Nina Ghosh

Association of Blood Pressure at Hospital Discharge With Mortality in Patients Diagnosed With Heart Failure

Background—Higher blood pressure in acute heart failure has been associated with improved survival; however, the relationship between blood pressure and survival in stabilized patients at hospital discharge has not been established. Methods and Results—In 7448 patients with heart failure (75.2±11.5 years; 49.9% men) discharged from the hospital in Ontario, Canada, we examined the association of systolic blood pressure (SBP) and diastolic blood pressure with long-term survival. Parametric survival analysis was performed, and survival time ratios were determined according to discharge blood pressure group. A total of 25 427 person-years of follow-up were examined. In those with left ventricular ejection fraction ≤40%, median survival was decreased by 17% (survival time ratio, 0.83; 95% CI, 0.71 to 0.98; P=0.029) when discharge SBP was 100 to 119 mm Hg and decreased by 23% (survival time ratio, 0.77; 95% CI, 0.62 to 0.97; P=0.024) when discharge SBP was <100 mm Hg, compared with those in the reference range of 120 to 139 mm Hg. Survival time ratios were 0.75 (95% CI, 0.60 to 0.92; P=0.007) and 0.75 (95% CI, 0.53 to 1.07; P=0.12) when discharge SBPs were 140 to 159 and ≥160 mm Hg, respectively. In those with left ventricular ejection fraction >40%, survival time ratios were 0.69 (95% CI, 0.51 to 0.93), 0.83 (95% CI, 0.71 to 0.99), 0.95 (95% CI, 0.80 to 1.14), and 0.76 (95% CI, 0.61 to 0.95) for discharge SBPs <100, 100 to 119, 140 to 159, and ≥160 mm Hg, respectively. Conclusions—In this long-term population-based study of patients with heart failure, the association of discharge SBP with mortality followed a U-shaped distribution. Survival was shortened in those with reduced or increased values of discharge SBP.

Computed tomography and echocardiography in patients with acute pulmonary embolism: part 2: prognostic value.

Purpose: The aim of the study was to compare the prognostic value of right ventricular (RV) dysfunction detected on computed tomography pulmonary angiography (CTPA) and transthoracic echocardiography (TTE) in patients with acute pulmonary embolism (PE). Materials and Methods: From all consecutive CTPAs performed between August 2003 and May 2010 that were positive for acute PE (n=1744), those with TTE performed within 48 hours of CTPA (n=785) were selected as the study cohort. Multivariate logistic regression analysis was performed to assess the association of CTPA RV/left ventricular (LV) diameter ratio and TTE RV strain with PE-related 30-day mortality, including other associated factors as covariates. The predictive ability (area under the curve) was compared between the model including the CT RV/LV diameter ratio and that including TTE RV strain. Test characteristics of the 2 modalities were calculated. Results: Both CT RV/LV diameter ratio and TTE RV strain were independently associated with PE-related 30-day mortality (adjusted odds ratio=1.14, P=0.023 for 0.1 increment of the CT RV/LV diameter ratio; and odds ratio=2.13, P=0.041 for TTE RV strain). History of congestive heart failure and malignancy were independent predictors of PE-related mortality, while there was significantly lower mortality associated with anticoagulation use. The model including TTE RV strain and that including CT RV/LV had similar predictive ability (area under the curve=0.80 vs. 0.81, P=0.50). The sensitivity, specificity, and positive and negative predictive values of TTE RV strain and CT RV/LV diameter ratio at a cutoff of ≥1.0 were similar for PE-related 30-day mortality. Conclusions: Both RV strain on TTE and an increased CT RV/LV diameter ratio are predictors of PE-related 30-day mortality with similar prognostic significance.

Computed tomography and echocardiography in patients with acute pulmonary embolism: part 1: correlation of findings of right ventricular enlargement.

Purpose: To evaluate the correlation between the computed tomography (CT)-derived right ventricle (RV) to left ventricle (LV) diameter ratio and the RV size determined by echocardiography in patients with acute pulmonary embolism. Materials and Methods: Consecutive CT pulmonary angiography examinations (August 2003 to May 2010) from a single, large, urban teaching hospital were retrospectively reviewed. For a cohort of 777 subjects who underwent echocardiography within 48 hours of the CT acquisition, the qualitative RV size (divided into 5 categories) extracted from the echocardiography report was correlated with the CT-derived RV/LV diameter ratio. Results: There was moderate correlation (Spearman rank correlation coefficient=0.54, P<0.001) between the CT-derived RV/LV ratio and the RV size as determined by echocardiography. The correlation coefficient and the concordance rate were inversely related to the time difference between the acquisitions of the 2 modalities. Conclusions: CT and echocardiography findings to assess the RV size after acute pulmonary embolism have moderate correlation.

