0.58–0.9). There was excellent interobserver agreement for dPAP from TR with the Lin correlation coefficient of 0.946 (95% CI: 0.803–0.986). Conclusion. Doppler estimation of dPAP from TR is a novel, reliable, noninvasive method and compares favorably with estimation from PR. Adequate TR signal for estimation of dPAP can be obtained more frequently in children than adequate PR signal, thereby increasing the proportion of patients in whom dPAP can be estimated noninvasively.     

Long-term effects of varying alcohol dosing in percutaneous septal ablation for obstructive hypertrophic cardiomyopathy: a randomized study with a follow-up up to 11 years

Background

Highly symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM) are candidates for alcohol septal ablation (ASA). We wanted to determine long-term (> 60 months) clinical and echocardiographic outcomes of patients treated with low (1-2 mL) or high (> 2 mL) doses of alcohol.

Methods

Seventy-six patients were randomized into 2 arms in a 1:1 ratio, and subsequently were treated by ASA with a low (1-2 mL) or high (> 2 mL) dose of alcohol. Clinical and echocardiographic examinations were performed at baseline, 1 year after the procedure, and at the end of follow-up (at least 60 months after ASA).

Results

Both groups of patients matched in all baseline clinical and echocardiographic data. In a total of 76 patients, 86 septal branches were ablated in 80 ASA procedures (2 repeat procedures in each group). There were no differences in postprocedural complications. Seven patients (4 vs 3 patients; not significant) died during follow-up (60-138 months; median 85 months). Pressure gradients decreased significantly in both groups (from 74 ± 36 to 24 ± 32 mm Hg in the low-dose group and from 74 ± 39 mm Hg to 18 ± 20 mm Hg in the high-dose group). There were no significant differences between the groups, and all main hemodynamic and echocardiographic changes occurred in the first postprocedural year. At final examination, there were no patients with New York Heart Association class > 2 dyspnea in either group.

Conclusions

This study demonstrates that ASA for obstructive hypertrophic cardiomyopathy is safe and effective in long-term follow-up. No differences in long-term efficacy and safety were found between low and high doses of alcohol.     

Alcohol use disorders and the heart

Alcohol use is an important preventable and modifiable cause of non‐communicable disease, and has complex effects on the cardiovascular system that vary with dose. Observational and prospective studies have consistently shown a lower risk of cardiovascular and all‐cause mortality in people with low levels of alcohol consumption when compared to abstainers (the ‘J’‐shaped curve). Maximum potential benefit occurs at 0.5 to one standard drinks (7–14 g pure ethanol) per day for women (18% lower all‐cause mortality, 95% confidence interval (CI) = 13–22%) and one to two standard drinks (14–28 g ethanol) per day for men (17% lower all‐cause mortality, 95% CI = 15–19%). However, this evidence is contested, and overall the detrimental effects of alcohol far outweigh the beneficial effects, with the risk of premature mortality increasing steadily after an average consumption of 10 g ethanol/day. Blood pressure (BP) is increased by regular alcohol consumption in a dose‐dependent manner, with a relative risk for hypertension (systolic BP > 140 mm Hg or diastolic > 90 mm Hg) of 1.7 for 50 g ethanol/day and 2.5 at 100 g/day. Important reductions in BP readings can be expected after as little as 1 month of abstinence from alcohol. Heavy alcohol consumption in a binge pattern is associated with the development of acute cardiac arrhythmia, even in people with normal heart function. Atrial fibrillation is the most common arrhythmia associated with chronic high‐volume alcohol intake, and above 14 g alcohol/day the relative risk increases 10% for every extra standard drink (14 g ethanol). Ethanol and its metabolites have toxic effects on cardiac myocytes, and alcoholic cardiomyopathy (ACM) accounts for a third of all cases of non‐ischaemic dilated cardiomyopathy. Screening people drinking alcohol above low‐volume levels and delivering a brief intervention may prevent the development of cardiovascular complications. Although people with established cardiovascular disease show improved outcomes with a reduction to low‐volume alcohol consumption, there is no safe amount of alcohol to drink and patients with ACM should aim for abstinence in order to optimize medical treatment.     

