Rafael Kuperstein

Left Atrial Contractile Function Following a Successful Modified Maze Procedure at Surgery and the Risk for Subsequent Thromboembolic Stroke

OBJECTIVES The aim of this study was to evaluate whether certain post-Maze left atrial (LA) contractile profiles may pose a risk for ischemic stroke. BACKGROUND The mechanical contraction of the left atrium may be modified after the Maze procedure. Whether this imposes a risk for stroke, even in the presence of sinus rhythm and after removal of the LA appendage, is not known. METHODS Clinical, surgery-related, and echocardiographic data from 150 patients who underwent radiofrequency and cryoablation Maze procedures without the use of atrial incisions between 2004 and 2009 and were in sustained sinus rhythm were collected and analyzed. The occurrence of stroke was evaluated by reviewing clinical records. All stroke events were adjudicated by a neurologist. RESULTS At a mean follow-up time of 24.5 months, 15 patients (10%) had experienced ischemic strokes. Forty-seven patients (31%) had no evidence of LA mechanical contraction at 3 months after surgery (baseline assessment) and on follow-up echocardiography. Multivariate analysis showed that a lack of LA mechanical contraction at baseline was associated with a 5-fold increase in the risk for stroke (p = 0.02) during follow-up. Larger atria imposed a significant risk as well; LA volume index ≥33 ml/m(2) was associated with a 3-fold risk increase (p = 0.03). These effects were maintained regardless of the lack of mechanical valve implantation and anticoagulation treatment. CONCLUSIONS Absence of LA contraction and LA volume index ≥33 ml/m(2) result in a significant increase in the risk for thromboembolic stroke after the Maze procedure for patients in sinus rhythm.

Reliability of Visual Assessment of Global and Segmental Left Ventricular Function: A Multicenter Study by the Israeli Echocardiography Research Group

BACKGROUND The purpose of this multicenter study was to determine the reliability of visual assessments of segmental wall motion (WM) abnormalities and global left ventricular function among highly experienced echocardiographers using contemporary echocardiographic technology in patients with a variety of cardiac conditions. METHODS The reliability of visual determinations of left ventricular WM and global function was calculated from assessments made by 12 experienced echocardiographers on 105 echocardiograms recorded using contemporary echocardiographic equipment. Ten studies were reread independently to determine intraobserver reliability. RESULTS Interobserver reliability for visual differentiation between normal, hypokinetic, and akinetic segments had an intraclass correlation coefficient of 0.70. The intraclass correlation coefficient for dichotomizing segments into normal versus other abnormal was 0.63, for hypokinetic versus other scores was 0.26, and for akinetic versus other scores was 0.58. Similar results were found for intraobserver reliability. Interobserver reliability for WM score index was 0.84 and for left ventricular ejection fraction was 0.78. Similar values were obtained for the intraobserver reliability of WM score index and ejection fraction. Compared to angiographic data, the accuracy of segmental WM assessments was 85%, and correct determination of the culprit artery was achieved in 59% of patients with myocardial infarctions. CONCLUSION Among experienced readers using contemporary echocardiographic equipment, interobserver and intraobserver reliability was reasonable for the visual quantification of normal and akinetic segments but poor for hypokinetic segments. Reliability was good for the visual assessment of global left ventricular function by WM score index and ejection fraction.

Left Atrial Volume and the Benefit of Cardiac Resynchronization Therapy in the MADIT-CRT Trial

Background— Left atrial volume (LAV) is an important marker of heart failure (HF) severity. We hypothesized that LAV independently correlates with clinical outcomes in patients who receive cardiac resynchronization therapy with a defibrillator (CRT-D) and can be used for improved risk assessment in this population. Methods and Results— The benefit of CRT-D versus defibrillator-only therapy in reducing the risk of HF or death was assessed by LAV (dichotomized at the upper quartile >52 mL/m2) among 1785 patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) study. Landmark analysis was used to evaluate the relationship between LAV response to CRT-D and subsequent clinical outcomes. Multivariable analysis showed that patients with a higher baseline LAV experienced 69% (P<0.001) and 59% (P=0.02) increased hazard for HF or death and for all-cause mortality, respectively, independently of baseline left ventricular volume. CRT-D was associated with a significant reduction in LAV compared with defibrillator-only therapy (−28% versus −10%, respectively; P<0.001). Landmark analysis showed that after CRT-D implantation each 1% reduction in LAV was independently associated with a corresponding 4% reduction in the hazard of subsequent HF or death (P<0.001). The assessment of LAV change after CRT implantation improved prediction of clinical response to the device compared with assessment of the corresponding changes in left ventricular volume. Conclusions— LAV is an independent correlate of clinical outcomes in mildly symptomatic HF patients treated with CRT-D. CRT exerts pronounced reverse remodeling effects on the left atrium that independently correlate with improved clinical outcomes after device implantation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00180271.

