Gian M. Novaro

Association Between Apolipoprotein E Alleles and Calcific Valvular Heart Disease

Background—Studies on apolipoprotein E (apoE) alleles have reported an increased risk of coronary heart disease in patients with the apoE4 allele. Given the risk factor and histological similarities between coronary and calcific valvular heart disease (aortic stenosis [AS] and mitral annular calcification [MAC]), we postulated that apoE alleles might be associated with the development of these valvular lesions. Methods and Results—We evaluated the association between apoE alleles and calcific valvular lesions in 802 patients undergoing transthoracic echocardiography using logistic regression analyses. No difference was noted in genotype distribution (P =0.59) or prevalence of apoE4 between those with or without MAC (30% versus 27%, respectively; P =0.57). Compared with patients without AS, the genotype distribution of patients with AS differed significantly (P =0.03), with increasing prevalences of the apoE 4 allele (27% in those without versus 40% in those with AS; P =0.01). In multivariate analyses adjusting for age, gender, low-density lipoprotein cholesterol levels, and coronary artery disease, increasing age and the apoE4 allele were significant independent predictors of AS (odds ratio, 1.94; 95% confidence interval, 1.01 to 3.71; P =0.046), whereas the apoE4 allele was not predictive of MAC. Conclusions—These findings support extension of the importance of the apoE4 allele beyond atherosclerosis and Alzheimer’s disease to calcific AS.

Features and predictors of ascending aortic dilatation in association with a congenital bicuspid aortic valve.

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Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week

Background: The use of the prehospital electrocardiogram (ECG) to identify patients with ST-segment elevation myocardial infarction (STEMI), coupled with a centralised system to alert the cardiac catheterisation team in preparation for prompt intervention, has been shown to reduce door-to-balloon times (DBT) effectively. A confounding variable in prolonging the recommended 90 min DBT is the time of day or day of the week of patient presentation. We postulated that use of the prehospital ECG, coupled with an emergency department initiated “Cath Alert” system, could neutralise DBT delays related to time of day or day of week. Methods: A prospective study was conducted on 167 consecutive patients presenting to our emergency department with acute STEMI. All patients were treated with primary percutaneous coronary intervention. Patients were grouped according to time of presentation: during regular hours (Monday to Friday 08:00 to 17:00) vs off hours (after 17:00 on weekdays and all hours on weekends). Baseline recorded variables included mode of presentation, transmission of prehospital ECG, and activation of Cath Alert system. Results: Overall, the mean (SD) DBT was 69 (35) mins, with the majority of patients (n = 131, 78%) achieving the recommended DBT of 90 mins. The shortest DBT occurred in patients who arrived by emergency medical services with use of the prehospital ECG and Cath Alert system (53 (21) min), while those who arrived as a walk-in without use of emergency medical services had the longest DBT (105 (38) min; p<0.001). Compared to regular hours, presentation during off hours prolonged DBT in patients presenting via emergency medical services (75 (16) vs 53 (18) min, p = 0.03). With transmission of the prehospital ECG, the delay in DBT was improved among those presenting off hours, nullifying the adverse effect of off hour presentation (54 (21) vs 49 (22) min; p = 0.26). Conclusion: Variables such as time of day and mode of presentation have an impact on achieving currently recommended DBT in patients with STEMI. With the addition of each prehospital variable in succession—that is, arrival by emergency medical services, Cath Alert system, and the prehospital ECG—the DBT can be progressively shortened and the adverse “off hour effect” nullified.

Left Atrial Appendage Exclusion and the Risk of Thromboembolic Events Following Mitral Valve Surgery

Objectives: We aimed to evaluate left atrial appendage (LAA) exclusion in patients undergoing mitral valve surgery with respect to thromboembolic events.

Reduced estrogen in menopause may predispose women to takotsubo cardiomyopathy

BACKGROUND Takotsubo cardiomyopathy (apical ballooning syndrome) has been reported with increased frequency, most commonly in postmenopausal women. Despite the gender disparity, no clear link between estrogen and its possible cardioprotective effects has been shown. OBJECTIVES We present a case series of takotsubo cardiomyopathy in women and examine the prevalence of estrogen replacement therapy (ERT), in addition to conducting a systematic literature review on this topic. METHODS Consecutive cases of takotsubo cardiomyopathy were identified at our institution, Cleveland Clinic Florida, from January 2006 to December 2008, and patient-level data were extracted for analysis. For the literature review, we searched the MEDLINE database from January 1990 to March 2008 for English-language publications, using the terms apical ballooning syndrome, takotsubo, and stress cardiomyopathy, and identified case reports and series of takotsubo cardiomyopathy. Articles describing female patients and their medication use at time of presentation were included in the study. RESULTS Eighteen cases of takotsubo cardiomyopathy were identified at our institution, all in postmenopausal women except for 2 who were still menstruating. Of the 16 postmenopausal cases, none were taking ERT at time of presentation. From the literature review, >400 publications were queried, of which 296 were recognized as case reports or series, with 7 articles meeting all of our inclusion criteria. From these reports, 13 women were identified, none of whom were taking ERT at time of presentation. CONCLUSIONS Lack of estrogen replacement in the postmenopausal state may predispose women to takotsubo cardiomyopathy. Further studies are needed to establish the link more firmly.

