Alexander Sagie

Right ventricular pacing increases tricuspid regurgitation grade regardless of the mechanical interference to the valve by the electrode

AIMSnThe effect of right ventricular (RV) pacing on tricuspid regurgitation (TR) is debatable and is presumed to be related to an interference with valve closure by the electrode. The aim of the study was to determine the impact of pacing per se on TR grade.nnnMETHODS AND RESULTSnThe study group included 23 clinically stable patients (13 males; mean age 78 +/- 12 years) with a permanent pacemaker at the RV apex (83% DDD mode) and normal left ventricular function. They were all non-dependent on pacing and were otherwise in sinus rhythm. None had a primary dysfunction of the tricuspid valve. TR grade and RV size were assessed in two consecutive echo studies with and without active RV pacing. Results showed that active RV pacing was associated with an increase in TR severity (TR vena contracta: 0.4 +/- 0.2 vs. 0.2 +/- 0.2 cm, P < 0.001; TR jet area: 4.1 +/- 2.3 vs. 2.3 +/- 1.8 cm(2), P < 0.001). This was also reflected in a significant decrease in the number of patients with mild TR (P = 0.003) and increase in the number with moderate regurgitation (P = 0.02). There was no change in RV areas with pacing.nnnCONCLUSIONnActive RV pacing is associated with a significant increase in TR grade. This effect is not induced by acute changes in the RV area and is unrelated to an interference with leaflet closure by the electrode.

Gender-related differences in hospitalized heart failure patients.

The burden of heart failure (HF)‐related hospitalization and mortality of female patients with HF is substantial. Currently, several gender‐specific distinctions have been recognized amongst HF patients, but their relationships to outcomes have not been fully elucidated. Accordingly, in the current work, we aimed to explore gender‐specific clinical and echocardiographic measures and to assess their potential impact on outcome.

The Diversity of Heart Failure in a Hospitalized Population: The Role of Age

BACKGROUNDnThe prevalence of heart failure (HF) among hospitalized elderly patients is high and steadily growing. However, because most studies have focused mostly on young patients, little is known about the clinical characteristics, echocardiographic measures, prognostic factors, and outcome of hospitalized elderly HF patients.nnnMETHODS AND RESULTSnWe identified all HF patients aged ≥50 years who had undergone ≥1 echocardiography study and had been hospitalized during January 2000 to December 2009. A comparative analysis was performed between 3,897 young patients (aged 50-75 years) and 5,438 elderly patients (agedxa0>75 years), followed for a mean 2.8xa0±xa02.6 years. Elderly HF patients were more often female (50% vs 35%; Pxa0<xa0.0001) and had a higher prevalence of HF with preserved ejection fraction (64.8% vs 53%; Pxa0<xa0.0001), more significant valvular disease (35.7% vs 32.5%; Pxa0<xa0.0001), and lower rates of ischemic heart disease (65.5% vs 70.9%; Pxa0<xa0.0001) and diabetes (34.4% vs 53.9%; Pxa0<xa0.0001). Thirty-day and 1-year mortality rates were significantly higher among the elderly population (12.2% vs 6.9% [Pxa0<xa0.0001] and 34.3% vs 21.2% [Pxa0<xa0.0001], respectively). Prognostic markers differed significantly between age groups. Young-specific predictors were chronic renal failure, diastolic dysfunction, malignancy, and tricuspid regurgitation, whereas elderly-specific predictors were HF with reduced ejection fraction, chronic obstructive pulmonary disease, pulmonary hypertension, and mitral regurgitation.nnnCONCLUSIONSnHospitalized elderly, compared with young, HF patients differed in prevalence of cardiac and noncardiac comorbid conditions, echocardiographic parameters, and predictors of short- and intermediate-term mortality. Identifying unique features in the elderly population may render age-tailored therapeutics.

Urgent Transcatheter Aortic Valve Implantation in Patients With Severe Aortic Stenosis and Acute Heart Failure: Procedural and 30-Day Outcomes.

