William R. Miranda

Changes in myocardial mechanics in patients with obesity following major weight loss after bariatric surgery

The purpose of this study was to evaluate myocardial mechanics in obese subjects using 2D‐speckle tracking echocardiography (2D‐STE).

Effect of bariatric surgery on cardiometabolic risk in elderly patients: A population‐based study

Obesity is a major cardiovascular (CV) risk factor. Bariatric surgery (BSx) is an approved therapeutic alternative for class II–III obesity, but little evidence focuses on older adults. We assessed the effect of BSx on cardiometabolic variables and long‐term CV risk in older adults.

Usefulness of Epicardial Adipose Tissue as Predictor of Cardiovascular Events in Patients With Coronary Artery Disease

Several studies have suggested that epicardial adipose tissue (EAT) is associated with coronary artery disease (CAD). However, the role of EAT as a potential risk factor for, and predictor of, long-term cardiovascular outcomes in patients with CAD requires additional investigation. We investigated the relation among EAT, cardiovascular events, and measures of adiposity in patients with CAD. The study was a prospective cohort study of 194 consecutive patients with CAD who entered a phase II cardiac rehabilitation program at the Mayo Clinic. EAT was measured using echocardiography. The primary outcome was the long-term recurrence of major adverse cardiovascular events (MACE). The outcomes were assessed using the Mayo Clinic electronic medical records. The mean age was 59.4 ± 10.8 years, the body mass index was 28.7 ± 4.6 kg/m(2), 80% were men, and 21% of the patients underwent coronary artery bypass grafting. The mean follow-up period was 3.6 ± 1.3 years, and 52 MACE occurred. EAT was not a predictor of MACE (hazard ratio 1.32, 95% confidence interval 0.75 to 2.31; p = 0.33) when used as a continuous variable and correlated poorly with the measures of adiposity. However, a nonsignificant trend was seen for a greater incidence of cardiovascular events when EAT was stratified by tertile (hazard ratio for third tertile 1.77, 95% confidence interval 0.84 to 3.32; p = 0.11), after statistical adjustments for age, gender, body mass index, and other covariates. In conclusion, the results of the present longitudinal study suggest that EAT, as measured using echocardiography, does not strongly predict for MACE and is poorly associated with measures of obesity in patients with CAD.

Constrictive Pericarditis: A Practical Clinical Approach

Constrictive pericarditis (CP) represents a form of severe diastolic heart failure (HF), secondary to a noncompliant pericardium. The true prevalence of CP is unknown but it is observed in 0.2-0.4% of patients who have undergone cardiac surgery or have had pericardial trauma or inflammation due to a variety of etiologies. Despite its poor prognosis if untreated, CP is a potentially curable disease and surgical pericardiectomy can now be performed at low perioperative mortality in tertiary centers with surgical expertise in pericardial diseases. Cardiologists should have a high index of suspicion for CP in patients presenting with predominant right-sided (HF), particularly when a history of cardiac surgery, pericarditis or pericardial effusion is present. Transthoracic two-dimensional and Doppler echocardiography is usually the first diagnostic tool in the evaluation of HF and can reliably identify CP in most patients by characteristic real-time motion of the heart and hemodynamic features. Computerized tomography and magnetic resonance imaging provide incremental data for the diagnosis and management of CP and are especially helpful when clinical or echocardiographic findings are inconclusive. Cardiac catheterization has been the gold-standard for the diagnosis of CP, but may not be necessary if non-invasive test(s) demonstrate diagnostic features of CP; it should then be reserved for selected cases or for assessment of concomitant coronary disease. Although most patients with CP require pericardiectomy, anti-inflammatory therapy may be curative in patients presenting with subacute symptoms, especially when evidence of marked ongoing inflammation is seen.

Prosthetic pulmonary valve and pulmonary conduit endocarditis: clinical, microbiological and echocardiographic features in adults.

AIMS To review clinical and microbiological findings in adults with prosthetic pulmonary valve (PPV) or right ventricle to pulmonary artery conduit (RVPAC) infective endocarditis (IE) and to assess the yield of transthoracic (TTE) and transesophageal echocardiography (TEE) as diagnostic tools. METHODS AND RESULTS Seventeen adults (age ≥18 years) with PPV/RVPAC who met diagnostic criteria for definite IE between 2000 and 2015 were included. Median age was 34 years and 29% were females; four patients (24%) had a previous episode of IE. IE occurred a median interval of 5.3 years after PPV/RVPAC insertion; median follow-up time was 206 days. The most common organisms were Staphylococcus aureus (29%), coagulase-negative staphylococci (24%), and streptococcal species (24%). Eleven patients (64.5%) required PPV/RVPAC replacement surgery as consequence of the IE episode. There were three deaths during follow-up; one non-operative and two post-operative. TTE was diagnostic for PPV/RVPAC IE in 10 (62%) and TEE was diagnostic in eight (57%) patients; when combined TTE/TEE were diagnostic in 15 of 17 (88%) cases. Severe PPV/RVPAC obstruction was present at the time of IE diagnosis in nine (53%) and severe regurgitation in five (29%). CONCLUSION PPV/RVPAC IE is associated with significant morbidity, mortality and high risk of requiring operative intervention. TTE and TEE are marginal diagnostic tools when used independently; they should be used as complementary techniques in the evaluation of those patients. Severe PPV/RVPAC stenosis was more common than regurgitation in patients with IE; thus IE should be considered in patients presenting with new PPV/RVPAC obstruction.

Diagnosing Obesity: Beyond BMI.

