Ahmed Almomani

Perioperative Heparin Bridging in Atrial Fibrillation Patients Requiring Temporary Interruption of Anticoagulation: Evidence from Meta-analysis.

BACKGROUND Patients with atrial fibrillation (AF) often require temporary interruption of warfarin for an elective operation or invasive procedure. However, the safety and efficacy of periprocedural bridging anticoagulation with unfractionated heparin (UH) or low-molecular-weight heparin (LMWH) are still unclear. We evaluated the safety of periprocedural heparin bridging in AF patients requiring temporary interruption of oral anticoagulation. METHODS We searched the literature for trials that compared heparin bridging with no bridging in AF patients for whom warfarin was temporarily interrupted. The incidence of all-cause mortality, thromboembolism, and major and all bleeding was included, and meta-analysis was performed. RESULTS A total of 13,808 patients with AF were included in 4 observational studies, 1 randomized trial, and 1 subgroup analysis of a randomized trial. The mean CHADS2 score for the no heparin bridging group was 2.49 and that for the heparin bridging group was 2.34. At 30 days and up to 3 months, when compared to the heparin bridging group, the no bridging group did not have any significant difference in mortality (odds ratio [OR], 1.29; 95% confidence interval [CI], .15-11.52; P = .82) or cerebrovascular accidents (OR, .93; 95% CI, .34-2.51; P = .88), but the no bridging group had significantly less major bleeding (OR, .41; 95% CI, .24-.68; P = .0006). CONCLUSION Among AF patients with intermediate CHADS2 scores who are anticoagulated with warfarin and who required temporary interruption of warfarin for an elective surgery or procedure, periprocedural bridging with UH or LMWH was associated with a higher rate of major bleeding with no significant difference in mortality or CVA.

Role of Multimodality Imaging in Transcatheter Aortic Valve Replacement

The treatment of aortic stenosis (AS) has reached an exciting stage with the introduction of transcatheter aortic valve replacement (TAVR). It is the treatment of choice in patients with severe AS who are considered very high risk for surgical valve replacement. Multimodality imaging (MMI) plays a crucial role in TAVR patient selection, intra‐procedure guidance, and follow‐up. With the ever‐increasing scope for TAVR, a better understanding of MMI is essential to improve outcomes and prevent complications.

Echocardiography in Patients with Complications Related to Pacemakers and Cardiac Defibrillators

The evolving indications and uses for implantable cardiac devices have led to a significant increase in the number of implanted devices each year. Implantation of endocardial leads for permanent pacemakers and cardiac defibrillators can cause many delayed complications. Complications may be mechanical and related to the interaction of the device leads with the valves and endomyocardium, e.g., perforation, infection, and thrombosis, or due to the electrical pacing of the myocardium and conduction abnormalities, e.g., left ventricular dyssynchrony. Tricuspid regurgitation, another delayed complication in these patients, may be secondary to both mechanical and pacing effects of the device leads. Echocardiography plays an important role in the diagnosis of these device‐related complications. Both two‐dimensional transthoracic echocardiography and transesophageal echocardiography provide useful diagnostic information. Real time three‐dimensional echocardiography is a novel technique that can further enhance the detection of lead‐related complications.

Correlation between Echocardiographic Pulmonary Artery Pressure Estimates and Right Heart Catheterization Measurement in Liver Transplant Candidates

BACKGROUND Patients undergoing liver transplant have worse outcomes in the presence of pulmonary hypertension. Correlation between echocardiography and catheterization derived pressures in this population is not well studied. Our studys aim is to show the relationship between pulmonary artery systolic pressure derived from transthoracic echo (ePASP) with pulmonary artery systolic pressure measured during right heart catheterization (cPASP). METHODS Single center retrospective study, patients being evaluated for liver transplant (n = 31) who had an interpretable Doppler signal for ePASP and had right heart catheterization (RHC) measurements within 3 months constituted the study group. Control group (n = 49) consisted of patients who did not have liver disease. RESULTS There was modest correlation between ePASP and cPASP (R = 0.58, p < 0.001) in LT candidates (n = 31) compared with the control group (R = 0.74, p < 0.001, n = 49). The 95% limits of agreement by Bland-Altman analysis ranged from +33.6 mmHg to −21.7 mmHg. Using receiver operating characteristic analysis, ePASP cut-off > 47 mmHg was 59% sensitive and 78% specific to diagnose pulmonary artery (PA) hypertension (mean PA pressure > 25 mmHg) in the LT candidates, while a similar cutoff performed well in the control group (cutoff > 43 mmHg, n = 47, 91% sensitive, 100% specific). CONCLUSIONS Compared with other disease states, ePASP correlates modestly with cPASP in patients with advanced liver disease. A higher ePASP cutoff should be used to screen for pulmonary hypertension. A multi-center prospective study with simultaneous transthoracic echocardiography and RHC measurements is required to determine the best cut-off in this population.

