Value of CMR for the Differential Diagnosis of Cardiac Masses

ObjectivesThe goal of this study was to evaluate the diagnostic value of CMR features for the differential diagnosis of cardiac masses.BackgroundDifferentiation of cardiac tumors and thrombi and differentiation of benign from malignant cardiac neoplasms is often challenging but important in clinical practice. Studies assessing the value of cardiac magnetic resonance (CMR) in this regard are scarce.MethodsWe reviewed the CMR scans of patients with a definite cardiac thrombus or tumor. Mass characteristics on cine, T1-weighted turbo spin echo (T1w-TSE) and T2-weighted turbo spin echo (T2w-TSE), contrast first-pass perfusion (FPP), post-contrast inversion time (TI) scout, and late gadolinium enhancement (LGE) sequences were analyzed.ResultsThere were 84 thrombi, 17 benign tumors, and 25 malignant tumors in 116 patients. Morphologically, thrombi were smaller (median area 1.6 vs. 8.5 cm²; p < 0.0001), more homogeneous (99% vs. 46%; p < 0.0001), and less mobile (13% vs. 33%; p = 0.007) than tumors. Hyperintensity compared with normal myocardium on T2w-TSE, FPP, and LGE were more common in tumors than in thrombi (85% vs. 42%, 70% vs. 4%, and 71% vs. 5%, respectively; all p < 0.0001). A pattern of hyperintensity/isointensity (compared with normal myocardium) with short TI and hypointensity with long TI was very frequent in thrombi (94%), rare in tumors (2%), and had the highest accuracy (95%) for the differentiation of both entities. Regarding the characterization of neoplastic masses, malignant tumors were larger (median area 11.9 vs. 6.3 cm²; p = 0.006) and more frequently exhibited FPP (84% vs. 47%; p = 0.03) and LGE (92% vs. 41%; p = 0.001). The ability of CMR features to distinguish benign from malignant neoplasms was moderate, with LGE showing the highest accuracy (79%).ConclusionsCMR features demonstrated excellent accuracy for the differentiation of cardiac thrombi from tumors and can be helpful for the distinction of benign versus malignant neoplasms.     

Redefining Diastolic Dysfunction Grading: Combination of E/A ≤0.75 and Deceleration Time >140 ms and E/ε′ ≥10

ObjectivesThis study sought to examine left atrial (LA) mechanics and the prognostic impact of patients with echocardiographic findings of E/A ratio ≤0.75, deceleration time (DcT) of mitral E-wave >140 ms, but E/ε′ ≥10.BackgroundTraditional diastolic dysfunction (DD) grading system could not classify every patient into a specific group. We considered the group of patients with E/A ≤0.75, DcT >140 ms, but E/ε′ ≥10 (proposed new DD grade) as a new group in the DD grading system.MethodsA total of 1,362 consecutive patients were stratified according to the new DD grading system, and the LA volumes, strain, and strain rates were measured by 2-dimensional speckle-tracking analysis. All patients were followed up to determine cardiac death and major adverse cardiac events.ResultsAn E/A ≤0.75, DcT >140 ms, but E/ε′ ≥10 was observed in 227 patients (17%). LA volumes in patients with the new DD grade were between those of the impaired relaxation group and the pseudonormal group. LA strain of the new DD grade was similar to that of the pseudonormal group, whereas LA booster function was preserved as in the impaired relaxation group. During a mean follow-up of 3.0 ± 1.1 years, 25 patients had cardiac death and 61 had major adverse cardiac events. Event-free survival for major adverse cardiac events of the new DD grade was worse than that of the impaired relaxation group but similar to that of the pseudonormal group.ConclusionsThe new DD grade is frequently observed and has a prognosis similar to that of the pseudonormal group but significantly worse than that of the impaired relaxation group. However, LA booster function was maintained at the expense of LA volume enlargement. Thus, the new grade should be a distinct entity for routine DD grading.     

