Justina C. Wu

Treatment of functional mitral regurgitation by percutaneous annuloplasty: results of the TITAN Trial

Functional mitral regurgitation (FMR) contributes to morbidity and mortality in heart failure (HF) patients. The aim of this study was to determine whether percutaneous mitral annuloplasty could safely and effectively reduce FMR and yield durable long‐term clinical benefit.

Cardiovascular manifestations of Fabry disease: relationships between left ventricular hypertrophy, disease severity, and α-galactosidase A activity

AIMS Fabry disease is a rare X-linked deficiency of alpha-galactosidase A (alphagal), which causes glycosphingolipid accumulation. This study analysed the cardiovascular manifestations of a cohort of Fabry patients, and sought to define relationships between disease severity, alphagal activity, and cardiac abnormalities. METHODS AND RESULTS We prospectively analysed Fabry patients (139 subjects: 92 males and 47 females) undergoing screening for potential enzyme replacement therapy. Baseline echocardiograms, electrocardiograms, and exams were obtained as part of two multinational clinical trials. Cardiovascular symptoms were present in 60.4%. By echocardiography, the mean left ventricular mass index (LVMI) was increased at 165.5 +/- 66.9 g/m(2), and 84.8% of patients displayed concentric left ventricular hypertrophy (LVH). Electrocardiographic LVH was present in >50% of adult subjects. In females, log-corrected plasma alphagal activity was inversely associated with LVMI (r = -0.45, P < 0.040). Males with extremely low alphagal activity and renal disease displayed the most LVH and cardiac symptoms, but LVH was prevalent even in females <20 years old. CONCLUSION Concentric LVH was the predominant cardiac pathology seen in patients with Fabry disease, and was prevalent in both genders by the third decade of life. Left ventricular mass index was inversely correlated with alphagal activity, but was prevalent even in younger females.

Coronary sinus-based percutaneous annuloplasty as treatment for functional mitral regurgitation: the TITAN II trial

Objective Functional (or secondary) mitral regurgitation (FMR) is associated with greater morbidity and worse outcomes in patients with congestive heart failure (CHF) and cardiomyopathy. The Carillon® Mitral Contour System® is a coronary sinus-based percutaneous therapy to reduce FMR. We evaluated the safety and efficacy of a modified version of the Carillon device in the treatment of patients with cardiomyopathy and FMR. Methods 36 patients with CHF, depressed left ventricular function (ejection fraction <40%) and at least moderate FMR underwent the Carillon device implant. Results There was 1 major adverse event within 30 days—a death (not device related)—occurring 17 days after the implant. Reductions in FMR and improvements in functional class and 6 min walk tests were seen, similar to prior studies. Device fractures in the high strain region of the proximal anchor (seen in prior studies) were not seen in this study. Conclusions The modified Carillon device was associated with improvements in clinical and echocardiographic parameters in treating patients with FMR, while successfully addressing the issue of anchor fracture. This version of the Carillon device will be used in a blinded randomised trial of symptomatic patients with FMR.

Design and methods of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen SignificantlY) study: An investigator-blinded randomized controlled trial of education and feedback intervention to reduce inappropriate echocardiograms

BACKGROUND Appropriate use criteria (AUC) for transthoracic echocardiography (TTE) were developed to address concerns regarding inappropriate use of TTE. A previous pilot study suggests that an educational and feedback intervention can reduce inappropriate TTEs ordered by physicians in training. It is unknown if this type of intervention will be effective when targeted at attending level physicians in a variety of clinical settings. AIMS The aim of this international, multicenter study is to evaluate the hypothesis that an AUC-based educational and feedback intervention will reduce the proportion of inappropriate echocardiograms ordered by attending physicians in the ambulatory environment. METHODS In an ongoing multicentered, investigator-blinded, randomized controlled trial across Canada and the United States, cardiologists and primary care physicians practicing in the ambulatory setting will be enrolled. The intervention arm will receive (1) a lecture outlining the AUC and most recent available evidence highlighting appropriate use of TTE, (2) access to the American Society of Echocardiography mobile phone app, and (3) individualized feedback reports e-mailed monthly summarizing TTE ordering behavior including information on inappropriate TTEs and brief explanations of the inappropriate designation. The control group will receive no education on TTE appropriate use and order TTEs as usual practice. CONCLUSIONS The Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly in an education RCT) study is the first multicenter randomized trial of an AUC-based educational intervention. The study will examine whether an education and feedback intervention will reduce the rate of outpatient inappropriate TTEs ordered by attending level cardiologists and primary care physicians (www.clinicaltrials.gov identifier NCT02038101).

Hemodynamic Correlates of Blood Pressure in Older Adults: The Atherosclerosis Risk in Communities (ARIC) Study

The primary aim of the present study was to identify the hemodynamic correlates of both steady and pulsatile blood pressure (BP) in community‐dwelling older adults. In 3762 adults aged 70 to 89 years, significant hemodynamic determinants of both brachial and carotid systolic BP included arterial stiffness as measured by aortic pulse wave velocity, stroke volume (via echocardiography), arterial wave reflection, left ventricular ejection time, and upstroke time. The strongest influence was exerted by arterial stiffness. The steady‐state component of blood pressure, mean arterial pressure, was associated with both cardiac index and total peripheral resistance (TPR), but was more strongly associated with TPR. Results were similar when participants taking antihypertensive medications were excluded from analyses. The overall findings suggest that mean arterial pressure is associated strongly with TPR and that significant hemodynamic correlates of systolic BP included arterial stiffness, stroke volume, and arterial wave reflection.

Echocardiography in Heart Failure

This chapter reviews the use of echocardiography in patients with heart failure, including heart failure with reduced and heart failure with preserved ejection fraction.

Long-Term Consequences and Prognosis After Myocardial Infarction

Once a myocardial infarction (MI) has occurred, alterations in cardiac structure and function may evolve over ensuing months and years. The changes include the formation of left ventricular scar and aneurysm, mural thrombus, adverse left ventricular remodeling, and functional (secondary) mitral regurgitation. Echocardiography can survey for these consequences, but also can be used to assess the prognosis of the patient after myocardial infarction. Specific predictors of survival and heart failure post-MI by echocardiography are presented here.

Cardiac Tumors and Masses

Cardiac masses may present themselves upon investigation of cardiovascular symptoms, systemic manifestations, or incidentally upon screening. The differential diagnosis, workup, and subsequent management are heavily dependent upon the presenting clinical setting and the individual patient. In the broadest terms, a mass may be a benign or malignant tumor, a degenerative or infectious process, a normal but prominent structure, or even merely an imaging artifact that has been misinterpreted.