Search

Constrictive pericarditis (CP) is a curable cause of diastolic heart failure with prior cardiac surgery being a recognizable etiology. We report a patient who developed CP one year following heart transplantation. Several clinical and imaging related factors may lead to diagnostic delays in similar patients, including the mistaken belief that transplanted hearts are devoid of pericardium and thus do not develop constriction. Post-transplantation pericardial effusion, mediastinitis, and cardiac rejection predispose to future CP. Caretakers should consider this entity in allograft recipients who develop heart failure symptoms of unclear etiology.

International audience; Ultrasound is the imaging modality of choice for the initial evaluation of disorders that involve the abdominal aorta (AA). The diagnostic value of ultrasound resides in its ability to allow assessment of the anatomy and structure of the AA using two- dimensional, three-dimensional, and contrast-enhanced imaging. Moreover, ultrasound permits evaluation of the physiologic and hemodynamic consequences of abnormalities through Doppler interrogation of blood flow, thus enabling the identification and quantification of disorders within the AA and beyond its boundaries. The approach to ultrasound imaging of the AA varies, depending on the purpose of the study and whether it is performed in a radiology or vascular laboratory or in an echocardiography laboratory. The aim of this review is to demonstrate the usefulness of ultrasound imaging for the detection and evaluation of disorders that involve the AA, detail the abnormalities that are detected or further assessed, and outline its value for echocardiographers, sonographers, and radiologists.

CDK 4/6 inhibitors, in combination with endocrine therapy, are the standard of care for patients with endocrine-sensitive advanced breast cancer. This class of drug, however, is associated with QT prolongation, which serves as a surrogate marker for Torsades de Pointes (TdP), a cause of life-threatening ventricular arrhythmias and sudden cardiac death. The ICH E14 guidance document uses the Bazett formula for reporting of cardio-dynamic and safety ECG data in clinical trials. While there is substantial familiarity with the Bazett (QTcB) formula (QT/(RR) 1/2), the Fridericia (QTcF) formula (QT/(RR) 1/3 ) is preferred in the cancer population as it is often more accurate at heart rate extreme. Accordingly, the Fridericia formula is currently the standard adopted by the FDA when submitting QT data for review. At the King Faisal Specialist Hospital and Research Center, a total of 82 patients with advanced breast cancer, had a baseline ECG on day 1 before the initiation of ribociclib based therapy. Of the enrolled 82 patients, 19 (23%) were initially excluded from receiving ribociclib based due to a prolonged QTc >450ms, however, when the QTc-interval was manually measured and recalculated using Fridericia and Framingham formulae using MDCalC (https//:www.mdcalc.com),17 of 19 patients successfully received their treatment without any arrhythmogenic effects. Repeat ECG on day14, and day 1 of cycle 2 demonstrated that none of these patients had QTc exceeding 480 ms. Our data highlights the complexities of evaluating the QT interval in oncology patients and the utility of the Fridericia/Framingham formulae in this population. Given these findings, we recommend the adoption of the Fridericia or Framingham formulae for measurement of QTc in all cancer patients exposed to potentially QT-prolonging cancer therapy.

Objective Cardiac allograft vasculopathy is one of the leading causes of late graft failure and subsequent death in orthotopic heart transplant. Although invasive coronary angiography is the gold standard modality for detection of cardiac allograft vasculopathy, dobutamine stress echocardiography has been recently frequently used as an alternative. Our aim was to evaluate the diagnostic performance of dobutamine stress echocardiography for detection of cardiac allograft vasculopathy in transplant patients. Methods A retrospective analysis was conducted using a total of 150 dobutamine stress echocardiographic exams that were performed on 99 patients in our institution, with paired coronary angiogram and no acute rejection, within a median of 538 [interquartile range 371–816] days. Sensitivity and specificity of dobutamine echocardiography to detect allograft vasculopathy was evaluated. Allograft vasculopathy was defined as Grade 1 or higher based on ISHLT criteria. A positive dobutamine stress echo result was defined by new or worsening wall motion abnormality. Results Median age of the population at transplant was 34 [interquartile range 22–46] years; 76 (77%) patients were male. Allograft vasculopathy was present in 31 (20.6%) out of 150 coronary angiograms. Only 7 (4.6%) of that number were positive on dobutamine stress echocardiography. Sensitivity and specificity for allograft vasculopathy detection was 3% and 94%, respectively. Out of 7 false positive dobutamine stress echocardiograms, two were in patients with myocardial bridging. Two patients with mild acute rejection had both negative dobutamine stress echo. Conclusions Overall, positivity of dobutamine stress echocardiography in patients after heart transplant is low. It has high specificity, but very low sensitivity for detection of cardiac allograft vasculopathy. Dobutamine stress echocardiography should only be cautiously used as an alternative to coronary angiography.