Surgical septal myectomy outcome for obstructive hypertrophic cardiomyopathy after alcohol septal ablation

BackgroundAlthough surgical treatment of residual obstruction after alcohol septal ablation (ASA) is often challenging in patients with obstructive hypertrophic cardiomyopathy (OHCM) there are very few relevant clinical reports. Thus, outcomes of surgical septal myectomy (SSM) in this subgroup of patients remain to be determined. Therefore, this study aimed to determine the surgical and follow-up outcomes in patients with OHCM exhibiting residual obstruction after ASA.MethodsWe collected case data for 62 patients with OHCM and residual obstruction after ASA who underwent SSM at Fuwai Hospital between January 2002 and June 2019. Propensity score matching with patients having had a myectomy as the only invasive procedure—was conducted in a 1:2 ratio. Echocardiography parameters, surgery results, and follow-up outcomes were compared between the groups.ResultsThe prior ASA group had a higher incidence of complete atrioventricular block (AVB) and subsequently postoperative permanent pacemaker (PPM) implantation than the primary myectomy group (9.7% vs. 1.6%, P=0.01). Two patients died within 30 days after surgery in the prior ASA group, and one patient died in the primary myectomy group, with an operative mortality rate of 3.2% and 0.8%, respectively (P=0.2). The 5-year event-free survival rate was 86.0% in the prior ASA group (median follow-up period: 3.2 years; mean: 3.9±2.6 years; maximum, 10.6 years) and 88.5% in the primary myectomy group (median follow-up period: 2.4 years; mean 2.8±1.7 years; maximum, 9.1 years) (P=0.2). During follow-up, four of 62 (6.5%) patients in the prior ASA group and one of 124 (0.8%) patients in the primary myectomy group progressed to advanced heart failure (P=0.025).ConclusionsPatients with OHCM following ASA are at an increased risk of developing AVB after SSM. Their surgical outcomes, and long-term survival rate were satisfactory and, osimilar to those for patients having had a myectomy as the only invasive procedure. In addition, they had an increased risk of advanced heart failure after SSM in the present study.     

Effectiveness of Alcohol Septal Ablation Versus Transaortic Extended Myectomy in Hypertrophic Cardiomyopathy with Midventricular Obstruction

Objectives

Investigate the effectiveness of alcohol septal ablation (ASA) and transaortic extended myectomy (TEM) in hypertrophic cardiomyopathy (HCM) with midventricular obstruction (MVO).

Background

MVO is less common than subaortic obstruction. Data on the effectiveness of ASA and TEM in MVO are lacking.

Methods

The clinical profiles of 22 patients undergoing ASA and 37 patients undergoing TEM were compared. No patient had apical aneurysm, abnormal chordae, mitral valve replacement or repair.

Results

Baseline midventricular pressure gradient and symptoms were comparable between the ASA and TEM groups. During follow‐up, both groups demonstrated substantial reduction in pressure gradient (the ASA group: 79.7 ± 21.2 mm Hg to 43.7 ± 28.9 mm Hg, P < 0.001; the TEM group: 69.0 ± 23.9 mm Hg to 15.0 ± 16.9 mm Hg, P < 0.001). The reduction in pressure gradient was greater (78.9 ± 18.6% vs. 46.4 ± 33.4%, P < 0.001) and the residual pressure gradient was lower after TEM versus ASA (P < 0.001). Patients with New York Heart Association class III/IV dyspnea decreased from 59.1 to 18.2% (P = 0.022) in the ASA group and from 56.8 to 5.6% (P < 0.001) in the TEM group. Patients with Canadian Cardiovascular Society class III/IV angina decreased from 40.9 to 9.1% (P = 0.016) in the ASA group and from 32.4 to 0% (P < 0.001) in the TEM group.

Conclusions

While ASA and TEM both improve gradients and symptoms, TEM may provide a more reliable reduction in gradients compared to ASA.