BACKGROUNDnTranscatheter aortic valve implantation (TAVI) is recommended for patients with severe symptomatic aortic stenosis (AS) who are at prohibitive/high risk for surgical aortic valve replacement (SAVR). Patients with severe AS may experience acute decompensated heart failure (HF) that is resistant to medical therapy. We report our TAVI experience in treating patients with unstable AS who require urgent intervention for their aortic valve disease.nnnMETHODSnPatients were restrictively included in the urgent TAVI registry if they were admitted with acute refractory and persistent HF despite medical therapy and had TAVI performed during the same hospital stay. All others were included in the elective TAVI group.nnnRESULTSnBetween November 2008 and April 2015, 410 consecutive patients underwent TAVI at our centre-27 (6.6%) urgently. Patients operated on urgently were more likely to be frail and carry higher SAVR mortality risk based on The Society of Thoracic Surgeons Predicted Risk of Mortality/logistic EuroSCORE (LES) measures. Pulmonary edema was the most common clinical presentation. Preprocedural assessment used fewer imaging modalities, yet implantation success remained high and reached 96.3% using an additional valve (valve-within-valve) required in 3 patients, with no difference in periprocedural complications according to the Valve Academic Research Consortium-2 definitions. Although 30-day functional capacity was reduced, patients had similar 30-day mortality and major adverse cardiovascular event rates compared with patients who underwent elective TAVI.nnnCONCLUSIONSnShort-term outcome after urgent TAVI appears to be reasonable. For patients with severe AS who experience acute decompensated HF that is recalcitrant to optimal medical therapy and who are at high risk with SAVR, urgent TAVI may be a viable treatment strategy. Larger prospective studies and data on long-term outcomes are needed.

Acute coronary syndromes in patients with prosthetic heart valves—a case-series

Background: There are few reports regarding acute coronary syndromes (ACS) in patients with prosthetic heart valves (PHV), mostly attributing the ACS to a PHV-derived coronary embolus. Objective: To characterize a case-series of ACS patients with PHV. Methods: All patients in our institution with previous PHV surgery and ACS during 1996–2005 were retrospectively analysed. Results: We identified 40 patients from the 15,878 patient database, whose mean age was 72.5±12.5 years and of whom 21 were male. The majority (n=28) had mechanical valves; 24 patients (60%) had an aortic prosthetic valve, 9 patients (22.5%) had a mitral valve prosthesis and 7 patients (17.5%) had both. The majority of patients had ≥2 risk factors for atherosclerotic disease. The median time from the PHV implantation to the subsequent ACS was 8.0 (4.7–12.1) years. Most patients had non-ST-segment elevation ACS rather than ST-segment elevation ACS (32 patients versus 8 patients). 12 patients (30%) had moderate to severe left ventricular dysfunction and 2 of them presented with cardiogenic shock. Atrial fibrillation on hospital admission was noted in 13 patients (32.5%). ACS management included coronary angiography in 32 patients (80%) which revealed coronary disease in 93%. Only 2 patients had normal coronary arteries and PHV-derived coronary emboli. The most frequent in-hospital complication was heart failure (n=11, 27.5%). Conclusions: Patients with PHV and ACS are a rare subgroup, more likely to be elderly with risk factors for atherosclerotic disease and to present with non-ST-segment-elevation ACS. The pathogenesis for ACS is commonly coronary atherosclerotic disease rather than PHV-derived emboli.

Clinical profile and outcome of patients with severe aortic stenosis at high surgical risk: single-center prospective evaluation according to treatment assignment.

The study sought to assess the clinical profile, outcome, and predictors for mortality of “real‐world” high‐risk severe aortic stenosis patients according to the mode of treatment assigned.

Transesophageal echocardiography evaluation and follow-up of left main coronary artery patch angioplasty.

