Srilakshmi M. Adhyapak

Intra-aortic balloon pump in toxic myocarditis due to aluminum phosphide poisoning.

IntroductionAluminum phosphide (ALP) is a pesticide that is highly toxic. It is a mitochondrial toxin that causes death by cardiac and metabolic toxicity. The most ominous effect is cardiac toxicity, which may range from minor electrocardiographic abnormalities to severe depression of cardiac contractility secondary to toxic myocarditis. There is no documented report of the use of Intra-aortic Balloon Pump (IABP) for toxic myocarditis from ALP poisoning, although it has been used effectively for toxic myocarditis due to other toxins.Case ReportWe are reporting a young female who presented with ALP poisoning, in cardiogenic shock due to myocarditis. We used an IABP for cardio-circulatory support until the effects of ALP resolved. She is the only reported survivor of ALP poisoning, presenting with cardiogenic shock.DiscussionSeveral reports describe the use of IABP for cardiogenic shock due to toxic myocarditis. There is no report in the medical literature using IABP for cardiogenic shock caused by ALP toxin-induced myocarditis. Our patient presented with cardio-circulatory shock, necessitating the use of inotropes and mechanical ventilation. As she did not improve despite ventilation and maximal doses of inotropes, IABP was used for cardio-circulatory support until the effects of ALP resolved.

Lessons from a mathematical hypothesis — modification of the endoventricular circular patch plasty

OBJECTIVE Surgical ventricular restoration has been the bailout therapy for end-stage heart failure due to ischemic cardiomyopathy in patients not suitable for cardiac transplantation. The recently concluded STICH trial has stated that surgical restoration of the left ventricle does not benefit this subgroup of patients clinically as compared with revascularization alone. The reasons for failure of this trial are multifactorial. The technique of surgical ventricular restoration employed in the STICH trial was circular endoventricular patch plasty. The various drawbacks related to this technique can be offset by a modification based on a mathematical hypothesis, which should result in a more physiological ventricular geometry, with consequent late reverse remodeling and improved left-ventricular performance. METHODS A total of 54 consecutive patients out of 102 patients with post-infarction left-ventricular aneurysms were studied before and 2 years after surgical ventricular restoration by linear endoventricular patch plasty using two-dimensional (2D) echocardiography and contrast ventriculography. RESULTS Linear endoventricular patch plasty resulted in a decrease in end-diastolic volume (EDV) of 40.2 ml (95% confidence interval (CI): 33.6, 46.7) and stroke volume (SV) of 10.0 ml (95% CI: 6.6, 13.5) and increase in ejection fraction (EF) of 6.7% (95% CI: 5.5, 7.9). There was a further 14% decrease in EDV and SV (30%) at 2 years with increase in EF (20%). There was a persistent significant improvement in sphericity index. The changes in EDV and SV were linearly related (r=0.72, p<0.001) and persisted at 2 years following surgery. The change in EDV was linearly related to the EF (r=0.35, p=0.02). The left-ventricular shape analysis showed improvements in the anterior and anterolateral segments (effect size=1.1, p<0.001) with nonsignificant changes in the inferior segments, conforming to an ellipsoid geometry. CONCLUSIONS Linear endoventricular patch plasty restored a physiological elliptical ventricular geometry with persistent late reverse remodeling. The decreases in EDVs following surgery were significantly linearly proportional to the decreases in SVs at rest, which conforms to the normal left-ventricular geometry.

Effect of right ventricular function and pulmonary pressures on heart failure prognosis.

The relationship of right ventricular function and pulmonary systolic pressure in patients with congestive heart failure was evaluated to risk-stratify them. The study included 147 consecutive patients with symptomatic heart failure who underwent clinical and laboratory examination and echocardiography including Doppler tissue echocardiography. They were followed for a mean of 11.2+/-6.4 months. During follow-up, 16 patients died and 45 patients had nonfatal cardiac events. There were 60 readmissions for heart failure. Pulmonary artery systolic pressure and right ventricular systolic function were inversely related (r(2)=0.66, P<.001). On Cox multivariate survival analysis, early worsening of pulmonary arterial pressures was an independent prognostic predictor (hazard ratio, 0.44; confidence interval, 0.28-0.91, P=.024). The patients with pulmonary hypertension and right ventricular systolic dysfunction had the worst prognosis. The assessments of right ventricular function help to risk-stratify patients with heart failure. The early worsening of pulmonary hypertension is a powerful predictor of worse prognosis.