     

Prevalence of uncontrolled hypertension in patients with Fabry disease

BACKGROUND: Fabry disease is a rare X-linked disease arising from deficiency of alpha-galactosidase A. It results in early death related to renal, cardiac, and cerebrovascular disease, which are also important outcomes in patients with elevated blood pressure (BP). The prevalence of uncontrolled hypertension, as well as the effect of enzyme replacement therapy on BP, in patients with Fabry disease is unknown. METHODS: We examined uncontrolled hypertension (systolic BP [SBP] >or=130 mm Hg or diastolic BP [DBP] >or=80 mm Hg) among 391 patients with Fabry disease who were participating in the Fabry Outcome Survey (FOS). RESULTS: Uncontrolled hypertension was present in 57% of men and 47% of women. In patients with chronic kidney disease (CKD) stage 1 (n100), median SBP was 120 mm Hg and median DBP was 74 mm Hg. In patients with CKD stage 2 (n172), median SBP was 125 mm Hg and median DBP was 75 mm Hg. In patients with CKD stage 3 (n63), median SBP was 130 mm Hg and median DBP was 75 mm Hg. There was a significant decrease in both SBP and DBP during a 2-year course of enzyme replacement therapy. CONCLUSIONS: This study revealed a high prevalence of uncontrolled hypertension among patients with Fabry disease. Thus there is a need to improve BP control and renoprotection in patients with Fabry disease.     

Individual variability in response to renin angiotensin aldosterone system inhibition predicts cardiovascular outcome in patients with type 2 diabetes: A primary care cohort study

Aims

To assess variability in systolic blood pressure (SBP) and albuminuria (urinary albumin creatinine ratio [UACR]) responses in patients with type 2 diabetes mellitus initiating renin angiotensin aldosterone system (RAAS) inhibition, and to assess the association of response variability with cardiovascular outcomes.

Material and Methods

We performed an observational cohort study in patients with type 2 diabetes who started RAAS inhibition between 2007 and 2013 (n = 1600). Patients were identified from general practices in the Netherlands. Individual response in SBP and UACR was assessed during 15 months’ follow‐up. Patients were categorized as: good responders (?SBP <0 mm Hg and ?UACR <0%); intermediate responders (?SBP <0 mm Hg and ?UACR >0% or ?SBP >0 mm Hg and ?UACR <0%); or poor responders (?SBP >0 mm Hg and ?UACR >0%). Multivariable Cox regression was performed to test the association between initial RAAS inhibition response and subsequent cardiovascular outcomes.

Results

After starting RAAS inhibition, the mean SBP change was ?13.2 mm Hg and the median UACR was ?36.6%, with large between‐individual variability, both in SBP [5th to 95th percentile: 48.5‐20] and UACR [5th to 95th percentile: ?87.6 to 171.4]. In all, 812 patients (51%) were good responders, 353 (22%) had a good SBP but poor UACR response, 268 (17%) had a good UACR but poor SBP response, and 167 patients (10%) were poor responders. Good responders had a lower risk of cardiovascular events than poor responders (hazard ratio 0.51, 95% confidence interval 0.30‐0.86; P = .012).

Conclusions

SBP and UACR response after RAAS inhibition initiation varied between and within individual patients with type 2 diabetes treated in primary care. Poor responders had the highest risk of cardiovascular events, therefore, more efforts are needed to develop personalized treatment plans for these patients.     

Alcohol Abstinence Improves Prognosis Across All Stages of Portal Hypertension in Alcohol-Related Cirrhosis

Background and AimsAlcohol-related liver disease is a leading cause of liver-related mortality. The effect of alcohol abstinence on the natural history of alcohol-related cirrhosis across distinct stages of portal hypertension has not been thoroughly investigated. In this study, we assessed the clinical implications of abstinence in patients with alcohol-related cirrhosis and clinically significant portal hypertension.MethodsAlcohol abstinence, hepatic decompensation, and mortality were assessed in patients with alcohol-related cirrhosis who underwent a baseline hepatic venous pressure gradient (HVPG) measurement and were diagnosed with clinically significant portal hypertension (HVPG ≥10 mm Hg).ResultsA total of 320 patients with alcohol-related cirrhosis (median age: 57 [interquartile range (IQR), 49.7-63.1] years; 75.6% male; 87.5% decompensated) and a median HVPG of 20 (IQR, 17-23) mm Hg were followed up for a median of 36 (IQR, 14-80) months. Overall, 241 (75.3%) patients remained abstinent, while 79 (24.7%) patients had active alcohol consumption. Alcohol abstinence was linked to a significantly reduced risk of hepatic decompensation (adjusted hazard ratio [aHR], 0.391; P < .001), as well as liver-related (aHR, 0.428; P < .001) and all-cause (aHR, 0.453; P < .001) mortality, after adjusting for baseline HVPG, MELD, and previous decompensation. Importantly, alcohol abstinence significantly reduced the cumulative incidence of hepatic decompensation in both groups with HVPG 10–19 mm Hg (P < .001) and HVPG ≥20 mm Hg (P = .002). The 3-year decompensation probability was 32.4% vs 60.0% in HVPG 10–19 mm Hg and 57.5% vs 82.6% in HVPG ≥20 mm Hg for abstinent patients vs active drinkers, respectively.ConclusionsAlcohol abstinence improves prognosis across all stages of portal hypertension in alcohol-related cirrhosis, including in patients who have already progressed to high-risk portal hypertension. (ClinicalTrials.gov, Number: NCT03267615).     