Objective: Postoperative atrial fibrillation is a major complication following coronary artery bypass graft. We hypothesized that, beyond clinical and electrocardiogram (ECG) data, transthoracic echocardiography could improve the prediction of postoperative atrial fibrillation. Methods: We prospectively studied 169 patients in sinus rhythm who underwent isolated coronary artery bypass graft in our institution. Clinical, biological, ECG and transthoracic echocardiography data were collected within 24 h before surgery. The patients were continuously monitored during the first five days, and then had daily 12-lead ECG afterwards until discharge. Postoperative atrial fibrillation was defined by any episode >10 min. Results: Postoperative atrial fibrillation was found in 65 patients (38%). Compared with those without, patients with postoperative atrial fibrillation were significantly older ( p=0.008), had more frequently a history of hypertension ( p=0.009), history of atrial fibrillation ( p2) of the model, from 34 to 57. Conclusion: A history of atrial fibrillation and indexed left atrial maximal volume are the best predictors of the occurrence of postoperative atrial fibrillation following coronary artery bypass graft. The identification of high risk population of postoperative atrial fibrillation using these two factors could lead to the development of targeted strategies to limit this frequent complication in these patients.

Doppler interrogation of blood flow in the hepatic veins (HVs) provides valuable information regarding a wide spectrum of pathological processes that affect the right heart. Systematic analysis of the direction, velocity, and phasicity of the HV waveforms allows one to distinguish normal from abnormal patterns and provides important diagnostic information. Abnormalities in heart rate, rhythm, and intracardiac conduction are commonly encountered during echocardiographic studies. Sinus bradycardia and tachycardia, bradyarrhythmias and tachyarrhythmias as well as atrioventricular conduction disturbances influence the flow pattern in the HVs and may pose a challenge to the correct interpretation of the HV Doppler. Alterations in HV flow that are induced by the electrical abnormalities may mimic right heart pathology. Awareness of these alterations allows one to avoid misinterpretation of the HV signal, helps diagnose the underlying rhythm or conduction abnormality, and permits assessment of the impact on right heart hemodynamics.

Introduction: Global left ventricular (LV) afterload as assessed by valvulo-arterial impedance (Zva), may be an independent predictor of mortality in patients with severe aortic stenosis (AS) and preserved LV ejection fraction (LVEF). However, its quantification using echocardiography may be subject to error measurement. We aimed to determine the prevalence and impact on long-term survival of high Zva, purposely measured by cardiac catheterization. Methods and results: 676 patients with preserved LVEF and severe AS without other valvular heart diseases underwent cardiac catheterization. Zva was derived from catheterization and calculated as follows: mean aortic gradient + systolic blood pressure/ indexed LV stroke volume. Zva was considered high when > 5mmHg/mL/m(2) based on previous studies. Overall, high Zva was found in 42% of all AS patients. Four-year survival and 8-year survival were significantly reduced in patients with high Zva (74 +/- 3% and 57 +/- 4%) as compared to those with low Zva (85 +/- 2% and 74 +/- 3%; p = 0.002). After adjustment for all other risk factors, Zva was independently associated with reduced long-term survival (hazard ratio [HR] = 1.47 95% CI: 1.04-2.09; p = 0.029). Of interest, high Zva remained associated with reduced survival as compared to low Zva, in patients with normal LV stroke volume, but was no longer significant in low flow patients (p = 0.98). Conclusion: High Zva, estimated invasively in our study, is frequent in patients with severe AS, and appears as a robust and independent predictor of survival. Zva should be used as an additional parameter for risk stratification of severe AS, more particularly in patients with normal flow. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

International audience; AIMS:The prognostic impact of elevated pulmonary arterial pressure (PAP) remains controversial in aortic stenosis (AS) and few studies focused on patients with preserved left ventricular ejection fraction (LVEF). We aimed to investigate the impact of pulmonary hypertension (PH), invasively derived, on survival in severe AS with preserved LVEF.METHODS AND RESULTS:Between 2000 and 2010, 749 patients (74 ± 8 years, 57% males) with preserved LVEF and severe AS without other valvular heart disease underwent cardiac catheterization. PH was defined as mean PAP > 25 mmHg. The mean follow-up was 4.6 ± 3.0 years. Overall, 32% (n = 241) of patients had PH. Surgical aortic valve replacement (SAVR) was performed in 91% of patients with 4.5% of 30-day mortality rate, significantly higher in patients with PH than without PH (7.5 vs. 3.5%, p = 0.014). In logistic regression, PH was an independent predictor of increased 30-day mortality (odds-ratio = 2.2, p = 0.04). Overall long-term survival was significantly reduced in patients with PH as compared to those without (10-year: 52 ± 5 vs. 68 ± 3%, p

