Evaluation of Left Ventricular Diastolic Function by Echocardiography

Despite the knowledge that the heart spends almost two-thirds of its time in diastole (relaxing and filling), its contractile activity was for a long time considered the core of its mechanical function and over which major concerns had been focused. It was after the 1980s that the scientific community began to realize the clinical significance of diastolic dysfunction among patients with signs and symptoms of heart failure (HF) but in whom ejection fraction was rather preserved. The recognition of the latter condition as “heart failure with preserved ejection fraction” (HF-PEF) impelled major efforts in order to identify the pathophysiological mechanisms underlying this emerging concept. The impact of diastolic dysfunction on cardiac morbidity and mortality is becoming increasingly understood. The hallmark of diastolic dysfunction is the impaired capacity to fill or maintain stroke volume without a compensatoy increase in filling pressures. Historically, invasive hemodynamics have provided useful information with respect to diastolic filling pressures, e.g., left atrial (LA) pressure and left ventricular (LV) end-diastolic pressure; left ventricular relaxation (time constant of relaxation-dP/dt) and operant chamber stiffness (pressure-volume loops, diastolic pressure contour). However, advances in echocardiographic assessment of LV diastolic function can lead to the replacement of invasive hemodynamics in the vast majority of patients. In the crucial question “can echocardiography accurately measure diastolic function?”, there are reasoned arguments on either side of the debate. Undoubtedly echocardiography has played a central role in the evaluation of LV diastolic function over the past two decades... (excerpt

How to Diagnose Low-Gradient Critical Aortic Stenosis

Aortic stenosis (AS) has become the most frequent type of valvular heart disease in Europe and North America, accounting for 34% of all native valve disease and 43% of all single valve disease

Cardiology News /Recent Literature Review / Third Quarter 2013

HCS Meeting: Athens, 10-12/10/2013 TCT Meeting: San Francisco, 28/10-1/11/13 AHA 2013: Dallas, 16-20/11/13   ACC 2014: Washington, DC, 29-31/3/2014 Athens Cardiology Update 2014: Athens (Crown Plaza Hotel), 10-12/4/2014 HRS Meeting: San Francisco, 7-10/5/2014 EuroPCR: Paris, 20-23/5/2014 CardioStim 2014: Nice, 18-21/6/2014 Percutaneous Left Atrial Appendage Closure May be a Therapeutic Alternative in Patients with Atrial Fibrillation (AF) and Absolute Contraindications to Anticoagulation TherapyLeft atrial appendage closure (LAAC) with the AMPLATZER Cardiac Plug (ACP) was successfully performed in 51 of 52 (98%) patients (aged 74+8 years) with AF and absolute contraindications to anticoagulation therapy. Most patients received dual-antiplatelet therapy after the procedure for 1-3 months and single antiplatelet therapy thereafter. Main complications were device embolization (1.9%) and pericardial effusion (1.9%), with no cases of periprocedural stroke. At follow-up (20+5 months), death rate was 5.8%, stroke 1.9%, systemic embolism 0%, pericardial effusion 1.9%, and major bleeding 1.9%. The presence of mild peridevice leak was observed in 16.2% of patients at the 6-month follow-up as evaluated by transesophageal echo. There were no cases of device thrombosis. The authors concluded that in patients with nonvalvular AF at high risk of cardioembolic events and absolute contraindications to anticoagulation, LAAC using the ACP device followed by dual-/single-antiplatelet therapy was associated with a low rate of embolic and bleeding events and no device thrombosis at short and midterm follow-up (Urena M et al, J Am Coll Cardiol 2013;62:96–102). Preliminary Favorable Experience With Percutaneous Left Atrial Appendage Suture Ligation Using the LARIAT Device in Patients With Atrial FibrillationPercutaneous ligation of the left atrial appendage (LAA) with the LARIAT device (a snare with a pre-tied suture guided epicardially over the LAA) was success-fully performed in 85 of 89 (96%) patients with complete closure achieved in 81 patients, while 4 had a <2-3-mm residual LAA leak. There were 3 complications (during pericardial access, n=2; & transseptal catheterization, n=1). Adverse events included severe pericarditis post-operatively (n=2), late pericardial effusion (n=1), sudden death (n=2), & late strokes (n=2). At 1 (81 of 85) & 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by transesophageal echo (TEE). Of the 65 patients undergoing 1-year TEE, there was 98% complete LAA closure, including patients with previous leaks. The authors concluded that LAA closure with the LARIAT device can be performed effectively with acceptably low complication rate (Bartus et al, J Am Coll Cardiol 2013;62:108–118)... (excerpt

