Mohammed A. Chamsi-Pasha

Utilization pattern of mineralocorticoid receptor antagonists in contemporary patients hospitalized with acute decompensated heart failure: a single-center experience.

BACKGROUND Recent studies have broadened the potential use of mineralocorticoid receptor antagonist (MRA) in patients with systolic heart failure after cardiovascular hospitalization. Real-world data on safety and tolerability of MRA initiation during hospitalization for acute decompensated heart failure (ADHF) are lacking. We examined the patterns of utilization of MRAs in patients admitted for ADHF in contemporary clinical practice. METHODS AND RESULTS We reviewed consecutive hospitalized patients admitted with a primary diagnosis of ADHF from March to June 2011. The treatment patterns of MRA use or discontinuation before, during, and after hospitalization were reviewed and analyzed retrospectively. In the study cohort of 500 patients, 106 patients (21%) were on MRAs before admission. During hospitalization, preadmission and newly started MRAs were discontinued in 64 out of 177 (36%), with worsening renal function being the most common identifiable reason. In a multivariate analysis, high admission creatinine was the only significant predictor of MRA discontinuation during hospitalization (P = .01). Of the 394 patients who did not receive MRA before admission, 81 were eligible for MRAs, but only 17 (21%) were initiated. After a median follow up of 57 days, 21 additional patients discontinued MRAs; of 72 eligible patients for MRA, 55 patients (76%) were still appropriately taking it. CONCLUSIONS Despite recent data, MRAs are still underutilized in patients admitted with ADHF who are otherwise eligible for it. Elevated serum creatinine and worsening of renal function are the most common cause of in-hospital discontinuation, which highlights the importance of meticulous follow-up after MRA initiation.

Transesophageal Speckle-Tracking Echocardiography Improves Right Ventricular Systolic Function Assessment in the Perioperative Setting

Background: Perioperative evaluation of right ventricular (RV) systolic function is important to follow intraoperative changes, but it is often not possible to assess with transthoracic echocardiographic (TTE) imaging, because of surgical field constraints. Echocardiographic RV quantification is most commonly performed using tricuspid annular plane systolic excursion (TAPSE), but it is not clear whether this method works with transesophageal echocardiographic (TEE) imaging. This study was performed to evaluate the relationship between TTE and TEE TAPSE distances measured with M‐mode imaging and in comparison with speckle‐tracking TTE and TEE measurements. Methods: Prospective observational TTE and TEE imaging was performed during elective cardiac surgical procedures in 100 subjects. Speckle‐tracking echocardiographic TAPSE distances were determined and compared with the TTE M‐mode TAPSE standard. Both an experienced and an inexperienced user of the speckle‐tracking echocardiographic software evaluated the images, to enable interobserver assessment in 84 subjects. Results: The comparison between TTE M‐mode TAPSE and TEE M‐mode TAPSE demonstrated significant variability, with a Spearman correlation of 0.5 and a mean variance in measurement of 6.5 mm. There was equivalence within data pairs and correlations between TTE M‐mode TAPSE and both speckle‐tracking TTE and speckle‐tracking TEE TAPSE, with Spearman correlations of 0.65 and 0.65, respectively. The average variance in measurement was 0.6 mm for speckle‐tracking TTE TAPSE and 1.5 mm for speckle‐tracking TEE TAPSE. Conclusions: Using TTE M‐mode TAPSE as a control, TEE M‐mode TAPSE results are not accurate and should not be used clinically to evaluate RV systolic function. The relationship between speckle‐tracking echocardiographic TAPSE and TTE M‐mode TAPSE suggests that in the perioperative setting, speckle‐tracking TEE TAPSE might be used to quantitatively evaluate RV systolic function in the absence of TTE imaging. HighlightsTTE M‐mode TAPSE and TEE M‐mode TAPSE do not agree, and TEE M‐mode TAPSE should not be used to quantify RV systolic function.Speckle‐tracking echocardiography allows accurate TAPSE measurements for TTE and TEE imaging compared with TTE M‐mode TAPSE.Speckle‐tracking TEE TAPSE could be used to quantify RV systolic function in the perioperative setting when standard TTE methods are not possible.

Angiotensin-Converting Enzyme 2 as a Therapeutic Target for Heart Failure

The renin-angiotensin system (RAS) plays a major role in the pathophysiology of cardiovascular disorders. Angiotensin II (Ang-II), the final product of this pathway, is known for its vasoconstrictive and proliferative effects. Angiotensin-converting enzyme 2 (ACE2), a newly discovered homolog of ACE, plays a key role as the central negative regulator of the RAS. It diverts the generation of vasoactive Ang-II into the vasodilatory and growth inhibiting peptide angiotensin(1–7) [Ang(1–7)], thereby providing counter-regulatory responses to neurohormonal activation. There is substantial experimental evidence evaluating the role of ACE2/Ang(1–7) in hypertension, heart failure, and atherosclerosis. In this review, we aim to focus on the conceptual facts of the ACE2-Ang(1–7) axis with regards to clinical implications and therapeutic targets in cardiovascular disorders, with emphasis on the potential therapeutic role in cardiovascular diseases.