International audience; Amyloidosis is a severe systemic disease. Cardiac involvement may occur in the three main types of amyloidosis (acquired monoclonal light-chain, hereditary transthyretin and senile amyloidosis) and has a major impact on prognosis. Imaging the heart to characterize and detect early cardiac involvement is one of the major aims in the assessment of this disease. Electrocardiography and transthoracic echocardiography are important diagnostic and prognostic tools in patients with cardiac involvement. Cardiac magnetic resonance imaging better characterizes myocardial involvement, functional abnormalities and amyloid deposition due to its high spatial resolution. Nuclear imaging has a role in the diagnosis of transthyretin amyloid cardiomyopathy. Cardiac biomarkers are now used for risk stratification and staging of patients with light-chain systemic amyloidosis. Different types of cardiac complications may occur, including diastolic followed by systolic heart failure, atrial and/or ventricular arrhythmias, conduction disturbances, embolic events and sometimes sudden death. Senile amyloid and hereditary transthyretin amyloid cardiomyopathy have better prognoses than light-chain amyloidosis. Cardiac treatment of heart failure is usually ineffective and is often poorly tolerated because of its hypotensive and bradycardiac effects. The three main types of amyloid disease, despite their similar cardiac appearance, have specific new aetiological treatments that may change the prognosis of this disease. Cardiologists should be aware of this disease to allow early treatment.

Objectives This study was designed to examine the prognostic value of systemic arterial compliance (SAC) by Doppler-echocardiography in patients with type 2 diabetes mellitus (T2D). Background Reduced SAC has been shown to predict outcomes in patients with hypertension. T2D is associated with accelerated arterial stiffening and increased cardiovascular events. We hypothesized that SAC measured by Doppler-echocardiography would independently predict mortality in patients with T2D. Methods Since 2001, SAC calculated as the ratio of stroke volume index to arterial pulse pressure by sphygmomanometer is routinely performed in our laboratory. Data from 505 consecutive patients with T2D were retrospectively analyzed. Based on a previously validated cut-off value of SAC 2 /mmHg, patients were divided into Group 1, reduced SAC, 255 patients (50%) and Group 2, preserved SAC, 250 patients (50%). The primary endpoint was overall mortality. Results Patients with reduced SAC had significantly lower 5-year survival than those with preserved SAC (66 ± 5 vs. 82 ± 5%, p = 0.02) and a 1.57-fold (95% CI: 1.04–2.43; p = 0.03) increased risk of mortality after adjusting for other risk factors. Blood pressure did not predict mortality and pseudo-normalized blood pressures related to LV dysfunction and low cardiac output were found in 75 patients (15%). Conclusion Reduced SAC is encountered frequently in T2D, is an independent predictor of mortality and allows identification of patients who, despite a normal blood pressure, are at increased risk. Future studies are necessary to further evaluate the clinical utility of this simple echocardiographic parameter and therapies are needed to alter vascular stiffness to improve clinical outcomes in these high-risk patients.

Background Cardiac involvement in systemic light-chain amyloidosis (AL) is characterized by 2D-echocardiography (TTE) normal or slithly decreased left ventricular (LV) ejection fraction and typically a diastolic dys-function with left atrial (LA) enlargement. To assess cardiac involvement, the Mayo Clinic staging (MC) using NTproBNP and troponin, has been validated and allows risk stratification of patients into 3 groups with different outcomes. Cardiac magnetic resonance (CMR) assesses accurately chambers size and function. We aimed to compare by TTE and by CMR respectively: features of LV systolic and diastolic function and by CMR, morphological functional parameters namely LV myocardial late gadolinium enhancement (LGE) and indexed max LA volume (LAVi) and emptying fraction (LAEF). Methods and results Forty-two consecutive patients (66±10 years, 57% males) in sinus rhythm with confirmed systemic AL, underwent simultaneously TTE and CMR within 24 hours. LAEF was calculated after assessing the maximal and minimal LAVi (by area/length formula) in CMR using 4 and 2 chambers views. Diastolic parameters and 2D-LV global longitudinal strain (GLS) obtained by TTE were stratified according to LAEF, to LAVi and to the presence or not of LGE. Patients in MC stage III had the worse TTE and CMR parameters. LV GLS (–10.1±3.1 vs. –17.3±3.7, p Conclusion In systemic AL, reduced LV GLS is associated with presence of LGE while impaired LV filling pressures are rather related to decreased LA emptying fraction. Multimodality imaging in patients with AL may allow better and complementary assessment of LV hemodynamics. Abstract 0430 - Table LA Emptying fraction CMR Maximal LAVICMR LGE >17.5% p >44 ml/m2 p – + p Mitral E/A ratio 2.98±1.82 0.89±0.28 1.51±1.4 2.22±1.8 0.2 1.35±1.3 2.43±1.9 0.055 DT TTE (ms) 158±45 217±56 190±65 183±53 0.7 219±51 145 ±39 Lateral E/e’ 16.9±6.8 12.1±6.4 14±7 14.8±7 0.8 13.6±7.4 15.7±6.4 0.4 GLS –10.1±3.1 –17.3±3.7 –14.2±5 –12.7±4.6 0.4 –16.5±5.2 –10.8±2.8