Echocardiographic assessment of right ventricular function in inferior wall myocardial infarction and angiographic correlation to proximal right coronary artery stenosis

BackgroundPresence of right ventricular (RV) infarction imposes a higher risk of adverse events in inferior wall myocardial infarction (IWMI). In this study, we attempted to correlate various indices of RV function assessed by echocardiography with presence of a proximal right coronary artery (RCA) stenosis in patients with first episode of acute IWMI.MethodsIn a prospective study, patients with first episode of acute IWMI underwent echocardiographic assessment within 24 h of symptom onset and indices of RV function viz. RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI) and tissue Doppler velocities from RV free wall were measured. Patients who underwent coronary angiogram (CAG) within one month and they were classified into group 1 and group 2 based on the presence or absence, respectively, of a significant proximal RCA stenosis.ResultsThere were 90 patients with first episode of IWMI of which 67 patients underwent CAG. There was significant difference between group 1 (n = 26) and group 2 (n = 41) in TAPSE (13.5 ± 1.3 vs 21.3 ± 1.7, p < 0.001), MPI by tissue Doppler (0.87 ± 0.1 vs 0.55 ± 0.2, p < 0.001) and in tissue Doppler systolic velocity from RV free wall (S′ 9.8 ± 1.1 vs 15.0 ± 1.5, p < 0.001). There was a good interobserver correlation for TAPSE, MPI by TDI, and S′ velocity. TAPSE ≤ 16 (sensitivity 93%, specificity 100%), MPI-TDI ≥ 0.69 (sensitivity 94.7%, specificity 93.5%), S ≤ 12.3 (sensitivity 90.3%, specificity 94.3%) were useful in predicting presence of proximal RCA stenosis.ConclusionRV function indices like TAPSE, MPI-TDI and S′ velocity are useful in predicting proximal RCA stenosis in first episode of acute IWMI.     

Clinical and Functional Outcomes Associated With Myocardial Injury After Transfemoral and Transapical Transcatheter Aortic Valve Replacement: A Subanalysis From the PARTNER Trial (Placement of Aortic Transcatheter Valves)

ObjectivesThis study sought to clarify the clinical and echocardiographic prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR).BackgroundThe clinical significance of cardiac biomarker elevation after TAVR remains unclear.MethodsPatients treated with TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) trial were divided into tertiles (T1, T2, T3) based on the difference between the values on post-procedure day 1 and the baseline values of 2 cardiac biomarkers: cardiac troponin I (ΔcTnI); and creatine kinase-myocardial band (ΔCK-MB) fraction. Patients were stratified according to their access route: transfemoral (TF) (n = 1,840) or transapical (TA) (n = 1,173).ResultsAt 30 days after TF-TAVR, patients in the highest tertile (T3) of cardiac biomarker elevation had a higher rate of all-cause mortality (ΔcTnI: T3: 5.4% vs. T1: 0.5%, p = 0.006; ΔCK-MB: T3: 5.7% vs. T1: 0.9%, p = 0.006) and cardiovascular mortality (ΔcTnI: T3: 4.9% vs. T1: 0.5%, p = 0.01; ΔCK-MB: T3: 3.9% vs. T1: 0.5%, p = 0.02). At 1 year, only patients in the highest CK-MB tertile had higher rates of all-cause (25.4% vs. 16.8%, p = 0.02) and cardiovascular (10.3% vs. 5.0%) mortality. Multivariable analysis demonstrated that greater release of cardiac biomarkers was independently associated with increased mortality in the TF population. After TA-TAVR, being in the highest tertile of cardiac biomarker elevation had no influence on clinical and echocardiographic outcomes at 30 days and 1 year.ConclusionsAfter TF-TAVR, a greater degree of myocardial injury was associated with higher rates of 30-day all-cause and cardiovascular mortality. At 1 year, being in the highest tertile of ΔCK-MB was correlated with a higher rate of all-cause and cardiac mortality. Finally, the level of myocardial injury after TA-TAVR had no impact on clinical and echocardiographic outcomes.     

Relationship between QRS characteristics and delayed-enhancement cardiac magnetic resonance in patients with ischemic cardiomyopathy