Rapid Quantification of Mean Myocardial Wall Velocity in Ischemic Cardiomyopathy by Cardiac Magnetic Resonance: An Index of Cardiac Functional Abnormalities during the Cardiac Cycle

Background: Characterization of regional Left Ventricular (LV) function in Heart Failure (HF) patients may have application in assessing response and choice of HF therapy. Methods: 4D LV endocardial function from cine cMR data in 12 NYHA Class III /IV Heart Failure (HF) patients with antero-apical aneurysms was compared against normal controls. The endocardial surface contours were extracted at each cardiac phase using Medviso Segment. An in-house plugin was used to compute a signed Hausdorff Distance (HD), establishing point-correspondences between endocardial segmentations at consecutive cardiac phases and tracking their surface motion throughout the cardiac cycle. The LV averaged myocardial velocity, was computed based on phase-to-phase displacement at several uniformly spaced endocardial surface points and the displacement histories of each point were recorded. The average and standard deviation in the endocardiumaveraged displacement history characteristic curves for the HF patients and normal controls were compared. Results: The endocardium-averaged phase-to-phase displacement history curves of HF cohort revealed diminished displacement magnitudes; and indistinct individual end-systolic and diastole instants with large standard deviations across the LV. When the cumulative phase to phase displacement plots for controls and HF patients were compared, there was a statistically significant difference between the two characteristic curves during the ejection phase, early filling phase of diastole, and the end diastolic phase. Conclusions: Shape-based Mean Myocardial Velocity (MMV) characterization constitutes a promising paradigm which may have application to prognosticate response to therapy.

Syphilitic Aortitis: An Uncommon Cause of Acquired Aortopulmonary Fistula

Cardiovascular syphilis has become a medical curiosity with the advent of widespread use of penicillin for the treatment of early syphilis. We report a case of a 37-year-old man who presented with sudden onset breathlessness that worsened insidiously for 1 year. Diagnosis of syphilitic aortopulmonary fistula was confirmed by aortography, contrast computed tomography, and histopathology. The patient underwent successful surgical correction. A high level of suspicion and awareness is needed for the diagnosis of this now rare disease. This entity is only amenable to surgical correction, even as existing surgical techniques need constant improvisation and individualization to each patient.

Restoration of optimal ellipsoid left ventricular geometry: lessons learnt from in silico surgical modelling

OBJECTIVES Several issues that are inherent in the surgical techniques of surgical ventricular restoration (SVR) need specialized devices or techniques to overcome them, which may not always result in optimal outcomes. We used a non-invasive novel in silico modelling technique to study left ventricular (LV) morphology and function before and after SVR. The cardiac magnetic resonance imaging derived actual pre- and postoperative endocardial morphology and function was compared with the in silico analysis of the same. METHODS Cardiac magnetic resonance steady state free precession (SSFP) cine images were employed to segment endocardial surface contours over the cardiac cycle. Using the principle of Hausdorff distance to examine phase-to-phase regional endocardial displacement, dyskinetic/akinetic areas were identified at the instant of peak basal contraction velocity. Using a three-dimensional (3D) surface clipping tool, the maximally scarred, dyskinetic or akinetic LV antero-apical areas were virtually resected and a new apex was created. A virtual rectangular patch was created upon the clipped surface LV model by 3D Delaunay triangulation. Presurgical endocardial mechanical function quantified from cine cardiac magnetic resonance, using a technique of spherical harmonics (SPHARM) surface parameterization, was applied onto the virtually clipped and patched LV surface model. Finally, the in silico model of post-SVR LV shape was analysed for quantification of regional left ventricular volumes (RLVVs) and function. This was tested in 2 patients with post-myocardial infarction antero-apical LV aneuryms. Left ventricular mechanical dysynchrony was evaluated by RLVV analysis of pre-SVR, in silico post-SVR and actual post-SVR LV endocardial surface data. RESULTS Following exclusion of the scarred areas, the virtual resected LV model demonstrated significantly lesser areas of akinesia. The decreases in regional LV volumes in the in silico modelling were significant and comparable with the actual decreases following SVR. Both the regional end diastolic volume (EDV) and end systolic volume (ESV) at the apex decreased significantly corresponding to greater reductions in apical volumes by the technique of rectangular patch plasty (apical EDV 2.1607 ± 0.20577 to 0.4774 ± 0.1775 ml, P = 0.007; apical ESV 1.9708 ± 0.36451 to 0.442 ± 0.047 ml, P = 0.013). CONCLUSIONS This pilot study was done using novel in silico techniques for virtual surgical modelling, which helped in accurate estimation and planning of optimal LV restoration by SVR.

