Tuesday, March 29, 2011

MRI: Embolism During MRI

Circulation 2011;123 e388-e389
Thombus in LV noted at 16 minutes of scan
Thrombus not seen at 18 minutes of scan
~ 3 hrs later, Renal embolism noted.

Anatomy: Aortic Stenosis, Quadricuspid Valve

J Am Coll Cardiol, 2011; 57:1567


Stenosed Quadricuspid Aortic Valve Treated by Transcatheter Aortic Valve Implantation

Philipp Blanke, MD et al.

A 79-year-old woman with known severe aortic stenosis and concomitant moderate aortic regurgitation underwent transesophageal echocardiography and electrocardiographically gated cardiac computed tomographic angiography for planning of transcatheter aortic valve implantation. On the midesophageal short-axis view (A, Online Video 1) and multiplanar reconstructed computed tomographic angiographic images (B and C, Online Video 2), the aortic valve was noted to be quadricuspid with 4 separate leaflets, thickened leaflet margins, and moderate calcifications. Diastolic reconstructions revealed a central zone of incomplete coaptation (B), whereas systolic images showed incomplete opening (aortic valve area 0.8 cm2) (C). The patient underwent implantation of a 26-mm Edwards Sapien transcatheter heart valve (Edwards Lifesciences, Irvine, California) via a transapical approach and post-operative follow-up computed tomographic angiography to ensure proper positioning of the valve (D).
Quadricuspid aortic valve is a rare congenital malformation with an incidence between 0.003% and 0.013% and is frequently associated with regurgitation (1). To our knowledge, this is the first documented case of a stenosed quadricuspid valve and the first documented case of a quadricuspid valve treated by transcatheter aortic valve implantation.(1)

1. Janssens U, Klues HG, Hanrath P. Congenital quadricuspid aortic valve anomaly associated with hypertrophic non-obstructive cardiomyopathy: a case report and review of the literature Heart 1997;78:83-87.[Abstract/Free Full Text]

Tuesday, March 22, 2011

ECG for Sports Screening

A pilot study of the feasibility of heart screening for sudden cardiac arrest in healthy children
Victoria L. Vetter et al.

American Heart Journal. Available online 12 March 2011

In children, sudden cardiac arrest (SCA) is associated with structural and electrical cardiac abnormalities. No studies have systematically screened healthy school children in the United States for conditions leading to SCA to identify those at risk.
From June 2006 to June 2007, we screened 400 healthy 5- to 19-year-olds (11.8 ± 3.9 years) in clinical offices at The Children's Hospital of Philadelphia using a medical and family history questionnaire, weight, height, blood pressure, heart rate, cardiac examination, electrocardiogram (ECG), and echocardiogram (ECHO). Our goals were to determine the feasibility of adding an ECG to history and physical examination and to identify a methodology to be used in a larger multicenter study. A secondary objective was to compare identification of cardiovascular abnormalities by history and physical examination, ECG, and ECHO.
Previously undiagnosed cardiac abnormalities were found in 23 subjects (5.8%); an additional 20 (5%) had hypertension. Potentially serious cardiac conditions were identified in 10 subjects (2.5%); 7 were suspected or identified by ECG and 3 more only by ECHO. Only 1 of the 10 had symptoms (previously dismissed); none had a positive family history.

Referral bias - is an important issue in this study. (Community pediatricians were told to refer children whom they thought were healthy and did not have any cardiac issues).

Saturday, March 19, 2011

HRV: Concept of Sympathetic Reserve


Cardiac Sympathetic Reserve and Response to Cardiac Resynchronization Therapy

  1. Yong-Mei Cha et al. (Mayo clinic and others)

Background—The objective of the study was to investigate the effect of cardiac resynchronization therapy (CRT) on cardiac autonomic function.

Methods and Results—This prospective study included 45 consecutive patients with heart failure who received CRT devices with defibrillator and 20 age-matched healthy controls. At baseline, 3 months and 6 months after CRT, we assessed New York Heart Association (NYHA) class, 6-minute walk distance, plasma sympathetic biomarker nerve growth factor, echocardiography, heart rate variability and cardiac presynaptic sympathetic function determined by iodine 123 metaiodobenzylguanidine scintigraphy. After CRT, NYHA class improved by 1 class (p<0.001), p="0.004)" p="0.004)," p="0.03)," p="0.01)." p="0.003)," p="0.003)">

Conclusions—CRT improved sympathetic function. Cardiac sympathetic reserve may be a marker for the reversibility of failing myocardial function.

