Journal of cardiology最新文献

Aims: Cardiac amyloidosis (CA) is associated with various complications, and one of them are thromboembolic events (TEEs), which can significantly impact patients' quality of life. Predicting and managing the risk of these TEEs in patients without atrial fibrillation (AF) pose significant challenges, as many occur independently of AF presence. Several predictors, particularly echocardiographic ones, have been linked to an increased risk, but there is no consensus on stratification or preventive treatment. The main objective was to determine the prevalence of TEEs in a cohort of CA patients without AF and identify echocardiographic predictors.

Methods: A retrospective, single-center study including confirmed CA patients. A prespecified list of variables was defined, and only patients with at least 70 % of these variables were included. Risk rates were analyzed through binary logistic regression, with a significance level set at p < 0.05.

Results: 75 patients were included. Baseline characteristics are depicted in Fig. 1. Fifteen TEEs (20 %) were described, with 80 % being ischemic strokes. While diastolic dysfunction and pulmonary systolic arterial pressure (PSAP) were predictors in univariate analysis, the multivariate backward LR model identified interventricular septum diameter (IVSD) as the sole predictor, OR 1.280 (1.061-1.543), p = 0.010. It is also interesting to mention that analyzing the increase of every 3 mm in SIV, the chance of developing ETES was: OR = 2.095 (1.195-3.671), p = 0.010.

Conclusions: An IVSD evaluated by echocardiography demonstrated good performance capacity as a factor associated with TEEs in this cohort of patients with AC without AF. For every 3 mm increase in IVSD, the risk of developing TEEs doubles.

Background: Dialysis patients undergoing transcatheter aortic valve replacement (TAVR) generally have poor prognosis compared with non-dialysis patients. Furthermore, there are few reliable risk models in this clinical setting. Therefore, we aimed to establish a risk model in dialysis patients undergoing TAVR that would be informative for their prognosis and the decision-making process of TAVR.

Methods: A total 118 dialysis patients (full cohort) with severe aortic stenosis underwent TAVR in our institute between 2012 and 2022. The patients of the full cohort were randomly assigned to two groups in a 2:1 ratio to form derivation and validation cohorts. Risk factors contributing to deaths were analyzed from the preoperative variables and a risk model was established from Cox proportional hazard model.

Results: There were 69 deaths following TAVR derived from infectious disease (43.5 %), cardiovascular-related disease (11.6 %), cerebral stroke or hemorrhage (2.9 %), cancer (1.4 %), unknown origin (18.8 %), and others (21.7 %) during the observational period (811 ± 719 days). The cumulative overall survival rates using the Kaplan-Meier method at 1 year, 3 years, and 5 years in the full cohort were 82.8 %, 41.9 %, and 24.2 %, respectively. An optimal risk model composed of five contributors: peripheral vascular disease, serum albumin, left ventricular ejection fraction < 40 %, operative age, and hemoglobin level, was established. The estimated C index for the developed models were 0.748 (95 % CI: 0.672-0.824) in derivation cohort and 0.705 (95 % CI: 0.578-0.832) in validation cohort. The prediction model showed good calibration [intraclass correlation coefficient = 0.937 (95%CI: 0.806-0.981)] between actual and predicted survival.

Conclusions: The risk model was a good indicator to estimate the prognosis in dialysis patients undergoing TAVR.

Background: Impella (Abiomed, Danvers, MA, USA) is a percutaneous ventricular assist device commonly used in cardiogenic shock, providing robust hemodynamic support, improving the systemic circulation, and relieving pulmonary congestion. Maintaining adequate left ventricular (LV) filling is essential for optimal hemodynamic support by Impella. This study aimed to investigate the impact of pulmonary vascular resistance (PVR) and right ventricular (RV) function on Impella-supported hemodynamics in severe biventricular failure using cardiovascular simulation.

Methods: We used Simulink® (Mathworks, Inc., Natick, MA, USA) for the simulation, incorporating pump performance of Impella CP determined using a mock circulatory loop. Both systemic and pulmonary circulation were modeled using a 5-element resistance-capacitance network. The four cardiac chambers were represented by time-varying elastance with unidirectional valves. In the scenario of severe LV dysfunction (LV end-systolic elastance set at a low level of 0.4 mmHg/mL), we compared the changes in right (RAP) and left atrial pressures (LAP), total systemic flow, and pressure-volume loop relationship at varying degrees of RV function, PVR, and Impella flow rate.

Results: The simulation results showed that under low PVR conditions, an increase in Impella flow rate slightly reduced RAP and LAP and increased total systemic flow, regardless of RV function. Under moderate RV dysfunction and high PVR conditions, an increase in Impella flow rate elevated RAP and excessively reduced LAP to induce LV suction, which limited the increase in total systemic flow.

Conclusions: PVR is the primary determinant of stable and effective Impella hemodynamic support in patients with severe biventricular failure.