Characteristics of a subset of patients with reversible systolic dysfunction in chronic kidney disease.

There exists a subgroup of uremic cardiomyopathy patients who experience resolution of heart failure symptoms with recovery of normal cardiac geometry following hemodialysis. The authors studied 52 patients with chronic kidney disease on hemodialysis over a period of 190 days. There were 29 patients with systolic dysfunction (left ventricular ejection fraction <40%). Twenty-three patients with preserved systolic function had diastolic dysfunction. Of the 29 patients with systolic dysfunction, 10 patients had significant improvement in New York Heart Association functional class and left ventricular internal diameter in diastole (LVIDd: 59.8 ± 2.6-55.92 mm and left ventricular internal diameter in systole [LVIDs]: 51.8 ± 1.8-34 ± 1.2 mm; P < .001) with significant increases in left ventricular ejection fraction (30.55%-50.14%; P < .001). These patients had the highest baseline serum levels of troponin I (P = .024), which decreased significantly with recovery of cardiac function. When the entire study group was regrouped as those below and those above the median change of C-reactive protein (CRP), patients with CRP greater than the median change had significant improvements in LVIDs and ejection fraction. A subgroup of patients with uremic cardiomyopathy who demonstrated reversible left ventricular systolic dysfunction had high levels of serum troponin I levels at presentation, which regressed with recovery of ventricular function in parallel with CRP levels.

Analysis of Cardiac MRI Based Regional Timing of Left Ventricular Mechanical Contraction as a Biomarker for Electrical Dyssynchrony in Heart-Failure Patients

Cardiac resynchronization therapy (CRT) is relatively new treatment for symptoms associated with congestive heart failure (HF) which is achieved by simultaneously pacing both the left and right ventricles of the heart. Current clinical guidelines support the use of CRT in moderate or severe HF patients with a left ventricular (LV) ejection fraction of ≤35% and a prolonged QRS interval (≥120 ms), characteristic of electrical dyssynchrony. Several clinical studies have reported high non-response rates to CRT and have questioned the accuracy of currently practiced patient-selection criteria for this therapy. In this study we demonstrate the translational application of medical imaging biomarkers of phase of ventricular contraction quantified from cardiac magnetic resonance (CMR) imaging, in defining correlations between mechanical dysynchrony (MD) and electrical dyssynchrony, in an effort to identify a means to relate the best-practices for positioning an LV pacing lead (viz. localized to the latest mechanically activating, non-scarred regions) with the clinical guidelines for electrical dyssynchrony in a cohort of heart failure (HF). We retrospectively examine two cohorts of HF patients with different electrical conduction characteristics: a) Left bundle branch block (LBBB) and wide QRS interval – defining the Class I indication for CRT – characteristic of electrical dyssynchrony as evidenced from electrocardiograms; and b) HF with large antero-apical aneurysms and scarring but narrow QRS interval. Indices of mean and standard deviation in phase of regional contraction were examined across the entire LV of each patient, including scarred territories. Additionally, contraction timing delay between the septal and lateral cardiac walls were also examined in the basal LV territories which were free from adverse remodelling and scar. The results from this pilot study show that MD assessment using CMR imaging based biomarkers of phase of LV contraction is highly accurate in predicting electrical dyssynchrony defined by QRS duration ≥150 ms, with receiver operator characteristics evidencing close to perfect accuracy when MD was analyzed in LV territories which excluded scar.