A highly unusual right atrial mass presented in two women

Intravenous leiomyomatosis is a rare, benign neoplasm of the uterine, affecting adult women. We report two cases in whom intravenous leiomyomatosis extended through the inferior vena cava into the right heart chambers and the pulmonary artery. Both patients underwent staged operation with excision of the cardiac and primary tumour. The differential diagnosis of a right atrial mass in middle-aged women should include intravenous leiomyomatosis.

Late clinical outcome of transient intraoperative systolic anterior motion post mitral valve repair.

OBJECTIVE Systolic anterior motion (SAM) after mitral valve repair with significant mitral regurgitation requires immediate reintervention. Transient SAM immediately after repair is usually managed by hemodynamic maneuvers. We investigated the late clinical and echocardiographic significance of postoperative transient SAM. METHODS Between 2004 and 2013, mitral valve repair was performed on 549 consecutive patients with degenerative mitral valve disease. Of the 45 patients (8.2%) identified with postrepair SAM, 5 needed immediate reintervention. Hemodynamic maneuvers, such as preload and afterload augmentation and rate control, effectively abolished SAM in 40 patients (SAM). They were followed and compared with the remaining 509 patients (non-SAM). RESULTS Mean clinical follow-up was 54 ± 28 and 31 ± 26 months and was available in 100% and 95% (SAM and non-SAM) patients, respectively. One hospital death occurred in each group (P = .14). At follow-up, 2 patients (0.3%) showed significant SAM with left ventricular outflow tract obstruction, which resolved in 1 patient after beta-blocker therapy. SAM patients underwent exercise stress echocardiography: 1 patient showed left ventricular outflow tract obstruction that worsened after exercise. At 5 years, freedom from moderate or severe mitral regurgitation and New York Heart Association functional class III-IV was 85% versus 92% (P = .27) and 81% versus 92% (P = .15), and freedom from reoperation was 100% and 96% (P = .4), in SAM and non-SAM patients, respectively. CONCLUSIONS Late postoperative exercise stress echocardiogram revealed low incidence of SAM in patients with immediate postrepair transient SAM. All other late clinical outcomes were similar to those of non-SAM repair patients. Conservative management of intraoperative transient SAM is both successful and reliable.

Survival after intervention in patients with low gradient severe aortic stenosis and preserved left ventricular function.

OBJECTIVE The outcome of aortic valve replacement for patients with low gradient severe aortic stenosis and preserved ejection fraction has been debated. The aim of the present study was to evaluate the effect of aortic valve intervention on survival in that group. METHODS A cohort of 416 consecutive patients with low gradient severe aortic stenosis (aortic valve area, ≤ 1 cm(2); mean pressure gradient, <40 mm Hg) and preserved ejection fraction (≥ 50%) were identified from the Sheba Medical Center echocardiography database. Clinical data, aortic valve intervention, and death were recorded. RESULTS During an average follow-up of 28 months, of 416 study patients (mean age, 76 ± 14 years, 42% men), 97 (23%) underwent aortic valve intervention and 140 (32%) died. Mantel-Byar analysis showed that the cumulative probability of survival was significantly greater after aortic valve intervention. Multivariate analysis revealed a 49% reduction in the risk of death after surgery (P < .05). The survival benefit of aortic valve intervention was comparable with adjustment to older age, aortic valve area ≤ 0.8 cm(2), and a low (≤ 35 cm(2)/m(2)) or normal (>35 cm(2)/m(2)) stroke volume index. CONCLUSIONS Our findings suggest that aortic valve intervention is associated with improved survival among patients with low gradient severe aortic stenosis and preserved left ventricular function. The presence of either a low or normal stroke volume index did not affect the mortality benefit.

Effects of tricuspid valve regurgitation on clinical and echocardiographic outcome in patients with cardiac resynchronization therapy