BackgroundWe explored the relationship between QRS characteristics and myocardial phenotype by delayed-enhancement cardiac magnetic resonance (DE-CMR) in patients with coronary heart disease (CHD).Methods and resultsEighty five consecutive patients with CHD that were referred for DE-CMR evaluation constituted the study population. Of a total of 1445 left ventricular (LV) segments evaluated, 346 (23.9%) segments had fibrosis.Compared to patients without pathological Q waves, patients with pathological Q waves showed a higher number of segments with fibrosis (5.9 ± 3.1 vs. 2.7 ± 2.8, p < 0.001), and lower left ventricular ejection fraction (LVEF) (42.9 ± 13.6% vs. 51.8 ± 18.3, p = 0.01); whereas no significant differences were observed regarding LV size.When discriminated in according to the QRS duration tertiles, no significant differences were observed regarding the number of segments with fibrosis (p = 0.34), whereas the highest QRS tertile was related to the presence of a low LVEF (p = 0.005) and larger LV size (p = 0.01). QRS fragmentation (fQRS), defined as the presence of an R′ or notching in the nadir of the R wave or the S wave, or the presence of >1 R′ in 2 contiguous leads, was significantly related to LV size (LV end diastolic volume 153.6 ± 81.6 ml, vs. 111.5 ± 41.4 ml, p = 0.003), function (LVEF 43.2 ± 15.9% vs. 53.6 ± 16.3%, p = 0.005), and extent of fibrosis (5.1 ± 3.4 segments vs. 3.2 ± 3.1 segments, p = 0.01).ConclusionsIn the present study, fQRS was the only QRS-derived variable systematically and more closely related to LV size, LV systolic function, and to the presence and extent of fibrosis.     

Post-operative nausea and vomiting in the cardiac surgery population: Who is at risk?

ObjectivesPost-operative nausea and vomiting (PONV) is a common and distressing complication following cardiac surgery. Therefore, our primary objective was to explore the predictors of severe PONV in the cardiac surgery population.MethodsA retrospective study was completed on cardiac surgery patients (N = 150). A modified preoperative PONV risk assessment tool was utilized to identify patients at high and low risk for PONV.Results54% of the high-risk group versus 13% of the low-risk group experienced ≥2 nausea events in the early post-operative period (p < 0.0001). The high-risk group had a uniquely elevated and sustained number of PONV events post-operatively. History of PONV (p = 0.03) and female gender (p = 0.01) emerged as significant predictors of any nausea event.ConclusionsA specific PONV risk assessment tool may be useful for predicting those at highest risk following cardiac surgery. Further research is required to identify strategies to reduce PONV.     

Heart rate variability parameters and ventricular arrhythmia correlate with pulmonary arterial pressure in adult patients with idiopathic pulmonary arterial hypertension

ObjectiveThis aim of this study was to correlate heart rate variability (HRV) parameters to pulmonary arterial pressure (PAP) in patients with purely idiopathic pulmonary arterial hypertension (IPAH).BackgroundHRV is decreased in patients with PAH. Whether HRV indices can be used to assess PAP in IPAH patients remains unclear.MethodsHRV parameters obtained by 24-h ECG were evaluated in 26 IPAH patients and 51 controls.ResultsTime-domain HRV parameters (SDNN, p < 0.0001; SDANN, p < 0.0001; RMSSD, p = 0.006) were lower in IPAH patients. Frequency-domain indices (high-frequency power, HFP, p = 0.001; low-frequency power, LFP, p = 0.003; total power, TP, p = 0.001) were also decreased in IPAH patients. In IPAH patients, RMSSD (p = 0.001), HFP (p = 0.015), and LFP (p = 0.027) were significantly correlated with PAP. IPAH patients had longer QTc intervals (p < 0.0001) and more premature ventricular contractions (p < 0.0001) than controls.ConclusionsIPAH is associated with autonomic dysfunction. RMSSD, HFP, and LFP may be used as a supplemental tool to assess PAP in IPAH patients. IPAH patients with autonomic dysfunction are at high risk for ventricular arrhythmia.     

Outcomes After Percutaneous Coronary Intervention With Stents in Patients Treated With Thoracic External Beam Radiation for Cancer