Cardiology News /Recent Literature Review / Second Quarter 2013

ESC Congress will be held in Amsterdam, 31/8-4/9/13 HCS Meeting: Athens, 10-12/10/2013 TCT Meeting: San Francisco, 28/10-1/11/13 AHA 2013: Dallas, 16-20/11/13   ACC 2014: Washington, DC, 29-31/3/2014 Athens Cardiology Update 2014: Athens (Crown Plaza Hotel), 10-12/4/2014 HRS Meeting: San Francisco, 7-10/5/2014 EuroPCR: Paris, 20-23/5/2014 CardioStim 2014: Nice, 18-21/6/2014 ARMYDA-9 CAROTID: Clopidogrel Load & Atorvastatin Reload Prevent Ischemic Cerebral Events After Protected Carotid StentingA total of 156 patients undergoing protected carotid stenting were randomized to a 600-mg (n=78) or 300-mg (n=78) clopidogrel load given 6 h before intervention and either an atorvastatin reload (n=76; 80 mg + 40 mg initiating 12 h before the procedure) or no statin reload (n=80). Occurrence of the primary outcome (30-day incidence of TIA/stroke or new ischemic lesions on cerebral MRI performed at 24-48 h) was lower in the 600-mg clopidogrel arm (18% vs. 35.9% in the 300-mg group; p = 0.019) and in the atorvastatin reload arm (18.4% vs 35.0% in the no statin reload group; p=0.031). High-dose clopidogrel also significantly reduced the TIA/ stroke rate at 30 days (0% vs 9%, p = 0.02), without an increase in bleeding risk. The authors concluded that in patients undergoing carotid stenting, a 600-mg clopido-grel load and a short-term reload with high-dose atorva-statin protects against early ischemic cerebral events (Patti G et al, J Am Coll Cardiol 2013;61:1379-1387) MADIT CRT: Carvedilol Produces 30% Reduction in Hospitalizations for HF or Death When Compared With MetoprololThe effects of metoprolol and carvedilol were compared in the MADIT-CR study. Hospitalization for HF or death occurred in 23% on carvedilol and 30% on metoprolol (hazard ratio-HR: 0.70, p=0.001), further attenuated in the subgroup of CRT-D patients (HR: 0.61, p = 0.001) and CRT-D patients with LBBB (HR: 0.51, p < 0.001). Ventricular arrhythmias occurred in 22% and in 26%, respectively, of the patients receiving carvedilol or metoprolol (HR: 0.80, p = 0.050). A dose-dependent relationship was found in carvedilol, but not in metoprolol. The authors concluded that in HF patients in NYHA class I/II & wide QRS, carvedilol was associated with a 30% reduction in hospitalizations for HF or death when compared with metoprolol. A novel beneficial and synergistic effect of carvedilol was seen in patients with CRT-D & LBBB. Finally, a dose-dependent effect was apparent in carvedilol, but not in metoprolol (Ruwald et al, J Am Coll Cardiol 2013;61:1518–1526)... (excerpt

