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Most infectious endocarditis patients can be managed medically. However, non-responders to antibiotics and ongoing sequelae such as septic emboli, may require mechanical interventions. AngioVac (Angiodynamics, Latham, NY, USA) is a percutaneous aspiration device used for removal of thrombi, emboli, masses, and vegetations. Main drawbacks are the requirement for a perfusionist, two large-bore accesses, and meticulous de-airing. These drawbacks make the procedure more time-consuming and possibly increase the risk of complications. AlphaVac (Angiodynamics) omits the motor element, thereby overcoming several of the limitations. In the current report, we describe two cases of percutaneous aspiration of tricuspid valve vegetations using AlphaVac. To consider manual percutaneous aspiration of infective valvular vegetations using the AlphaVac cannula in case of insufficient response to antibiotics or for prevention of emboli. [ABSTRACT FROM AUTHOR]

With aging society, one of the more challenging obstacles in percutaneous coronary interventions are calcified coronary lesions. Calcified lesions may impede stent delivery, limit balloon and stent expansion, cause uneven drug distribution, and hinder wire advancement. Even in the setting of acceptable procedural success, vessel calcification is independently associated with increased target lesion revascularization rates at follow-up and lower survival rates. In order to effectively manage such lesions, dedicated technologies have been developed. Atherectomy aims at excising tissue and debulking plaques, as well as compressing and reshaping the atheroma, generally referred to as lesion preparation that enables further balloon and/or stent expansion in contemporary clinical practice. In the current review, we will discuss the available methods for atherectomy, including rotational, orbital, and excimer laser coronary atherectomy, as well as intravascular lithotripsy. In addition, we will review the role of imaging in calcified lesions. [ABSTRACT FROM AUTHOR]

The release of troponin in patients with acute pulmonary embolism (PE) is assumed to be secondary to elevated intracardiac chamber pressure. Since right ventricular (RV) hypertrophy does not develop in the acute setting, pressure overload correlates with chamber dilatation, causing myocardial injury. The aim of the present study was to investigate correlations between cardiac chamber volume, troponin and subsequent early mortality in patients with acute PE and refine risk stratification. Patients who underwent a computerized tomographic pulmonary angiogram (CTPA) and a troponin test within 24 h of the CTPA were included. Automated software calculated the volumes of the four cardiac chambers indexed to body surface area (BSA) and correlated them to troponin and early all-cause mortality. The final cohort consisted of 370 patients (56% females) with acute PE. RV volume and right to left ventricular volume ratio (VVR) were the most significant indicators for elevated troponin (receiving operating characteristic [ROC] 0.796, confidence interval [CI]: 0.749–0.843, p < 0.001, and ROC 0.802, CI: 0.753–0.851, p < 0.001, respectively). VVR cutoff values, which are predictive of elevated troponins, correlated with higher 30-day mortality (odds ratio = 3.1, CI 1.5–6.7, p = 0.003) for a VVR >3 compared to a VVR <2. Cardiac chamber volume correlates to elevated troponin in patients with acute PE. A higher VVR reflects an increased likelihood for myocardial ischemia, as well as an increased short-term mortality risk. These data are available seconds after CTPA performance and may contribute to refining patients' risk stratification. [ABSTRACT FROM AUTHOR]

Previously we found that cardiac chambers' volumes correlate with estimated glomerular filtration rate (eGFR) of hospitalized patients. Currently we aimed to demonstrate this relation among apparently healthy individuals. Ambulatory participants who underwent electrocardiography-gated cardiac computed tomography angiography (CCTA) were included. Subjects with an eGFR<60 ml/min/1.73m2, cardiovascular risk factors, and co-morbidities or medications which may influence cardiac chambers' volumes were excluded. Chambers' sizes were obtained by automatic four chamber volumetric analysis of the CCTAs, and calcium score was assessed using the Agatston score. The cohort consisted of 89 apparently healthy individuals, mostly of male gender (70%), with a mean age of 51 years and a mean eGFR of 79.5 ml/min/1.73m2. A low calcium score (≤10HU) was found in 67.4%(n = 60) of the cohort. After adjustment for baseline characteristics, renal function was associated exclusively with the volume of the left atrium (LA; b-coefficient-0.15, 95%CI -0.3- -0.01, p =.041). A 15.9% (95%CI 0.3–33.9%, p =.045) increase in LA volume index (LAVI) was found among participants with eGFR of 80–90 when compared to those with eGFR>90 ml/min/1.73m2. Participants with a low calcium score showed an increase in LAVI only when eGFR was reduced from normal (>90 ml/min/1.73m2) to 70-80 ml/min/1.73m2 (and not to 80-90 ml/min/1.73m2), revealing a percentage increase of 24.7% (95%CI 5.5–47.4%, p =.011). Renal function is closely related to LA volume even in the absence of overt renal failure, demonstrating that minor changes in eGFR instigate an increase in volumes. Risk factors for this interaction should be identified and treated prior to the development of cardio-renal syndrome. • Cardiorenal interactions were investigated among apparently healthy individuals. • LA volume increased by 15% when eGFR was reduced from 90 to 80 ml/min/1.73m2. • Including only patients with a low calcium score did no eliminate the relation. • Volumetric analyses may possibly detect signs prior to a cardio-renal syndrome. [ABSTRACT FROM AUTHOR]