ObjectivesThe aim of this study was to assess outcomes after percutaneous coronary intervention (PCI) with stents in patients treated with thoracic external beam radiation therapy (EBRT).BackgroundThoracic EBRT for cancer is associated with long-term cardiotoxic sequelae. The impact of EBRT on patients requiring coronary stents is unclear.MethodsWe analyzed outcomes after PCI in cancer survivors treated with curative thoracic EBRT before and after stenting between 1998 and 2012. Reference groups were propensity-matched cohorts with stenting but no EBRT. Primary endpoint was target lesion revascularization (TLR), a clinical surrogate for restenosis. Secondary endpoints included myocardial infarction (MI) and cardiac and overall mortality.ResultsWe identified 115 patients treated with EBRT a median 3.6 years after stenting (group A) and 45 patients treated with EBRT a median 2.2 years before stenting (group B). Long-term mean TLR rates in group A (3.2 vs. 6.6%; hazard ratio: 0.6; 95% confidence interval: 0.2 to 1.6; p = 0.31) and group B (9.2 vs. 9.7%; hazard ratio: 1.2; 95% confidence interval: 0.4 to 3.4; p = 0.79) were similar to rates in corresponding control patients (group A: 1,390 control patients; group B: 439 control patients). Three years post-PCI, group A had higher overall mortality (48.6% vs. 13.9%; p < 0.001) but not MI (4.8% vs. 4.3%; p = 0.93) or cardiac mortality (2.3% vs. 3.6%; p = 0.66) rates versus control patients. There were no significant differences in MI, cardiac, or overall mortality rates in group B.ConclusionsThoracic EBRT is not associated with increased stent failure rates when used before or after PCI. A history of PCI should not preclude the use of curative thoracic EBRT in cancer patients or vice versa. Optimal treatment of cancer should be the goal.     

Myeloperoxidase levels predict accelerated progression of coronary atherosclerosis in diabetic patients: Insights from intravascular ultrasound

ObjectiveWhile inflammation has been proposed to contribute to the adverse cardiovascular outcome in diabetic patients, the specific pathways involved have not been elucidated. The leukocyte derived product, myeloperoxidase (MPO), has been implicated in all stages of atherosclerosis. The relationship between MPO and accelerated disease progression observed in diabetic patients has not been studied.MethodsWe investigated the relationship between MPO and disease progression in diabetic patients. 881 patients with angiographic coronary artery disease underwent serial evaluation of atherosclerotic burden with intravascular ultrasound. Disease progression in diabetic (n = 199) and non-diabetic (n = 682) patients, stratified by baseline MPO levels was investigated.ResultsMPO levels were similar in patients with and without diabetes (1362 vs. 1255 pmol/L, p = 0.43). No relationship was observed between increasing quartiles of MPO and either baseline (p = 0.81) or serial changes (p = 0.43) in levels of percent atheroma volume (PAV) in non-diabetic patients. In contrast, increasing MPO quartiles were associated with accelerated PAV progression in diabetic patients (p = 0.03). While optimal control of lipid and the use of high-dose statin were associated with less disease progression, a greater benefit was observed in diabetic patients with lower compared with higher MPO levels at baseline.ConclusionsIncreasing MPO levels are associated with greater progression of atherosclerosis in diabetic patients. This finding indicates the potential importance of MPO pathways in diabetic cardiovascular disease.     

Echocardiographic Evaluation of Hemodynamics in Patients With Systolic Heart Failure Supported by a Continuous-Flow LVAD

BackgroundHemodynamics assessment is important for detecting and treating post-implant residual heart failure, but its accuracy is unverified in patients with continuous-flow left ventricular assist devices (CF-LVADs).ObjectivesWe determined whether Doppler and 2-dimensional transthoracic echocardiography reliably assess hemodynamics in patients supported with CF-LVADs.MethodsSimultaneous echocardiography and right heart catheterization were prospectively performed in 50 consecutive patients supported by using the HeartMate II CF-LVAD at baseline pump speeds. The first 40 patients were assessed to determine the accuracy of Doppler and 2-dimensional echocardiography parameters to estimate hemodynamics and to derive a diagnostic algorithm for discrimination between mean pulmonary capillary wedge pressure ≤15 versus >15 mm Hg. Ten patients served as a validation cohort.ResultsDoppler echocardiographic and invasive measures of mean right atrial pressure (RAP) (r = 0.863; p < 0.0001), systolic pulmonary artery pressure (sPAP) (r = 0.880; p < 0.0001), right ventricular outflow tract stroke volume (r = 0.660; p < 0.0001), and pulmonary vascular resistance (r = 0.643; p = 0.001) correlated significantly. Several parameters, including mitral ratio of the early to late ventricular filling velocities >2, RAP >10 mm Hg, sPAP >40 mm Hg, left atrial volume index >33 ml/m², ratio of mitral inflow early diastolic filling peak velocity to early diastolic mitral annular velocity >14, and pulmonary vascular resistance >2.5 Wood units, accurately identified patients with pulmonary capillary wedge pressure >15 mm Hg (area under the curve: 0.73 to 0.98). An algorithm integrating mitral inflow velocities, RAP, sPAP, and left atrial volume index was 90% accurate in distinguishing normal from elevated left ventricular filling pressures.ConclusionsDoppler echocardiography accurately estimated intracardiac hemodynamics in these patients supported with CF-LVAD. Our algorithm reliably distinguished normal from elevated left ventricular filling pressures.     