Esophageal pneumatic dilation for postfundoplication dysphagia: safety,efficacy, and predictors of outcome

OBJECTIVE: Persistent dysphagia occurs in 5-10% of patients after fundoplication. The cause is obscure in most cases, and the management has not been well established. The aim of this study is to evaluate the clinical outcomes and the predictors of success for esophageal pneumatic dilations in patients with dysphagia after fundoplication. METHODS: We retrospectively reviewed 14 patients who underwent pneumatic dilation for persistent postfundoplication dysphagia. All patients had esophageal manometry before dilations. RESULTS: There were nine responders to pneumatic dilations (30-40-mm balloons). The nadir lower esophageal sphincter (LES) relaxation pressure was the only significant predictor for successful dilation and was higher among the responders than nonresponders (median 10 mm Hg vs 5 mm Hg). All six of 14 patients with nadir LES pressure > or = 10 mm Hg had a good response. There was no significant difference in the LES basal pressure between the responders and nonresponders (median 20 mm Hg vs 12 mm Hg). The median distal peristaltic amplitude (74 mm Hg vs 69 mm Hg), percent of failed peristalsis (8% vs 45%), and ramp pressure (19 mm Hg vs 17 mm Hg) did not differ significantly between the responders and nonresponders. No perforations occurred. CONCLUSIONS: Pneumatic dilation is a reasonably safe and effective treatment for patients with postfundoplication dysphagia. Raised nadir LES relaxation pressure seems to be a useful predictor of successful outcome.     

Innovative resource utilization to fashion individualized covered stents in the setting of aortic coarctation

Objectives: We describe our experience with self‐fabricated covered stents in the setting of coarctation of the aorta (CoA). Background: Balloon‐expandable covered stents are increasingly being utilized to treat CoA in older children and adults. These stents however, are not available in the United States limiting the interventionalist's ability to treat this condition safely and effectively. Methods: Retrospective analysis and follow‐up data review of our complete experience with self‐fabricated covered stents for CoA. Stents were fashioned by suturing an appropriate length of tubular polytetraflouroethylene to a bare metal stent and deploying this stent across the coarctation in a standardized fashion. Results: Over a 9‐year period we implanted 53 balloon‐expandable stents in 49 patients with CoA. Of these 13 were self‐fabricated covered stents deployed in 13 patients (7 male). Median age at implantation was 25.4 years (range, 8.7–49.5 years) with median weight of 65.5 kg (range, 28–168 kg). Indications for stent placement were native coarctation/aortic atresia (n = 9), aneurysm formation (n = 3), and re‐coarctation (n = 1). The median systolic pressure gradient across the coarctation of 33 mm Hg (range, 12–69 mm Hg) was reduced to 3 mm Hg (range, 0–19 mm Hg) post procedure (P < 0.001). There were no deaths on median follow‐up of 44 months (range, 1–83 months). One patient developed acute contained extravasation at implantation, treated with a self‐expanding stent graft. Another patient required thrombectomy for femoral arterial thrombosis. Conclusions: Innovative application of available materials adds to the armamentarium of the interventionalist. Our self‐fabricated covered stent provides effective gradient reduction with no compromise in stent delivery or durability on follow‐up. © 2011 Wiley‐Liss, Inc.     

