Ajay Yadlapati

Safety of Short-Term Use of Dabigatran or Rivaroxaban for Direct-Current Cardioversion in Patients With Atrial Fibrillation and Atrial Flutter

Direct-current cardioversion (DCCV) for persistent atrial fibrillation or atrial flutter (AF) carries a risk of thromboembolic events (TEs). Therapeutic anticoagulation with warfarin is recommended for 3 to 4 weeks before and 4 weeks after DCCV to reduce TE; however, the safety of short-term anticoagulation with the novel oral anticoagulants (dabigatran and rivaroxaban) before DCCV has not been assessed. A retrospective cohort study was performed on all patients undergoing elective DCCV for AF at Northwestern Memorial Hospital from June 1, 2012 to September 30, 2013. Inclusion criteria included patients taking any of the novel oral anticoagulants for 21 to 60 days before DCCV and successful DCCV to sinus rhythm. Patients were monitored for a minimum of 60 days after DCCV to evaluate for TEs including stroke, transient ischemic attack, systemic emboli, and death. In total, 53 patients (47 men, 89%; age 65±10 years, median 66) were evaluated. Agents used were dabigatran (30 patients, 57%) and rivaroxaban (23 patients, 43%) for an average of 38±9 days. The mean CHADS2 score was 1.2±1.1 (score=0, 26%; 1, 43%; 2, 17%; and >3, 13%). Eleven patients (21%) underwent a transesophageal echocardiography before their DCCV; all showed no thrombus. No patients were found to have episodes of TE within 60 days of DCCV. No patients were found to have major bleeding events. In conclusion, the use of short-term dabigatran or rivaroxaban therapy for DCCV of AF appears safe.

Comparison of outcomes and presentation in men-versus-women with bicuspid aortic valves undergoing aortic valve replacement.

Gender disparities in short- and long-term outcomes have been documented in cardiac and valvular heart surgery. However, there is a paucity of data regarding these differences in the bicuspid aortic valve (BAV) population. The aim of this study was to examine gender-specific differences in short- and long-term outcomes after surgical aortic valve (AV) replacement in patients with BAV. A retrospective analysis was performed in 628 consecutive patients with BAV who underwent AV surgery from April 2004 to December 2013. To reduce bias when comparing outcomes by gender, propensity score matching obtained on the basis of potential confounders was used. Women with BAV who underwent AV surgery presented with more advanced age (mean 60.7 ± 13.8 vs 56.3 ± 13.6 years, p <0.001) and less aortic regurgitation (29% vs 44%, p <0.001) and had a higher risk for in-hospital mortality (mean Ambler score 3.4 ± 4.4 vs 2.5 ± 4.0, p = 0.015). After propensity score matching, women received more blood products postoperatively (48% vs 34%, p = 0.028) and had more prolonged postoperative lengths of stay (median 5 days [interquartile range 5 to 7] vs 5 days [interquartile range 4 to 6], p = 0.027). Operative, discharge, and 30-day mortality and overall survival were not significantly different. In conclusion, women with BAV who underwent AV surgery were older, presented with less aortic regurgitation, and had increased co-morbidities, lending higher operative risk. Although women received more blood products and had significantly longer lengths of stay, short- and long-term outcomes were similar.

Statin Use and Aneurysm Risk in Patients With Bicuspid Aortic Valve Disease

No medical therapy has been proven to prevent the progression of aortic dilatation in bicuspid aortic valve (BAV) disease, and prophylactic aortic surgery remains the mainstay of treatment.

Real-Time Continuous Left Atrial Pressure Monitoring During Mitral Valve Repair Using the MitraClip NT System: A Feasibility Study

Transcatheter mitral valve repair with the Abbott MitraClip device (Abbott Park, Illinois) is indicated for patients with symptomatic, degenerative mitral regurgitation (MR) of 3+ or greater severity with prohibitive surgical risk [(1)][1]. The mainstay for procedural success is the use of

HIV-Related Myocardial Vulnerability to Infarction and Coronary Artery Disease

Human immunodeficiency virus-infected (HIV+) persons have significantly greater risks for myocardial infarction (MI), heart failure, and sudden death than the general population [(1–3)][1]. HIV-related inflammation and immune dysfunction have been implicated in atherogenesis and MI, but the extent

New Heart…New Rhythm.