Pre-Load Stress Echocardiography for Predicting the Prognosis in Mild Heart Failure

ObjectivesThis study sought to introduce and confirm the efficacy of pre-load stress echocardiography with leg-positive pressure (LPP) for improving risk stratification of patients with mild stable heart failure.BackgroundHeart failure patients with mild symptoms and a poor prognosis should be identified and treated aggressively to improve clinical outcome.MethodsWe performed transthoracic echocardiography with LPP in 202 patients with chronic cardiac disease. Twenty-two of these patients also underwent cardiac catheterization, and left ventricular pressure was measured during LPP along with simultaneous Doppler recordings. Patients were classified into 3 groups on the basis of their left ventricular (LV) diastolic dysfunction as assessed by transmitral flow velocity: restrictive or pseudonormal (PN) at rest, impaired relaxation (IR) at rest and during LPP (stable IR), and IR at rest and PN during LPP (unstable IR). Clinical outcome was compared among these groups.ResultsThe LPP increased LV end-diastolic pressure from 15.8 ± 4.7 mm Hg to 20.5 ± 5.0 mm Hg in the unstable IR group and from 10.5 ± 2.6 mm Hg to 14.7 ± 3.8 mm Hg in the stable IR group (both p < 0.001). During an average follow-up of 548 ± 407 days, 5 patients had cardiac death, 37 had acute heart failure, 4 had an acute myocardial infarction, and 7 had a stroke. The all-cause cardiac event rate in unstable IR was higher than in stable IR (p < 0.001), and was similar in the PN group (p = 0.81). Event-free survival was significantly lower in unstable IR than in stable IR (p = 0.003). In a Cox proportional hazards model, unstable IR was an independent predictor of all-cause cardiac events (hazard ratio: 8.0; p < 0.001).ConclusionsThe left LV end-diastolic pressure-volume relationship can be estimated by changes in transmitral flow velocity during LPP. Thus, pre-load stress echocardiography using LPP provides additional prognostic information in mild heart failure beyond that provided by conventional Doppler echocardiography at rest.     

Outcomes of Comatose Cardiac Arrest Survivors With and Without ST-Segment Elevation Myocardial Infarction: Importance of Coronary Angiography

ObjectivesThe aim of this study was to compare outcomes and coronary angiographic findings in post–cardiac arrest patients with and without ST-segment elevation myocardial infarction (STEMI).BackgroundThe 2013 STEMI guidelines recommend performing immediate angiography in resuscitated patients whose initial electrocardiogram shows STEMI. The optimal approach for those without STEMI post–cardiac arrest is less clear.MethodsA retrospective evaluation of a post–cardiac arrest registry was performed.ResultsThe database consisted of 746 comatose post–cardiac arrest patients including 198 with STEMI (26.5%) and 548 without STEMI (73.5%). Overall survival was greater in those with STEMI compared with those without (55.1% vs. 41.3%; p = 0.001), whereas in all patients who underwent immediate coronary angiography, survival was similar between those with and without STEMI (54.7% vs. 57.9%; p = 0.60). A culprit vessel was more frequently identified in those with STEMI, but also in one-third of patients without STEMI (80.2% vs. 33.2%; p = 0.001). The majority of culprit vessels were occluded (STEMI, 92.7%; no STEMI, 69.2%; p < 0.0001). An occluded culprit vessel was found in 74.3% of STEMI patients and in 22.9% of no STEMI patients. Among cardiac arrest survivors discharged from the hospital who had presented without STEMI, coronary angiography was associated with better functional outcome (93.3% vs. 78.7%; p < 0.003).ConclusionsEarly coronary angiography is associated with improved functional outcome among resuscitated patients with and without STEMI. Resuscitated patients with a presumed cardiac etiology appear to benefit from immediate coronary angiography.     