Self‐expanding and balloon expandable covered stents in the treatment of aortic coarctation with or without aneurysm formation

Objectives: We describe our complete experience with covered stent implantation for aortic coarctation including short‐ to medium‐term outcomes. Background: Coarctation of the aorta is a heterogeneous disease process with multiple associated complications both with and without treatment. Covered stents have evolved to provide greater support to the aortic wall and a varied approach with choice of stent tailored to the anatomy of the patient is required. Methods: We retrospectively analyzed consecutive patient data from two congenital heart centers from March 2003 to October 2007. Results: We implanted 38 covered stents in 37 patients (20 female) of which three were self‐expanding stents. Median age was 29.6 years (9–65) with median weight of 71.5 kg (35–95). The indications for stent placement were native coarctation (n = 13); recurrent coarctation following surgical treatment (n = 11); aneurysm associated with previous coarctation surgery (n = 7); aorto‐bronchial fistula leading to acute hemoptysis (n = 2); stent fracture (n = 1); associated arterial duct (n = 2). One patient had a combination of acquired coarctation and false aneurysm. The median screening time was 10 min (3–22). The median systolic gradient of 26 mm Hg (10–60) was reduced to 4 mm Hg (0–20) postprocedure (P < 0.001). There were no deaths on median follow up of 11.5 months (1–56). One patient developed aortic rupture during the procedure and required emergency surgery. Conclusion: Covered stent implantation for treatment of aortic coarctation is safe and highly effective in selected patients. Self‐expanding stent grafts may be preferable to balloon expandable stents when there is aneurysm formation in the setting of aortopathy. © 2008 Wiley‐Liss, Inc.     

Short‐Term and Long‐Term Reproducibility of Hypertension Phenotypes Obtained by Office and Ambulatory Blood Pressure Measurements

The authors aimed to assess the reproducibility of normotension and white‐coat, masked, and sustained hypertension in 839 untreated patients who underwent two separate assessments (median, 3; interquartile range, 0–13 months) by both office and ambulatory blood pressure (BP) monitoring (ABPM). The proportion of patients falling into the same category in the two assessments was: 52% normotension and 55% white‐coat, 47% masked, and 82% sustained hypertension. The most frequent switch was to sustained hypertension (26% of white‐coat and 33% of masked hypertension). No clinical factors predicted the change in category, except for higher office diastolic BP in patients with masked hypertension who developed sustained hypertension, compared with those who remained with masked hypertension (84±4 mm Hg vs 80±5 mm Hg; P=.006). The reproducibility of hypertension phenotypes was highly dependent on the time between assessments. The authors conclude that white‐coat and masked hypertension phenotypes are only reproducible in the short‐term, while they frequently shift towards sustained hypertension in the long‐term.     

Relationship Between Inter‐Arm Difference in Systolic Blood Pressure and Arterial Stiffness in Community‐Dwelling Older Adults

A significant inter‐arm difference in systolic blood pressure (IADSBP) has recently been associated with worse cardiovascular outcomes. The authors hypothesized that part of this association is mediated by arterial stiffness, and examined the relationship between significant IADSBP and carotid‐femoral pulse wave velocity (CF‐PWV) in a sample from the Baltimore Longitudinal Study of Aging. Of 1045 participants, 50 (4.8%) had an IADSBP ≥10 mm Hg at baseline, and 629 had completed data from ≥2 visits (for a total of 1704 visits during 8 years). CF‐PWV was significantly higher in patients with an IADSBP ≥10 mm Hg (7.3±1.9 vs 8.2±2, P=.002). Compared with others, patients with IADSBP ≥10 mm Hg also had higher body mass index, waist circumference, and triglycerides; higher prevalence of diabetes; and lower high‐density lipoprotein (HDL) cholesterol (P<.001 for all). A significant association with IADSBP ≥10 mm Hg was observed for CF‐PWV in both cross‐sectional (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.06–1.87; P=.01) and longitudinal (OR, 1.15; 95% CI, 1.03–1.29; P=.01) multivariate analyses. Female sex, Caucasian race, high body mass index (plus diabetes and low HDL cholesterol only cross‐sectionally) were other independent correlates of IADSBP ≥10 mm Hg. Significant IADSBP is associated with increased arterial stiffness in community‐dwelling older adults.     

