Endomyocardial Biopsy of Right Atrial Angiosarcoma Guided by Intracardiac Echocardiography

We report a case of a 22-year-old female who presented with pericardial effusion and cardiac tamponade. She was diagnosed with a right atrial mass by computed tomography and was referred to our institution for biopsy of this mass. Transcatheter biopsy was performed with intracardiac echocardiography (ICE) guidance, avoiding the need for transesophageal echocardiography or surgery to obtain the biopsy. ICE for transcatheter biopsy of an intracardiac mass is an attractive modality which provides precise localization of the cardiac structures

TCT-749 The Impact of Race and Gender on Procedural Outcomes After Alcohol Septal Ablation for Symptomatic Hypertrophic Obstructive Cardiomyopathy

Digitalitzat per Artypla

Impact of Interatrial Shunts on Invasive Hemodynamics and Exercise Tolerance in Patients With Heart Failure

Approximately 50% of patients with heart failure have preserved ejection fraction. Although a wide variety of conditions cause or contribute to heart failure with preserved ejection fraction, elevated left ventricular filling pressures, particularly during exercise, are common to all causes. Acute elevation in left-sided filling pressures promotes lung congestion and symptoms of dyspnea, while chronic elevations often lead to pulmonary vascular remodeling, right heart failure, and increased risk of mortality. Pharmacologic therapies, including neurohormonal modulation and drugs that modify the nitric oxide/cyclic GMP-protein kinase G pathway have thus far been limited in reducing symptoms or improving outcomes in patients with heart failure with preserved ejection fraction. Hence, alternative means of reducing the detrimental rise in left-sided heart pressures are being explored. One proposed method of achieving this is to create an interatrial shunt, thus unloading the left heart at rest and during exercise. Currently available studies have shown 3- to 5-mm Hg decreases of pulmonary capillary wedge pressure during exercise despite increased workload. The mechanisms underlying the hemodynamic changes are just starting to be understood. In this review we summarize results of recent studies aimed at elucidating the potential mechanisms of improved hemodynamics during exercise tolerance following interatrial shunt implantation and the current interatrial shunt devices under investigation

The Feasibility, Tolerability, Safety, and Accuracy of Low-radiation Dynamic Computed Tomography Myocardial Perfusion Imaging With Regadenoson Compared With Single-photon Emission Computed Tomography

Objectives: Computed tomography (CT) myocardial perfusion imaging (CT-MPI) with hyperemia induced by regadenoson was evaluated for the detection of myocardial ischemia, safety, relative radiation exposure, and patient experience compared with single-photon emission computed tomography (SPECT) imaging. Materials and Methods: Twenty-four patients (66.5 y, 29% male) who had undergone clinically indicated SPECT imaging and provided written informed consent were included in this phase II, IRB-approved, and FDA-approved clinical trial. All patients underwent coronary CT angiography and CT-MPI with hyperemia induced by the intravenous administration of regadenoson (0.4 mg/5 mL). Patient experience and findings on CT-MPI images were compared to SPECT imaging. Results: Patient experience and safety were similar between CT-MPI and SPECT procedures and no serious adverse events due to the administration of regadenoson occurred. SPECT resulted in a higher number of mild adverse events than CT-MPI. Patient radiation exposure was similar during the combined coronary computed tomography angiography and CT-MPI (4.4 [2.7] mSv) and SPECT imaging (5.6 [1.7] mSv) (P-value 0.401) procedures. Using SPECT as the reference standard, CT-MPI analysis showed a sensitivity of 58.3% (95% confidence interval [CI]: 27.7-84.8), a specificity of 100% (95% CI: 73.5-100), and an accuracy of 79.1% (95% CI: 57.9-92.87). Low apparent sensitivity occurred when the SPECT defects were small and highly suspicious for artifacts. Conclusions: This study demonstrated that CT-MPI is safe, well tolerated, and can be performed with comparable radiation exposure to SPECT. CT-MPI has the benefit of providing both complete anatomic coronary evaluation and assessment of myocardial perfusion

Predictive Value of Cardiac CTA, Cardiac MRI, and Transthoracic Echocardiography for Cardioembolic Stroke Recurrence