Objectives This study was designed to evaluate the effect of valve prosthesis-patient mismatch (PPM) on late survival after aortic valve replacement (AVR) and to determine if this effect is modulated by patient age, body mass index (BMI), and pre-operative left ventricular (LV) function. Background We recently reported that PPM is an independent predictor of operative mortality after AVR, particularly when associated with LV dysfunction. Methods The indexed valve effective orifice area (EOA) was estimated in 2,576 patients having survived AVR and was used to define PPM as not clinically significant if it was >0.85 cm2/m2, as moderate if >0.65 and ≤0.85 cm2/m2, and severe if ≤0.65 cm2/m2. Results After adjustment for other risk factors, severe PPM was associated with increased late overall mortality (hazard ratio [HR]: 1.38; p = 0.03) and cardiovascular mortality (HR: 1.63; p = 0.0006) in the whole cohort. Severe PPM was also associated with increased overall mortality in patients Conclusions Moderate PPM is associated with increased late mortality in patients with LV dysfunction, but with normal prognosis in those with preserved LV function. Notwithstanding the previously demonstrated deleterious effect of severe PPM on early mortality, this factor appears to increase late mortality only in patients

Post-operative atrial fibrillation (POAF) is a frequent complication occurring in 30% to 50% of patients after cardiac surgery. It is associated with an increased risk of mortality and morbidity, predisposes patients to a higher risk of stroke, requires additional treatment, and increases the costs of the post-operative care. The aim of this review is to present the current state of knowledge about the risk factors, mechanisms, prevention, and treatment of this complication. In addition to the well known risk factors for the development of POAF such as age, left atrial enlargement, and valvular surgery, new metabolic risk factors related to visceral obesity have been identified. With regard to the prevention of POAF, beta-blocker drugs are effective and safe and can be used in most patients, whereas amiodarone can be added in high-risk patients. Biatrial pacing was shown to be effective; however, its complexity might limit its application. Although there are only few data regarding the usefulness of magnesium, statins, N-3 polyunsaturated fatty acids, and corticosteroids, their addition to beta-blocker drugs might be of benefit for further reducing POAF. Treatment includes the use of an AV nodal blocking agent to achieve the rate control. If AF does not spontaneously convert to sinus rhythm within 24 h, anticoagulation should be initiated and a rhythm control strategy should be attempted. More investigations are warranted to explore mechanisms by which POAF occurs. This new knowledge would undoubtedly translate into a more efficient prevention and treatment of this common post-operative complication that is associated with a major health and economic burden.

International audience; AIMS:Previous studies using echocardiography suggested that a low flow (LF) defined as an indexed stroke volume (SVi) 50%) and severe AS (valve area ≤1 cm(2)) without other valvular heart disease underwent cardiac catheterisation. The long-term overall mortality was assessed as the primary end-point.RESULTS:Mean age was 74±8 years, 58% were men, 46% had coronary artery disease and mean LVEF was 72±10%. Low SVi was found in 27% (n=210) of patients with AS. As compared with patients with normal SVi, those with low SVi were significantly older (p

BackgroundCardiac involvement is frequent in systemic light chain amyloidosis (AL). Left-sided valvular thickening (LVT) have been described in AL reflecting heavy infiltration of the valvular endocardium by amyloid proteins. However, the exact prevalence at diagnosis and the prognostic significance of LVT in AL patients have never been investigated.Aimsto study the prevalence and the impact on long-term survival LVT in AL patients.Methods and resultsBetween 1998 and 2013, 150 AL patients were included at diagnosis (mean age was 68±11 ans, 59% were male). A comprehensive transthoracic echocardiography was performed at baseline. The presence of LVT was assessed visually and was found in 42% of patients. Compared to patients without LVT, those with LVT have more frequently advanced NYHA functional class. They also had significantly higher left ventricular (LV) wall thickening (p=0.01), LV mass (p=0.02), and mitral E/e’ (p=0.0009) and larger left atrial size (p

IntroductionThe non-invasive assessment of left ventricular (LV) filling and LA pressure in patients with aortic stenosis (AS) remains challenging. The aim of our study was to identify the echocardiographic parameters that may predict elevated pulmonary capillary wedge pressures (PCWP) measured by cardiac catheterization in patients with severe AS without other valve disease.Methods and resultsFrom January 2010 to December 2012, we included 85 consecutive patients with severe AS scheduled for clinically indicated cardiac catheterization study. Comprehensive transthoracic echocardiography (TTE) was performed in all patients within 24 hours of the hemodynamic study. Mean age was 75±9 years, 65% of them were male, 65%, 22% and 54% had respectively a history of hypertension, diabetes, and dyslipidemia. NYHA functional class was≥III in 63% of patients. By TTE, mean LV ejection fraction, max left atrial (LA) volume indexed, were respectively 60±9%, and 38±16mL/m 2. Mean mitral septal E/e’ ratio was 18.6±9. Cardiac catheterization found 60% cases of coronary artery disease and the mean PCWP was 13.5±7mmHg. As compared to patients with low PCWP (29ml/m 2 predicted a PCWP>13mmhg with a sensitivity of 77% and a specificity of 62% (area under the curve=0.73). Similarly, mitral annular septal E/e’>12 predicted PCP>13mmHg with a sensitivity of 90% and a specificity of 60% (area under the curve=0.73).ConclusionIn severe AS patients, maximal LA indexed volume>29/ml/m2 and E/e’ ratio>12, derived from TTE, appear as good markers of elevated PCWP. Further studies are needed to investigate their prognostic values.

