Ahmad Masri

Outcomes of persistent pulmonary hypertension following transcatheter aortic valve replacement

Objectives To determine the prevalence and factors associated with persistent pulmonary hypertension (PH) following transcatheter aortic valve replacement (TAVR) and its relationship with long-term mortality. Methods Consecutive patients who underwent TAVR from July 2011 through January 2016 were studied. The prevalence of baseline PH (mean pulmonary artery pressure ≥25 mm Hg on right heart catheterisation) and the prevalence and the predictors of persistent≥moderate PH (pulmonary artery systolic pressure (PASP)>45 mm Hg on 1 month post-TAVR transthoracic Doppler echocardiography) were collected. Cox models quantified the effect of persistent PH on subsequent mortality while adjusting for confounders. Results Of the 407 TAVR patients, 273 (67%) had PH at baseline. Of these, 102 (25%) had persistent≥moderate PH. Mortality at 2 years in patients with no baseline PH versus those with PH improvement (follow-up PASP≤45 mm Hg) versus those with persistent≥moderate PH was 15.4%, 16.6% and 31.3%, respectively (p=0.049). After adjusting for Society of Thoracic Surgeons Predicted Risk of Mortality and baseline right ventricular function (using tricuspid annular plane systolic excursion), persistent≥moderate PH remained associated with all-cause mortality (HR=1.82, 95% CI 1.06 to 3.12, p=0.03). Baseline characteristics associated with increased likelihood of persistent≥moderate PH were ≥moderate tricuspid regurgitation, ≥moderate mitral regurgitation, atrial fibrillation/flutter, early (E) to late (A) ventricular filling velocities (E/A ratio) and left atrial volume index. Conclusions Persistency of even moderate or greater PH at 1 month post-TAVR is common and associated with higher all-cause mortality.

Setting the stage for the next step in cardiac amyloidosis imaging: Serial quantitative studies to assess disease activity

The term ‘‘amyloid’’ refers to misfolded proteins that tend to aggregate into fibrils, usually with a betapleated structural conformation. The latter imparts the characteristic apple-green birefringence when stained with Congo-red and viewed under polarized light. The term is attributed to Rudolf Virchow who used it to describe the observed ‘‘lardaceous’’ infiltration of tissues, which was incorrectly thought to be a substance derived from starch (from latin ‘‘amylum’’). Due to already established widespread use, the nomenclature persisted even after the proteinaceous origin of amyloid was subsequently identified. The deposition of amyloid proteins is the basis of several recognized organ-specific and systemic amyloidosis syndromes, neurodegenerative disorders, and prion diseases. Cardiac amyloid may derived from (1) immunoglobulin light chains produced in excess by a malignant proliferation of plasma cells (AL amyloidosis), or (2) transthyretin (‘‘carrier of thyroxine and retinol’’, TTR amyloidosis). TTR amyloidosis may be the result of one of several gene mutations ([100 identified) manifesting variably as familial neuropathy and/or cardiomyopathy. It may also occur as a senile form, without a gene mutation. The inherent tendency resident in any protein toward an amyloid state may be the basis of the intriguing condition of senile cardiac amyloidosis. The near coincidence of three factors accounts for a recent focus of interest in cardiac amyloidosis, and the resulting proliferation of literature on the subject. These are as follows: (1) the development of several noninvasive imaging approaches, described below, which have enabled the accurate diagnosis of cardiac amyloidosis without a biopsy. This capability has revealed a much higher prevalence of cardiac amyloidosis than hitherto recognized; (2) an improved understanding of the variable phenotypes associated with the genetic mutations; and (3) the development of several therapeutic agents, currently in pre-clinical and clinical trials, with the promise of improved patient outcome in an area where therapeutic nihilism currently dominates. The field of cardiac imaging has seen many recent developments in the area of amyloidosis. The rather nonspecific morphological features on two-dimensional echocardiography including biventricular wall thickening with a speckled pattern, enlargement of both atria, thickening of the interventricular septum, and a pericardial effusion, that have long been the tip-off for a referral to cardiac biopsy, have been complemented with a characteristic and more specific apical sparing abnormality of global longitudinal strain. In the inaugural paper describing this finding, its sensitivity and specificity were reported to be 93% and 82%, respectively, when the echocardiogram showed left ventricular hypertrophy and coronary artery disease was excluded. Morphological changes analogous to those seen on echocardiography may also be detected by cardiac magnetic resonance (CMR) imaging. CMR offers a superior diagnostic accuracy by virtue of a unique pattern of global subendocardial enhancement of the myocardium, combined with abnormal myocardial and blood-pool gadolinium kinetics (difficulty to null the myocardium, with quick disappearance of gadolinium Reprint requests: Prem Soman MD, PhD, FRCP (UK), FACC, Division of Cardiology, and the Heart and Vascular Institute, University of Pittsburgh Medical Center, A-429 Scaife Hall, 200 Lothrop Street, Pittsburgh, PA 15213; premsoman@usa.net J Nucl Cardiol 2018;25:1571–3. 1071-3581/

