Christina S. Reuss

Preoperative Dobutamine Stress Echocardiographic Findings and Subsequent Short-Term Adverse Cardiac Events After Orthotopic Liver Transplantation

Cardiovascular (CV) complications are the leading cause of non–graft‐related death in orthotopic liver transplant (OLT) patients. Pretransplant cardiac evaluation using dobutamine stress echocardiography (DSE) is commonly utilized for risk stratification of OLT candidates. To determine if clinical and echocardiographic variables identify patients with increased CV risk, we performed a retrospective chart review of all 284 patients that underwent OLT at our institution between June 1999 and August 2005. Of these patients, 157 had a DSE prior to their OLT. Serious adverse CV events occurring during surgery and up to 4 months post‐transplantation were defined as cardiac‐related death, myocardial infarction (MI), new heart failure, or asystole or unstable ventricular arrhythmia requiring acute treatment. Sixteen of 157 patients (10%) had an adverse CV event with 2 deaths. These included ventricular tachycardia (n = 8), asystole (n = 2), MI (n = 5), and new heart failure (n = 1). Nine of the 16 CV events occurred at the time of surgery (including both deaths), 5 occurred postoperatively, and 3 occurred after hospital discharge. Variables that correlated with increased CV events were inability during DSE to achieve >82% of the maximum predicted heart rate (22% versus 6%, P = 0.01), a peak rate pressure product during DSE of <16,333 (17% versus 5%, P = 0.02), and a Model for End‐Stage Liver Disease (MELD) score of >24 at the time of OLT. A multivariate model calculated from the DSE maximum achieved heart rate (MAHR) and MELD score (result = 3.78 + 0.07 MELD − 0.05 MAHR) identified a 47% risk for a value > 0 versus a 6% risk for a value < 0 (P < 0.001). In conclusion, the maximum heart rate achieved during DSE together with the MELD score may be a predictor of adverse CV events up to 4 months post‐OLT. A large prospective study is needed to more decisively support this conclusion. Liver Transpl 14:886–892, 2008.

Long‐term cardiovascular risk in the orthotopic liver transplant population

In theoperative and peri-operative period, these events in-clude life-threatening arrhythmias at the time of donorliver reperfusion, myocardial ischemia or myocardialinfarction (MI) or congestive heart failure. In long termOLTx survivors, CV events include unstable angina, MIor death. Therefore, assessing short and long term CVrisk is an important aspect of the ESLD pretransplantevaluation.Currently, there is no widely accepted algorithm toidentify patients that are at high risk of perioperativetransplant CV events from the hemodynamic stress ofsurgery. Contrary to data in the vascular surgery pop-ulation

Effect of Echocardiographic Contrast on Velocity Vector Imaging Myocardial Tracking

BACKGROUND Two-dimensional speckle tracking is an evolving ultrasound technology that allows objective evaluation of left ventricular function. The effect of echocardiographic contrast with 2-dimensional speckle tracking image processing is poorly defined. METHODS A total of 11 patients undergoing clinically indicated transthoracic echocardiography who also required echocardiographic contrast for left ventricular endocardial border enhancement were prospectively studied. Offline velocity vector imaging analysis was performed to calculate global and regional longitudinal strain from the apical 4-chamber view while corresponding circumferential strain was obtained from the parasternal short-axis view at the papillary muscle level. Images were isochronally normalized and the systolic phase was studied precontrast and postcontrast opacification. RESULTS Intraclass correlation coefficients were high for global circumferential strain in the short-axis view (0.77) and global longitudinal strain in the apical 4-chamber view (0.87) precontrast and postcontrast. Significant regional variability was present, more pronounced in the apical 4-chamber view (intraclass correlation coefficient 0.24-0.64) versus short-axis view (intraclass correlation coefficient 0.64-0.68). CONCLUSIONS Velocity vector imaging is able to quantify global and regional strain with and without contrast. There is, however, wide interindividual variability in regional strain quantification with and without contrast, potentially limiting the clinical applicability.

Pregnancy and the Heart

The prevalence of heart disease in women is approximately 1% with an overall complication rate of 13% to 18%. Congenital heart disease accounts for more than 50% of pregnant patients with heart disease. The patients at highest risk are those with critical aortic stenosis (AS), Marfan’s syndrome with an aortic diameter of 40 mm or more, cyanotic heart disease, pulmonary hypertension, mechanical prostheses, or severe left ventricle (LV) dysfunction. Suggested guidelines for safety of pregnancy in patients with cyanotic congenital heart disease include maternal functional status, O2 saturation of 85% to 90% or more, hemoglobin of 16 g/dL or more, pulmonary artery to systemic blood pressure ratio of 70% or more, and a left ventricular ejection fraction (EF) of 35% to 40% or less. Women who have significant ventricular dysfunction (New York Heart Association class III or IV) have a poor prognosis in pregnancy. Pregnancy should be discouraged when the EF is less than 25%. Hypertension affects as many as 10% of all pregnancies and remains a major cause of maternal and fetal morbidity and mortality. Half of the aortic dissections that develop in women younger than 40 years of age occur in association with pregnancy. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II blockers are contraindicated in pregnancy.

Eosinophilic Heart Disease in Acute Myeloproliferative Disorder

A 34-year-old man with no past medical history presented to our emergency department with facial droop and dysarthria. He had a 1-day history of dyspnea and nonproductive cough, which he attributed to a viral illness. Examination was notable only for the neurological abnormalities in the chief complaint, which resolved during the emergency department evaluation. A 12-lead ECG showed sinus tachycardia, a prolonged corrected QT interval (530 ms), and T-wave inversion suggestive of ischemia (Figure 1). MRI of the brain was negative for acute stroke. Laboratory values were notable for a hemoglobin of 8.8 g/dL, white blood cell count of 75 400 cells/mL with absolute eosinophilia to 22 620 cells/mL, and a platelet count of 31 000/mL. Troponin T was elevated to 0.40 μg/mL (normal <0.03) with a normal creatine kinase of 22 U/L. An urgent transthoracic echocardiogram demonstrated a …