Wednesday, March 16, 2011

Ventricular Assist Device: "HeartWare" - Intrapericardial placement

JACC 2011;57:1375-82.

J Am Coll Cardiol, 2011; 57:1375-1382,

Multicenter Evaluation of an Intrapericardial Left Ventricular Assist System

Martin Strueber, MD*,*, Gerry O'Driscoll, MD, PhD, Paul Jansz, MB, PhD, Asghar Khaghani, MD, Wayne C. Levy, MD, George M. Wieselthaler, MD¶ HeartWare Investigators

Objectives: The aim of this study was to conduct an initial clinical evaluation of the new HeartWare Ventricular Assist System (HeartWare, Inc., Framingham, Massachusetts) in a multicenter, prospective, nonrandomized single-arm clinical trial.

Background: Heart failure is a worldwide epidemic. The effectiveness of heart transplantation and medical therapy is limited, resulting in the emergence of mechanical circulatory support as a primary treatment for end-stage heart disease. Left ventricular assist devices that use rotary pumps are small and durable, which might reduce morbidity and mortality during support.

Methods: Fifty heart transplant candidates with New York Heart Association functional class IV symptoms were supported at 5 international centers by the HeartWare System for 180 days, until heart transplant, myocardial recovery and device explant, or death. Patients who continue to be supported have been followed for a minimum of 2 years.

Results: Of the 50 patients, 20 (40%) received transplants, 4 (8%) had the pump explanted after myocardial recovery, and 17 (34%) continue support at 2 years. Nine (18%) patients died during support from sepsis (n = 3), multiple organ failure (n = 3), or hemorrhagic stroke (n = 3). The actual survival at 6, 12, and 24 months was 90%, 84%, and 79%, respectively. In the survivors, measures of quality of life showed a significant improvement over baseline values. Significant improvements were found for recognition memory at 3 months after implant (p = 0.006). The most frequent adverse events were infection and bleeding.

Conclusions: Patients with end-stage heart failure can be safely and effectively supported by the HeartWare Ventricular Assist System with improved quality of life and neurocognitive function.

Tuesday, March 15, 2011

hs-CRP in Pericarditis (Adult)

Circulation. 2011;123:1092-1097

Prevalence of C-Reactive Protein Elevation and Time Course of Normalization in Acute Pericarditis.
Implications for the Diagnosis, Therapy, and Prognosis of Pericarditis
Massimo Imazio, MD; Antonio Brucato, MD; Silvia Maestroni, MD; Davide Cumetti, MD; Antonio Dominelli, MD; Giuseppe Natale, MD; Rita Trinchero, MD

Background— The role of inflammatory markers is not well defined for either diagnosis or treatment of pericarditis. The aim of this study is to prospectively evaluate the frequency of high-sensitivity C-reactive protein (hs-CRP) elevation in patients with acute pericarditis, its time course of normalization, and the possible importance for diagnosis, therapy, and prognosis.

Methods and Results— Two hundred consecutive patients with viral or idiopathic acute pericarditis (mean age, 53±15.5 years; 103 men) were studied from August 2005 to August 2007 in 2 Italian referral centers. Hs-CRP was determined at presentation and then every week until normalization. Hs-CRP elevation was recorded in 156 of 200 cases (78%) at presentation. Recognized causes of a negative hs-CRP at presentation were early assessment in 15 of 44 cases (34%) and previous anti-inflammatory therapies in 22 of 44 cases (50%). Hs-CRP normalization was achieved with the following time course: 120 of 200 (60%) at week 1, 170 of 200 (85%) at week 2, 190 of 200 (95%) at week 3, and all cases (100%) at week 4. In multivariable analysis, incomplete response to empirical anti-inflammatory therapy at week 1 (hazard ratio, 2.98; 95% confidence interval, 1.80 to 4.94; P<0.001), corticosteroid therapy (hazard ratio, 2.80; 95% confidence interval, 1.59 to 4.95; P<0.001), and the presence of elevated hs-CRP at week 1 (hazard ratio, 2.36; 95% confidence interval, 1.32 to 4.21; P=0.004) were independent risk factors for recurrence.

