Majesh Makan

Transthoracic Echocardiographic Assessment of Continuous-Flow Left Ventricular Assist Devices

An increasing number of patients are implanted with continuous-flow left ventricular assist devices (LVAD) for the treatment of severe congestive heart failure. In parallel with this growing experience has been an increase in knowledge of how these devices alter cardiac physiology and the important implications this has for cardiac function. Echocardiography offers the ability to provide serial noninvasive evaluation before and after LVAD implantation to document these changes, guide management decisions, and identify LVAD dysfunction. The authors detail a comprehensive assessment of LVAD function by transthoracic echocardiography.

Worsening of Nose Bleeding Heralds High Cardiac Output State in Hereditary Hemorrhagic Telangiectasia

BACKGROUND Hereditary hemorrhagic telangiectasia is characterized by arteriovenous malformations or telangiectasias in multiple organs. Nose bleeding is the most common manifestation of hereditary hemorrhagic telangiectasia and can be debilitating. Cardiac involvement in the form of high-output cardiac failure is a poorly studied complication of hereditary hemorrhagic telangiectasia. The objective of this study is to describe the natural history of high-output cardiac failure in hereditary hemorrhagic telangiectasia and define the relation between bleeding complications and high-output cardiac failure. METHODS In this case-control study at the Washington University hereditary hemorrhagic telangiectasia center, all patients evaluated for hereditary hemorrhagic telangiectasia and found to have high cardiac output between 1999 and 2006 were enrolled as cases (n = 17) and compared with 17 hereditary hemorrhagic telangiectasia controls without high-output cardiac failure. RESULTS During lifetime, cases needed more transfusions, emergency department visits, and hospital admission for nose bleeding. Cases experienced significant worsening of nose bleeding immediately before heart failure diagnosis. During the 2 years before study-related evaluation, 16 (94%) cases needed transfusions every month as compared with 2 (12%) controls (P <.001). The number of transfusions required during these 2 years also was higher in cases (median 3, range 0-12) as compared with controls (median 0, range 0-1.5, P <.001). CONCLUSIONS Hereditary hemorrhagic telangiectasia patients with high-output cardiac failure have significantly greater nose bleeding as compared with patients without high-output cardiac failure. In addition, nose bleeding worsens around the time of development of high-output cardiac failure. Early recognition of the relationship between severe nose bleeding and high-output cardiac failure can lead to earlier diagnosis and provide an opportunity for earlier institution of therapy for high-output cardiac failure.

Right Ventricular Outflow Tract Obstruction by Lymphoma: Case Series and Review of the Literature

External compression of the right ventricular outflow tract (RVOT) by lymphoma is a rare clinical entity. We present a series of three adult patients with varying clinical presentations, in which RVOT compression by lymphoma was diagnosed using echocardiogram. Review of the literature identified a total of 13 prior cases of RVOT obstruction by lymphoma diagnosed with echocardiogram. We have summarized the clinical features and echocardiographic findings of this disorder, and comment on the role of echocardiography in diagnosis and follow‐up. (Echocardiography 2011;28:1164‐1167)

Abnormal Global Longitudinal Strain Predicts Future Deterioration of Left Ventricular Function in Heart Failure Patients With a Recovered Left Ventricular Ejection FractionCLINICAL PERSPECTIVE

Background— Patients with recovery of left ventricular ejection fraction (LVEF) remain at risk for future deterioration of LVEF. However, there are no tools to risk stratify these patients. We hypothesized that global longitudinal strain (GLS) could predict sustained recovery within this population. Methods and Results— We retrospectively identified 96 patients with a reduced LVEF <50% (screening echocardiogram), whose LVEF had increased by at least 10% and normalized (>50%) on evidence-based medical therapies (baseline echocardiogram). We examined absolute GLS on the baseline echocardiogram in relation to changes in LVEF on a follow-up echocardiogram. Patients with recovered LVEF had a wide range of GLS. The GLS on the baseline study correlated with the LVEF at the time of follow-up (r=0.33; P<0.001). The likelihood of having an LVEF >50% on follow-up increased by 24% for each point increase in absolute GLS on the baseline study (odds ratio, 1.24; P=0.001). An abnormal GLS (⩽16%) at baseline had a sensitivity of 88%, a specificity of 46%, and an accuracy of 0.67 (P<0.001) as a predictor of a decrease in LVEF >5% during follow-up. A normal GLS (>16%) on the baseline study had a sensitivity of 47%, a specificity of 83%, and an accuracy of 0.65 (P=0.002) for predicting a stable LVEF (−5% to 5%) on follow-up. Conclusions— In patients with a recovered LVEF, an abnormal GLS predicts the likelihood of having a decreased LVEF during follow-up, whereas a normal GLS predicts the likelihood of stable LVEF during recovery.

IMPROVED RIGHT VENTRICULAR MYOCARDIAL PERFORMANCE DESPITE REDUCED LONGITUDINAL DEFORMATION AFTER LEFT VENTRICULAR ASSIST DEVICE IMPLANTATION IN PATIENTS WITH SEVERE HEART FAILURE

Methods: Echocardiography was performed in 29 consecutive patients both before and within 12 months after implantation of LVAD in patients with severe heart failure. Tricuspid annular plane systolic excursion (TAPSE) and annular systolic velocity (RV TDI Sa) were measured to assess RV longitudinal deformation. These were compared to RV MPI a Doppler based calculation in which lower values signify increased ventricular efficiency.

GLOBAL LONGITUDINAL STRAIN PREDICTS SUSTAINED RECOVERY OF LV EJECTION FRACTION IN HEART FAILURE PATIENTS ON EVIDENCE BASED MEDICAL THERAPIES

Background: Recovered LVEF often returns sub-normal during follow up but there are no tools to stratify the risk of this event. We sought to characterize Global Longitudinal Strain (GLS) in patients with recovered LVEF and to test the hypothesis that GLS at the time of recovery might be able to risk

A Pregnant Woman in the Third Trimester Diagnosed With Acute Respiratory Failure and Severe Lower-Extremity Edema

A previously healthy 33-year-old pregnant woman gravida 4, para 1, with good prenatal care, presented to an obstetric clinic at 34 weeks’ gestation with new-onset shortness of breath, activity intolerance, and worsening lower-extremity edema. The patient had had an uncomplicated pregnancy 10 years earlier as well as a remote history of methamphetamine abuse. Pulse oximetry revealed oxygen saturation in the low 80% range with a mild response to oxygen supplementation through a nonrebreather mask. A heparin drip was started because of a concern about pulmonary embolism (PE), and the patient was admitted to the ICU for further management.

An echocardiographic abnormality in an HIV patient with coronary disease

A patient with a history of HIV and known coronary artery disease presented with fevers. Chest x-ray showed bilateral infiltrates, and a trans-thoracic echocardiogram (TTE) obtained on the first hospital day showed an ejection fraction of 43% with hypokinesis of the basal and mid-anterior segments. The patients course was complicated by continued fevers but blood cultures remained negative; upon rereview of the initial TTE, a highly mobile echogenic linear mass was appreciated on the left ventricular outflow tract side of the aortic valve (see online …