Taiyeb M. Khumri

Acute Mortality in Hospitalized Patients Undergoing Echocardiography With and Without an Ultrasound Contrast Agent : Results in 18,671 Consecutive Studies

OBJECTIVES We sought to define acute mortality in hospitalized patients undergoing clinically indicated echocardiography with and without use of an ultrasound contrast agent. BACKGROUND The U.S. Food and Drug Administration recently issued a boxed warning and new contraindications for the perflutren-containing ultrasound contrast agents following post-marketing reports of 4 patient deaths that were temporally related to Definity (Bristol-Myers Squibb Medical Imaging, Billerica, Massachusetts) administration. To appreciate the incremental risk of any medical procedure, the ambient risk of untoward outcome in the population in question must first be defined. There are no published data on short-term major adverse cardiac events in hospitalized patients undergoing echocardiography, either with or without administration of an ultrasound contrast agent. METHODS A retrospective analysis of hospitalized patients undergoing clinically indicated echocardiography between January 2005 and October 2007, within Saint Lukes Health System, Kansas City, Missouri, was performed. Studies were separated into 2 groups, those performed without contrast enhancement (n = 12,475) and those performed with Definity (n = 6,196). Vital status within 24 h of the echocardiographic study was available for all patients using a combination of the Social Security Death Master File and Saint Lukes Health System medical records. Incidence of death within 24 h was compared by chi-square test between Definity and unenhanced procedures. RESULTS Of the 18,671 patient events, 72 patients died within 24 h. Of those that underwent unenhanced echocardiography, 46 died within 24 h (0.37%). Of patients receiving Definity during the echocardiogram, 26 died within 24 h (0.42%). There was no statistical difference between these 2 groups (p = 0.60). No patient died within 1 h of the echocardiographic study. In a random sampling from the unenhanced (n = 201) and Definity groups (n = 202), patients who underwent Definity-enhanced echocardiography exhibited higher clinical acuity, and more significant comorbidities. CONCLUSIONS Approximately 0.4% of hospitalized patients die within 24 h of echocardiography. There is no increased mortality risk associated with Definity-enhanced examinations, despite evidence for higher clinical acuity and more comorbid conditions in patients undergoing contrast studies.

Echocardiographic Dyssynchrony and Health Status Outcomes From Cardiac Resynchronization Therapy: Insights From the PROSPECT Trial

OBJECTIVES This study sought to assess the prognostic utility of echocardiographic dyssynchrony for health status improvement after cardiac resynchronization therapy (CRT). BACKGROUND Echocardiographic measures of dyssynchrony have been proposed for patient selection for CRT, but prospective validation studies are lacking. METHODS A prospective cohort of 324 patients from 53 centers with moderate to severe heart failure, left ventricular dysfunction, QRS > or =130 ms, and available echocardiographic and health status information were identified from the PROSPECT (Predictors of Response to Cardiac Re-Synchronization Therapy) trial, which evaluated the prognostic utility of dyssynchrony measures in CRT recipients. The association of 12 echocardiographic dyssynchrony parameters with 6-month improvement in health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), was assessed both as a continuous variable and by responder status (DeltaKCCQ > or =+10 points reflecting moderate to large improvement). RESULTS Of 12 pre-defined dyssynchrony parameters, only 3 were consistently reported: interventricular mechanical delay (IVMD), left ventricular filling time relative to the cardiac cycle (LVFT), and left ventricular pre-ejection interval. After multivariable adjustment, IVMD (+5.18, 95% confidence interval [CI]: +0.76 to +9.60; p = 0.02) and LVFT (+5.19, 95% CI: +0.45 to +0.94; p = 0.03) were independently associated with 6-month improvements in KCCQ. Patients with 6-month improvements in KCCQ had lower subsequent mortality (adjusted hazard ratio [HR] for each 5-point improvement: 0.83; 95% CI: 0.72 to 0.93; p = 0.03). Additionally, IVMD was associated with CRT responder status (for DeltaKCCQ > or =+10 points: odds ratio [OR]: 1.85; 95% CI: 1.12 to 3.05; p = 0.03), whereas LVFT was not (OR: 1.63; 95% CI: 0.85 to 3.11; p = 0.14). Patients classified as health status responders had a 76% lower subsequent risk of all-cause mortality (adjusted HR: 0.24; 95% CI: 0.07 to 0.84; p = 0.03). CONCLUSIONS The presence of pre-implantation IVMD and LVFT was associated with 6-month health status improvement, and IVMD was associated with a significant CRT response. These echocardiographic factors may help clinicians counsel patients regarding their likelihood of symptomatic improvement with CRT. ( PROSPECT Predictors of Response to Cardiac Re-Synchronization Therapy; NCT00253357).

Mortality Rates and Clinical Predictors of Reduced Survival After Cardioverter Defibrillator Implantation

We aimed to identify mortality rates and clinical predictors of reduced survival in a large cohort of patients after implantation of an implantable cardioverter-defibrillator (ICD). Although existing data from clinical trials report annual mortality after ICD implantation from 2% to 9%, there are few data available on mortality rates or predictors of reduced survival in this patient population in clinical practice. In this single-center, retrospective analysis of 286 patients who underwent ICD implantation between June 1, 2000 and December 30, 2003, candidate predictors of mortality were assessed and subjected to multivariable analysis. Outcomes were documented using the Social Security Death Master File and hospital medical records. Overall annualized mortality was 11.3% after ICD implantation. Mortality rates in patients with left ventricular ejection fraction (LVEF) <25% were 27.2% at 1 year and 50.5% at 3 years. Digoxin (hazard ratio 1.86, 95% confidence interval [CI] 1.21 to 2.86, p = 0.0046) and loop diuretics (hazard ratio 1.59, 95% CI 1.06 to 2.38, p = 0.024) were associated with reduced survival. Angiotensin-converting enzyme inhibitor or aldosterone receptor blocker use was associated with reduced mortality (hazard ratio 0.50, 95% CI 0.31 to 0.80, p = 0.0038). In conclusion, mortality after ICD implantation is higher than demonstrated in primary or secondary prevention ICD trials; LVEF remains a potent predictor of mortality after ICD implantation, particularly in patients with an LVEF <25%; loop diuretic and digoxin use is associated with an approximate twofold increase in mortality in this population; and angiotensin-converting enzyme inhibitor or aldosterone receptor blocker use is associated with improved survival after ICD implantation.

