Vedant Gupta

Congenital Heart Disease and Pulmonary Hypertension

Many patients with congenital heart disease and systemic-to-pulmonary shunts develop pulmonary arterial hypertension (PAH), particularly if the cardiac defect is left unrepaired. A persistent increase in pulmonary blood flow may lead to obstructive arteriopathy and increased pulmonary vascular resistance, a condition that can lead to reversal of shunt and cyanosis (Eisenmenger syndrome). Cardiac catheterization is crucial to confirm diagnosis and facilitate treatment. Bosentan is the only medication to date to be compared with placebo in a randomized controlled trial specifically targeting congenital heart disease-associated PAH. Lung transplantation with repair of the cardiac defect or combined heart-lung transplantation is reserved for recalcitrant cases.

Role of Echocardiography in the Diagnostic Assessment and Etiology of Heart Failure in Older Adults

Echocardiography allows the assessment of systolic and diastolic function and identifies many of the common causes of heart failure (HF). Patients with minimally symptomatic or unsuspected left ventricular systolic dysfunction may be identified and receive the benefits of angiotensin-converting enzyme inhibitor therapy. Echocardiography is also for assessing prognosis and can be used serially to evaluate treatment. Ventricular filling pressures, pulmonary artery pressures, and cardiac output can be sequentially determined. The authors believe that all patients with HF should receive careful assessment echocardiography. The authors believe using echocardiography is especially valuable in the elderly.

Atrioventricular dyssynchrony from empiric device settings is common in cardiac resynchronization therapy and adversely impacts left ventricular morphology and function

Echocardiographic atrioventricular (AV) optimization after cardiac resynchronization therapy (CRT) is uncommon due to time constraints and the use of vendor‐specific device algorithms. It remains unclear whether optimization of mitral inflow velocities can still be useful. We aimed to investigate post implantation left ventricular (LV) inflow patterns to determine the incidence of AV dyssynchrony from empirically set devices.

Coronary artery calcification predicts cardiovascular complications after sepsis.

Purpose: Sepsis is a highly prevalent and fatal condition, with reported cardiovascular event rates as high as 25–30% at 1 year. Risk stratification in septic patients has been extremely limited. Material and methods: 267 septic patients with detectable troponin levels, APACHE II scores, and CT scans of the chest or abdomen were assessed. Patients with a recent cardiac intervention were excluded. Coronary artery calcification (CAC) was identified as present or absent on body CT scans. Cardiovascular death, acute myocardial infarction (AMI), or PCI at 1 year was assessed using multivariate logistic regression analysis. Results: Patients with CAC were older, predominantly male with more risk factors for coronary disease, but similar peak troponin levels and APACHE II scores. In a multivariate analysis, CAC was predictive of the primary outcome (OR 6.827; 95% CI 1.336–54.686; p = 0.037). Patients with no CAC, history of CHF or CKD were at low risk (<1%) for cardiovascular complications at 1 year even at very high troponin levels (<8.0 ng/dL). Conclusion: CAC risk stratifies septic patients for cardiovascular complications better than traditional risk factors and can be identified on body CT scans. This novel, risk stratifying framework built on CAC can help guide individualized management of septic patients. HighlightsCardiovascular complications after sepsis are common and maybe underappreciated.CAC identifies patients at risk for cardiovascular complication and all‐cause mortality after an admission for sepsis.Absence of CAC confers a low risk (≤ 1%) of acute myocardial infarction or need for revascularization at 1 year.