A Prospective,Single-Arm,Multicenter Trial of Ultrasound-Facilitated,Catheter-Directed,Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study

ObjectivesThis study conducted a prospective, single-arm, multicenter trial to evaluate the safety and efficacy of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis, using the EkoSonic Endovascular System (EKOS, Bothell, Washington).BackgroundSystemic fibrinolysis for acute pulmonary embolism (PE) reduces cardiovascular collapse but causes hemorrhagic stroke at a rate exceeding 2%.MethodsEligible patients had a proximal PE and a right ventricular (RV)-to-left ventricular (LV) diameter ratio ≥0.9 on chest computed tomography (CT). We included 150 patients with acute massive (n = 31) or submassive (n = 119) PE. We used 24 mg of tissue-plasminogen activator (t-PA) administered either as 1 mg/h for 24 h with a unilateral catheter or 1 mg/h/catheter for 12 h with bilateral catheters. The primary safety outcome was major bleeding within 72 h of procedure initiation. The primary efficacy outcome was the change in the chest CT–measured RV/LV diameter ratio within 48 h of procedure initiation.ResultsMean RV/LV diameter ratio decreased from baseline to 48 h post-procedure (1.55 vs. 1.13; mean difference, −0.42; p < 0.0001). Mean pulmonary artery systolic pressure (51.4 mm Hg vs. 36.9 mm Hg; p < 0.0001) and modified Miller Index score (22.5 vs. 15.8; p < 0.0001) also decreased post-procedure. One GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries)–defined severe bleed (groin hematoma with transient hypotension) and 16 GUSTO-defined moderate bleeding events occurred in 15 patients (10%). No patient experienced intracranial hemorrhage.ConclusionsUltrasound-facilitated, catheter-directed, low-dose fibrinolysis decreased RV dilation, reduced pulmonary hypertension, decreased anatomic thrombus burden, and minimized intracranial hemorrhage in patients with acute massive and submassive PE. (A Prospective, Single-arm, Multi-center Trial of EkoSonic® Endovascular System and Activase for Treatment of Acute Pulmonary Embolism (PE) [SEATTLE II]; NCT01513759)     

Manual Thrombus Aspiration Is Not Associated With Reduced Mortality in Patients Treated With Primary Percutaneous Coronary Intervention: An Observational Study of 10,929 Patients With ST-Segment Elevation Myocardial Infarction From the London Heart Attack Group

ObjectivesThis study aimed to assess the impact of thrombus aspiration on mortality in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI).BackgroundThe clinical effect of routine intracoronary thrombus aspiration before primary PCI in patients with ST-segment elevation myocardial infarction is uncertain.MethodsWe undertook an observational cohort study of 10,929 ST-segment elevation myocardial infarction patients from January 2005 to July 2011 at 8 centers across London, United Kingdom. Patients’ details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society PCI dataset. Primary outcome was all-cause mortality at a median follow-up of 3.0 years (interquartile range: 1.2 to 4.6 years).ResultsIn our cohort, 3,572 patients (32.7%) underwent thrombus aspiration during primary PCI. Patients who had thrombus aspiration were younger, had lower rates of previous myocardial infarction but were more likely to have poor left ventricular function. Procedural success rates were higher (90.9% vs. 89.2%; p = 0.005) and in-hospital major adverse cardiac event rates were lower (4.4% vs. 5.5%; p = 0.012) in patients undergoing thrombus aspiration. However, Kaplan-Meier analysis demonstrated no significant difference in mortality rates between patients with and without thrombus aspiration (14.8% aspiration vs. 15.3% PCI only; p = 0.737) during the follow-up period. After multivariate Cox analysis (hazard ratio [HR]: 0.89, 95% confidence interval [CI]: 0.65 to 1.23) and the addition of propensity matching (HR: 0.85 95% CI: 0.60 to 1.20) thrombus aspiration was still not associated with decreased mortality.ConclusionsIn this cohort of nearly 11,000 patients, routine thrombus aspiration was not associated with a reduction in long-term mortality in patients undergoing primary PCI, although procedural success and in-hospital major adverse cardiac event rates were improved.     