Cardiology News /Recent Literature Review / First Quarter 2013

HRS Meeting will take place in Denver, 8-11/5/13 EuroPCR to be held in Paris, 21-24/5/13  EuroPace will be held in Athens, 23-26/6/13 ESC Congress will be held in Amsterdam, 31/8-4/9/13 TCT Meeting: San Francisco, 28/10-1/11/13 AHA 2013: Dallas, 16-20/11/13   Pre-RELAX-AHF and RELAX-AHF Trials: Relaxin Reduces 6-month Mortality in Acute Heart Failure Patients In the Pre-RELAX-AHF (Relaxin in Acute Heart Failure) phase II study and RELAX-AHF phase III study patients hospitalized for acute heart failure were randomized within 16 h to IV placebo or serelaxin. Serelaxin reduced 6-month mortality in both studies (combined studies: N = 1,395; hazard ratio: 0.62; p = 0.0076). In RELAX-AHF, serelaxin improved the markers of cardiac (high-sensitivity cardiac troponin T), renal (creatinine/cystatin-C), and hepatic (AST/ALT) damage and of decongestion (N-T pro–BNP), while changes in these markers at day 2 and worsening heart failure during admission were associated with 6-month mortality. The authors concluded that early administration of serelaxin was associated with a reduction of 6-month mortality, while fewer signs of organ damage and more rapid relief of congestion were noted during the first days after admission (Metra et al, J Am Coll Cardiol 2013;61:196–206) Favorable 5-Year Outcome after TAVI The 5-year outcome was evaluated in 88 patients undergoing successful TAVI with a balloon-expandable valve. Mean aortic valve gradient decreased from 46 + 18 mm Hg to 10 + 4.5 mm Hg after TAVI and maintained at 11.8 + 5.7 mm Hg at 5 years (p for post-TAVI trend = 0.06). Mean aortic valve area increased from 0.62 + 0.17 cm2 to 1.67 + 0.41 cm2 after TAVI and 1.40 + 0.25 cm2 at 5 years (p for post-TAVI trend <0.01). At 5 years, 3 patients (3.4%) had moderate prosthetic valve dysfunction. Survival rates at 1 to 5 years were 83%, 74%, 53%, 42%, and 35%, respectively. Median survival time after TAVI was 3.4 years, and the risk of death was significantly increased in patients with chronic obstructive pulmonary disease (hazard ratio [HR]: 2.17) and at least moderate paravalvular regurgitation (adjusted HR: 2.98). Thus, a favorable long-term outcome after TAVI was demonstrated. Signs of moderate prosthetic valve failure were observed in 3.4% of patients. No patients developed severe prosthetic regurgitation or stenosis. Comorbidities, mainly chronic lung disease and at least moderate paravalvular regurgitation, were associated with reduced long-term survival (Toggweiler et al, J Am Coll Cardiol 2013;61:413–419)... (excerpt

Cardiology News /Recent Literature Review / Fourth Quarter 2013

ACC Congress 2014: Washington, DC, 29-31/3/2014 Athens Cardiology Update 2014: Athens (Crown Plaza Hotel), 10-12/4/2014HRS Meeting: San Francisco, 7-10/5/2014EuroPCR: Paris, 20-23/5/2014CardioStim 2014: Nice, 18-21/6/2014ESC Congress 2014 (Barcelona, 30/8-3/9/14)Only One Fifth of the Sudden Cardiac Arrest Victims in the Community are Eligible for a Primary Prevention ICD Before the Event, but Among These, a Small Proportion (13%) are Actually Implanted According to data from the Oregon Sudden Unexpected Death study, among 2093 victims of sudden cardiac arrest (SCA) over a decade, of 448 having information about left ventricular ejection fraction (LVEF), 92 (20.5%) were eligible for primary ICD implantation, 304 (67.9%) were ineligible because of LVEF>35%, & the remainder (52, 11.6%) had LVEF ≤35% but were ineligible on the basis of clinical criteria. Among eligible subjects, only 12 (13%) received a primary ICD. Compared with recipients, ICD nonrecipients were older (age at LVEF assessment, 67.1±13.6 vs 58.5±14.8 years, P=0.05), with 20% aged ≥80 years (vs 0% among recipients, P=NS). Additionally, a subgroup (26%) had either a clinical history of dementia or were undergoing chronic dialysis. The authors concluded that only one fifth of the SCA cases in the community were eligible for a primary prevention ICD before the event, but among these, a small proportion (13%) were actually implanted. Although older age and comorbidity may explain nondeployment in a subgroup of these cases, other determinants such as socioeconomic factors, health insurance, patient preference, and clinical practice patterns may play a role (Narayanan K, et al, Circulation 2013;128:1733-1738).Appropriate ICD Therapies over 10 Years are More Prevalent in Symptomatic Brugada Syndrome (19-48%) but Still Occur in Asymptomatic Patients (12%)A total of 378 patients (310 men; aged 46±13 years) with a type 1 Brugada ECG pattern were implanted with an implantable cardioverter-defibrillator-ICD; 31 for aborted sudden cardiac arrest, 181 for syncope, and 166 asymptomatic. During a mean follow-up of 77±42 months for 363 patients, 7 patients (2%) died (1 as a result of an inappropriate shock), and 46 patients (12%) had appropriate device therapy (5±5 shocks per patient). Appropriate device therapy rates at 10 years were 48% for patients whose ICD indication was aborted sudden cardiac arrest, 19% for those with syncope, and 12% for the asymptomatic patients. At 10 years, rates of inappropriate shock and lead failure were 37% and 29%, respectively. Inappropriate shock occurred in 91 patients (24%) because of lead failure (n=38), supraventricular tachycardia (n=20), T-wave oversensing (n=14), or sinus tachycardia (n=12). Reduced inappropriate shocks were noted with introduction of remote monitoring, programming a high single ventricular fibrillation zone (>210–220 bpm), and a long detection time. The authors concluded that appropriate therapies are more prevalent in symptomatic Brugada syndrome but are not insignificant in asymptomatic patients (1%/y). Optimal ICD programming and remote monitoring dramatically reduce inappropriate shocks. However, lead failure remains a major problem in this population (Sacher F et al, Circulation 2013;128: 1739-1747)... (excerpt