BMI is useful as a general indicator of body composition, particularly at the extreme ends of the spectrum, but has some limitations. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Infective Endocarditis Involving the Pulmonary Valve

Pulmonary valve (PV) infective endocarditis (IE) is a rare entity, accounting for 1.5% to 2% of cases of IE. Published data are limited to a few case series and reports. We sought to review the Mayo Clinic experience and describe clinical, echocardiographic, and microbiologic features. We included all patients aged ≥18 years seen from 2000 to 2014 who had a diagnosis of native PV IE and unequivocal echocardiographic involvement of the PV. Nine patients with PV IE were identified. Isolated PV IE was present in 7 (78%) of 9 cases. The median age was 59 years and 22% were women. Three patients had congenital heart disease, 2 had central venous catheters, and 3 had cardiovascular implantable electronic devices. Five patients (56%) received chronic immunosuppressive therapy. Enterococcus faecalis and viridans group streptococci were the most common pathogens, isolated in 22% of cases each. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) were done in 6 and 7 patients, respectively. Four patients underwent both procedures. TTE was diagnostic in all cases, but TEE failed to detect PV involvement in 1 patient. Median follow-up was 1.8 years. Five patients (56%) underwent PV replacement. There were no operative deaths. One patient had sudden death during follow-up, unrelated to his PV IE episode. Our results suggest that PV IE is rare but carries significant morbidity. TTE and TEE provide complementary information with TEE providing better visualization of other cardiac structures. Our findings of a high prevalence of immunosuppressive therapy and cardiovascular implantable electronic devices have not been previously reported and deserve further investigation.

Carcinoid Heart Disease without Severe Tricuspid Valve Involvement

Carcinoid syndrome causes a rare form of acquired valvular heart disease which typically occurs in the setting of liver metastases. In carcinoid-induced valvular heart disease, the tricuspid valve is almost universally affected; left-sided valve disease occurs infrequently in affected patients. Herein, we report 2 cases of carcinoid-induced valvular heart disease; one case had no evidence of tricuspid valve involvement despite severe involvement of all other valves, while the other case was without severe tricuspid valve involvement.

Filling pressures in Fontan revisited: Comparison between pulmonary artery wedge, ventricular end-diastolic, and left atrial pressures in adults

BACKGROUND Pulmonary artery wedge pressure (PAWP) has been shown to correlate better with left atrial pressure (LAP) than ventricular end-diastolic pressure (VEDP) in acquired heart disease. The correlation between VEDP and PAWP and their performance as surrogates for LAP in Fontan patients is unknown. METHODS Offline single-beat simultaneous measurement of PAWP and VEDP was performed in 50 adult Fontan patients and non-simultaneous hemodynamic data abstracted for calculation of pulmonary vascular resistance (PVR). For the evaluation of PAWP and VEDP as surrogates for LAP, 14 fenestrated adult Fontan patients were included. RESULTS Mean age was 34.2±10years and 54% of patients were female. Tricuspid atresia and double inlet left ventricle were the most common congenital defects (44% and 20%, respectively). Simultaneous mean VEDP was 10.8±4.6mmHg and mean PAWP was 11±4.6mmHg; the PAWP-VEDP correlation was 0.91 (p<0.001). Using non-simultaneous data, right-sided (mean difference 0.6WU·m2, 95% CI 0.2-1.0; p=0.005) and left-sided (mean difference 0.5WU·m2, 95% CI 0.1-0.9; p=0.02) PVRs were significantly higher when PAWP rather than VEDP was used. In fenestrated patients, LAP-right PAWP and LAP-left PAWP correlations were 0.97 and 0.95 (p<0.0001 for both), respectively, whereas the correlation between LAP-VEDP was 0.76 (p=0.007). CONCLUSIONS PAWP and VEDP correlate reasonably well in adult Fontan patients but PAWP is a better surrogate for LAP. The use of VEDP instead of PAWP appears to significantly underestimate PVR in these patients.

Hemodynamics of Fontan Failure: The Role of Pulmonary Vascular Disease

Background Nonpulsatile pulmonary blood flow in Fontan circulation results in pulmonary vascular disease, but the potential relationships between pulmonary vascular resistance index (PVRI) and Fontan failure have not been studied. The objective was to determine whether the absence of subpulmonary ventricle in the Fontan circulation would make patients more vulnerable to even low-level elevations in PVRI, and when coupled with low cardiac index, this would identify patients at increased risk of Fontan failure. Methods and Results Two hundred sixty-one adult Fontan patients underwent cardiac catheterization; age 26±3 years, men 146 (56%), atriopulmonary Fontan 144 (55%). Patients were divided into 2 groups: those with high PVRI (>2 WU·m2) and low cardiac index <2.5 L min−1 m−2 (group 1, n=70, 30%), and those with normal PVRI and normal cardiac index (group 2, n=182, 70%). Fontan failure was defined by the composite of all-cause mortality, listing for heart transplantation, or initiation of palliative care. There were 68 (26%) cases of Fontan failure during a mean follow-up of 8.6±2.4 years. When compared with group 2, freedom from Fontan failure was significantly lower in group 1: 66% versus 89% at 5 years. The combination of high PVRI and low cardiac index was an independent risk factor for Fontan failure (hazard ratio, 1.84; 95% confidence interval, 1.09–2.85). Conclusions When coupled with low cardiac index, even mild elevations in PVRI identify patients at high risk of Fontan failure. This suggests that pulmonary vascular disease is a key mechanism underlying Fontan failure and supports further studies to understand the pathophysiology and target treatments to pulmonary vascular tone in this population.