Background— Patients with severe aortic stenosis (AS) and paradoxical low flow (PLF) have worse outcome compared with those with normal flow. Furthermore, prosthesis–patient mismatch (PPM) after aortic valve replacement is a predictor of reduced survival. However, the prevalence and prognostic impact of PPM in patients with PLF-AS are unknown. We aimed to analyze the prevalence and long-term survival of PPM in patients with PLF-AS. Methods and Results— Between 2000 and 2010, 677 patients with severe AS, preserved left ventricular ejection fraction, and aortic valve replacement were included (74±8 years; 42% women; aortic valve area, 0.69±0.16 cm 2 ). A PLF (indexed stroke volume ≤35 mL/m 2 ) was found in 26%, and after aortic valve replacement, 54% of patients had PPM, defined as an indexed effective orifice area ≤0.85 cm 2 /m 2 . The combined presence of PLF and PPM was found in 15%. Compared with patients with noPLF/noPPM, those with PLF/PPM were significantly older, with more comorbidities. They also received smaller and biological bioprosthesis more often (all P P =0.002), even after multivariable adjustment (hazard ratio, 2.58; 95% confidence interval, 1.5–4.45; P =0.0007). Conclusions— In this large catheterization-based study, the coexistence of PLF-AS before surgery and PPM after surgery is associated with the poorest outcome.

Violi et al. [(1)][1] are to be commended for their large study on the prevalence of subclinical peripheral artery disease (PAD) among patients with nonvalvular atrial fibrillation. Indeed, the ankle-brachial index (ABI) enables the detection of a substantial subset of individuals with asymptomatic

Background— The clinical relevance and management of paradoxical low-flow, low-gradient aortic stenosis (LFLG-AS) with preserved left ventricular ejection fraction remain debated. The aim of this study is to determine the features and outcome of LFLG-AS assessed using cardiac catheterization. Methods and Results— Between 2000 and 2010, 768 patients with preserved left ventricular ejection fraction (>50%) and severe AS (valve area ≤1cm 2 ) without other valvular disease underwent cardiac catheterization. Mean age was 74±8 years, 42% were women, and 46% had associated coronary artery disease. The prevalence of LFLG (indexed left ventricular stroke volume 2 and mean gradient P P =0.0002). After adjustment for other risk factors, LFLG-AS was independently associated with reduced long-term survival (hazard ratio, 1.85; 95% confidence interval, 1.08–3.07; P =0.02). However, despite higher operative mortality, patients with LFLG-AS undergoing aortic valve replacement seemed to have better long-term survival than those managed conservatively (5-year survival rate: 63±6% versus 38±15%; P =0.007; hazard ratio, 0.23; 95% confidence interval, 0.09–0.59; P =0.002). Conclusions— This large cardiac catheterization–based study reports that the LFLG-AS entity is not rare and is associated with worse outcome whether treated medically or surgically. However, these patients may have better long-term survival if treated surgically. Further prospective studies are needed to confirm this finding.

International audience; BACKGROUND: Primary systemic amyloidosis is a severe plasma cell disorder characterized by the extracellular deposition of amyloid fibrils in different organs. Echocardiography is usually performed to assess cardiac involvement. We hypothesized that in patients with systemic amyloidosis, simple echocardiographic measurement of the left atrial (LA) diameter indexed to the body surface area might provide an important risk marker for this disease. METHODS: Between 1997 and 2011, 134 patients were diagnosed with primary systemic amyloidosis and had echocardiography within 28 days; we collected their baseline characteristics and biological and echocardiographic data retrospectively. LA enlargement was defined as recommended as M-mode LA diameter greater or equal to 23 mm/m(2). RESULTS: One hundred and eleven patients (83%) had echocardiographic LA dimension data available (mean age 63±11 years; 61% men; 31% previously diagnosed with systemic hypertension). Mean left ventricular ejection fraction (LVEF) and interventricular septum thickness (IVST) were 62±12% and 14±4 mm, respectively. Mean follow-up was 2.8±2.9 years (maximum 12 years). Patients with LA enlargement had a slightly lower LVEF (P=0.08) and a significantly greater IVST (P