Usefulness of left ventricular diastolic dysfunction as a predictor of one-year rehospitalization in survivors of acute myocardial infarction.

Presence of severe left ventricular (LV) diastolic function has been shown to independently predict risk of heart failure or death after acute myocardial infarction (AMI). We aimed to determine whether common echocardiographic parameters and (LV) diastolic function evaluated during AMI hospitalization can predict the risk of rehospitalization, up to 1 year after AMI. One hundred ninety consecutive patients with AMI, who were prospectively enrolled in a longitudinal post-AMI registry, had survived for 1 year, and had a clinically indicated echocardiogram during the index admission, were included in the study. The independent effect of diastolic dysfunction on 1-year all-cause rehospitalization was assessed using multivariable proportional hazards regression. Average age was 62.5 years, 93% were Caucasian, 66% were men, and mean LV ejection fraction was 46%. At 1 year, 78 patients (41%) had been rehospitalized >or=1 time. In multivariable analysis, presence of severe LV diastolic dysfunction was the only echocardiographic variable that predicted increased risk of rehospitalization 1 year after AMI (hazard ration 3.31, 95% confidence interval 1.26 to 8.69). Seventy-eight percent of patients with severe LV diastolic dysfunction (restrictive diastolic physiology) compared with 30% with normal diastolic function (p = 0.0052) and 37% with nonrestrictive physiology during the index admission were rehospitalized. In conclusion, severe LV diastolic dysfunction is the only echocardiographic predictor of rehospitalization in survivors of AMI and routine assessment of diastolic function during AMI hospitalization can provide additional prognostic risk stratification at dismissal.

Apical Pseudoaneurysm Following Continuous Flow Left Ventricular Assist Device Placement

The HeartMate II continuous flow left ventricular assist device (LVAD) (Thoratec Inc) provides circulatory support for patients with medically refractory systolic heart failure as both a bridge to transplantation and destination therapy. Although left ventricular apical pseudoaneurysm has rarely been reported with first-generation pulsatile flow LVADs, this has not been previously reported with the HeartMate II device.1–3 A 25-year-old woman with advanced heart failure secondary to nonischemic cardiomyopathy underwent LVAD implantation with the HeartMate II device as a planned bridge to transplantation. In the early postoperative period, she experienced left-sided chest pain exacerbated with movement and reproduced with palpation. She also experienced …

Combined assessment of myocardial perfusion and diastolic function enhances risk stratification in patients with anterior wall myocardial infarction.

Objective: Evaluate the utility of a combined risk stratification scheme including diastolic dysfunction and “no‐reflow,” to identify high‐risk patients following acute myocardial infarction (AMI). Background: Recent studies have demonstrated that the “no‐reflow” phenomenon (defined by myocardial contrast echocardiography) and severe diastolic dysfunction (identified by Doppler echocardiography) identify patients at high risk for mortality following AMI. Methods: We evaluated 111 patients with recent anterior acute myocardial infarction from July 2000 to June 2004. Diastolic function and myocardial perfusion was evaluated by echocardiography. Patients were placed into 1 of 3 groups based on diastolic function and myocardial perfusion: Group 1 (normal perfusion and normal diastolic function), Group 2 (abnormal perfusion or abnormal diastolic function), and Group 3 (abnormal perfusion and abnormal diastolic function). We compared the long term all‐cause mortality within these groups. Results: Patients in each group were similar with respect to myocardial infarction size as defined by biomarkers, extent and severity of coronary artery disease, and medical and interventional therapy. Mortality was much higher in Group 3 (26.9%) compared to Group 1 (0%) and Group 2 (15.2%) (p = 0.048). Conclusion: Combined assessment of diastolic function and myocardial perfusion enhances risk stratification post myocardial infarction.

Transesophageal echocardiographic guidance of transcatheter closure of the aortic valve in a patient with left ventricular assist device-related severe aortic regurgitation

A 68-year-old man with a severe ischemic cardiomyopathy underwent left ventricular assist device (LVAD) implantation (Heart Mate II device) for destination therapy. He presented 49 months after LVAD implantation with worsening heart failure symptoms and new severe aortic regurgitation. Given high risk for both surgical and transcatheter aortic valve replacement, he was admitted for transcatheter closure of the aortic valve under transesophageal echocardiographic (TEE) guidance. TEE imaging revealed severe aortic regurgitation (Fig. 1A and B and Videos 1 and 2). Under TEE and fluoroscopic guidance, a 25 mm Amplatzer cribriform atrial septal defect closure device was advanced across the aortic valve (Fig. 1C and D and Videos 3 and 4). Immediately after device deployment, TEE revealed a well-seated device with complete aortic valve closure and trivial aortic regurgitation (Fig. 2A, B, C and D and Videos 5, 6, 7 and 8). Subsequent transthoracic echocardiograms obtained from 74 to 172 days after the procedure revealed no residual aortic regurgitation. The patient awoke with diffuse 10.1530/ERP-17-0003 ID: 17-0003