Restoration of optimal left ventricular apical geometry and rotation following surgical ventricular restoration using rectangular patch plasty technique: a pilot study using cardiac magnetic resonance

OBJECTIVES Clinical outcomes of surgical ventricular restoration (SVR) have been confirmed by Registry data. Accurate assessment of left ventricular (LV) morphology and function can help optimize these outcomes. METHODS LV remodelling in 7 patients (NYHA class 3 ± 1.2) with post-myocardial infarction LV aneurysms was characterized by the regional LV volume (RLVV) computed by dividing the LV in cine steady-state free precession cardiac magnetic resonance imaging (CMR) at each slice level into six radial segments. Rotation of the LV apex and base was analysed using tagged CMR. The apical conicity ratio was used to characterize the restored apical geometry. RESULTS The mean end-diastolic volume (EDV) was 174.8 ± 100.3 ml and the mean ejection fraction (EF) was 18.8 ± 7.8%. Following SVR, all patients had significant clinical improvements (NYHA Class I), and significant increases in the left ventricular ejection fraction (LVEF) to 38.8 ± 4.4%. The LV volumes and regional volumes at the base and apex decreased with a trend towards significance. The mean preoperative apical conicity ratio (ACR) was 1.90 ± 0.43 and, following SVR by endoventricular linear patch plasty (EVLPP), was 1.35 ± 0.3 (P = 0.02). The percent decrease in the ACR following SVR from baseline was 28.68 ± 10.98%. The apical EF increased from 1.19 ± 13.9 to 15.8 ± 8.2% (P = 0.028). The basal rotations improved from 3.13 ± 2.1 to 4.69 ± 2.94° (P = 0.04). The apical rotations also improved significantly from 2.48 ± 1.23 to 3.93 ± 2.45° (P = 0.05) and reversed to the normal anticlockwise direction. CONCLUSIONS SVR by geometric repair using a rectangular intracavitary patch helps restoration of a physiological apex with normalization of apical rotation reflecting a near-physiological LV function.

The association of severity of retinal vascular changes and cardiac remodelling in systemic hypertension

Objectives: The aim of the study was to explore the association between hypertensive retinopathy, grades of retinopathy and cardiac remodelling. Methods: This was a cross-sectional observational study. A total of 500 consecutive hypertensive adults from the in-patient population were studied for the presence of hypertensive retinopathy by dilated fundoscopy. The presence of cardiac remodelling due to hypertension was studied both by electrocardiography (ECG) and echocardiography. Hypertensive target organ damage in other organs was also screened. In addition, the association of grades of hypertensive retinopathy with target organ damage was also analyzed. Results: Systolic blood pressure (BP) at presentation and duration of hypertension showed no relationship with markers of hypertensive heart disease. However, diastolic BP was significantly higher in patients with retinopathy. Hypertensive retinopathy was diagnosed in 324 subjects of whom 90 had grades 3 and 4 retinopathy. Patients with grades 3 and 4 retinopathy had significant associations with ECG evidence of left ventricular (LV) strain pattern and left atrial enlargement, and a weaker association with left ventricular hypertrophy (LVH) using QRS voltage criteria (Sokolov–Lyon). On echocardiography, grades 3 and 4 retinopathy were significantly associated with LVH, left atrial enlargement and reduced left ventricular ejection fraction (LVEF), as well as with higher creatinine values. A large number of these patients presented with heart failure. Cardiac remodelling was not seen in patients without retinopathy and was uncommon in patients with grades 1 and 2 retinopathy. Conclusion: Grades 3 and 4 retinopathy demonstrated a significant association with LV strain pattern and left atrial enlargement on ECG, LVH and reduced LVEF on echocardiography as well as with heart failure. There was no relationship with systolic BP and duration of hypertension, while diastolic BP showed a significant positive correlation. Signs of hypertensive heart disease were practically absent in patients without hypertensive retinopathy and uncommon in those with grade 1–2 alterations.