Conclusions— Hs-CRP is elevated at the initial presentation in 3 of 4 cases of acute pericarditis, identifies patients at higher risk of recurrence, and could be used to monitor disease activity and select appropriate therapy length

Saturday, March 12, 2011

Adult: Echo evaluation of hemodynamics in heart failure


Echocardiographic Evaluation of Hemodynamics in Patients with Decompensated Systolic Heart Failure


Background—Doppler echocardiography is currently applied for the assessment of left ventricular (LV) and right ventricular (RV) hemodynamics in patients with cardiovascular disease. However, there are conflicting reports about its accuracy in patients with unstable decompensated heart failure. The objective of this study was to evaluate the accuracy of the technique in patients with unstable heart failure.

Methods and Results—Consecutive patients with decompensated heart failure had simultaneous assessment of LV and RV hemodynamics invasively and by Doppler echocardiography. In 79 patients, the non-invasive measurements of stroke volume (r=0.83, p<0.001), r="0.83," r="0.51," p="0.009)," r="0.85,">15 mmHg (AUC from 0.86 to 0.92). The recent ASE/EAE guidelines were highly accurate (sensitivity : 98%, specificity : 91%) in identifying patients with increased wedge pressure. In 12 repeat studies, Doppler echocardiography readily detected the changes in mean wedge pressure (r=0.75, p=0.005) as well as changes in pulmonary artery systolic pressure and mean right atrial pressure.

Conclusions—Doppler echocardiography provides reliable assessment of LV hemodynamics in patients with decompensated heart failure.

Copyright © 2011, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited

Wednesday, March 9, 2011

ICU: Prolonged stay after cardiac surgery

Eur J Cardiothorac Surg. 2011 Jan 10. [Epub ahead of print]

Predictors of long intensive care unit stay following cardiac surgery in children.

Pagowska-Klimek I, Pychynska-Pokorska M, Krajewski W, Moll JJ.
The Department of Anesthesiology and Intensive Care, Polish Mother's Memorial Hospital Institute, Lodz, ul. Rzgowska 288/293, Poland.

Objective: Prolonged length of stay in intensive care units after congenital heart disease surgery is associated with poor outcome, places a considerable burden on the financial resources of hospitals, and is an organizational challenge as well. This research discusses the impact of perioperative factors on prolonged stay in intensive care units.

Methods: This is a retrospective study examining the determinants of prolonged intensive care length of stay in 693 children after cardiac surgery. Univariate and multivariate analyses were performed for an intensive care unit stay over 3 and over 14 days.

Results: Neonatal age, preoperative mechanical ventilation and preoperative myocardial dysfunction, complexity and duration of procedures, as well as postoperative complications (low cardiac output syndrome, bleeding, re-operation, acute kidney injury, sepsis, respiratory insufficiency, pulmonary hypertension, pneumothorax, postoperative cardiac arrest, pneumonia, and delayed sternum closure) prolong intensive care unit hospitalization over 3 days. Patients with acute kidney injury requiring renal replacement therapy, pneumothorax, pulmonary hypertension, need for re-operation during the same admission, and myocardial dysfunction prior to surgery are at high risk of intensive care unit stay over 14 days.

Conclusions: Some patients with a risk of prolonged hospitalization may be identified preoperatively, the others just after the operation. Optimizing preoperative status and aggressive treatment of complications may have significant influence on the duration of hospitalization in intensive care units. The knowledge of risk factors may facilitate organizational procedures and rational bed management.

Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Monday, March 7, 2011

EKG screening for Pre-participation Sports Screening (Israel)

J Am Coll Cardiol, 2011; 57:1291-1296


Mandatory Electrocardiographic Screening of Athletes to Reduce Their Risk for Sudden Death. Proven Fact or Wishful Thinking?

Arie Steinvil, MD et al.
Tel Aviv University, Tel-Aviv, Israel

Objectives: The purpose of this study was to determine if pre-participation screening of athletes with a strategy including resting and exercise electrocardiography (ECG) reduces their risk for sudden death.