Background: In contrast to surgical aortic valve replacement, left ventricle (LV) hypertrophy (LVH) had not been clearly associated with mortality following transcatheter aortic valve replacement (TAVR).Methods: We performed a retrospective analysis of patients enrolled in the Israeli multicenter TAVR registry for whom preprocedural LV mass index (LVMI) data were available. Patients were divided into categories according to LVMI: normal LVMI and mild, moderate, and severe LVH. Mild LVH was regarded as the reference group. Additionally, LV geometry patterns were examined (concentric and eccentric LVH, and concentric remodeling).Results: The cohort consisted of 1,559 patients, 46.5% male, with a mean age of 82.2 (±6.8) years and mean LVMI of 121 (±29) g/m2. Rates of normal LVMI and mild, moderate, and severe LVH were 31% (n = 485), 21% (n = 322), 18% (n = 279), and 30% (n = 475), respectively. Three-year mortality rates for normal LVMI and mild, moderate, and severe LVH were 19.8%, 18.3%, 23.7%, and 24.4%, respectively. Compared to mild LVH, moderate LVH and severe LVH were independently associated with an increased risk for all-cause mortality (hazard ratio [HR] 1.58, 95% CI 1.15-2.18, P = .005; HR 1.46, 95% CI 1.1-1.95, P = .009; respectively). Concentric LVH was independently associated with a decreased risk for mortality compared to normal LV geometry (HR 0.75, 95% CI 0.63-0.89, P = .001). Compared to concentric LVH, eccentric LVH was independently associated with a 33% increased risk for mortality (HR 1.33, 95% CI 1.11-1.60, P = .002).Conclusions: Mild concentric LVH confers a protective effect among patients with severe aortic stenosis undergoing TAVR. However, hypertrophy becomes maladaptive, and an increased baseline LVMI, eccentric pattern particularly, may be associated with all-cause mortality in this population. [ABSTRACT FROM AUTHOR]

Abstract Background Small scale cohorts demonstrated an association between body mass index (BMI) and diastolic function in a metabolically healthy population. We aimed to characterize the relation between BMI and diastolic function in a relatively large cohort of metabolically healthy obese with preserved ejection fraction. Methods and results Echocardiograms of metabolically healthy patients between 2011 and 2016, who had no significant valvulopathies or atrial fibrillation, and had preserved ejection fraction, were retrospectively identified and analyzed. Metabolically healthy was defined as lack of known diabetes mellitus, hypertension, and hyperlipidemia. Patients were categorized into 4 groups according to BMI - normal BMI 18.5‐25, overweight 25.01‐30, obese 30.01‐35, morbidly obese >35 kg/m2. The cohort consisted of 7057 individuals, 54.9% males, with a mean age 54 years. Patients in higher BMI groups more commonly demonstrated abnormalities in most echocardiographic parameters associated with diastolic dysfunction, including left atrial volume index>34 ml/m2, E/e′>14, e' lateral<10 cm/s, e' septal<7 cm/s, tricuspid regurgitation velocity>2.8 m/s and systolic pulmonary artery pressure≥36 mmHg (p <0.01 for all comparisons). Morbidly obese carried the highest risk compared to those with normal BMI. There were no significant differences between the groups in rates of readmission due to heart failure. Conclusion High BMI is associated with increased risk of diastolic dysfunction even in metabolically healthy patients. Additional trials are needed in order to evaluate whether these echocardiographic findings translate into clinical implications. Highlights • The cohort included 7057 metabolically healthy individuals with preserved ejection fraction • Patients with higher BMI had higher rates of parameters associated with diastolic dysfunction • Morbidly obese carried the highest risk compared to those with normal BMI [ABSTRACT FROM AUTHOR]