Electrocardiographic changes associated with insulin resistance

Background and aimCardiac steatosis has been related to increased risk of heart disease. We investigated the association between cardiac steatosis, electrocardiographic (ECG) abnormalities, and individual components of the metabolic syndrome (MetS).Methods and resultsA 12-lead ECG and laboratory data were examined in 31 men with the MetS and in 38 men without the MetS. Myocardial triglyceride (MTG) content was measured with 1.5 T magnetic resonance (MR) spectroscopy and epicardial and pericardial fat by MR imaging. MTG content, epicardial and pericardial fat depots were higher in men with the MetS compared with subjects without the MetS (p < 0.001). The heart rate was increased (p < 0.001), the PR interval was longer (p < 0.044), the frontal plane QRS axis shifted to the left (p < 0.001), and the QRS voltage (p < 0.001) was lower in subjects with the MetS. The frontal plane QRS axis and the QRS voltage were inversely correlated with MTG content, waist circumference (WC), body mass index (BMI), TGs, and fasting blood glucose. High-density lipoprotein cholesterol correlated positively and measures of insulin resistance negatively with the QRS voltage. MTG content and hypertriglyceridemia were determinants of the frontal plane QRS and WC and hyperglycemia were predictors of the QRS voltage.ConclusionThe MetS and cardiac steatosis appear to associate with multiple changes on 12-lead ECG. The frontal plane QRS axis is shifted to the left and the QRS voltage is lower in subjects with the MetS. Standard ECG criteria may underestimate the presence of left ventricular hypertrophy in obese subjects with cardiometabolic risk factors.     

Follow-up of asymptomatic pancreatic cysts in clinical practice: A vignette questionnaire

Background/ObjectivesIn absence of evidence-based guidelines of pancreatic cystic neoplasms (PCN), the management might vary among physicians. The aim of this survey was to assess the attitude of Dutch gastroenterologists (GE) towards the management of asymptomatic PCNs.MethodsAn anonymous online questionnaire was distributed to all practicing GE (n = 381) in The Netherlands, in which four vignette patients with PCN were presented.ResultsIn total 45% of GE responded. Most respondents would perform surveillance for a 10 mm PCN (78%) mainly with an interval of one year (57%). A shorter interval of three (26%) or six (57%) months was chosen for a 25 mm BD-IPMN. Ultrasound was recommended for surveillance by 19% for a 10 mm cyst. GE with EUS experience were more likely to apply EUS for surveillance of 10 mm cyst than those without (56% vs 28%; p < 0.001). The presence of a branch-duct intraductal mucinous neoplasm (BD-IPMN) with a mural nodule, dilated pancreatic duct (8 mm) or increased serum CA 19.9 (300 U/ml) were considered an indication for resection by respectively 88%, 68% and 51% of respondents.ConclusionDutch GE demonstrate substantial variability in the management of asymptomatic PCNs. A significant proportion of general GE still use ultrasound for surveillance of small PCNs, while GE with EUS experience were more likely to perform EUS. The presence of risk factors for malignant degeneration of IPMN were not recognized by a substantial proportion of GE. Data on the natural history of PCNs is required to provide input for evidence-based guidelines, which should lead to a more uniform approach.     

Thrombocytopenia is an independent predictor of mortality in pulmonary hypertension

BackgroundEstablished prognostic factors for pulmonary hypertension (PH) include brain natriuretic peptide, troponins and hemodynamic measures such as central venous pressure and cardiac output. The prognostic role of thrombocytopenia, however, has yet to be determined in patients with PH. The aim of this study was to evaluate effect of thrombocytopenia on mortality in patients with PH.Methods521 patients with severe PH, defined by a pulmonary artery systolic pressure >60 mm Hg on transthoracic echocardiography and a platelet count measured within one month after diagnosis were enrolled from three hospitals of Montefiore Medical Center. The cohort was divided into two groups: mild thrombocytopenia to a normal platelet count (platelet count 100,000–450,000 per uL); and moderate to severe thrombocytopenia (platelet count <100,000 per uL). Inpatient and social security death records were used to determine 1-year all-cause mortality.ResultsMean age was 70.3 ± 15.6 with 40% of patients being male. Overall mortality at 1 year was 30.7%, with increased mortality in PH patients with mild thrombocytopenia compared to those with moderate to severe thrombocytopenia (46.5% vs. 27.0%, p < 0.001). In multivariate analysis, moderate to severe thrombocytopenia remained an independent predictor of mortality (HR 1.798, 95% CI 1.240–2.607, p = 0.002).ConclusionsModerate to severe thrombocytopenia is an independent predictor of higher mortality in patients with severe PH. These findings may support the use of thrombocytopenia as a useful prognostic indicator in patients with severe PH.     

