The heart failure (HF) syndrome is heterogeneous. While it can be defined by ejection fraction (E... more The heart failure (HF) syndrome is heterogeneous. While it can be defined by ejection fraction (EF) and diastolic function, data on the characteristics of HF in the community are scarce, as most studies are retrospective, hospital-based, and rely on clinically indicated tests. Further, diastolic function is seldom systematically assessed based on standardized techniques. To prospectively measure EF, diastolic function, and brain natriuretic peptide (BNP) in community residents with HF. Echocardiographic measures of EF and diastolic function, measurement of blood levels of BNP, and 6-month mortality. Olmsted County residents with incident or prevalent HF (inpatients or outpatients) between September 10, 2003, and October 27, 2005, were prospectively recruited to undergo assessment of EF and diastolic function by echocardiography and measurement of BNP. A total of 556 study participants underwent echocardiography at HF diagnosis. Preserved EF (> or =50%) was present in 308 (55%) and was associated with older age, female sex, and no history of myocardial infarction (all P<.001). Isolated diastolic dysfunction (diastolic dysfunction with preserved EF) was present in 242 (44%) patients. For patients with reduced EF, moderate or severe diastolic dysfunction was more common than when EF was preserved (odds ratio, 1.67; 95% confidence interval [CI], 1.11-2.51; P = .01). Both low EF and diastolic dysfunction were independently related to higher levels of BNP. At 6 months, mortality was 16% for both preserved and reduced EF (age- and sex-adjusted hazard ratio, 0.85; 95% CI, 0.61-1.19; P = .33 for preserved vs reduced EF). In the community, more than half of patients with HF have preserved EF, and isolated diastolic dysfunction is present in more than 40% of cases. Ejection fraction and diastolic dysfunction are independently related to higher levels of BNP. Heart failure with preserved EF is associated with a high mortality rate, comparable to that of patients with reduced EF.
PURPOSE Bicuspid aortic valve (BAV) is a common congenital abnormality. The diagnosis is usually ... more PURPOSE Bicuspid aortic valve (BAV) is a common congenital abnormality. The diagnosis is usually made by echocardiography. The ability of cardiac MRI to accurately identify BAV or a comparison with echocardiography has not been reported. METHOD AND MATERIALS A series of 53 patients with a diagnosis of BAV (n=43) or possible BAV (n=9) after transthoracic echocardiography (TTE) or a trileaflet aortic valve on TTE that was later categorized as BAV by TEE (n=1), as well as 20 control patients with a trileaflet valve subsequently underwent MRI with accurate positioning of the imaging plane perpendicular to the valve leaflets to evaluate valve morphology. Both steady-state free precession (SSFP) and cine-phase contrast images were obtained. RESULTS Cardiac MRI identified the presence of BAV in all 43 patients with a similar diagnosis by TTE. Of these, 24 patients underwent surgery or TEE which confirmed BAV. In the 9 patients with possible BAV by TTE, MRI identified 5 with BAV and 4 with ...
European heart journal cardiovascular Imaging, Jan 20, 2015
Reduced stroke volume index (SVI) in patients with severe aortic stenosis (AS) and preserved ejec... more Reduced stroke volume index (SVI) in patients with severe aortic stenosis (AS) and preserved ejection fraction (EF) is associated with adverse outcomes even after aortic valve replacement (AVR), although specific reasons for impaired survival in this group are unknown. We investigated predictors of post-AVR survival and specific cause of death in patients with AS according to SVI. Among 1120 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and preserved EF (≥50%) using 2-D and Doppler echocardiography who had AVR, 61 (5%) patients had reduced SVI [<35 mL/m(2) (low flow, LF)] and 1059 (95%) had normal SVI [≥35 mL/m(2) (normal flow, NF)]. Survival post-AVR was lower in patients with LF compared with NF [3-year survival in LF group 76% (95% CI 70-82) vs. 89% (95% CI 88-90%), P = 0.03] primarily due to higher cardiac mortality [3-year event rate 13% (95% CI 8-18%) in LF vs. 5% (95% CI 5-7%) in NF, P = 0.02]. Congestive heart failure (CHF) was the most common caus...