Background: An increasing number of countries mandate pre-participation ECG screening of athletes for the prevention of sudden death. However, the evidence showing that such a strategy actually reduces the risk of sudden death in athletes is limited. We therefore analyzed the impact of the National Sport Law enacted in Israel in 1997—which mandates screening of all athletes with resting ECG and exercise testing—on the incidence of sudden death among competitive athletes.

Methods: We conducted a systematic search of the 2 main newspapers in Israel to determine the yearly number of cardiac arrest events among competitive athletes. The size of the population at risk was retrieved from the Israel Sport Authority and was extrapolated to the changes in population size over time.

Results: There were 24 documented events of sudden death or cardiac arrest events among competitive athletes during the years 1985 through 2009. Eleven occurred before the 1997 legislation and 13 occurred after it. The average yearly incidence of sudden death or cardiac arrest events was 2.6 events per 100,000 athlete-years. The respective averaged yearly incidence during the decade before and the decade after the 1997 legislation was 2.54 and 2.66 events per 100,000 person years, respectively (p = 0.88).

Conclusions: The incidence of sudden death of athletes in our study is within the range reported by others. However, mandatory ECG screening of athletes had no apparent effect on their risk for cardiac arrest.

Saturday, March 5, 2011

ICU: ECMO + CRRT Outcome

Pediatric Critical Care Med 2011;12:153-8
Conclusions: (i) No evidence that CRRT with ECMO leads to chronic renal failure any more than CRRT does on its own. (ii) Mortality is higher for CRRT+ECMO than ECMO alone & is similar to patients receiving CRRT without ECMO.

Friday, March 4, 2011

ICU: Hypoventilation strategy after Glenn Operation

Scott Bradley et al. JTCVS 2003;126:1033-9

See entry in PediCardiology.

Body Adiposity Index

Obesity (2011) doi:10.1038/oby.2011.38

A Better Index of Body Adiposity

Richard N. Bergman et al.
Correspondence: Richard N. Bergman (rbergman@usc.edu)
Received 8 September 2010; Accepted 27 January 2011; Published online 3 March 2011.
Excerpts in Heartwire

Obesity is a growing problem in the United States and throughout the world. It is a risk factor for many chronic diseases. The BMI has been used to assess body fat for almost 200 years. BMI is known to be of limited accuracy, and is different for males and females with similar %body adiposity. Here, we define an alternative parameter, the body adiposity index (BAI = ((hip circumference)/((height)1.5)–18)). The BAI can be used to reflect %body fat for adult men and women of differing ethnicities without numerical correction. We used a population study, the “BetaGene” study, to develop the new index of body adiposity. %Body fat, as measured by the dual-energy X-ray absorptiometry (DXA), was used as a “gold standard” for validation. Hip circumference (R = 0.602) and height (R = −0.524) are strongly correlated with %body fat and therefore chosen as principal anthropometric measures on which we base BAI. The BAI measure was validated in the “Triglyceride and Cardiovascular Risk in African-Americans (TARA)” study of African Americans. Correlation between DXA-derived %adiposity and the BAI was R = 0.85 for TARA with a concordance of C_b = 0.95. BAI can be measured without weighing, which may render it useful in settings where measuring accurate body weight is problematic. In summary, we have defined a new parameter, the BAI, which can be calculated from hip circumference and height only. It can be used in the clinical setting even in remote locations with very limited access to reliable scales. The BAI estimates %adiposity directly.

Wednesday, March 2, 2011

Diuretics - High dose vs. Low dose (Adult study)

Diuretic Strategies in Patients with Acute Decompensated Heart Failure
G. Michael Felker, M.D., et al. for the NHLBI Heart Failure Clinical Research Network
N Engl J Med 2011; 364:797-805
March 3, 2011

Loop diuretics are an essential component of therapy for patients with acute decompensated heart failure, but there are few prospective data to guide their use.

In a prospective, double-blind, randomized trial, we assigned 308 patients with acute decompensated heart failure to receive furosemide administered intravenously by means of either a bolus every 12 hours or continuous infusion and at either a low dose (equivalent to the patient's previous oral dose) or a high dose (2.5 times the previous oral dose). The protocol allowed specified dose adjustments after 48 hours. The coprimary end points were patients' global assessment of symptoms, quantified as the area under the curve (AUC) of the score on a visual-analogue scale over the course of 72 hours, and the change in the serum creatinine level from baseline to 72 hours.