Failure of CT angiogram to detect an ascending aortic dissection

34.00 Copyright 2017 American Society of Nuclear Cardiology.

PREDICTORS OF A POSITIVE TECHNETIUM PYROPHOSPHATE SCAN IN PATIENTS WITH SUSPECTED CARDIAC AMYLOIDOSIS

Computed tomography angiography (CTA) is currently the imaging modality of choice to evaluate acute aortic pathology. Their quality may be enhanced with 3D modeling and 3D navigation with virtual angioscopy to assist in determing the best surgical strategy. However, dissections may still be missed on two-dimensional CTAs. A 70-year-old hypertensive male presented for evaluation of an episode of chest pain 1 week previously. His physical examination was unremarkable. A transthoracic echocardiogram revealed a 6.5-cm ascending aortic aneurysm without a dissection flap and mild aortic insufficiency (AI) (Figure 1A). A non-gated contrast-enhanced CTA revealed a 6.8 × 6.2-cm ascending aortic aneurysm without evidence for a dissection flap (Figures 1B and 1C). A transesophageal echocardiogram was performed to better assess the aortic valve and now revealed a dissection flap in the ascending aorta and mild AI (Figures 1D and 1E). The patient was taken emergently to the operating room where he was found to have a tear localized to the ascending aorta just above the sinotubular junction. This was repaired with an ascending and hemiarch replacement with a #28 Dacron graft and an aortic valve resuspension. The patient tolerated the procedure well and had an uncomplicated postoperative course.

Abdominal Aorta Dilatation and Cardiovascular Outcomes: Another Dimension of Arterial Age?

Background: Transthyretin cardiac amyloidosis (ATTR CA) is an underdiagnosed cause of heart failure with reported worse outcomes. Technetium Pyrophosphate scintigraphy (PYP) has re-emerged as a tool to non-invasively diagnose ATTR CA. We sought to determine the clinical and echocardiographic

Outcomes of Heart Failure Admissions Under Observation Versus Short Inpatient Stay

Aortic aneurysm is defined as having a permanent localized dilatation of the aorta, with at least 50% increase in diameter compared with the expected normal diameter of that aortic segment.1 The same guidelines do not offer a definition for a localized aortic dilatation of <50% of the expected normal diameter, commonly referred to in clinical practice as mild aortic dilatation. Further, this definition does not specify what represents a normal diameter. It has been recognized that aortic diameters are affected by age, sex, body size, and imaging modality.1 Thus, without taking these factors into account, normal diameters can be misclassified as abnormal. See Article by Qazi et al The lack of standardized cutoffs for the aorta represented a challenge in which normal needed to be defined before defining what is abnormal but nonaneurysmal. Many smaller studies attempted to address this,1–4 but it was not until a landmark study using the Framingham Heart Study Offspring and Third Generation cohorts data took a comprehensive approach defining sex-specific normal diameters of the aorta at multiple segments stratified by age and body surface area, using noncontrasted multidetector computed tomography (CT) in a community-based cohort.5 However, the question remained, what is the clinical significance of having a dilated, nonaneurysmal aorta? Abdominal aortic aneurysm has been recognized to be associated with atherosclerotic risk factors, supported by an abundance of prospective studies from national screening programs which showed increased mortality in patients with mild aortic aneurysms.6–9 Years later, the Tromso study was published.10 This was a population-based study of 6295 men and women aged 25 to 84 years and followed up for 10 years who did not have aneurysmal abdominal aorta using ultrasonography. In the study, subjects with age- and sex-adjusted infrarenal aortic diameter 27 to …