Clinical and angiographic predictors of persistently ischemic fractional flow reserve after percutaneous revascularization

Aims Despite optimal angiographic results after percutaneous coronary intervention (PCI), some lesions may continue to produce ischemia under maximal hyperemia. We evaluated the factors associated with persistently ischemic fractional flow reserve (FFR) after angiographically successful PCI. Methods and results A total of 574 consecutive patients with 664 lesions undergoing PCI who had FFR pre‐ and post‐PCI were analyzed. Percutaneous coronary intervention led to effective ischemia reduction from pre‐FFR (0.65 ± 0.14) to post‐FFR (0.87 ± 0.08; &Dgr;FFR 0.22 ± 0.16, P < .001). There were 63 (9.5%) lesions with a persistently ischemic FFR of ≤0.80 despite optimal angiographic PCI results. Multivariate analysis revealed the presence of diffuse disease (odds ratio [OR] 3.54, 95% CI 1.80‐6.94, P < .01), left anterior descending artery PCI (OR 8.35, 95% CI 3.82‐18.27, P < .01), use of intravenous adenosine for inducing hyperemia (OR 3.95, 95% CI 2.0‐7.84, P < .01), and pre‐PCI FFR (OR 0.03, 95% CI 0.004‐0.23, P < .01) as independent predictors of persistently ischemic FFR (≤0.80) after PCI. The predictive accuracy of this model was robust, with an area under the curve of 0.85 (95% CI 0.82‐0.88). Conclusion Multiple factors are associated with persistently ischemic FFR after angiographically optimal PCI. It is recommended that in lesions with the above‐identified factors, FFR should be remeasured after PCI, and if abnormal, further measures should be undertaken for functional optimization.

PREDICTIVE ACCURACY OF RESTING GRADIENT (PD/PA) FOR IDENTIFYING ISCHEMIC CORONARY LESIONS

Adenosine is used to induce maximal hyperemia during fractional flow reserve (FFR) measurement. Adenosine administration can be time consuming, with added cost and sometimes may have undesirable side effects. We evaluated the predictive accuracy of resting trans-lesional gradient (distal coronary

Incremental value of transthoracic real time three-dimensional echocardiography in assessment of a right ventricular mass.

A 52-year-old male with a right ventricular mass that filled the entire right ventricle and assumed its shape was evaluated by two-dimensional and real time three-dimensional (3D) echocardiography. Contrast enhanced 3D imaging and quantitative assessments of the size of the mass were performed. The clinical correlation, the imaging characteristics of the mass, and the pattern of vascularity were consistent with metastatic hepatocellular carcinoma. The case illustrates the incremental role of 3D echo in defining the size, shape, spatial relationship, attachments, consistency, and vascularity of the right ventricular mass.

Sex-Based Differences in Risk Determinants and Management of Heart Failure

In the United States, more than 40% of heart failure (HF) patients are women, and among the elderly the prevalence of HF is greater in women than in men. Generally, HF affects women at a more advanced age with better global left ventricular systolic function, compared with men. The risk factors associated with HF and its underlying pathophysiology partially differ by sex. Hypertension and diabetes mellitus impose a greater risk of HF in women than in men, who are more likely to have coronary artery disease as an etiology. Most large HF trials have under-represented women in their enrollment numbers, and this has narrowed our understanding of sex-related differences in HF pathophysiology, diagnosis, and treatment. Among patients with HF, survival seems to be better in women than men, with the likely exception of patients with HF due to ischemic heart disease where prognosis is similar in both sexes. Current treatment guidelines are not sex-specific because sufficient data is not available, however, as the therapeutic options for HF expand, sex-based modifications to HF management may be considered in future revisions.

Outcomes of Fractional Flow Reserve-Based Deferral in Saphenous Vein Graft Narrowing

Fractional flow reserve (FFR) has been shown to improve clinical decision-making for revascularization in intermediate coronary stenosis in native coronary arteries of patients with stable coronary disease. However, its use for saphenous vein graft (SVG) lesions has not been well validated. We sought to determine the prognostic value of deferring intervention in lesions with FFR >0.8 in SVG lesions. Clinical, angiographic, and hemodynamic variables and long-term outcomes were recorded in consecutive patients in whom percutaneous coronary intervention was deferred based on an FFR >0.8 for intermediate native coronary artery or SVG stenosis. Thirty-three patients underwent FFR of SVG lesions and were compared with 532 patients who underwent native vessel FFR during the same period. There were no differences in age (66.6 [interquartile range, IQR 63 to 76] vs 65 years [IQR 61 to 70]; p = 0.12), diabetes (41% vs 50%; p = 0.35), or hypertension (94% vs 97%; p = 0.71). During a median follow-up of 3.2 years (IQR 1.7 to 4.6 years) major adverse cardiac event was significantly higher in SVG group (36% vs 21%; log rank p = 0.01). Similarly, the rate of target vessel failure was significantly higher in the SVG group (27% vs 14%; p = 0.01). Deferred SVG lesions had the worst survival free of target vessel failure compared with deferred native lesions in both patients with and without previous CABG. An SVG lesion was an independent predictor of major adverse cardiac events on Cox proportional hazards analysis (hazard ratio 2.26; confidence interval 1.19, 4.28; p = 0.01). In conclusion, nonischemic FFR carries a significantly worse prognosis in SVG compared with non-SVG lesions. Caution is warranted in utilizing FFR for clinical decision-making in SVG lesions.

CORRELATION BETWEEN ECHOCARDIOGRAPHIC PULMONARY ARTERY PRESSURE ESTIMATES AND RIGHT HEART CATHETERIZATION MEASUREMENTS IN PATIENTS UNDERGOING LIVER TRANSPLANT EVALUATION: A SINGLE CENTER STUDY

Background: Pulmonary hypertension is a major adverse outcome indicator in patients undergoing liver transplant evaluation. We aim to examine the correlation between pulmonary artery systolic pressure calculated from echocardiography (ePASP) and measurement from right heart catheterization (cPASP)