In the comparison of bolus with continuous infusion, there was no significant difference in patients' global assessment of symptoms (mean AUC, 4236±1440 and 4373±1404, respectively; P=0.47) or in the mean change in the creatinine level (0.05±0.3 mg per deciliter [4.4±26.5 μmol per liter] and 0.07±0.3 mg per deciliter [6.2±26.5 μmol per liter], respectively; P=0.45). In the comparison of the high-dose strategy with the low-dose strategy, there was a nonsignificant trend toward greater improvement in patients' global assessment of symptoms in the high-dose group (mean AUC, 4430±1401 vs. 4171±1436; P=0.06). There was no significant difference between these groups in the mean change in the creatinine level (0.08±0.3 mg per deciliter [7.1±26.5 μmol per liter] with the high-dose strategy and 0.04±0.3 mg per deciliter [3.5±26.5 μmol per liter] with the low-dose strategy, P=0.21). The high-dose strategy was associated with greater diuresis and more favorable outcomes in some secondary measures but also with transient worsening of renal function.

Among patients with acute decompensated heart failure, there were no significant differences in patients' global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus as compared with continuous infusion or at a high dose as compared with a low dose. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00577135.)

Editorial on the above article:
Comparative Effectiveness of Diuretic Regimens
Gregg C. Fonarow, M.D.
N Engl J Med 2011; 364:877-878
March 3, 2011

Acute decompensated heart failure is associated with substantial morbidity, mortality, and health care expenditures.1 Most patients present with symptoms related to fluid overload, which may be complicated by concomitant renal dysfunction.2 Treating the signs and symptoms of heart failure while preserving or improving renal function is a crucial therapeutic goal.
For more than five decades, the administration of intravenous loop diuretics has been the mainstay of therapy to reduce congestion, decrease ventricular filling pressures, and improve symptoms of heart failure, with such therapy becoming an empirically accepted standard of care for this condition.1,3,4 However, there is little evidence . . .

Tuesday, March 1, 2011

Epidemiology: Prevalence of Congenital Heart Disease in Europe

Circulation. 2011;123:841-849

Congenital Heart Defects in Europe: Prevalence and Perinatal Mortality, 2000 to 2005

Helen Dolk, DrPh; Maria Loane, MA; Ester Garne, MD; a European Surveillance of Congenital Anomalies (EUROCAT) Working Group
Correspondence to Helen Dolk, Professor of Epidemiology and Health Services Research, University of Ulster, Jordanstown Campus, Shore Rd, Co Antrim, BT370QB, Northern Ireland, UK. E-mail h.dolk@ulster.ac.uk

Background— This study determines the prevalence of Congenital Heart Defects (CHD), diagnosed prenatally or in infancy, and fetal and perinatal mortality associated with CHD in Europe.

Methods and Results— Data were extracted from the European Surveillance of Congenital Anomalies central database for 29 population-based congenital anomaly registries in 16 European countries covering 3.3 million births during the period 2000 to 2005. CHD cases (n=26 598) comprised live births, fetal deaths from 20 weeks gestation, and terminations of pregnancy for fetal anomaly (TOPFA). The average total prevalence of CHD was 8.0 per 1000 births, and live birth prevalence was 7.2 per 1000 births, varying between countries. The total prevalence of nonchromosomal CHD was 7.0 per 1000 births, of which 3.6% were perinatal deaths, 20% prenatally diagnosed, and 5.6% TOPFA. Severe nonchromosomal CHD (ie, excluding ventricular septal defects, atrial septal defects, and pulmonary valve stenosis) occurred in 2.0 per 1000 births, of which 8.1% were perinatal deaths, 40% were prenatally diagnosed, and 14% were TOPFA (TOPFA range between countries 0% to 32%). Live-born CHD associated with Down syndrome occurred in 0.5 per 1000 births, with >4-fold variation between countries.

Conclusion— Annually in the European Union, we estimate 36 000 children are live born with CHD and 3000 who are diagnosed with CHD die as a TOFPA, late fetal death, or early neonatal death. Investing in primary prevention and pathogenetic research is essential to reduce this burden, as well as continuing to improve cardiac services from in utero to adulthood.