AIMS The severity of tricuspid regurgitation (TR) is a predictor of outcome among heart failure patients. The interaction between cardiac resynchronization therapy (CRT) and TR has not been described. In this study, we examined the effect of pre-implant TR, and worsened TR post-implant, on response to CRT and overall survival. METHODS AND RESULTS We included all patients with successfully implanted CRT systems between 2007 and 2010. Patients were divided into two groups pre-implant: (Gp 1) no-or-mild TR; and (Gp 2) moderate-or-severe TR. Post-implant, patients were divided into two groups: (Gp A) improved or stable TR; and (Gp B) worsened TR. The clinical and echocardiographic outcome of all patients was assessed. The study included 193 patients. Thirty-five subjects (18%) had moderate or severe TR pre-implant (Gp 2). Baseline echo parameters and 6 min walk distance were worse in Gp 2 compared with Gp 1 (mild or no TR). There was no significant difference in clinical response to CRT between the two groups. However, Gp 2 had a significantly lower echocardiographic response (35 vs. 60%, P = 0.01) and higher mortality over 3 years (OR = 6.70, 95% CI = 1.8-24.5, P = 0.004). Post-implant, 25 patients (13%) developed worsened TR (Gp B), not associated with deterioration in right ventricle function or elevation in pulmonary artery pressure. Worsened TR predicted a reduced clinical response to CRT (42 vs. 70%, P = 0.006), when compared with Gp A. CONCLUSIONS The presence of baseline moderate or severe TR is associated with increased mortality but does not predict clinical or echocardiographic response to CRT. Patients with worsened TR following CRT are less likely to clinically respond to CRT. Pacing leads passing through the tricuspid valve may worsen TR. It is conceivable that avoidance of lead-induced TR by alternative implantation techniques could improve the response rate to CRT.

Effects of Tricuspid Valve Regurgitation on Outcome in Patients With Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) has a symptomatic and survival benefit for patients with heart failure (HF), but the percentage of nonresponders remains relatively high. The aims of this study were to assess the clinical significance of baseline tricuspid regurgitation (TR) or worsening TR after implantation of a CRT device on the response to therapy. This is a multicenter retrospective analysis of prospectively collected databases that includes 689 consecutive patients who underwent implantation of CRT. The patients were divided into groups according to baseline TR grade and according to worsening TR within 15 months after device implantation. Outcome was assessed by clinical and echocardiographic response within 15 months and by estimated survival for a median interquartile range follow-up time of 3.3 years (1.6, 4.6). TR worsening after CRT implantation was documented in 104 patients (15%). These patients had worse clinical and echocardiographic response to CRT, but worsening of TR was not a significant predictor of mortality (p = 0.17). According to baseline echocardiogram, 620 patients (90%) had some degree of TR before CRT implant. Baseline TR was an independent predictor of worse survival (p <0.001), although these patients had significantly better clinical and echocardiographic response compared with patients without TR. In conclusion, worsening of TR after CRT implantation is a predictor of worse clinical and echocardiographic response but was not significantly associated with increased mortality. Baseline TR is associated with reduced survival despite better clinical and echocardiographic response after CRT implantation.

An innovative appendage invagination procedure to reduce thrombus formation – a numerical model

Abstract Invagination is an innovative technique for closing the left atrial appendage (LAA) to reduce the risk of thrombi formation. The influence of LAA invagination on the flow fields in the atria was investigated based on a computational fluid dynamics. The simulation results demonstrated that the novel invagination process can eliminate low velocities (blood stasis) and low shear rate and thus decrease the risk of thrombus formation during atrial fibrillation. This innovative technique may enhance the clinical treatment of patients with atrial fibrillation by improving the atrial flow field while lowering the risk of creating emboli.

Reverse remodeling and the mechanism of mitral regurgitation improvement in patients with dilated cardiomyopathy.

BACKGROUND Functional mitral regurgitation (MR) is a common finding in dilated cardiomyopathy. Left ventricular (LV) reverse remodeling with LV size reduction and improvement in LV function is a well recognized phenomenon. We aimed to evaluate the impact of LV remodeling on the mechanism leading to functional MR. METHODS Among 188 patients with non-ischemic dilated cardiomyopathy, 10 patients significantly improved their LV function, reduced LV size and MR severity during follow-up (RRMR). A comparison was made between their baseline and follow-up echocardiographic examinations and to a matched-control group of patients who did not improve (no RRMR). LV and left atrium (LA) dimensions and volumes, LV mass (LVM), LV ejection fraction (LVEF) (Simpsons), sphericity index (SI), mitral valve tenting area (TA) coaptation distance (CD), effective regurgitant orifice (ERO), and regurgitant volume were calculated. Multivariable analysis was performed in order to evaluate which echocardiographic parameters related to MR improvement in reverse remodeling. RESULTS LV and LA dimensions and volumes, LVM, SI, TA, CD, ERO and right ventricle, in the RRMR group significantly decreased at follow-up (p < 0.04 for all). When compared to no RRMR, despite a similar ERO (0.2 ± 0.05 vs. 0.2 ± 0.08, p = 0.13) and a larger regurgitant volume (38 ± 9 vs. 29 ± 8 mL, p = 0.05) and despite similar clinical characteristics and medical treatment we found significantly higher LVEF, smaller LV dimensions and volumes, smaller LVM and SI in the RRMR group (p < 0.05 for all). On multivariable analysis the SI was the sole predictor of RRMR (p = 0.04, OR = 0.76, CI 0.58-0.99). CONCLUSIONS Reverse remodeling characterized by improvement in LV function, reduction in LV size and an associated reduction in MR severity is related to LV SI at baseline.