Right ventricular apical pacing may cause or worsen mitral regurgitation (MR). Potential mechanis... more Right ventricular apical pacing may cause or worsen mitral regurgitation (MR). Potential mechanisms for this adverse sequelae include intraventricular dyssynchrony, altered papillary muscle function, pacing-induced cardiomyopathy with left ventricular dilation, and annular dilation. In contrast, biventricular (BiV) pacing may improve MR presumably by opposing the negative effects. Whether or not left ventricular lead location is important in treating mitral regurgitation in patients with pacemakers is unknown. We report a case of severe MR and left ventricular (LV) systolic failure in a patient with right ventricular pacing. Multiple potential etiologies for the worsening valve function were noted, and a stepwise iterative optimizing scheme that included basal lateral LV pacing improved mitral valve function and ameliorated heart failure symptoms.
OBJECTIVES The aim of this study was to assess the outcome of isolated tricuspid regurgitation (T... more OBJECTIVES The aim of this study was to assess the outcome of isolated tricuspid regurgitation (TR) and the added value of quantitative evaluation of its severity.
Outcome data are limited on aortic valve replacement (AVR) in nonagenarian patients. This study r... more Outcome data are limited on aortic valve replacement (AVR) in nonagenarian patients. This study reports our experience in the treatment of this elderly population. A retrospective review was conducted of 59 patients 90 years of age or greater with severe aortic valve stenosis operated on with isolated AVR from January 1993 through August 2013. Valve replacement was surgical in 33 patients (55.9%) and transcatheter in 26 (44.1%). Median age of the patients was 91 years (range, 90 to 97 years), sex was female in 38 (64.4%), and The Society of Thoracic Surgeons predicted risk of mortality was 10.1% (range, 4.7% to 27.9%). Operative complications occurred in 22 patients (37.3%) and included acute renal failure in 7 patients (11.9%) and stroke in 1 patient (1.7%). Vascular injury occurred only in patients treated with transfemoral SAPIEN transcatheter heart valve transcatheter AVR and included 6 patients (42.9%). Discharge to home occurred in 17 patients (34.7%), with no difference betwe...
Transesophageal echocardiography (TEE) is often performed during cardiac operations. The need to ... more Transesophageal echocardiography (TEE) is often performed during cardiac operations. The need to repeat TEE to exclude left atrial or left atrial appendage thrombus before direct current cardioversion (DCCV) in patients with a recent intraoperative TEE showing no thrombus is unclear. We sought to determine the incidence of and risk factors for new thrombus in patients undergoing TEE-guided DCCV after cardiac operations. We reviewed 817 patients referred for TEE-guided DCCV within 30 days of a cardiac operation and an intraoperative TEE. Patients were excluded if the intraoperative TEE showed thrombus or a surgical left atrial appendage intervention was performed. Univariate logistic regression identified risk factors for thrombus. The study included 362 patients (71% male) with a mean age of 69 years. Median time from the operation to DCCV was 6 days. Thrombus was present in 13 patients (3.6%) on TEE before cardioversion; DCCV was cancelled in these patients. Heart failure was assoc...
We describe a case of isolated right ventricular myocardial infarction as the cause of anterior p... more We describe a case of isolated right ventricular myocardial infarction as the cause of anterior precordial lead ST segment elevation. This case illustrates that anterior ST segment elevation may occur with occlusion of the right coronary artery. It is important to recognize this scenario as the treatment of right ventricular myocardial infarction differs from that of left ventricular myocardial infarction.
Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosi... more Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosis before the availability of transcatheter valve technology. Historically, many patients with severe aortic stenosis had not been offered surgery, largely related to professional and patient perception regarding the risks of operation relative to anticipated benefits. Such patients have been labeled as &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;high risk&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;inoperable&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; with respect to their suitability for surgery. The availability of transcatheter aortic valve replacement affords a new treatment option for patients previously not felt to be optimal candidates for surgical valve replacement and allows for the opportunity to reexamine the methods for assessing operative risk in the context of more than 1 available treatment. Standardized risk assessment can be challenging because of both the imprecision of current risk scoring methods and the variability in ascertaining risk related to operator experience as well as local factors and practice patterns at treating facilities. Operative risk in actuality is not an absolute but represents a spectrum from very low to extreme, and the conventional labels of high risk and inoperable are incomplete with respect to their utility in clinical decision making. Moving forward, the emphasis should be on developing an individual assessment that takes into account procedure risk as well as long-term outcomes evaluated in a multidisciplinary fashion, and incorporating patient preferences and goals in a model of shared decision making.
To determine the frequency and clinical impact of noncardiovascular incidental findings (IFs) det... more To determine the frequency and clinical impact of noncardiovascular incidental findings (IFs) detected on preoperative computed tomographic angiography (CTA) of the chest/abdomen/pelvis performed in elderly patients with severe aortic stenosis being considered for transcatheter aortic valve replacement (TAVR). The CTA studies for 424 consecutive patients being evaluated for TAVR between January 1, 2009, through January 24, 2012, were reviewed for noncardiovascular IFs (62.0% male; median ± SD age, 82 ± 8.3 years). The electronic medical record was reviewed to assess for subsequent clinical management and survival. Potentially pathologic IFs (PPIFs) were present in 285 patients (67.2%). The mean ± SD number of PPIFs per patient was 1.1 ± 1.0 (range, 0-4). Factors associated with higher numbers of PPIFs were reduced ejection fraction (P=.02) and history of smoking (P=.06). Potentially pathologic incidental findings prompted clinical work-up in 39 patients (9.2%) and delayed or canceled treatment plans for aortic stenosis in 7 patients (1.7%). The number needed to image to diagnose a new malignancy or medical condition was 19. The number of PPIFs was predictive of poor overall survival before (hazard ratio, 1.58; 95% CI, 1.31-1.88) and after (hazard ratio, 1.45; 95% CI, 1.19-1.76) adjustment for baseline clinical variables (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001 for both). This investigation found that PPIFs are common in elderly patients undergoing TAVR-CTA scans and, once discovered, commonly generate further clinical evaluation. Higher numbers of PPIFs may be predictive of poorer survival, but further study is required to guide the appropriateness of pursuing diagnostic evaluations for asymptomatic PPIFs in this elderly population.
uncertain. Methods-In the community of Olmsted County (Minn), we identified all MVP diagnosed (19... more uncertain. Methods-In the community of Olmsted County (Minn), we identified all MVP diagnosed (1989 to 1998) in patients in sinus rhythm with no prior history of INE. We measured INE rates and compared them with expected rates in our community to define the excess risk of INE. Results-Among 777 eligible subjects (age, 49Ϯ20 years; 66% female; follow-up, 5.5Ϯ3.0 years), 30 patients had at least 1 INE during follow-up (at 10 years, 7Ϯ1%). Compared with expected INEs in the same community, subjects with MVP showed excess risk of lifetime INE (relative risk [RR], 2.2; 95% CI, 1.5 to 3.2; PϽ0.001) and during follow-up under purely medical management (RR, 1.8; 95% CI, 1.1 to 2.8; Pϭ0.009). Independent determinants of INE were older age (RR, 1.08 per year; 95% CI, 1.04 to 1.11; PϽ0.001), mitral thickening (RR, 3.2; 95% CI, 1.4 to 7.4; Pϭ0.008), atrial fibrillation (AFib) during follow-up (RR, 4.3; 95% CI, 1.9 to 10.0; PϽ0.001), and need for cardiac surgery (RR, 2.5; 95% CI, 1.1 to 5.8; Pϭ0.03). INE 10-year rates were low in patients Ͻ50 years of age (0.4Ϯ0.4%, Pϭ0.60 versus expected) but were excessive in patients Ͼ50 years of age (16Ϯ3%, PϽ0.001 versus expected) or with thickened leaflets (7Ϯ2%, PϽ0.001 versus expected). Predictors of follow-up AFib were age, mitral regurgitation, and left atrium diameter (all PϽ0.01). Conclusions-In the community, subjects with MVP display a lifetime excess rate of INE compared with expected. Clinical (older age) and echocardiographic (leaflets thickening) characteristics define patients with MVP at high risk for INE, and subsequent AFib or need for cardiac surgery, both related to the degree of mitral regurgitation, increase the risk of INE. (Stroke. 2003;34:1339-1345.)