Transcatheter Aortic Valve Implantation in Severe Left Ventricular Dysfunction: A Viable Option in a Patient With Low-Flow, Low-Gradient Critical Aortic Stenosis

Images are provided from a successful procedure of transcatheter aortic valve implantation (TAVI) in an elderly patient with symptomatic low-flow, low-gradient critical aortic stenosis, and associated severe left ventricular dysfunction, who had a very high-risk for surgery

Percutaneous Extraction of Chronically Implanted Left Ventricular Lead Aided by Telescopic Sheaths Spares Patient Major Cardiac Surgery

A 70-year-old patient sustained a severe pocket infection of a biventricular pacemaker system implanted 4 years ago. Patient opted for a percutaneous approach to lead extraction over open heart surgery. However, use of special locking stylets to facilitate lead traction was hampered by inability to insert the stylets due to mechanical lumen blockage and/or uncoiling and fracture of lead conductors. Hence, the procedure was finally carried out successfully only with use of telescoping sheaths, which facilitated extraction by freeing leads from multiple adhesions along their intravascular and intracardiac course, sparing patient major open cardiac surgery which would have been the only alternative should the percutaneous technique have failed

Cardiology News / Recent Literature Review / First Three Quarters 2013

Cardiology News /Recent Literature Review / First Quarter 2013 HRS Meeting will take place in Denver, 8-11/5/13 EuroPCR to be held in Paris, 21-24/5/13 EuroPace will be held in Athens, 23-26/6/13 ESC Congress will be held in Amsterdam, 31/8-4/9/13 TCT Meeting: San Francisco, 28/10-1/11/13 AHA 2013: Dallas, 16-20/11/13 Pre-RELAX-AHF and RELAX-AHF Trials: Relaxin Reduces 6-month Mortality in Acute Heart Failure Patients In the Pre-RELAX-AHF (Relaxin in Acute Heart Failure) phase II study and RELAX-AHF phase III study patients hospitalized for acute heart failure were randomized within 16 h to IV placebo or serelaxin. Serelaxin reduced 6-month mortality in both studies (combined studies: N = 1,395; hazard ratio: 0.62; p = 0.0076). In RELAX-AHF, serelaxin improved the markers of cardiac (high-sensitivity cardiac troponin T), renal (creatinine/cystatin-C), and hepatic (AST/ALT) damage and of decongestion (N-T pro–BNP), while changes in these markers at day 2 and worsening heart failure during admission were associated with 6-month mortality. The authors concluded that early administration of serelaxin was associated with a reduction of 6-month mortality, while fewer signs of organ damage and more rapid relief of congestion were noted during the first days after admission (Metra et al, J Am Coll Cardiol 2013;61:196–206) Favorable 5-Year Outcome after TAVI The 5-year outcome was evaluated in 88 patients undergoing successful TAVI with a balloon-expandable valve. Mean aortic valve gradient decreased from 46 + 18 mm Hg to 10 + 4.5 mm Hg after TAVI and maintained at 11.8 + 5.7 mm Hg at 5 years (p for post-TAVI trend = 0.06). Mean aortic valve area increased from 0.62 + 0.17 cm2 to 1.67 + 0.41 cm2 after TAVI and 1.40 + 0.25 cm2 at 5 years (p for post-TAVI trend <0.01). At 5 years, 3 patients (3.4%) had moderate prosthetic valve dysfunction. Survival rates at 1 to 5 years were 83%, 74%, 53%, 42%, and 35%, respectively. Median survival time after TAVI was 3.4 years, and the risk of death was significantly increased in patients with chronic obstructive pulmonary disease (hazard ratio [HR]: 2.17) and at least moderate paravalvular regurgitation (adjusted HR: 2.98). Thus, a favorable long-term outcome after TAVI was demonstrated. Signs of moderate prosthetic valve failure were observed in 3.4% of patients. No patients developed severe prosthetic regurgitation or stenosis. Comorbidities, mainly chronic lung disease and at least moderate paravalvular regurgitation, were associated with reduced long-term survival (Toggweiler et al, J Am Coll Cardiol 2013;61:413–419)... (excerpt