OBJECTIVEnIsolated ostial stenosis of the left main coronary artery is a rare but serious condition. The treatment is surgical with two options: coronary artery bypass grafting or surgical angioplasty of the left main coronary artery. Assessing surgical results as well as follow-up were traditionally done by angiography.nnnMETHODSnWe describe the use of transesophageal echocardiography (TEE) for evaluating and follow the surgical left main coronary artery (LMCA) angioplasty results in eight patients with isolated ostial left main stenosis.nnnRESULTSnAll patients were alive and free of ischemic events 8 months to 7 years post-surgery. TEE demonstrated a widely opened left main coronary artery with a good flow.nnnCONCLUSIONSnSurgical angioplasty is an alternative option for treating ostial LMCA stenosis. TEE is an additional excellent non-invasive technique for assessing left main anatomy pre- and postoperatively, as well as being on of the quality control tools for evaluating new surgical techniques.

Limitations in exercise and functional capacity in long-term postpneumonectomy patients.

INTRODUCTION: Pneumonectomy results in impairments of pulmonary function and exercise intolerance associated with respiratory limitations. However, exercise capacity and functional capacity are less known at long-term followup. The aims of this study were to assess exercise tolerance and functional capacity among long-term postpneumonectomy patients and to identify the limiting factors in exercise related to comorbidities and which lung was involved. METHODS: Seventeen postpneumonectomy patients aged 59 ± 13 years and 5.5 ± 4.2 years postoperation were prospectively studied. Pulmonary function tests (PFTs), cardiopulmonary exercise test (CPET), Doppler-echocardiography, 6-minute walk test (6MWT) distance, and “senior fitness tests” (SFTs) were conducted with all patients. RESULTS: Exercise capacity and PFT were diminished ( O2 peak; 11.5 ± 3.3 mL−1·kg−1·min−1, 48 ± 17% predicted, forced vital capacity % predicted; 55 ± 13, FEV1% predicted; 46 ± 14, respectively). Most patients presented with low exercise cardiovascular parameters and normal breathing reserve (17 ± 12 L) during CPET. No significant differences were shown between right and left pneumonectomy and comorbidities related to exercise limitations (&khgr;2= 1.96, P = .376). Functional capacity in walking and SFTs were near normal (6MWT distance; 490 ± 15 m, 89 ± 25% predicted). Echocardiography showed normal left ventricle systolic function (ejection fraction, 60 ± 4%) with mildly elevated systolic pulmonary arterial pressure (38 ± 12 mm Hg). CONCLUSIONS: Long-term postpneumonectomy patients demonstrated decreased exercise capacity, limited primarily by the cardiovascular system regardless of lung resection side or comorbidities, although tests of functional capacity were near normal. Most patients can maintain near normal life in activities of daily living, but the long-term cardiopulmonary exercise function should be considered for meticulous evaluation and clinical care to preserve physiological reserves.

Modalities to assess myocardial viability in the modern cardiology era.

Detection of viable myocardium in patients with left ventricular dysfunction has become an increasingly important guide to prognosis and treatment. This article reviews the current status and future potential for the application of modalities to assess myocardial viability. Imaging and other techniques that are reviewed are myocardial perfusion imaging by single-photon-emission computed tomography, positron-emission tomography, echocardiography, cardiac magnetic resonance technology, computed tomography and catheter-based endocardial mapping.

The Quandary of Oral Anticoagulation in Patients With Atrial Fibrillation and Chronic Kidney Disease

Compared to patients with normal renal function, the prevalence of atrial fibrillation (AF) in chronic kidney disease (CKD) is increased, as is consequently the stroke prevalence in these patients. This increased risk of stroke in patients with CKD is caused not only by the increased prevalence of AF, but also by associated co-morbidities, and inherent platelet and vascular dysfunction. Paradoxically, imbalance in the same factors also increases the bleeding risk, imposing a dilemma as to whether anticoagulation should be prescribed or deferred, particularly in patients with end-stage renal disease (ESRD), in whom the bleeding diathesis and thromboembolic predisposition are most recalcitrant. Unfortunately, it is in this vulnerable population, in whom therapeutic options are most limited, that evidence-based studies relating to stroke prophylaxis are scarce, discordant and based only on registry observations. Pending randomized controlled studies on this issue, we will review important epidemiologic data and major recent registry-based studies that the clinician has to weigh when making the best decision on the issue of the prophylactic use of warfarin in patients with CKD with AF, focusing on patients with end-stage renal disease.