Current therapies for cancer have improved life expectancy of patients. Breast cancer and lymphom... more Current therapies for cancer have improved life expectancy of patients. Breast cancer and lymphoma survivors in up to 26% of cases can develop complications as a consequence of the chemotherapeutic and radiotherapeutic treatments. Echocardiography is a noninvasive method that can in all stages of cancer treatment perform a comprehensive evaluation and detect coronary, myocardial, valve and pericardial disease complications secondary to the therapeutic regimen used (radiotherapy and/or chemotherapy). Three-dimensional echocardiography derived left ventricular ejection fraction (LVEF) has an excellent correlation with cardiac magnetic resonance imaging and can be used to monitor LVEF; 2-dimensional speckle tracking echocardiography (2D-STE) derived strain and strain rate can detect changes in myocardial mechanics before changes in LVEF occur and can predict a future decrease in ejection fraction to less than 50% or of greater than 10% indicative of cardiotoxicity. Echocardiography should be used as the method of choice to evaluate serial changes in heart function, detect late side effects of treatment, and to identify patients at risk of a future decrease in LVEF.
The clinical outcome of asymptomatic mitral regurgitation is poorly defined, and the treatment is... more The clinical outcome of asymptomatic mitral regurgitation is poorly defined, and the treatment is uncertain. We studied the effect on the outcome of quantifying mitral regurgitation according to recent guidelines.
The Journal of Thoracic and Cardiovascular Surgery, 2014
To study the determinants of functional tricuspid regurgitation (TR) progression after surgical c... more To study the determinants of functional tricuspid regurgitation (TR) progression after surgical correction of mitral regurgitation, including the influence of mitral valve (MV) repair (MVr) versus replacement (MVR) for degenerative mitral regurgitation. From January 1995 to January 2006, 747 adults with MV prolapse underwent isolated MVr (n=683) or MVR (n=64; mechanical in 32). The mean age was 60.8 years, and 491 were men (66.0%). Moderate preoperative functional TR was present in 115 (15.4%). The MVR group had a greater likelihood of New York Heart Association class III or IV (75.0% vs 34.4%, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001), atrial fibrillation (20.3% vs 8.3%, P=.002), a lower left ventricular ejection fraction (61.0% vs 65.2%, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.003), and a higher pulmonary artery pressure (50.1 vs 41.2 mm Hg, P=.001). The patients were monitored for a mean of 6.9 years (MVr) or 7.7 years (MVR; P=.075). During late follow-up, no difference was found between the groups in the development of moderately severe or severe TR: 1 to 5 years (3.0% vs 3.3%, P=.91) and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;5 years (6.1% vs 6.5%; P=.93). The univariate predictors of severe TR after 5 years were older age (hazard ratio [HR], 1.1; P=.011), female gender (HR, 6.86; P=.005), higher pulmonary artery pressure (HR, 1.05; P=.022), and larger left atrial size (HR, 2.11; P=.035). Two patients (0.26%) who had undergone initial MVr required reoperation for late functional TR. Another 2 patients had had the tricuspid valve addressed concurrent with reoperation for MVr failure. No tricuspid reoperations were required in the MVR group. The risk of TR progression was low after MVr or MVR for MV prolapse. Timely MV surgery before the development of left atrial dilatation or pulmonary hypertension could further decrease the risk of TR progression during follow-up.