Right ventricular systolic pressure assessed by echocardiography: a predictive factor of mortality in patients with scleroderma

Background:

Pulmonary arterial hypertension (PAH) is a well‐known complication of systemic sclerosis (SSc). Doppler echocardiographic screening for the detection of PAH (by measuring right ventricular systolic pressure [RVSP]) is therefore recommended for all patients with SSc. However, the validity of RVSP as a predictor of mortality in patients with SSc is not well established.

Hypothesis:

Doppler‐determined PAH identifies a high‐risk subset of patients with SSc with decreased survival.

Methods:

We performed echocardiography in 155 consecutive patients with SSc between May 2005 and July 2006 and tested the value of an RVSP level of ≥36 mm Hg to predict mortality. Cox proportional hazards model was used to examine the individual relationship between each variable and the mortality rate.

Results:

Tricuspid regurgitant jets for RVSP determination were quantified in 129 patients (82.6%), of which 47 (36.4%) had RVSP ≥36 mm Hg. The median follow‐up time was 34 months. The 1‐, 2‐, and 3‐year survival rates were significantly lower among SSc patients with RVSP ≥36 vs ≤36 mm Hg (82%, 78%, and 67% vs 98%, 90%, and 86%, respectively, P < 0.01 by Wilcoxon test). In a multivariate analysis including echocardiographic and clinical variables, only an RVSP ≥36 mm Hg and a New York Heart Association III/IV class were associated with increased mortality; the respective Cox hazard ratios were 2.22 (95% confidence interval [CI]: 1.01–4.89, P = 0.048) and 4.77 (95% CI: 2.09–10.90, P = 0.000).

Conclusions:

Our results indicate that Doppler RVSP identifies a high‐risk subset and supports the use of Doppler RVSP as a screening test in patients with SSc who may warrant early treatment of their PAH. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Premere occlusion system for transcatheter patent foramen ovale closure: Mid‐term results of a single‐center registry

Background: Transcatheter closure of patent foramen ovale (PFO) with rigid devices may be problematic in patients with long channel PFO: alternative devices with asymmetrical opening and more physiological positioning may be preferable in such cases. We present the mid‐term results of transcatheter closure of PFO with Premere Occlusion System, a device studied for this specific anatomy, in a single‐center registry of adults with previous cerebral ischemia. Methods: During a 53‐months period (July 1, 2005 to December 1, 2009) 70 patients (48 females and 22 males, mean age 38 ± 6.7 years) with previous stroke were admitted in our center for transcatheter closure of PFO with Premere Occlusion System on the basis of absence of moderate or severe atrial septal aneurysm (ASA) on Transesophageal echocardiography and intracardiac echocardiography (< 3RL or 3LR ASA and length of PFO channel >10 mm). Results: The procedure was successful in all of the patients with no peri‐operative and in‐hospital complications. Forty‐six 20 mm and twenty‐four 25 mm Premere devices were implanted. Rates of procedural success, predischarge occlusion, and complication were: 100%, 95.7% and 0%, respectively. On mean follow‐up of 40 ± 10.9 months (range 6–54), the follow‐up occlusion rate was 98.5%. During follow‐up, no cases of permanent atrial fibrillation, aortic/atrial erosion, device thrombosis, or atrioventricular valve inferences were noted. Conclusion: The mid‐term outcomes of our registry suggests that the Premere Occlusion System may be an excellent device for patients with long‐channel PFO and absence of moderate/severe ASA, offering a physiological and anatomically respective closure of PFO also in patients with hypertrophic rims. © 2010 Wiley‐Liss, Inc.     

Redilation of e‐PTFE covered CP stents

Objectives: To evaluate the possibility to redilate covered Cheatham‐Platinum stents during follow‐up, in particular in growing children with aortic coarctation. Background: There are no data in the literature about the redilation of ePTFE covered CP stents. Methods: Sixty covered CP stents were implanted in patients with aortic coarctation or recoarctation between January 2004 and October 2007. Seven patients (mean age 14.2 ± 3.7 years) needed to repeat the hemodynamic study due to somatic growth and increase of aortic gradient with the occurrence of systemic hypertension. Two had near‐atretic aortic coarctation, three had postsurgical recoarctation and aneurysm formation, one had native aortic coarctation associated with aneurysm of the arterial wall, and one had severe native aortic coarctation. Results: Procedures were performed a mean of 20 ± 5 months (range, 12–24 months) after the primary stent implantation. Fluoroscopy time ranged between 7 and 15 min (median, 10 min) whereas procedure time ranged between 60 and 75 min (median, 65 min). After redilation the gradient across the stenosis decreased from a median value of 35 mm Hg to a median value of 5 mm Hg. The stent diameter increased of 20–50% the predilation value. No complications occurred and angiographic controls showed that the stenoses have been relieved. Follow‐up: During a median follow‐up of 12 months (6–30 months) the results were stable without complications. Conclusion: Covered Cheatham‐Platinum stents can be easily redilated © 2008 Wiley‐Liss, Inc.     