Background: Transthoracic echocardiography (TTE) is the standard of care for initial evaluation of patients with suspected cardioembolic stroke. While TTE is useful for assessing certain sources of cardiac emboli, its diagnostic capability is limited in the detection of other sources, including left atrial thrombus and aortic plaques. Objectives: To investigate sensitivity, specificity and predictive value of cardiac CT angigography (cCTA), cardiac MRI (CMR), and TTE for recurrence in patients with suspected cardioembolic stroke. Methods: We retrospectively included 151 patients with suspected cardioembolic stroke who underwent TTE and either CMR (n=75) or cCTA (n=76) between January 2013 and May 2017. We evaluated for presence of left atrial thrombus, left ventricular thrombus, vulnerable aortic plaque, cardiac tumors, and valvular vegetation as causes of cardioembolic stroke. The end-point was stroke recurrence. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for recurrent stroke were calculated; the diagnostic accuracy of CMR, cCTA, and TTE was compared between and within groups using area under the curves (AUCs). Results: Twelve and 14 recurrent strokes occurred in the cCTA and CMR groups, respectively. Sensitivity, specificity, PPV and NPV were: 33.3%, 93.7%, 50.0%, and 88.2% for cCTA; 14.3%, 80.3%, 14.3%, and 80.3% for CMR; 14.3%, 83.6%, 16.7%, 80.9% for TTE in the CMR group, and 8.3%, 93.7%, 20.0% and 84.5% for TTE in the cCTA group. Accuracy was not different (p>0.05) between cCTA (0.63, 95% CI [0.49, 0.77]), CMR (0.53, [0.42, 0.63]), TTE in CMR group (0.51, [0.40, 0.61], and TTE in cCTA group (0.51, [0.42, 0.59]). In cCTA group, atrial and ventricular thrombus were detected by cCTA in 3 patients and TTE in 1 patient; in CMR group, thrombus was detected by CMR in 1 patient and TTE in 2 patients. Conclusion: cCTA, CMR, and TTE showed comparably high specificity and NPV for cardioembolic stroke recurrence. cCTA and CMR may be valid alternatives to TTE. cCTA may be preferred given potentially better detection of atrial and ventricular thrombus. Clinical impact: cCTA and CMR have similar clinical performance as TTE for predicting cardioembolic stroke recurrence. This observation may be especially important when TTE provides equivocal findings

Prognostic Value of Normal Stress Echocardiography in Obese Patients

Background. Chest pain is a common problem in obese patients. Because of the body habitus, the results of noninvasive evaluation for CAD may be limited in this group. Methods. We reviewed the records of 1446 consecutive patients who had undergone clinically indicated stress echocardiography (SE). We compared major adverse cardiac events (MACE; myocardial infarction, cardiac intervention, cardiac death, subsequent hospitalization for cardiac events, and emergency department visits) at 1 year in normal weight, overweight, and obese subjects with normal SE. Results. Excluding patients with an abnormal and indeterminate SE and those who were lost to follow-up, a retrospective analysis of 704 patients was performed. There were 366 obese patients (BMI ≥ 30), 196 overweight patients (BMI 25-29.9), and 142 patients with normal BMI (18.5-24.9). There was no MACE in the groups at 1-year follow-up after a normal SE. Conclusions. In obese patients including those with multiple risk factors and symptoms concerning for cardiac ischemia, stress echocardiography is an effective and reliable noninvasive tool for identifying those with a low 1-year risk of cardiac events

Contribution Of Impaired Myocardial Insulin Signaling To Mitochondrial Dysfunction And Oxidative Stress In The Heart

Background—Diabetes-associated cardiac dysfunction is associated with mitochondrial dysfunction and oxidative stress, which may contribute to LV dysfunction. The contribution of altered myocardial insulin action, independently of associated changes in systemic metabolism is incompletely understood. The present study tested the hypothesis that perinatal loss of insulin signaling in the heart impairs mitochondrial function. Methods and Results—In 8-week-old mice with cardiomyocyte deletion of insulin receptors (CIRKO), inotropic reserves were reduced and mitochondria manifested respiratory defects for pyruvate that was associated with proportionate reductions in catalytic subunits of pyruvate dehydrogenase. Progressive age-dependent defects in oxygen consumption and ATP synthesis with the substrates glutamate and the fatty acid derivative palmitoyl carnitine (PC) were observed. Mitochondria were also uncoupled when exposed to PC due in part to increased ROS production and oxidative stress. Although proteomic and genomic approaches revealed a reduction in subsets of genes and proteins related to oxidative phosphorylation, no reduction in maximal activities of mitochondrial electron transport chain complexes were found. However, a disproportionate reduction in TCA cycle and FA oxidation proteins in mitochondria, suggest that defects in FA and pyruvate metabolism and TCA flux may explain the mitochondrial dysfunction observed. Conclusions—Impaired myocardial insulin signaling promotes oxidative stress and mitochondrial uncoupling, which together with reduced TCA and FA oxidative capacity impairs mitochondrial energetics. This study identifies specific contributions of impaired insulin action to mitochondrial dysfunction in the heart