Background Diastolic mitral regurgitation (DMR) results from atrioventricular conduction disturbances, acute aortic regurgitation, and/or marked elevation of left ventricular filling pressure. Generally benign, in some clinical circumstances DMR has presumed to result in hemodynamic decompensation. The aforementioned causes of DMR are frequently encountered in patients treated by transcatheter aortic valve replacement (TAVR) but its clinical significance in this setting has not been studied. We sought to investigate the incidence of DMR and its prognostic implications following TAVR. Methods Baseline clinical and echocardiographic variables from a prospective TAVR registry were analyzed to determine the correlates of post-procedural DMR and its impact on late outcomes (all-cause mortality and the composite of mortality and readmission due to heart failure). Results Of 267 patients undergoing TAVR, post-procedural DMR was present in 25 (9.3%). Independent predictors of DMR included pacemaker implantation [OR = 2.7 (95%CI 1.03–6.50)], post-procedural systolic MR and aortic regurgitation [OR = 3.7 (1.20–10.80) and OR = 4.1 (1.50–10.60), respectively], and use of self-expanding bioprostheses [OR = 4.9 (1.60–21.0)]. The incidence of the combined endpoint of death and/or readmission for heart failure was higher in patients with versus those without DMR (25% vs. 41%, respectively, p = 0.08), although this association did not attain statistical significance on multivariable analyses. Interaction term analysis indicated a trend toward a heightened risk for the composite endpoint among patients with post-procedural aortic regurgitation (≥moderate) in whom DMR occurred ( χ 2 2.94, p = 0.09). Conclusions Although DMR following TAVR is common (occurring in approximately 1 of 10 patients), it is not independently associated with an increased risk of death and/or readmission for heart failure. Therefore, DMR post TAVR is more likely a marker of cardiac dysfunction than a causative factor. [ABSTRACT FROM AUTHOR]

Background: The conveyed risk of mild diastolic dysfunction (MDD) according to age had not been thoroughly studied. We aimed to investigate the mortality-risk of MDD by age-groups among inpatients with preserved ejection fraction (EF), and determine ranges of diastolic function parameters by prognosis. Methods: In a single-center retrospective study we identified inpatients who underwent echocardiography between 2012 and 2018 and had preserved EF without significant valvulopathies. Propensity scores were used to adjust for baseline characteristics and main diagnoses at discharge. Comparisons for all-cause mortality between MDD and normal diastolic function were conducted by age groups. Using classification and regression trees (CART) modeling we determined age-specific cut-offs according to outcome. Results: The cohort consisted of 15,777 inpatients. Mortality rate during a 33.9-months median follow-up was 21.6%. MDD was associated with increased mortality risk among all ages up to 90 years, thereafter no difference was detected. Adjusted hazard ratios inversely related to age – 1.99(95%CI 1.25–3.16, p = 0.004), 1.82(95%CI1.46–2.26, p < 0.001), 1.88(95%CI1.64–2.15, p < 0.001), 1.78(95%CI1.59–2.01, p < 0.001), and 1.32(95%CI0.95–1.83, p = 0.093), for 18–44, 45–59, 60–74, 75–89, and ≥90 years, respectively (Pinteraction = 0.009). New cut-offs of E/e' for ages 75–89(16), e' lateral for ages ≥90(6 cm/s), e' septal for ages 60–74(5 cm/s), and E/A ratio for ages 18–44(1.5), predicted outcome more accurately than guidelines-based recommendations. The remaining cut-offs were not better predictors compared to guidelines-based recommendations. Conclusions: MDD is a consequential finding at all ages up to 90 years among inpatients with preserved EF, although its significance decreases with age. Diastolic function of several age-groups may be better delineated by cut-offs that presage adverse prognoses. Helsinki committee approval number: 0170-17-TLV. • Prognostic implications of mild diastolic dysfunction (MDD) remain understudied. • We studied the mortality risk of MDD among hospitalized patients. • MDD was associated with an increased mortality risk among all ages up to 90 years. • New age-appropriate cut-off values for MDD derived by outcome were proposed. • Certain new values were better prognostic predictors vs the current recommendations. [ABSTRACT FROM AUTHOR]