Background:Limb girdle muscular dystrophy type 1B is an autosomal dominant disease characterized by late onset proximal muscle involvement associated with cardiac complications such as atrioventricular conduction blocks, dilated cardiomyopathy, and sudden death.Objective:Define the full phenotypic spectrum of a new mutation in the LMNA gene causing limb girdle muscular dystrophy type 1B.Methods:We identified a large French Canadian family with the LGMD 1B phenotype and a cardiac conduction disease phenotype that carried a new mutation in the LMNA gene and sought to define its full phenotypic spectrum by performing complete neurological and cardiac evaluations, muscle biopsy, RNA and DNA studies.Results:The proband and 12 living at risk relatives were tested. In total, we identified seven carriers of a new (IVS9-3C>G) LMNA gene mutation. Of the three symptomatic patients, all had cardiac involvement, but only two presented proximal limb weakness. The one available muscle biopsy demonstrated a normally expressed lamin A/C protein, localized at the nuclear envelope. RNA study revealed a loss of exon 10 transcription caused by the IVS9-3C to G splicing mutation.Conclusions:We have identified a new mutations in the LMNA gene in a French-Canadian family. This diagnosis has important implications for affected patients and their siblings since they may eventually require pacemaker implantation.

This study was designed to evaluate the effect of valve prosthesis-patient mismatch (PPM) on late survival after aortic valve replacement (AVR) and to determine if this effect is modulated by patient age, body mass index (BMI), and pre-operative left ventricular (LV) function.We recently reported that PPM is an independent predictor of operative mortality after AVR, particularly when associated with LV dysfunction.The indexed valve effective orifice area (EOA) was estimated in 2,576 patients having survived AVR and was used to define PPM as not clinically significant if it was0.85 cm(2)/m(2), as moderate if0.65 andor =0.85 cm(2)/m(2), and severe ifor =0.65 cm(2)/m(2).After adjustment for other risk factors, severe PPM was associated with increased late overall mortality (hazard ratio [HR]: 1.38; p = 0.03) and cardiovascular mortality (HR: 1.63; p = 0.0006) in the whole cohort. Severe PPM was also associated with increased overall mortality in patients70 years old (HR: 1.77; p = 0.002) and in patients with a BMI30 kg/m(2) (HR: 2.1; p = 0.006), but had no impact in older patients or in obese patients. Moderate PPM was a predictor of mortality in patients with LV ejection fraction50% (HR: 1.21; p = 0.01), but not in patients with preserved LV function.Moderate PPM is associated with increased late mortality in patients with LV dysfunction, but with normal prognosis in those with preserved LV function. Notwithstanding the previously demonstrated deleterious effect of severe PPM on early mortality, this factor appears to increase late mortality only in patients70 years old and/or with a BMI30 kg/m(2) or an LV ejection fraction50%.

Background: Several complications may occur during catheter ablation for atrial fibrillation (AF). We report an unusual case of left atrial wall hematoma without pericardial effusion secondary to a right inferior pulmonary vein (PV) laceration. The use of real-time transesophageal echocardiography (TEE) during the procedure can be useful for early detection of this potentially lethal complication. Case report: A 49-year-old woman was referred for AF ablation. Her past medical history included severe systemic lupus with chronic renal failure treated with immunosuppressive and steroid drugs. A TEE-guided hybrid approach for AF ablation was performed with circular PV lesions and antrum and ostial electrical isolation. While performing the mitral isthmus line, the TEE showed a growing hematoma at the posterior left atrial wall. Rapidly, left atrium (LA) collapse associated with hemodynamic compromise occurred without any pericardial effusion. The patient was brought to the operating room. No pericardial effusion was seen at the time of surgery. The cardiac exploration showed a right inferior PV laceration. The visual inspection of the LA revealed thin and friable tissue. The patient survived. After 25 months of follow-up, she is still free from symptomatic AF. Conclusions: Left atrial wall hematoma without pericardial effusion is a rare and life-threatening complication after catheter-based AF ablation. TEE is a valuable monitoring tool to accurately diagnose several acute complications and prompt rapid intervention.

Background— Postoperative atrial fibrillation (POAF) is a highly prevalent complication after cardiac surgery with substantial effects on outcomes. Previous studies have reported that obesity is a risk factor for POAF after cardiac surgery. However, it is unknown whether the metabolic syndrome (MS) also increases the risk of postoperative atrial fibrillation. Methods and Results— We retrospectively analyzed the association between obesity and MS and the incidence of new-onset POAF in a total of 5085 patients who underwent isolated coronary artery bypass grafting surgery with no concomitant valvular surgery. Of these patients, 1468 (29%) were obese (body mass index ≥30 kg/m 2 ) and 2320 (46%) had a MS as defined by the NCEP-ATPIII. POAF occurred in 1374 (27%) of the patients. Obesity was associated ( P 50 years old but not in patients ≤50 years old. In these patients, MS was the only metabolic factor to be significantly associated with higher incidence of POAF (12% versus 6%, P =0.01). In >50-year-old patients, mild (30 ≤ body mass index 2 ) and moderate–severe (body mass index ≥35 kg/m 2 ) obesity were independently associated with a 1.4-fold (95% CI: 1.10 to 1.71; P =0.004) and 2.3-fold (95% CI: 1.71 to 3.13; P P =0.02) but not obesity was independently associated with POAF. Conclusion— This study demonstrates that obesity is a powerful risk factor for the occurrence of POAF after isolated coronary artery bypass grafting surgery in patients older than 50 years. However, in the younger population, this association is not observed and MS is the only metabolic risk factor to be independently associated with POAF.

