Tanyanan Tanawuttiwat

New-Onset Atrial Fibrillation After Aortic Valve Replacement : Comparison of Transfemoral, Transapical, Transaortic, and Surgical Approaches

OBJECTIVES This study sought to determine the incidence of new-onset atrial fibrillation (AF) associated with different methods of isolated aortic valve replacement (AVR)-transfemoral (TF), transapical (TA), and transaortic (TAo) catheter-based valve replacement and conventional surgical approaches. BACKGROUND The relative incidences of AF associated with the various access routes for AVR have not been well characterized. METHODS In this single-center, retrospective cohort study, we evaluated a total of 231 consecutive patients who underwent AVR for degenerative aortic stenosis (AS) between March 2010 and September 2012. Patients with a history of paroxysmal, persistent, or chronic AF, with bicuspid aortic valves, and patients who died within 48 h after AVR were excluded. A total of 123 patients (53% of total group) qualified for inclusion. Data on documented episodes of new-onset AF, along with all clinical, echocardiographic, procedural, and 30-day follow-up data, were collated. RESULTS AF occurred in 52 patients (42.3%). AF incidence varied according to the procedural method. AF occurred in 60% of patients who underwent surgical AVR (SAVR), in 53% after TA-TAVR, in 33% after TAo-TAVR cases, and 14% after TF-TAVR. The episodes occurred at a median time interval of 53 (25th to 75th percentile, 41 to 87) h after completion of the procedure. Procedures without pericardiotomy had an 82% risk reduction of AF compared with those with pericardiotomy (adjusted odds ratio: 0.18; 95% confidence interval: 0.05 to 0.59). CONCLUSIONS AF was a common complication of AVR with a cumulative incidence of >40% in elderly patients with degenerative AS who underwent either SAVR or TAVR. AF was most common with SAVR and least common with TF-TAVR. Procedures without pericardiotomy were associated with a lower incidence of AF.

Combined use of Impella left ventricular assist device and extracorporeal membrane oxygenation as a bridge to recovery in fulminant myocarditis.

Myocarditis may result in cardiogenic shock, and when medical therapy is unable to maintain adequate cardiac output, mechanical circulatory support is indicated. This is the first reported case of a percutaneous left ventricular assist device being used in combination with extracorporeal membrane oxygenation in a patient with biventricular and respiratory failure, as a bridge to recovery.

Comparison of inferolateral early repolarization and its electrocardiographic phenotypes in pre- and postadolescent populations.

Inferolateral early repolarization (ER) patterns on standard electrocardiogram (ECG) are associated with increased risk for cardiac and arrhythmic death in general adult population cohorts. We sought to determine the prevalence of inferolateral ER on surface ECG in multiracial pre- and postadolescent populations and to analyze its association with age, race, gender, and ST-segment patterns. A retrospective review was conducted of all ECGs recorded from preadolescent (aged 8-12 years, n = 719) and postadolescent (aged 21-25 years, n = 755) patients seen at a large academic medical center between January 1, 2009, and December 31, 2010. The overall prevalence of inferolateral ER was similar in the preadolescent and postadolescent populations (17% vs 16%, NS). The prevalence of ER increased after puberty in male patients (16% to 25%, p <0.001) and decreased in female patients (18% to 9%, p <0.001). Prevalence of ascending early repolarization (benign variant) also increased in males after puberty (15% to 23%, p <0.004) and decreased in females (11% to 4%, p <0.001). There were no differences in the prevalence of the risk-associated horizontal/descending pattern (3% in both groups). Subgroup analysis was performed on ECGs from the cohort of outpatients without cardiac disease, and the statistical trends remained the same. In conclusion, the overall prevalence of inferolateral ER was higher in pre- and postadolescent populations than in adult populations. However, the prevalence of the risk-associated horizontal/descending ST-segment pattern was only 3%, comparable to prevalence rates in the adult population. The variations in prevalence by gender and age suggest a possible influence of reproductive hormones.

TRANSCATHETER AORTIC VALVE REPLACEMENT VERSUS SURGICAL AORTIC VALVE REPLACEMENT IN A LOW TO INTERMEDIATE RISK POPULATION

The results of studies comparing the clinical efficacy of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (AVR) in low to intermediate risk patients are not yet available. We compared outcomes in patients undergoing TAVR with low Society for Thoracic Surgery (

An unexpected cause of massive hemolysis in percutaneous left ventricular assist device

We present the case of a 24 year-old patient that developed massive hemolysis shortly after percutaneous left ventricular assist device, Impella 2.5, was placed. The hemolysis occurred without device alarm while the device was in the correct position. Further investigation of the device revealed fiber wrapped around the tip of the device, as a culprit. This case emphasizes on the special caution applied during device preparation to minimize the possible adverse events.