The heart failure (HF) syndrome is heterogeneous. While it can be defined by ejection fraction (E... more The heart failure (HF) syndrome is heterogeneous. While it can be defined by ejection fraction (EF) and diastolic function, data on the characteristics of HF in the community are scarce, as most studies are retrospective, hospital-based, and rely on clinically indicated tests. Further, diastolic function is seldom systematically assessed based on standardized techniques. To prospectively measure EF, diastolic function, and brain natriuretic peptide (BNP) in community residents with HF. Echocardiographic measures of EF and diastolic function, measurement of blood levels of BNP, and 6-month mortality. Olmsted County residents with incident or prevalent HF (inpatients or outpatients) between September 10, 2003, and October 27, 2005, were prospectively recruited to undergo assessment of EF and diastolic function by echocardiography and measurement of BNP. A total of 556 study participants underwent echocardiography at HF diagnosis. Preserved EF (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =50%) was present in 308 (55%) and was associated with older age, female sex, and no history of myocardial infarction (all P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Isolated diastolic dysfunction (diastolic dysfunction with preserved EF) was present in 242 (44%) patients. For patients with reduced EF, moderate or severe diastolic dysfunction was more common than when EF was preserved (odds ratio, 1.67; 95% confidence interval [CI], 1.11-2.51; P = .01). Both low EF and diastolic dysfunction were independently related to higher levels of BNP. At 6 months, mortality was 16% for both preserved and reduced EF (age- and sex-adjusted hazard ratio, 0.85; 95% CI, 0.61-1.19; P = .33 for preserved vs reduced EF). In the community, more than half of patients with HF have preserved EF, and isolated diastolic dysfunction is present in more than 40% of cases. Ejection fraction and diastolic dysfunction are independently related to higher levels of BNP. Heart failure with preserved EF is associated with a high mortality rate, comparable to that of patients with reduced EF.
PURPOSE Bicuspid aortic valve (BAV) is a common congenital abnormality. The diagnosis is usually ... more PURPOSE Bicuspid aortic valve (BAV) is a common congenital abnormality. The diagnosis is usually made by echocardiography. The ability of cardiac MRI to accurately identify BAV or a comparison with echocardiography has not been reported. METHOD AND MATERIALS A series of 53 patients with a diagnosis of BAV (n=43) or possible BAV (n=9) after transthoracic echocardiography (TTE) or a trileaflet aortic valve on TTE that was later categorized as BAV by TEE (n=1), as well as 20 control patients with a trileaflet valve subsequently underwent MRI with accurate positioning of the imaging plane perpendicular to the valve leaflets to evaluate valve morphology. Both steady-state free precession (SSFP) and cine-phase contrast images were obtained. RESULTS Cardiac MRI identified the presence of BAV in all 43 patients with a similar diagnosis by TTE. Of these, 24 patients underwent surgery or TEE which confirmed BAV. In the 9 patients with possible BAV by TTE, MRI identified 5 with BAV and 4 with ...
European heart journal cardiovascular Imaging, Jan 20, 2015
Reduced stroke volume index (SVI) in patients with severe aortic stenosis (AS) and preserved ejec... more Reduced stroke volume index (SVI) in patients with severe aortic stenosis (AS) and preserved ejection fraction (EF) is associated with adverse outcomes even after aortic valve replacement (AVR), although specific reasons for impaired survival in this group are unknown. We investigated predictors of post-AVR survival and specific cause of death in patients with AS according to SVI. Among 1120 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and preserved EF (≥50%) using 2-D and Doppler echocardiography who had AVR, 61 (5%) patients had reduced SVI [<35 mL/m(2) (low flow, LF)] and 1059 (95%) had normal SVI [≥35 mL/m(2) (normal flow, NF)]. Survival post-AVR was lower in patients with LF compared with NF [3-year survival in LF group 76% (95% CI 70-82) vs. 89% (95% CI 88-90%), P = 0.03] primarily due to higher cardiac mortality [3-year event rate 13% (95% CI 8-18%) in LF vs. 5% (95% CI 5-7%) in NF, P = 0.02]. Congestive heart failure (CHF) was the most common caus...