Background New imaging strategies for atrial fibrillation (AF) ablation should enhance the safety of this technique. The role of transesophageal echocardiography (TEE) in this setting has not been prospectively evaluated. Methods Under general anesthesia, 85 patients underwent TEE-guided AF ablation. A hybrid technique was performed with circular pulmonary veins (PV) lesions and antrum and ostial electrical isolation guided by TEE. TEE excluded left atrial (LA) thrombus, guided transseptal puncture and catheter positioning, and helped to identify PV ostia and their velocities. The TEE probe localized the esophagus, its temperature (T degrees ) and micro bubbles formation. Results Overall, one patient had a LA clot. The esophagus was located close to left PV in 38%, the right PV in 28%, midline in 17% and with an oblique course in 17% of patients. Right and left superior PV velocities were detected in 100%, left inferior PV in 88% and right inferior PV in 82% of patients. Microbubbles were detected in 9 patients (11%). Elevation of TEE T degrees occurred in 14 patients (16%) and was regularly observed when lesions were applied over the TEE probe shadow, in close proximity to the posterior wall. Two major complications (1 tamponade, 1 PV laceration) occurred and were detected early by TEE. Conclusions TEE offers advantages compared to a map-guided only approach. It is a reliable tool to assess esophagus T degrees and localization, guide transseptal puncture, delineate the PV ostia, and monitor complications.

ObjectivesThe aim of this study was to determine the impact of the metabolic syndrome (MS) on operative mortality after a coronary artery bypass grafting surgery (CABG).BackgroundDiabetes and obesity are highly prevalent among patients undergoing CABG. However, it remains unclear whether these factors have a significant impact on operative mortality after this procedure. We hypothesized that the metabolic abnormalities associated with MS could negatively influence the operative outcome of CABG surgery.MethodsWe retrospectively analyzed the data of 5,304 consecutive patients who underwent an isolated CABG procedure between 2000 and 2004. Of these 5,304 patients, 2,411 (46%) patients met the National Cholesterol Education Program–Adult Treatment Panel III criteria for MS. The primary end point was operative mortality.ResultsThe operative mortality after CABG surgery was 2.4% in patients with MS and 0.9% in patients without MS (p < 0.0001). The MS was a strong independent predictor of operative mortality (relative risk 3.04 [95% confidence interval (CI) 1.73 to 5.32], p = 0.0001). After adjusting for other risk factors, the risk of mortality was increased 2.69-fold (95% CI 1.43 to 5.06; p = 0.002) in patients with MS and diabetes and 2.36-fold (95% CI 1.26 to 4.41; p = 0.007) in patients with MS and no diabetes, whereas it was not significantly increased in the patients with diabetes and no MS.ConclusionsThis is the first study to report that MS is a highly prevalent and powerful risk factor for operative mortality in patients undergoing a CABG surgery. Thus, interventions that could contribute to reduce the prevalence of MS in patients with coronary artery disease or that could acutely modify the metabolic perturbations of MS at the time of CABG might substantially improve survival in these patients.

Introduction The coexistence of Mahaim fibbers (MF) and hypertrophic cardiomyopathy (HCM) is exceptional. We report an unusual case of a young female patient presenting with HCM and MF. Case-report A 17 y/o woman was referred in 1998 for a familial HCM screening. She had no symptoms; her surface EKG revealed a preexcitation suggesting a right anteroseptal WPW syndrome. The transthoracic echocardiogram (TTE) demonstrated an asymmetric septal HCM without LV outflow tract (LVOT) obstruction. The electrophysiological study (EPS) demonstrated the presence of MF (normal AH interval, a short and fixed HV interval and atrial pacing produced AH prolongation without change of preexcitation degree, indicating fasciculo-ventricular MF). Eight years later (25 y/o) while the patient was doing well, the ECG was similar and TEE demonstrated the same aspect of asymmetric septal HCM without obstruction. Three months later the patient was pregnant and gave birth to a healthy baby. (During pregnancy: Delta wave was present and there was no LVOT obstruction). After delivery, Surprisingly there was no more preexcitation on her ECG and the TEE demonstrated now a significant LVOT obstruction with a systolic anterior motion of the mitral valve and an LVOT gradient of 36 mmHg. A second EPS was performed in 2008 and showed no more preexcitation. We speculate the hypothesis that FV fiber played in this case a similar pathogenic role as does the apical right ventricular pacing when it is used to decrease LVOT gradient in patients with HCM. Conclusion This case deserves to be reported because the association of MF and HCM is rare (only 3 cases reported in english litterature), the disappearance of MF during pregnancy has never been reported and the hypothesis that the RV preexcitation via FV Mahaim fiber played a role in decreasing LVOT gradient in this patient with HCM.