Myocarditis and ARVC/D: Variants or mimics?

Overview Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a disease characterized by fibrofatty replacement of the right ventricular (RV) myocardium, which is generally considered to be based on variations in desmosomal genes. However, its pathogenesis is not completely clear since myocarditis and high-intensity athletics have both been postulated to contribute to the onset and progression of the disease pattern. We observed a 21-year-old woman who presented with fulminant lymphocytic myocarditis and subsequently fulfilled the diagnostic criteria for ARVC/D by imaging and electrocardiographic characteristics after complete resolution of left ventricular (LV) abnormalities associated with myocarditis. None of the known common mutations associated with ARVC/D were identified in this patient. This report supports the hypothesis of a common pathophysiology of ARVC/D associated with desmosomal dysfunction, which can be based on genetic predisposition or acquired injury.

Dual percutaneous mechanical circulatory support as a bridge to recovery in fulminant myocarditis

To the Editor: Fulminant myocarditis is a rare clinical manifestation of cardiac inflammation characterized by its distinct, rapid onset, and severe hemodynamic compromise. With appropriate management, often including mechanical support, the majority of patients will experience full recovery. To maintain adequate cardiac output in the acute setting, intraaortic balloon pump (IABP) is often insufficient, and additional support may be needed. We herein describe an alternative method using a combination of percutaneous mechanical circulatory support with both IABP and Impella 2.5 in a 21-year-old patient with fulminant myocarditis as a bridge to recovery. The Impella 2.5 is a catheter-mounted left ventricular assist device (LVAD), which is percutaneously inserted through the femoral artery. It provides mechanical hemodynamic support in patients with severe left ventricular dysfunction by aspirating blood from left ventricle through an inlet area near the tip in left ventricle and propelling it forward across the aortic valve into the systemic vasculature. Impella has been used in various clinical settings, including hemodynamic support during highrisk percutaneous coronary interventions, cardiogenic shock, etc.; however, the combined use of Impella and IABP is rare; only a few cases have been reported.1–3 We report a successful bridge to recovery of a patient with fulminant lymphocytic myocarditis using dual mechanical support with an Impella 2.5 percutaneous VAD in conjunction with an IABP. In a recent case, a 21-year-old previously healthy woman presented with a 3-day history of gastrointestinal symptoms and chest pain (informed consent was obtained from the patients.). Her initial assessment revealed hypotension (systolic blood pressure of 50 mm Hg), complete heart block with diffuse ST elevation on electrocardiogram, and nondilated left ventricle with severe biventricular dysfunction (left ventricular ejection fraction [LVEF] of 10%) on echocardiogram. Laboratory studies disclosed elevated troponin levels (12.79 ng/ml, normal 0.03 ng/ml) and evidence of multiorgan failure (Table 1). Coronary angiography demonstrated no coronary artery disease. An IABP, a right-heart catheter, and a transvenous pacemaker were placed. Milrinone was initiated at an infusion rate of 0.375 g/kg/min, and the patient was transferred to a tertiary care center with a presumptive diagnosis of fulminant myocarditis. On hospital arrival, the patient was alert and oriented. Her blood pressure was 72/56 (61) mm Hg, and she remained in complete heart block with an accelerated junctional rhythm at a rate of 90 bpm. Hemodynamic measures demonstrated elevated right and left heart pressures with low cardiac output (Table 1). Repeat echocardiography demonstrated severe biventricular systolic dysfunction with an LVEF of 30% and severe global hypokinesis but with a left ventricular internal dimension diastole of 3.3 cm. Dobutamine infusion of 3 g/ kg/min was added to her treatment. A right ventricular septal biopsy was performed, revealing a severe lymphocytic myocarditis with a predominant T-cell infiltration and absence of giant cells, granuloma, or eosinophils (Figure 1). Despite IABP and inotropic support, the patient’s cardiac index and mixed venous saturation continued to deteriorate, and she suffered multiple episodes of nonsustained ventricular tachycardia, dyspnea, desaturation, and oliguria. The patient was brought to the cardiac catheterization laboratory where an Impella 2.5 was percutaneously placed by the left femoral artery (Figure 2). It was considered providing adequate support for her body surface area of 1.76 m, and the flow was titrated up to a maximal support of 2.5 L/min. The IABP was left in place as a synergistic and backup support. With both devices functioning, the patient’s cardiac index rose from 1.5 to 2.0 L/min/m (Table 1). Over the next 48 hours, the patient developed hemolysis (LDH 6,779 unit/L, haptoglobin 10 mg/dL, and indirect bilirubin 2.2 mg/dL), thrombocytopenia, and mild hemorrhage from her nose and femoral sheath insertion sites, requiring blood transfusion (Table 1). Because of hemolysis and her improved hemodynamic status from myocardial recovery, the IABP was removed. Heparin dosing was titrated down to maintain the minimal anticoagulation necessary to support Impella 2.5 use. On day 4, she regained normal sinus rhythm with a rate of 70–80 bpm, and the transvenous pacemaker was removed. Because of significant clinical and hemodynamic improvement, the performance level of Impella was gradually lowered on day 4 of support, and the device was removed on day 7. Milrinone and dobutamine were successfully weaned off 3 and 10 days after device removal, respectively. The patient was discharged after 23 days of hospitalization with New York Heart Association (NYHA) class II symptoms. Her discharge medication included carvediol 6.25 mg oral twice a day and candesartan 8 mg oral daily. Six weeks after discharge, her symptoms had improved to NYHA class I, and repeat echocardiography revealed a LVEF of 45–50% with a mildly enlarged right ventricle and moderately impaired right ventricular systolic function. This case illustrates the opportunities and challenges of using percutaneous support devices in patients with fulminant myocarditis. Fulminant myocarditis is usually associated with favorable long-term outcomes with conventional therapies despite severe ventricular dysfunction and the frequent need for aggressive hemodynamic support in the acute phase; in fact, the survival rate has been reported to be 93% at 1 year with sustained recovery lasting over a decade. Therefore, the definitive diagnosis, by using all clinical, echocardiographic and histology finding, is crucial to determine the need and type of mechanical circulatory support. In our patient, her rapid hemodynamic instability, typical echocardiographic finding including nondilated left ventricle with high normal septal thickness, and diffuse lymphocytic infiltration with significant myocardial necrosis on histology finding are consistent with fulminant myocarditis. In patients refractory to medical treatment, mechanical circulatory support devices such as IABP and VADs are the treatment of choice to maintain end-organ perfusion and unload the ventricle during the acute phase. Traditionally, surgical LVAD is a mainstay mechanical circulatory support in the patients with fulminant myocarditis in whom IABP fails to ASAIO Journal 2011