Right ventricular apical pacing may cause or worsen mitral regurgitation (MR). Potential mechanis... more Right ventricular apical pacing may cause or worsen mitral regurgitation (MR). Potential mechanisms for this adverse sequelae include intraventricular dyssynchrony, altered papillary muscle function, pacing-induced cardiomyopathy with left ventricular dilation, and annular dilation. In contrast, biventricular (BiV) pacing may improve MR presumably by opposing the negative effects. Whether or not left ventricular lead location is important in treating mitral regurgitation in patients with pacemakers is unknown. We report a case of severe MR and left ventricular (LV) systolic failure in a patient with right ventricular pacing. Multiple potential etiologies for the worsening valve function were noted, and a stepwise iterative optimizing scheme that included basal lateral LV pacing improved mitral valve function and ameliorated heart failure symptoms.
OBJECTIVES The aim of this study was to assess the outcome of isolated tricuspid regurgitation (T... more OBJECTIVES The aim of this study was to assess the outcome of isolated tricuspid regurgitation (TR) and the added value of quantitative evaluation of its severity.
Outcome data are limited on aortic valve replacement (AVR) in nonagenarian patients. This study r... more Outcome data are limited on aortic valve replacement (AVR) in nonagenarian patients. This study reports our experience in the treatment of this elderly population. A retrospective review was conducted of 59 patients 90 years of age or greater with severe aortic valve stenosis operated on with isolated AVR from January 1993 through August 2013. Valve replacement was surgical in 33 patients (55.9%) and transcatheter in 26 (44.1%). Median age of the patients was 91 years (range, 90 to 97 years), sex was female in 38 (64.4%), and The Society of Thoracic Surgeons predicted risk of mortality was 10.1% (range, 4.7% to 27.9%). Operative complications occurred in 22 patients (37.3%) and included acute renal failure in 7 patients (11.9%) and stroke in 1 patient (1.7%). Vascular injury occurred only in patients treated with transfemoral SAPIEN transcatheter heart valve transcatheter AVR and included 6 patients (42.9%). Discharge to home occurred in 17 patients (34.7%), with no difference betwe...
Transesophageal echocardiography (TEE) is often performed during cardiac operations. The need to ... more Transesophageal echocardiography (TEE) is often performed during cardiac operations. The need to repeat TEE to exclude left atrial or left atrial appendage thrombus before direct current cardioversion (DCCV) in patients with a recent intraoperative TEE showing no thrombus is unclear. We sought to determine the incidence of and risk factors for new thrombus in patients undergoing TEE-guided DCCV after cardiac operations. We reviewed 817 patients referred for TEE-guided DCCV within 30 days of a cardiac operation and an intraoperative TEE. Patients were excluded if the intraoperative TEE showed thrombus or a surgical left atrial appendage intervention was performed. Univariate logistic regression identified risk factors for thrombus. The study included 362 patients (71% male) with a mean age of 69 years. Median time from the operation to DCCV was 6 days. Thrombus was present in 13 patients (3.6%) on TEE before cardioversion; DCCV was cancelled in these patients. Heart failure was assoc...
We describe a case of isolated right ventricular myocardial infarction as the cause of anterior p... more We describe a case of isolated right ventricular myocardial infarction as the cause of anterior precordial lead ST segment elevation. This case illustrates that anterior ST segment elevation may occur with occlusion of the right coronary artery. It is important to recognize this scenario as the treatment of right ventricular myocardial infarction differs from that of left ventricular myocardial infarction.
Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosi... more Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosis before the availability of transcatheter valve technology. Historically, many patients with severe aortic stenosis had not been offered surgery, largely related to professional and patient perception regarding the risks of operation relative to anticipated benefits. Such patients have been labeled as &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;high risk&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;inoperable&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; with respect to their suitability for surgery. The availability of transcatheter aortic valve replacement affords a new treatment option for patients previously not felt to be optimal candidates for surgical valve replacement and allows for the opportunity to reexamine the methods for assessing operative risk in the context of more than 1 available treatment. Standardized risk assessment can be challenging because of both the imprecision of current risk scoring methods and the variability in ascertaining risk related to operator experience as well as local factors and practice patterns at treating facilities. Operative risk in actuality is not an absolute but represents a spectrum from very low to extreme, and the conventional labels of high risk and inoperable are incomplete with respect to their utility in clinical decision making. Moving forward, the emphasis should be on developing an individual assessment that takes into account procedure risk as well as long-term outcomes evaluated in a multidisciplinary fashion, and incorporating patient preferences and goals in a model of shared decision making.
To determine the frequency and clinical impact of noncardiovascular incidental findings (IFs) det... more To determine the frequency and clinical impact of noncardiovascular incidental findings (IFs) detected on preoperative computed tomographic angiography (CTA) of the chest/abdomen/pelvis performed in elderly patients with severe aortic stenosis being considered for transcatheter aortic valve replacement (TAVR). The CTA studies for 424 consecutive patients being evaluated for TAVR between January 1, 2009, through January 24, 2012, were reviewed for noncardiovascular IFs (62.0% male; median ± SD age, 82 ± 8.3 years). The electronic medical record was reviewed to assess for subsequent clinical management and survival. Potentially pathologic IFs (PPIFs) were present in 285 patients (67.2%). The mean ± SD number of PPIFs per patient was 1.1 ± 1.0 (range, 0-4). Factors associated with higher numbers of PPIFs were reduced ejection fraction (P=.02) and history of smoking (P=.06). Potentially pathologic incidental findings prompted clinical work-up in 39 patients (9.2%) and delayed or canceled treatment plans for aortic stenosis in 7 patients (1.7%). The number needed to image to diagnose a new malignancy or medical condition was 19. The number of PPIFs was predictive of poor overall survival before (hazard ratio, 1.58; 95% CI, 1.31-1.88) and after (hazard ratio, 1.45; 95% CI, 1.19-1.76) adjustment for baseline clinical variables (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001 for both). This investigation found that PPIFs are common in elderly patients undergoing TAVR-CTA scans and, once discovered, commonly generate further clinical evaluation. Higher numbers of PPIFs may be predictive of poorer survival, but further study is required to guide the appropriateness of pursuing diagnostic evaluations for asymptomatic PPIFs in this elderly population.
uncertain. Methods-In the community of Olmsted County (Minn), we identified all MVP diagnosed (19... more uncertain. Methods-In the community of Olmsted County (Minn), we identified all MVP diagnosed (1989 to 1998) in patients in sinus rhythm with no prior history of INE. We measured INE rates and compared them with expected rates in our community to define the excess risk of INE. Results-Among 777 eligible subjects (age, 49Ϯ20 years; 66% female; follow-up, 5.5Ϯ3.0 years), 30 patients had at least 1 INE during follow-up (at 10 years, 7Ϯ1%). Compared with expected INEs in the same community, subjects with MVP showed excess risk of lifetime INE (relative risk [RR], 2.2; 95% CI, 1.5 to 3.2; PϽ0.001) and during follow-up under purely medical management (RR, 1.8; 95% CI, 1.1 to 2.8; Pϭ0.009). Independent determinants of INE were older age (RR, 1.08 per year; 95% CI, 1.04 to 1.11; PϽ0.001), mitral thickening (RR, 3.2; 95% CI, 1.4 to 7.4; Pϭ0.008), atrial fibrillation (AFib) during follow-up (RR, 4.3; 95% CI, 1.9 to 10.0; PϽ0.001), and need for cardiac surgery (RR, 2.5; 95% CI, 1.1 to 5.8; Pϭ0.03). INE 10-year rates were low in patients Ͻ50 years of age (0.4Ϯ0.4%, Pϭ0.60 versus expected) but were excessive in patients Ͼ50 years of age (16Ϯ3%, PϽ0.001 versus expected) or with thickened leaflets (7Ϯ2%, PϽ0.001 versus expected). Predictors of follow-up AFib were age, mitral regurgitation, and left atrium diameter (all PϽ0.01). Conclusions-In the community, subjects with MVP display a lifetime excess rate of INE compared with expected. Clinical (older age) and echocardiographic (leaflets thickening) characteristics define patients with MVP at high risk for INE, and subsequent AFib or need for cardiac surgery, both related to the degree of mitral regurgitation, increase the risk of INE. (Stroke. 2003;34:1339-1345.)