Outcomes of Patients With Hypertrophic Obstructive Cardiomyopathy and Pacemaker Implanted After Alcohol Septal Ablation

BackgroundAtrioventricular block is a frequent major complication after alcohol septal ablation (ASA).ObjectivesThe aim of this study was to evaluate the outcomes of patients with implanted permanent pacemaker (PPM) related to a high-grade atrioventricular block after ASA for hypertrophic obstructive cardiomyopathy.MethodsWe used a multinational registry (the Euro-ASA registry) to evaluate the outcome of patients with PPM after ASA.ResultsA total of 1,814 patients were enrolled and followed up for 5.0 ± 4.3 years (median = 4.0 years). A total of 170 (9.4%) patients underwent PPM implantation during the first 30 days after ASA. Using propensity score matching, 139 pairs (n = 278) constituted the matched PPM and non-PPM groups. Between the matched groups, there were no long-term differences in New York Heart Association functional class (1.5 ± 0.7 vs 1.5 ± 0.9, P = 0.99) and survival (log-rank P = 0.47). Patients in the matched PPM group had lower long-term left ventricular (LV) outflow gradient (12 ± 12 mm Hg vs 17 ± 19 mm Hg, P < 0.01), more pronounced LV outflow gradient decrease (81% ± 17% vs 72% ± 35%, P < 0.01), and lower LV ejection fraction (64% ± 8% vs 66% ± 8%, P = 0.02) and were less likely to undergo reintervention (re-ASA or myectomy) (log-rank P = 0.02).ConclusionsPatients with hypertrophic obstructive cardiomyopathy treated with ASA have a 9% probability of PPM implantation within 30 days after ASA. In long-term follow-up, patients with PPM had similar long-term survival and New York Heart Association functional class but lower LV outflow gradient, a more pronounced LV outflow gradient decrease, a lower LV ejection fraction, and a lower likelihood of reintervention compared with patients without PPM.     

Prognostic impact of baseline low blood pressure in hypertensive patients with stable coronary artery disease of daily clinical practice

J Clin Hypertens (Greenwich). 2012;00:00–00 ©2012 Wiley Periodicals, Inc. The authors’ aim was to investigate the prognostic value of first‐visit systolic and diastolic blood pressure (SBP/DBP) in hypertensive patients with stable coronary artery disease (sCAD) in conditions of contemporary daily clinical practice. From February 1, 2000, to January 31, 2004, 690 consecutive hypertensive patients with sCAD (mean age 68±10 years, 65% male) were prospectively followed in the outpatient cardiology clinic for major events (acute coronary syndrome, revascularization, stroke, heart failure, or death) and associations with baseline SBP/DBP were investigated. At first visit, median SBP/SDP were 130/75 mm Hg (interquartile range, 25–75; 120–140/70–80 mm Hg). After 25 months of follow‐up (median), 19 patients died (2.8%); 10 from cardiovascular causes (1.5%), 87 patients experienced a coronary event (13%), and 130 patients (19%) a major event. After adjusting for baseline variables, DBP <75 mm Hg or SBP <130 mm Hg resulted in independent predictors of major events (hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.07–2.16, P=.02; HR, 1.68; 95% CI, 1.18–2.40, P=.004, respectively), coronary events (HR, 1.78; 95% CI, 1.15–2.75, P=.009; HR, 1.84; 95% CI, 1.20–2.83, P=.005, respectively), and cardiovascular mortality (HR, 7.02; 95% CI, 1.26–39.04, P=.03; HR, 9.26; 95% CI, 1.33–64.32, P=.02, respectively). In this study, a low first‐visit SBP or DBP was associated with an adverse prognosis in hypertensive patients with sCAD of contemporary daily clinical practice.