A 26-year-old female with a history of nonischemic dilated cardiomyopathy secondary to valvular disease from Marfan syndrome underwent an orthotopic heart transplant for stage D systolic heart failure with concurrent removal of her previously implanted defibrillator. Her posttransplant course was complicated by hyperacute rejection. Prior to hospital discharge, the following electrocardiogram (Fig. 1) was obtained. What is the diagnosis?

Letter to the EditorResearch LetterReal-Time Continuous Left Atrial Pressure Monitoring During Mitral Valve Repair Using the MitraClip NT System: A Feasibility Study

Transcatheter mitral valve repair with the Abbott MitraClip device (Abbott Park, Illinois) is indicated for patients with symptomatic, degenerative mitral regurgitation (MR) of 3+ or greater severity with prohibitive surgical risk [(1)][1]. The mainstay for procedural success is the use of

Preoperative Cardiac Variables of Diastolic Dysfunction and Clinical Outcomes in Lung Transplant Recipients

Background. Orthotopic lung transplantation is now widely performed in patients with advanced lung disease. Patients with moderate or severe ventricular systolic dysfunction are typically excluded from lung transplantation; however, there is a paucity of data regarding the prognostic significance of abnormal left ventricular diastolic function and elevated pretransplant pulmonary pressures. Methods. We reviewed the characteristics of 111 patients who underwent bilateral and unilateral lung transplants from 200 to 2009 in order to evaluate the prognostic significance of preoperative markers of diastolic function, including invasively measured pulmonary capillary wedge pressure (PCWP) and echocardiographic variables of diastolic dysfunction including mitral A > E and A′ > E′. Results. Out of 111 patients, 62 were male (56%) and average age was 54.0 ± 10.5 years. Traditional echocardiographic Doppler variables of abnormal diastolic function, including A′ > E′ and A > E, did not predict adverse events (P = 0.49). Mildly elevated pretransplant PCWP (16–20 mmHg) and moderately/severely elevated PCWP (>20 mmHg) were not associated with adverse clinical events after transplant (P = 0.30). Additionally, all clinical endpoints did not show any statistical significance between the two groups. Conclusions. Pre-lung transplant invasive and echocardiographic findings of elevated pulmonary pressures and abnormal left ventricular diastolic function are not predictive of adverse posttransplant clinical events.

Global longitudinal strain from resting echocardiogram is associated with long-term adverse cardiac outcomes in patients with suspected coronary artery disease

Purpose: Measuring myocardial strain using two-dimensional speckle tracking echocardiography has emerged as a new tool to identify subclinical ventricular dysfunction. Abnormal strain has been shown to have superior sensitivity compared with dobutamine stress echocardiography for viability assessment; however, there is a paucity of data regarding the prediction of long-term major adverse cardiac events. We compared the prognostic ability of both global longitudinal strain (GLS) from resting echocardiograms to regional wall motion score index (WMSI) from stress echocardiograms in their ability to predict long-term major adverse cardiac events. Methods: Patients referred for stress echocardiography, who also underwent coronary angiography within 3 months of stress echo (n=122), were enrolled. Patients with reduced ejection fractions (<40%) were excluded. Patients were followed for a median of 3.4 years for major adverse cardiac events, readmissions and repeat cardiac testing. Results: Patients with abnormal GLS (GLS <16.8%) from the resting echocardiogram obtained as part of the exercise echocardiogram experienced a significantly shorter time to major adverse cardiac events (p=0.026), first cardiovascular hospitalization and repeat cardiac testing (p=0.0011) compared to those with normal GLS. Abnormal GLS appears to be a better predictor than abnormal WMSI in predicting major adverse cardiac events (p=0.174) and time to first cardiovascular hospitalization or repeat cardiac testing (p=0.0093). Conclusion: GLS may be a better predictor of long-term major adverse cardiac events, readmissions and repeat cardiac testing than WMSI in patients undergoing stress echocardiography.

MYOCARDIAL FIBROSIS FOLLOWING ISCHEMIA AND INFARCTION IS GREATER AMONG PERSONS WITH HUMAN IMMUNODEFICIENCY VIRUS THAN UNINFECTED CONTROLS

Persons with human immunodeficiency virus (HIV) have greater risks for myocardial infarction and sudden cardiac death (SCD) than the general population. Associations between coronary artery disease (CAD) and myocardial fibrosis - a mediator of SCD - in the setting of HIV are unknown. We hypothesized