Background: The clinical outcomes of ST-segment elevation myocardial infarction (STEMI) due to the occlusion of left coronary artery are worse in patients with proximal occlusion than in those with non-proximal occlusion. However, there are few reports that focus on the comparison of clinical outcomes in patients with STEMI between proximal and non-proximal right coronary artery (RCA) occlusions.

Methods: We included 356 patients with STEMI whose infarct-related artery is RCA and divided them into the proximal group (n = 129) and the non-proximal group (n = 227). We defined segment 1 of RCA as proximal, and segments 2, 3, and 4 as non-proximal according to the reporting system of the American Heart Association. The primary endpoint was major cardiovascular events (MACE), which was defined as the composite of all-cause death, non-fatal myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization.

Results: Incidence of shock at admission, requirement for catecholamine during percutaneous coronary intervention (PCI), or mechanical support during PCI tended to be higher in the proximal group (42.6 %) than in the non-proximal group (33.5 %) (p = 0.088). Although the incidence of right ventricular infarction tended to be higher in the proximal group (17.8 %) than in the non-proximal group (10.6 %) without reaching statistical significance (p = 0.072), the incidence of in-hospital death was similar between the 2 groups (1.6 % versus 1.8 %, p = 1.000). The MACE-free survival curves were not different between the 2 groups (p = 0.400). Multivariate Cox hazard analysis revealed that proximal RCA occlusion was not associated with MACE (HR 1.095, 95%CI 0.691-1.737, p = 0.699).

Conclusions: Although the acute phase conditions such as shock or right ventricular infarction tended to be more severe in patients with proximal occlusion, overall clinical outcomes including long-term outcomes were comparable between the proximal and distal RCA occlusions. Furthermore, multivariate analysis showed that the proximal RCA occlusion was not associated with MACE after hospital discharge.

This article reviews roles of the left atrium as regulator of left ventricular filling, as compensatory reserve in left ventricular dysfunction and as diagnostic marker in patients with cardiovascular disorders. Application of novel imaging tools to assess left atrial function and their integration with conventional clinical methods are discussed. This includes a review of clinical applications of left atrial strain as a method to quantify the reservoir and booster pump components of left atrial function. Emerging methods for assessing left atrial wall stiffness and active work by pressure-strain loop analysis are discussed. Recommendations for how to apply left atrial strain in clinical routine to diagnose elevated left ventricular filling pressure are provided. Furthermore, a role for left atrial strain in the diagnostic work-up in patients suspected of pre-capillary pulmonary hypertension is proposed. The article also reviews how to implement parameters of atrial structure and function in clinical routine as recommended by recent international guidelines for imaging of heart failure.

Hypertrophic cardiomyopathy (HCM) is a genetic disorder in which left ventricular outflow tract obstruction critically affects symptoms and prognosis. Traditionally, left ventricular outflow tract obstruction was primarily attributed to septal hypertrophy with systolic anterior motion of the mitral valve. However, recent evidence highlights significant contributions from the mitral valve and papillary muscle anomalies, as well as an apical-basal muscle bundle observed in HCM patients. Accurate morphological assessment is essential when considering septal reduction therapy. While transesophageal echocardiography and cardiac magnetic resonance are recommended for assessing the anomalous structures, four-dimensional computed tomography offers superior spatial resolution and multiplanar reconstruction capabilities. These features enable the evaluation of details of the morphological anomalies, such as the apical-basal muscle band, papillary muscle anomalies, subaortic stenosis, and right ventricular outflow tract obstruction. Based on the detailed assessment of these morphological features, four-dimensional computed tomography has been utilized for planning of surgical correction in a comprehensive HCM center. This approach facilitates the intervention strategies and may improve outcomes in septal reduction therapy for obstructive HCM.

Background: Identification of transthyretin cardiac amyloidosis (ATTR-CA) patients is largely based on pattern recognition by providers, and this can be automated through electronic medical systems (EMR).

Methods: All patients in a large academic hospital with age > 60, ICD-10 code for chronic diastolic heart failure and no previous diagnosis of any amyloidosis were included. An Epic EMR scoring logic assigned risk scores to patients for ICD-10 and CPT codes associated with ATTR-CA, as follows: carpal tunnel syndrome (score 5), aortic stenosis/TAVR (5), neuropathy (4), bundle branch block (4), etc. The individual patients' scores were added, and patients were arranged in descending order of total scores- ranging from 50 to 0. Data is reported as median (interquartile range) and analyzed with non-parametric tests.

Results: Of the total 11,648 patients identified, 132 consecutive patients with highest risk scores (score ≥ 30) were enrolled as cases, while 132 patients with scores between 10 and 19 with available echocardiography data served as age-matched controls. Strain echocardiography is not routinely performed. Patients with high scores were more likely to have CA associated findings- African-American race, higher left ventricular (LV) mass index and left atrial volume and lower LV ejection fraction. High score patients had higher troponin and a trend towards high NT-proBNP.

Conclusion: The modern EMR can be used to flag patients with high risk for ATTR-CA (score ≥ 30 using the proposed logic) through best practice advisory. This could encourage screening during echocardiography using strain or during unsuspected clinic visits.