Sometimes You Have to Tilt Your Head and Strain to Take a Picture of the Truth

Fifty years ago, Apollo 8 orbited the Moon. Instead of only discovering the moon on that voyage, however, the astronauts turned their camera back toward the Earth and took the first photograph of our planet, essentially proving Sir Fred Hoyle’s quote from two decades earlier. This photograph profoundly altered forever our understanding of what was always right in front of us. Since then, more than 500 astronauts have been in orbit and most have experienced a cognitive shift in their understanding of their home planet. This recognition of the Earth (as seen from afar) as a tiny, fragile blue ball of life racing through space but appearing to be suspended in a void, nourished by a paper-thin atmosphere, is termed the ‘‘overview effect.’’ A similar photograph of the heart that serves to shift our understanding of myocardial performance has yet to be taken. Instead, we continue to measure and report various portions of this phenomenally complex organ that, like the Earth, is composed of uniquely developed, geographically separate, and operationally diverse regions working in unison to stay alive. We often question the importance of the contributions from ‘lesser’ regions and focus our attention on an aspect of performance we think we understand, only to dismiss our results when they are not in keeping with our expectations. The draw of space seems to be as uniform as intellectual curiosity. Negishi et al. used tilt-table testing to study astronauts and to assess the effects of various levels of preload on measures of left ventricular (LV) filling and function (mimicking the effects of altering gravity), as reported in this issue of the JASE. This work provides an important assessment of LV performance in different loading conditions, and represents another important step along this profound journey toward better understanding the important contribution of regional myocardial deformation to global myocardial performance. It raises new questions, but enticingly emphasizes our need to continue to accumulate a greater understanding of the gravity of the situation. It demonstrates that there are many contributing factors, even body position, that may alter what we currently refer to as global longitudinal strain (GLS). It is obvious that NASAwould have a vested interest in the effects of gravity on cardiovascular performance. For simplification, however, the authors studied the heart using a tilt table to create acute changes in preload in an effort to mimic different gravitational forces. How these findings compare to the actual impact of zero-

35% OF EMPIRIC ATRIOVENTRICULAR DELAY SETTINGS MAY BENEFIT FROM ADDITIONAL OPTIMIZATION

Vendor-specific atrioventricular (AV) delay settings in Cardiac Resynchronization Therapy (CRT) offer a convenient alternative to Echocardiographic Doppler-Guided optimization yet it is still unclear how optimized these settings are. This study investigates the effect of empiric device settings on

DO PATIENTS WHO MEET CLASS IIA INDICATIONS FOR CARDIAC RESYNCHRONIZATION THERAPY ATTAIN A THERAPEUTIC BENEFIT

Per the 2012 ACC guidelines, Cardiac Resynchronization Therapy (CRT) is a Class IIa recommendation for low EF patients with: 1) left bundle branch block (LBBB) pattern, QRS of 120-149 ms, and NYHA class II-IV symptoms and 2) non-LBBB pattern, QRS > 150 ms, and NYHA class III/IV symptoms, however the

THE RAILROAD TRACK SIGN: INTENSE GASTRIC WALL UPTAKE ON TC-99M SESTAMIBI SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY MYOCARDIAL PERFUSION IMAGING IN PATIENTS WITH END-STAGE LIVER DISEASE

methods: This is a single-center, retrospective study of 50 patients with ESLD who underwent regadenoson Tc-99m sestamibi SPECT MPI. From the raw data, an anterior planar image was selected to minimize overlap of abdominal viscera. Standard 20-pixel regions-ofinterest were drawn over the anterior (A) and inferior (I) myocardium and the gastric (G) fundus; ratios of A to G (A:G) and I to G (I:G) were calculated. Clinical data included endoscopy. Analysis of continuous variables with Pearson’s correlations and binary variables with T-tests were performed.

Inhaled treprostinil sodium for pulmonary hypertension

Introduction: Pulmonary arterial hypertension is an increasingly recognized heterogeneous disease with significant morbidity and mortality, requiring a multimodal approach to treatment. Inhalation administration of treprostinil sodium (Tyvaso®) permits higher local drug concentration without some of the side effects of parenteral prostanoids. Areas covered: After a broad discussion centering on available prostacyclins, a thorough literature review of treprostinil is undertaken, focusing on the timeline of clinical studies, specifically highlighting the major trials that shape current indications and usage. The literature search was undertaken via multiple search engines and strategies with review of cited and associated articles to provide a comprehensive discussion on the topic. Expert opinion: While safe and well tolerated, inhaled treprostinil sodium should be limited, based on available data, to use as add-on therapy for patients with Group I pulmonary hypertension not effectively controlled on oral therapy. Despite documented safety for the conversion from inhaled iloprost to inhaled treprostinil, the transition of patients stable on parenteral agents to inhaled treprostinil should be cautioned due to the potential for clinical decompensation.