Complications of Aortic Valve Surgery: Manifestations at CT and MR Imaging

Aortic valve replacement accounts for a significant portion of cardiac surgeries in the United States. Despite advances in prosthetic heart valve design, surgical technique, and postoperative care, complications after aortic valve replacement remain a leading cause of morbidity and mortality. Routine surveillance of prosthetic heart valves with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and fluoroscopy is important, as these techniques allow accurate detection of prosthetic valve dysfunction. However, echocardiography and fluoroscopy may not allow identification of the specific underlying cause, including paravalvular leak, dehiscence, endocarditis, obstruction, structural failure, pseudoaneurysm formation, aortic dissection, and hemolysis. Magnetic resonance (MR) imaging and computed tomography (CT) have an emerging role as diagnostic tools complementary to conventional imaging for detection and monitoring of complications after aortic valve replacement. The choice between CT and MR imaging depends on individual patient characteristics, the type of prosthetic valve, and the acuity of the clinical situation. In general, screening with TTE followed by TEE is recommended. When results of TTE and TEE are inconclusive, cardiac CT and MR imaging should be considered. The choice between these imaging techniques depends on the presence of patient-specific contraindications to CT or MR imaging.

Caseous calcification of the mitral annulus: an underappreciated variant

A 74 year old woman was found to have a calcified mass on a plain chest radiograph. Follow up studies identified a large, densely calcified mitral periannular mass, consistent with mitral annular calcification (MAC). Three months later, she presented with the acute onset of lethargy. Initial laboratory studies were remarkable only for an elevated …

Pulmonary Vein Stenosis After Catheter Ablation of Atrial Arrhythmias

A 78-year-old woman presented with a 2-month history of worsening dyspnea, orthopnea, and cough with hemoptysis. Her past medical history was significant for hypertension and severe mitral regurgitation for which she had undergone mitral valve repair 3 years previously. In addition, she had recurrent atrial tachycardia requiring 2 radiofrequency ablations, which included ablation of several left-sided pathways. The last ablation was performed 3 months before her presentation. A transesophageal echocardiogram was performed and showed turbulent Doppler flow and increased systolic and diastolic velocities in the right lower (Figure 1) and left upper pulmonary veins. A …

Predictors of 30-day readmission in patients hospitalized with decompensated heart failure.

Heart failure (HF) is the leading cause of hospitalizations and readmissions in the United States. Approximately one‐third of patients admitted for HF are readmitted within 3 months; however, there are few markers that can identify those at highest risk for readmission. The purpose of this study was to identify clinical and laboratory markers associated with hospital readmission in decompensated HF.

Meta-Analysis Comparing Reported Frequency of Atrial Fibrillation After Acute Coronary Syndromes in Asians Versus Whites

The development of atrial fibrillation (AF) in cardiac patients is multifactorial, including not well defined genetic factors. To determine if Asian ethnicity is associated with the development of AF in patients with coronary disease, a meta-analysis was conducted of patient-level data from 7 prospective randomized clinical trials that prospectively collected information on the development of AF: 3 trials in patients with ST-elevation myocardial infarction (Global Use of Strategies to Open Occluded Coronary Arteries [GUSTO] I, GUSTO III, and GUSTO V), 3 trials in patients with non-ST-elevation acute coronary syndromes (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy [PURSUIT], Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis-II [IMPACT II], and Platelet IIb/IIIa Antagonist for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network [PARAGON A]), and 1 trial in patients with both conditions (GUSTO IIb). A total of 94,785 patients were identified (93,050 white, 1,735 Asian). At baseline, Asian patients were younger; had lower body mass indexes; had a lower prevalence of female gender, previous angioplasty, and previous coronary artery bypass grafting; and had a greater prevalence of diabetes compared with white patients. The development of AF was lower in Asian than in white patients (4.7% vs 7.6%, p <0.001), while rates of ventricular tachycardia and fibrillation were similar in the 2 groups. In multivariate logistic regression analysis, Asian ethnicity was associated with significantly lower rates of AF (odds ratio 0.65, 95% confidence interval 0.50 to 0.84, p = 0.001) compared with white ethnicity. In conclusion, similar to previous studies showing a lower incidence of AF in non-Caucasian populations, Asians experiencing acute ischemic syndromes have a significantly lower frequency of AF compared with whites. Further study is needed to investigate the mechanisms and potential genetic underpinnings behind this association.