Current therapies for cancer have improved life expectancy of patients. Breast cancer and lymphom... more Current therapies for cancer have improved life expectancy of patients. Breast cancer and lymphoma survivors in up to 26% of cases can develop complications as a consequence of the chemotherapeutic and radiotherapeutic treatments. Echocardiography is a noninvasive method that can in all stages of cancer treatment perform a comprehensive evaluation and detect coronary, myocardial, valve and pericardial disease complications secondary to the therapeutic regimen used (radiotherapy and/or chemotherapy). Three-dimensional echocardiography derived left ventricular ejection fraction (LVEF) has an excellent correlation with cardiac magnetic resonance imaging and can be used to monitor LVEF; 2-dimensional speckle tracking echocardiography (2D-STE) derived strain and strain rate can detect changes in myocardial mechanics before changes in LVEF occur and can predict a future decrease in ejection fraction to less than 50% or of greater than 10% indicative of cardiotoxicity. Echocardiography should be used as the method of choice to evaluate serial changes in heart function, detect late side effects of treatment, and to identify patients at risk of a future decrease in LVEF.
The clinical outcome of asymptomatic mitral regurgitation is poorly defined, and the treatment is... more The clinical outcome of asymptomatic mitral regurgitation is poorly defined, and the treatment is uncertain. We studied the effect on the outcome of quantifying mitral regurgitation according to recent guidelines.
The Journal of Thoracic and Cardiovascular Surgery, 2014
To study the determinants of functional tricuspid regurgitation (TR) progression after surgical c... more To study the determinants of functional tricuspid regurgitation (TR) progression after surgical correction of mitral regurgitation, including the influence of mitral valve (MV) repair (MVr) versus replacement (MVR) for degenerative mitral regurgitation. From January 1995 to January 2006, 747 adults with MV prolapse underwent isolated MVr (n=683) or MVR (n=64; mechanical in 32). The mean age was 60.8 years, and 491 were men (66.0%). Moderate preoperative functional TR was present in 115 (15.4%). The MVR group had a greater likelihood of New York Heart Association class III or IV (75.0% vs 34.4%, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001), atrial fibrillation (20.3% vs 8.3%, P=.002), a lower left ventricular ejection fraction (61.0% vs 65.2%, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.003), and a higher pulmonary artery pressure (50.1 vs 41.2 mm Hg, P=.001). The patients were monitored for a mean of 6.9 years (MVr) or 7.7 years (MVR; P=.075). During late follow-up, no difference was found between the groups in the development of moderately severe or severe TR: 1 to 5 years (3.0% vs 3.3%, P=.91) and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;5 years (6.1% vs 6.5%; P=.93). The univariate predictors of severe TR after 5 years were older age (hazard ratio [HR], 1.1; P=.011), female gender (HR, 6.86; P=.005), higher pulmonary artery pressure (HR, 1.05; P=.022), and larger left atrial size (HR, 2.11; P=.035). Two patients (0.26%) who had undergone initial MVr required reoperation for late functional TR. Another 2 patients had had the tricuspid valve addressed concurrent with reoperation for MVr failure. No tricuspid reoperations were required in the MVR group. The risk of TR progression was low after MVr or MVR for MV prolapse. Timely MV surgery before the development of left atrial dilatation or pulmonary hypertension could further decrease the risk of TR progression during follow-up.
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