Changes in Left Atrial Appendage Dimensions Following Volume Loading During Percutaneous Left Atrial Appendage Closure

ObjectivesThis study sought to determine whether volume loading alters the left atrial appendage (LAA) dimensions in patients undergoing percutaneous LAA closure.BackgroundPercutaneous LAA closure is increasingly performed in patients with atrial fibrillation and contraindications to anticoagulation, to lower their stroke and systemic embolism risk. The safety and efficacy of LAA closure relies on accurate device sizing, which necessitates accurate measurement of LAA dimensions. LAA size may change with volume status, and because patients are fasting for these procedures, intraprocedural measurements may not be representative of true LAA size.MethodsThirty-one consecutive patients undergoing percutaneous LAA closure who received volume loading during the procedure were included in this study. After an overnight fast and induction of general anesthesia, patients had their LAA dimensions (orifice and depth) measured by transesophageal echocardiography before and after 500 to 1,000 ml of intravenous normal saline, aiming for a left atrial pressure >12 mm Hg.ResultsSuccessful implantation of LAA closure device was achieved in all patients. The average orifice size of the LAA at baseline was 20.5 mm at 90°, and 22.5 mm at 135°. Following volume loading, the average orifice size of the LAA increased to 22.5 mm at 90°, and 23.5 mm at 135°. The average increase in orifice was 1.9 mm (p < 0.0001). The depth of the LAA also increased by an average of 2.5 mm after volume loading (p < 0.0001).ConclusionsIntraprocedural volume loading with saline increased the LAA orifice and depth dimensions during LAA closure. Operators should consider optimizing the left atrial pressure with volume loading before final device sizing.     

Left ventricular diastolic performance at rest is essential for exercise capacity in patients with non-complicated myocardial infarction

IntroductionIn patients with recent myocardial infarction (MI) limited exercise capacity during physical activity is an important symptom and the base for future treatment. The myocardial injury after MI leads to both systolic and diastolic left ventricular (LV) dysfunction.ObjectiveThe aim of this study was to assess the relevance of systolic and diastolic LV function for cardiopulmonary exercise capacity in patients with prior MI.MethodsSixty-five consecutive patients after first MI without signs and symptoms of heart failure, aged 52 ± 6 years, were included in the study. The following echo parameters were evaluated: LV ejection fraction (LVEF), peak early and late diastolic velocities (E, A), deceleration time of E wave (dec t E), ratio of early trans-mitral to early annular diastolic velocities (E/e′), velocity propagation of early filling (Vp), and diameters and volumes of LV and left atrium (LA). CPET variables included: oxygen uptake at peak exercise (peak VO₂), oxygen pulse (VO₂ HR), VE/VCO₂ slope, circulatory power (CP) and recovery half time (T1/2).ResultsSignificant correlations were demonstrated between peak VO₂ and E/e’ (p < 0.001), peak VO₂ and dec t E (p < 0.001), VO₂ HR and E/e′ (p = 0.002) and between VE/VCO₂ and E/e′ (p < 0.001). Twenty patients with elevated LV filling pressure achieved significantly lower peak VO₂ (1624 vs. 1932 ml, p = 0.027) VO₂ HR (11.70 vs. 14.05, p = 0.011) and CP (287,073 vs. 361,719, p = 0.014). By using multivariate regression model we found that only E/e′ (p = 0.001) and dec t E (p = 0.008) significantly contributed to peak VO₂.ConclusionsDiastolic dysfunction, particularly LV filling pressure, determine exercise capacity, despite differences in LV ejection fraction in patients with prior MI.     

Improved survival of Korean patients with idiopathic pulmonary arterial hypertension after the introduction of targeted therapies

ObjectivesWe compared the survival of patients with idiopathic pulmonary arterial hypertension (IPAH), receiving conventional and targeted therapies.BackgroundIPAH is an incurable disease with high mortality. To manage IPAH, several targeted therapies have been used in Korea.MethodsWe performed a retrospective study of 71 patients diagnosed with IPAH in a tertiary hospital between January 1994 and February 2013. Patients were classified into “conventional therapy group” (treated with conventional therapies and/or beraprost) and “targeted therapy group” (treated with targeted therapies other than beraprost).ResultsThe median age of the patients was 33 years and 50 patients were female. The survival rate at 1, 3, 5, and 10 years was 80.1% 62.0%, 51.5%, and 26.8%, respectively. The survival rate in the targeted therapy group was greater than in the conventional therapy group (p-value = 0.026).ConclusionsWe believe targeted therapies would improve survival benefits in IPAH patients.