Cardiotoxicity has become a significant adverse effect of cancer therapy, with Anthracyclines (ANT) in particular. There is a crucial need for new imaging techniques for the early subclinical detection of cardiotoxic effect. We aimed to evaluate left atrial strain (LAS) changes during ANT therapy and to assess the correlation between LAS and the routine echocardiographic diastolic parameters. Data were prospectively collected as part of the Israel Cardio-Oncology Registry (ICOR). All female patients with breast cancer, planned for ANT therapy were included. All patients underwent serial echocardiography exams including baseline LAS (before chemotherapy, T1) and shortly after the completion of ANT therapy (T3). LAS was assessed in 3 phases: Reservoir (LASr), Conduit (LASc) and Pump (LASp). Significant reduction in LASr was determined by either a relative reduction of >10% or an absolute value of <35%. From September 2016 to June 2019, 40 patients were evaluated with a mean Doxorubicin (type of ANT) dose of 237±13.24mg/m2. At T3, significant reduction in LASr was observed among 50% of the patients with a mean LASr reduction from 40.15 ± 6.83% to 36.04 ± 7.73% (p < 0.001). LASc showed significant reduction as well (p < 0.004) as opposed to LASp (p=0.076). Both LASr and LASc showed significant correlation to the routine diastolic parameters. LASr and LASc reduction are frequent and occur early in the course of ANT therapy, showing significant correlation to the routine echocardiographic diastolic parameters, which may imply a role in the detection of early cardiotoxicity. • Novel echocardiography strain evaluation among breast cancer patients • Left Atrial Strain changes for early cardiac injury assessment • Left Atrial Strain reduction is frequent among anthracycline patients • Left Atrial Strain showed significant correlation to diastolic parameters [ABSTRACT FROM AUTHOR]

Objectives: There is an ongoing discussion on the optimal right to left (RV/LV) diameter ratio threshold and the best definition of RV dysfunction on computed tomography pulmonary angiography (CTPA) for risk assessment of pulmonary embolism (PE).Methods: On routine diagnostic CTPA, volumetric and diameter measurements (axial and reconstructed views) of the ventricles and reflux of contrast medium into the inferior vena cava (IVC) and hepatic veins were assessed in consecutive PE patients enrolled in a prospective single-center registry. In-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration.Results: Of 609 patients (median age, 69 [IQR, 56-77] years; 47 % male) included in the analysis, 68 patients (11.2 %) had an adverse outcome and 35 (5.7 %) died. While neither a RV/LV volume ratio ≥1.0 nor RV/LV diameter ratios ≥1.0 were able to predict an adverse outcome, higher thresholds increased specificity. Further, neither volumetric measurements nor reconstruction of images provided superior prognostic information compared to RV/LV ratios measured in axial planes. The combination of an axial RV/LV diameter ratio ≥1.5 with substantial reflux of contrast medium was present in 134 patients (22 %) and associated with the best prognostic performance to predict an adverse outcome in unselected (OR 3.7 [95 % CI, 2.0-6.6]) and normotensive (OR 2.8 [95 % CI, 1.1-6.7]) patients.Conclusion: A new definition of RV dysfunction (axial RV/LV diameter ratio ≥1.5 and substantial reflux of contrast medium to the IVC and hepatic veins) allows an optimized CTPA-based prediction of PE-related adverse outcome. [ABSTRACT FROM AUTHOR]

Various physical, emotional, and extrinsic triggers have been attributed to acute coronary syndrome. Whether a correlation can be drawn between identifiable ischemic triggers and the nature of coronary artery disease (CAD) still remains unclear. In the present study, we evaluated the correlation between triggered versus nontriggered ischemic symptoms and the extent of CAD in patients with ST-segment elevation myocardial infarction (STEMI). We conducted a retrospective, single-center observational study including 1,345 consecutive patients with STEMI, treated with primary percutaneous coronary intervention. Acute physical and emotional triggers were identified in patients' historical data. Independent predictors of multivessel CAD were determined using a logistic regression model. A potential trigger was identified in 37% of patients. Physical exertion was found to be the most dominant trigger (65%) followed by psychological stress (16%) and acute illness (12%). Patients with nontriggered STEMI tended to be older and more likely to have co-morbidities. Patients with nontriggered STEMI showed a higher rate of multivessel CAD (73% vs 30%, p <0.001). In a multivariate regression model, nontriggered symptoms emerged as an independent predictor of multivessel CAD (odds ratio 8.33, 95% CI 5.74 to 12.5, p = 0.001). No specific trigger was found to predict independently the extent of CAD. In conclusion, symptoms onset without a recognizable trigger is associated with multivessel CAD in STEMI. Further studies will be required to elucidate the putative mechanisms underlying ischemic triggering. [ABSTRACT FROM AUTHOR]