Abstract 4621 Background: Primary systemic amyloidosis (AL) is a severe plasma cell disorder characterized by amyloid fibrils extracellular deposition in different organs. Myocardial involvement is frequent and has major impact on prognosis. Echocardiography (TTE) is the most common test performed when cardiac involvement is suspected. We hypothesized that a simple measurement of left atrium enlargement (LA) by TTE may provide an important risk marker for this disease. Methods and results: Between 1997 and 2010, 114 patients were diagnosed with systemic AL. Sixty one patients of the cohort (54%) had cardiac involvement on the basis of standard criteria defined as: mean LV wall thickness >12mm with no other cardiac causes. They had first TTE within 16 days of diagnosis. Patients were mainly treated with conventional chemotherapy (M-Dex) or with new agents for refractory or relapsing patients We retrospectively collected demographic baseline characteristics along with biological and echo data of these patients. Mean age was 61±11 years; 60% were male; 19% had hypertension. Mean left ventricular ejection fraction and mean LV wall thickness were respectively 58±13% and 15±3 mm. Mean follow up time was 2.1±2 years. None had significant valvular heart disease. LA enlargement was defined by M mode as > 40 mm in male and > 36 mm in female. Patients with enlarged LA had significantly more hypertension and lower ejection fraction and more hypertrophied LV walls (All P< 0.05). At 3 years, survival rate was markedly reduced in patients with enlarged LA vs. those with normal LA: 34±9% vs.75 ±9% (P =0.02). By multivariate analysis, after adjusting for age, gender, and presence of hypertension, LA enlargement remained an independent predictor of overall mortality at 3 years (HR=2.88; CI (1.12-8.84); P=0.03). Conclusion: In patients with systemic AL amyloidosis and cardiac involvement, LA enlargement, a surrogate marker of diastolic dysfunction and elevated LV filling pressure, is a powerful independent predictor of long-term mortality. Therefore LA enlargement may help to enhance risk stratification in patients presenting with this disease. Disclosures: No relevant conflicts of interest to declare.

BackgroundThe exact prevalence, characteristics and impact on both short- and long-term outcome of low flow, low gradient severe aortic stenosis (LFLG) despite preserved left ventricular ejection fraction (LVEF), remain debatable. The aim of our study is to describe the outcome of a large group of patients with LFLG AS using cardiac catheterization data.Methods and ResultsBetween 2000 and 2010, 770 patients with preserved LVEF (>50%) and severe AS (valve area

BackgroundThe prognostic impact of pulmonary arterial pressure (PAP) remains controversial in aortic stenosis (AS) and few studies focused only on patients with preserved left ventricular ejection fraction (LVEF). We therefore aimed to investigate the impact of PAP, derived from our large catheterization database, on survival in severe AS with preserved LVEF.Methods and resultsBetween 2000 and 2010, 749 patients (74±8y, 57% of males) with preserved LVEF and severe AS without other valvular heart disease underwent cardiac catheterization, including right heart hemodynamic assessment. Pulmonary hypertension (PH) was defined as mean PAP>25mmHg.Systolic and mean PAP were 34.5±12 and 21.9±9mmHg, respectively. Overall, 29% (n=215) of patients had PH, and these patients were significantly older (p

BackgroundPrimary systemic amyloidosis (AL) is a severe plasma cell disorder characterized by amyloid fibrils extracellular deposition in different organs. Myocardial involvement is frequent and has major impact on prognosis. Echocardiography (TTE) is the most common test performed when cardiac involvement is suspected. We hypothesized that a simple measurement of left atrium enlargement (LA) by TTE may provide an important risk marker for this disease.Methods and resultsBetween 1997 and 2010, 109 patients were diagnosed with systemic AL and had first TTE within 21 days. Patients were mainly treated with conventional chemotherapy (M-Dex) with new agents for refractory or relapsing patients We retrospectively collected demographic baseline characteristics along with biological and echo data of these patients. Mean age was 63±11 years; 58% were male; 24% had hypertension. Mean left ventricular ejection fraction and mean LV wall thickness were respectively 62±13% and 13±3mm. Mean follow up time was 2.42±2 years. None had significant valvular heart disease. LA enlargement was defined by M mode as > 40mm in male and > 36mm in female. Patients with enlarged LA were more often male, slightly older (p=0.05) and with slightly more hypertension (p=0.07) but had significantly lower ejection fraction and more hypertrophied LV walls (All P

Previous studies suggested valvulo arterial impedance (Zva) may be an independent predictor of mortality in patients with severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF). However, its quantification using echocardiography may be subject to error measurement. Aim