Multidetector computed tomography diagnosis and cine imaging of left main coronary arterial dissection.

Coronary artery dissection (CD) is a rare cause of acute myocardial ischemia. It is often diagnosed by invasive coronary angiography, which is the principal diagnostic tool and gold standard in the diagnosis and triage of patients with CD. More recently, electrocardiogram-gated multidetector computerized tomography has emerged as a complementary imaging tool primarily for follow-up purposes. To our knowledge, this is the first published report of the primary diagnosis and dynamic cine interrogation of a left main CD using retrospective electrocardiogram-gated multidetector computerized tomography, which was not disclosed on invasive coronary angiography.

Assessment of Diastolic Function in Hypertrophic Cardiomyopathy by Computed Tomography–Derived Analysis of Left Ventricular Filling

Objectives Hypertrophic cardiomyopathy (HCM) is characterized by diastolic dysfunction, which is difficult to assess by noninvasive methods. We hypothesized that measurement of simultaneous left ventricular (LV) and left atrial (LA) volume changes by cardiac computed tomography would be useful in the assessment of diastolic function in HCM. Methods We studied 21 patients with HCM and 21 age-matched controls. The LA and LV volumes were calculated and early and late diastolic volume changes derived. Results The HCM patients had significantly larger LA volumes and reduced LA total emptying fraction (30 ± 7% vs 42 ± 6%; P < 0.0001). Conduit volume was increased (30 ± 6 vs 22 ± 4 mL/m2; P < 0.0001) and contributed a significantly higher proportion of total LV diastolic filling, suggesting that passive filling of the LV compensates for LA dysfunction, but at the expense of increased pulmonary filling pressure. Conclusions This study suggests that simultaneous depiction of computed tomography–derived LV and LA volume changes can characterize diastolic dysfunction in HCM.

Hemodynamic evaluation of suspected severe aortic stenosis leads to a diagnosis of renal cell carcinoma.

The evaluation of aortic stenosis is not always straightforward. When symptoms of severe aortic stenosis are present with supporting Doppler echocardiographic or cardiac catheterization data, replacement of the aortic valve is recommended. Occasionally, Doppler- and catheter-derived data are discordant; appropriate treatment in such cases becomes less clear. We report a case in which a 66-year-old mans symptoms and Doppler data suggested severe aortic stenosis. However, heart catheterization data suggested otherwise, and ultimately it led to the diagnosis of a highly vascular renal tumor. Shunting within the tumor resulted in high cardiac output, which, in combination with a small aortic root, masqueraded as severe aortic stenosis.