Diagnostic and prognostic value of myocardial blood flow quantification as non-invasive indicator of cardiac allograft vasculopathy

Aims Cardiac allograft vasculopathy (CAV) is a leading cause of death in orthotopic heart transplant (OHT) survivors. Effective non-invasive screening methods are needed. Our aim was to investigate the added diagnostic and prognostic value of myocardial blood flow (MBF) to standard myocardial perfusion imaging (MPI) with positron emission tomography (PET) for CAV detection. Methods and results We studied 94 OHT recipients (prognostic cohort), including 66 who underwent invasive coronary angiography and PET within 1 year (diagnostic cohort). The ISHLT classification was used as standard definition for CAV. Positron emission tomography evaluation included semiquantitative MPI, quantitative MBF (mL/min/g), and left ventricular ejection fraction (LVEF). A PET CAV severity score (on a scale of 0-3) was modelled on the ISHLT criteria. Patients were followed for a median of 2.3 years for the occurrence of major adverse events (death, re-transplantation, acute coronary syndrome, and hospitalization for heart failure). Sensitivity, specificity, positive, and negative predictive value of semiquantitative PET perfusion alone for detecting moderate-severe CAV were 83% [52-98], 82% [69-91], 50% [27-73], and 96% [85-99], respectively {receiver operating characteristic (ROC area: 0.82 [0.70-0.95])}. These values improved to 83% [52-98], 93% [82-98], 71% [42-92], and 96% [97-99], respectively, when LVEF and stress MBF were added (ROC area: 0.88 [0.76-0.99]; P = 0.01). There were 20 major adverse events during follow-up. The annualized event rate was 5%, 9%, and 25% in patients with normal, mildly, and moderate-to-severely abnormal PET CAV grading (P < 0.001), respectively. Conclusion Multiparametric cardiac PET evaluation including quantification of MBF provides improved detection and gradation of CAV severity over standard myocardial perfusion assessment and is predictive of major adverse events.

Serial Classic and Inverted Pattern Takotsubo Cardiomyopathy in a Middle-Aged Woman

We report the case of a 56-year-old woman with no significant medical history who was diagnosed with recurrent Takotsubo cardiomyopathy with variations in ventricular regional involvement including the classic and inverted patterns. She presented on 3 separate occasions with these findings; emotional stressors provoked all presentations. We present echocardiography, cardiac catheterization, and magnetic resonance images from her consecutive presentations. This case of emotional stress repeatedly eliciting classic and inverted forms of Takotsubo cardiomyopathy within the same patient highlights the importance of elucidating the pathological mechanisms of regional ventricular dysfunction.

Utility of multimodality imaging in diagnosis and follow-up of aortitis.

A 47-year-old male of European descent without any cardiac risk factors initially presented in 2005 with chest discomfort precipitated by emotional stress. Figure 1 illustrates work-up with multiple non-invasive cardiac imaging and invasive angiography studies prior to referral with suspected aortitis in 2013. At the time of his evaluation in 2013, he continued to have fleeting episodes of chest discomfort with emotional stress. Review of symptoms included recurrent aphthous ulcers and acne. Serologic work-up for relevant immunologic and infectious etiologies was negative, except for mildly elevated high sensitivity-C reactive protein (2.8 mg/L). Based on the findings of multimodality imaging in 2013, which included magnetic resonance angiogram (MRA) (limited due to motion), computed tomography angiogram (CTA) and Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG-PET/CT) (Figure 2) and chronic symptoms with serologic work-up, a diagnosis of aortitis of undetermined etiology vs Behcet’s disease was considered. Follow-up imaging on corticosteroid therapy (initial high dose of prednisone 50 mg daily followed by taper to 20 mg) (Figure 3) and after termination of steroid therapy (Figure 4) demonstrated initial improvement followed by recrudescence.