Ethical Challenges of Deactivation of Cardiac Devices in Advanced Heart Failure

More than 23 million adults worldwide have heart failure (HF). Although survival after heart failure diagnosis has improved over time, mortality from heart failure remains high. At the end of life, the chronic HF patient often becomes increasingly symptomatic, and may have other life-limiting comorbidities as well. Multiple trials have shown a clear mortality benefit with the use of implantable cardioverter defibrillators (ICDs) in patients with cardiomyopathy and ventricular arrhythmia. However, patients who have an ICD may be denied the chance of a sudden cardiac death, and instead are committed to a slower terminal decline, with frequent DC shocks that can be painful and decrease the quality of life, greatly contributing to their distress and that of their families during this period. While patients with ICDs are routinely counseled with regard to the benefits of ICDs, they have a poor understanding of the options for device deactivation and related ethical and legal implications. Deactivating an ICD or not performing a generator change is both legal and ethical, and is supported by guidelines from both sides of the Atlantic. Patient autonomy is paramount, and no patient is committed to any therapy that they no longer wish to receive. Left ventricular assist devices (LVADs) were initially used as bridge in patients awaiting heart transplantation, but they are currently implanted as destination therapy (DT) in patients with end-stage heart failure who have failed to respond to optimal medical therapy and who are ineligible for cardiac transplantation. The decision-making process for initiation and deactivation of LVAD is becoming more and more ethically and clinically challenging, particularly for elderly patients.

Avicenna's contribution to cardiology.

Ibn Sina, known in the West as Avicenna, was the most famous and influential of all the Islamic philosopher-scientists. His most important medical works are the Canon of Medicine medical encyclopedia and a treatise on cardiac drugs. His Canon of Medicine remained the standard text in both the East and West until the 16 th century. Avicenna′s description of cardiac diseases was logically presented perhaps for the first time in the history of medicine. Avicenna was the first to describe carotid sinus hypersensitivity, which presents with vasovagal syncope. He was a pioneer in pulsology and the first correct explanation of pulsation was given by Avicenna, after he refined Galen′s theory of the pulse. Besides, he discussed the action of available drugs on the heart in details and mentioned their indications and contraindications. In conclusion, Avicenna made important contributions to cardiology. This article describes some of his contributions in this field.

Differences in patient outcomes after conventional versus real time perfusion stress echocardiography in men versus women: a prospective randomised trial

Objective The purpose of our study was to determine whether sex affects the predictive value of perfusion and wall motion imaging obtained with real time myocardial contrast echocardiography (RTMCE) when compared with conventional stress echocardiography (CSE). Methods We prospectively enrolled 1649 age-matched men and women with intermediate pretest probability of coronary artery disease (CAD) undergoing stress echocardiography for suspicion of CAD. Patients with known CAD were excluded. Those who consented to participate in the study were randomised to undergo either CSE or RTMCE. Events were defined as death, non-fatal myocardial infarction (MI) and need for revascularisation. Results Median follow-up was 2.6 years (927 women, 722 men). Mean age was 58±13 years in both sexes. There were a total of 62 deaths, 12 MIs and 85 revascularisations with a 2-year event rate of 3.5% (95% CI 2.7% to 4.7%). Male sex was a significant independent predictor of adverse outcome (death, non-fatal MI) in both CSE and RTMCE (CSE HR 2.07, 95% CI 1.07 to 4.02, RTMCE HR 2.14; 95% CI 1.04 to 4.33). Higher 2-year event rates were noted in men in comparison with women after a normal CSE (men 5.4%, women 1.6%, p=0.02), but not after a normal RTMCE (men 5.8%, women 3.7%, p=0.41). Event rates were also significantly higher in men after an abnormal RTMCE (men 34.8%, women 16.4%, p=0.02) but no difference in outcome between sexes was observed after an abnormal CSE (men 17.8%, women 18.6%, p=0.90). Conclusions The addition of perfusion imaging with RTMCE improves the predictive value of stress echocardiography in men with no known CAD, but does not improve the predictive value in age-matched women.

Ostial coronary occlusion during TAVR in bicuspid aortic valve, should we redefine what is a safe ostial height?

Article history: Received 10 February 2016 Accepted 19 March 2016 Available online 24 March 2016 by the bicuspid leaflets (Fig. 2, A). We were able to wire down the RCA and performed percutaneous transluminal coronary angioplasty (PTCA) followed by stenting with a drug eluting stent with restoration of normal flow (Fig. 2, B). As the TEE showed more than mild perivalvular leak, we performed TAVR post-dilatationwith significant improvement. The patients post-operative course was complicated with a complete

Real-time 3-dimensional transesophageal echocardiography in the assessment of ventriculoatrial shunt (gerbode defect) complicating simultaneous mitral and tricuspid valve repair

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5][![Graphic][6] ][6] A 67-year-old man presented with worsening dyspnea 1 month after double mitral and tricuspid valve repair. Physical examination revealed high-pitched holosystolic murmur across the

Prognostic Value of Demand Stress Real-Time Perfusion Imaging in Patients With Advanced Kidney Disease Undergoing Renal Transplantation

Cardiovascular disease accounts for 50% to 60% of all deaths in patients with end-stage renal disease (ESRD) [(1)][1]. By adding myocardial perfusion (MP) imaging to wall motion (WM) analysis, real-time myocardial contrast echocardiography (RTMCE) increases the diagnostic sensitivity and prognostic

Critical congenital heart disease screening

Critical congenital heart disease (CCHD) is a heart lesion for which neonates require early surgical intervention to survive. Without intervention, the rates of mortality and survival with significant disability are extremely high. Early diagnosis can potentially improve health outcomes in newborns with CCHD. Until recent years, no routine screening protocol existed. In the last few years, pulse oximetry screening for CCHD in newborns has been added to the list of recommended uniform screening panels and advocated by several health-care authorities. A positive screening test result warrants an echocardiogram to evaluate for CCHD. Newborn screens do not usually require parental consent. However, most of the states mandates in the United States include a statement allowing exemption from the screen on the basis of parental religious or personal beliefs.