Multimodality non-invasive imaging of a coronary cameral fistula

A 69-year-old asymptomatic man was referred for transthoracic echocardiography to evaluate a diastolic heart murmur. Colour and pulse Doppler imaging demonstrated prominent diastolic transmyocardial flow from the epicardial surface into the left ventricular cavity (Supplementary data online, Video S1 ; Panels A and B ), and an intramyocardial diastolic, bi-directional colour flow Doppler signal suggestive of tortuous epicardial vessels ( Panel C …

Evaluation of Bend Relief Disconnection in Patients Supported by a HeartMate II Left Ventricular Assist Device

Left ventricular assist devices (LVADs) are an established treatment for patients with end-stage heart failure as either a bridge to cardiac transplantation1 or as lifelong support, also known as destination therapy.2 The HeartMate II (HM II) LVAD (Thoratec Corporation, Pleasanton, CA) is a continuous-flow device that was approved by the US Food and Drug Administration in 2008, after a pivotal trial in 133 patients awaiting transplantation.3 More patients have been implanted with the HM II than any other durable LVAD. Actuarial survival with continuous-flow LVADs has improved to 80% at 1 year and 70% at 2 years, leading to a growing population of patients with heart failure living with long-term mechanical circulatory support.4 The HM II titanium axial flow rotary pump is placed in the abdominal musculature or within a preperitoneal pocket in the left upper quadrant. Blood enters the LVAD via an inflow cannula at the LV apex and exits through an outflow cannula connected via a graft to the ascending aorta. The outflow bend relief is a polytetrafluoroethylene tube at the junction of the outflow cannula and the pump housing designed to prevent kinking of the outflow cannula. In February 2010, Thoratec modified the outflow cannula bend relief with a snap ring design that allowed disconnection of the bend relief to facilitate assessment of the underlying cannula for bleeding or malposition. Between February 2010 and February 2012, the manufacturer distributed >3800 modified outflow cannula bend reliefs to 226 hospitals and distributors worldwide. In April 2012, the US Food and Drug Administration issued a class I recall for the HM II LVAD after reports of disconnection of the bend relief from the outflow grafts.5 The initial reported worldwide incidence of disconnected outflow graft bend reliefs was 0.75% (29 of 3852 patients), with 1 death …

It’s Time to Study Cardiac Magnetic Resonance Imaging as a Strategic Tool in Nonischemic Cardiomyopathy

Left ventricular systolic dysfunction without overt symptoms of heart failure is a common problem, with a prevalence of ranging from 0.9% to 20.8% in the general population depending on the definition of left ventricular systolic dysfunction and age group studied.1–4 The morbidity and mortality of this condition remain significant. In the SOLVD (Studies Of Left Ventricular Dysfunction) prevention trial, 30% of untreated participants progressed to clinical heart failure and experienced a high mortality rate.5 Although medical treatment reduces mortality, heart failure hospitalizations, and improves adverse remodeling,6,7 better strategies for monitoring and guiding treatment are necessary. The need for more effective methods of risk stratification is heightened by the observation that the natural history of nonischemic dilated cardiomyopathy (NIDCM) is highly variable.8 Methods to identify subgroups of patients with NIDCM who are at higher risk of adverse outcomes, especially sudden cardiac death and heart failure hospitalization, may help allocate potentially costly therapy to those who would benefit the most or to target yet unproven therapies to those most likely to benefit. Beyond medical treatments, evidence on the appropriate use of invasive strategies such as novel instruments to monitor hemodynamic status in this patient population is limited. Detection of fibrosis by late gadolinium enhancement (LGE) imaging by cardiac magnetic resonance (CMR) is a promising tool for the risk stratification in this patient population. Fibrosis reduces left ventricular compliance, affects adverse remodeling, and creates a substrate for re-entry ventricular tachycardia. Therefore, the presence of myocardial LGE would provide a logical risk marker for future adverse events relating to either mechanical pump function impairment or ventricular dysrhythmias. Article see p 448 In this issue of Circulation: Heart Failure , Masci et al …

Multimodality Imaging for the Assessment of Total Artificial Heart Function : Complementary Utility of 2- and 3-Dimensional Transesophageal Echocardiography and Computed Tomography

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 37-year-old man with a history of heart transplantation developed graft dysfunction and underwent total artificial heart (TAH) implantation. Post-implantation, the patient developed hypoxemia. Chest radiograph (A) showed