Cardiology

Roberts, W. C., V. S. Won, A. Vasudevan, J. M. Ko, S. A. Hall and G. V. Gonzalez-Stawinski (2016). “Frequency of massive cardiac adiposity (floating heart) in the native hearts of patients having heart transplantation at a single texas hospital (2013 to 2015) and comparison of various clinical and morphologic variables in the patients with massive versus nonmassive cardiac adiposity.” American Journal of Cardiology 117(8): 1375-1380.

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Body weight continues to increase worldwide due primarily to. the increase in body fat. This study analyzes the frequency of massive adiposity at hearts of patients who underwent heart transplantation (HT) determined by the ability of the heart to float in a container of 10% formaldehyde (because adipose tissue is lighter than myocardium) and compares certain characteristics of those patients with and without floating hearts. The hearts studied at HT during a 3-year period (2013 to 2015) at Baylor University Medical Center were carefully “cleaned” and weighed by the same individual and tested as to their ability to float in a container of formaldehyde, an indication of severe cardiac adiposity. Of the 220 hearts studied, 84 (38%) floated in a container of formaldehyde and 136 (62%) did not. Comparison of the 84 patients with floating hearts to the 136 with nonfloating hearts showed a significant difference in ages, but a nonsignificant difference in gender, body mass index, frequency of systemic hypertension, or diabetes mellitus. The odds of a heart being a floating one was increased in patients with a diagnosis of ischemic cardiomyopathy (un-adjusted odds ratio 2.12, 95% CI 1.21 to 3.70). The frequency of massive cardiac adiposity in the native hearts of patients having HT (38%) is striking and appears to have increased in frequency in the recent decades.

McCullough, P. A., M. K. Fallahzadeh and K. M. Tecson (2016). “Predicting acute kidney injury in the catheterization laboratory.” Journal of the American College of Cardiology 67(14): 1723-1724.

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There has been considerable advancement in catheters, wires, balloons, stents, and adjunctive strategies for procedures performed in the cardiac catheterization laboratory. Despite these improvements, angiographic procedures remain dependent on the use of water-soluble iodinated contrast that has inherent nephrotoxicity (1) . In addition, coronary angiography with percutaneous coronary intervention (PCI) poses additional risks of renal atheroembolism, which may occur on a subclinical basis and contribute to acute kidney injury (AKI). In the settings of acute myocardial infarction and heart failure, there are hemodynamic, neurohormonal, and cytokine mechanisms of action, which are determinants for acute tubular injury in the absence of exposure to the catheterization procedure. With this backdrop, Inohara et al. (2) in this issue of the Journal analyzed 11,041 consecutive patients enrolled in a Japanese PCI registry with the goal of validating the U.S. National Cardiovascular Data Registry’s (NCDR) CathPCI registry prediction models for AKI and the need for renal replacement therapy (dialysis). The CathPCI registry prediction model included 11 variables for AKI and 6 for AKI requiring dialysis (AKI-D) (3) . Both models were strongly influenced by 4 variables, in importance: 1) baseline renal function; 2) cardiogenic shock; 3) ST-segment elevation myocardial infarction (STEMI); and 4) heart failure. For patients without cardiogenic shock, STEMI, or heart failure, the most important predictor was baseline renal function (estimated glomerular filtration rate or chronic kidney disease [CKD] stage) followed by diabetes as shown in the first original models developed for AKI and AKI-D (4).

Grayburn, P. A. (2016). “Sex differences in mitral regurgitation before and after mitral valve surgery.” Jacc-Cardiovascular Imaging 9(4): 397-399.

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In this issue of iJACC, Mantovani et al. (3) provide evidence that there are important differences between men and women referred for surgery for primary MR in an experienced mitral valve center of excellence. The authors report a retrospective analysis of 217 women and 447 men who underwent surgery at Mayo Clinic between 1990 and 2000 with comprehensive echocardiographic imaging, including MR quantitation performed pre-operatively (27 ± 35 days) and post-operatively (6 ± 10 months). Age and other demographic characteristics were very similar between the sexes, but women had smaller body surface area (BSA) and were more likely to have heart failure (HF) symptoms (41% vs. 19%, respectively; p < 0.0001) and be prescribed HF therapy. LV diastolic and systolic diameters, left atrial (LA) diameter, LV mass, regurgitant volume (RVol), and effective regurgitant orifice area (EROA) were all significantly smaller in women, and fewer women were classified with severe MR, presumably due to lower RVol and EROA. After they were indexed for BSA, women had slightly higher LV and LA diameters than men, with no differences in RVol, suggesting that the LV volume overload was similar between men and women when BSA was taken into account. This hypothesis is further supported by strikingly similar reductions in men and women in LV and LA diameters post-operatively. Reduction in PA systolic pressure post-operatively was slightly greater in women, despite starting with higher PA pressures.

Hamm, C. W., M. Arsalan and M. J. Mack (2016). “The future of transcatheter aortic valve implantation.” European Heart Journal 37(10): 803-U876.

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Since the introduction of transcatheter aortic valve implantation (TAVI) into clinical practice, the treatment of aortic stenosis has changed dramatically. In the past, medical therapy with or without balloon aortic valvuloplasty was the only option for inoperable patients. More recently, TAVI has become the treatment of choice for these patients and the preferred alternative for high-risk operable patients. Surgical aortic valve replacement (SAVR) currently remains the gold standard for patients at low or intermediate operative risk. As randomized trials have demonstrated comparable results between TAVI and SAVR in the high-risk population, there is now a clear trend towards performing TAVI even in intermediate-risk patients while awaiting the results of randomized trials in that population. Nevertheless, there are still questions regarding TAVI involving paravalvular leak (PVL), stroke, pacemaker requirements, and durability that remain to be more definitively answered before TAVI can routinely be performed in a broader, lower risk population. Improvements in patient selection, imaging, and second and third generation devices have decreased the incidence of PVLs and vascular complications that followed the earliest TAVI procedures, but the rates of perioperative stroke and permanent pacemaker implantation must still be addressed. Furthermore, the long-term durability of TAVI devices and a role for post-procedure antithrombotic management remain unanswered. Until these questions are more clearly answered, it is the Heart Team’s task to determine the optimal treatment for each patient based on risk scores, frailty metrics, comorbidities, patient preference, and potential for improvement in quality of life.

Cedars, A. M., A. S. Schmidt, C. Broberg, A. Zaidi, A. Opotowsky, J. Grewal, J. Kay, A. B. Bhatt, E. Novak and J. Spertus (2016). “Adult congenital heart disease patients experience similar symptoms of disease activity.” Circulation-Cardiovascular Quality and Outcomes 9(2): 161-170.

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Background There is a lack of objective data on the symptoms characterizing disease activity among adults with congenital heart disease (ACHD). The purpose of this study was to elicit the most important symptoms from patients across the spectrum of ACHD and to examine whether reported symptoms were similar across the spectrum of ACHD as a foundation for creating a patient-reported outcome measure(s). Methods and Results We constructed a 39-item survey using input from physicians specializing in ACHD to assess the symptoms patients associate with disease activity. Patients (n=124) prospectively completed this survey, and the results were analyzed based on underlying anatomy and disease complexity. A confirmatory cohort of patients (n=40) was then recruited prospectively to confirm the validity of the initial data. When grouped based on underlying anatomy, significant differences in disease-related symptom rankings were found for only 6 of 39 symptoms. Six symptoms were identified which were of particular significance to patients, regardless of underlying anatomy. Patients with anatomy of great complexity experienced greater overall symptom severity than those with anatomy of low or moderate complexity, attributable exclusively to higher ranking of 5 symptoms. The second patient cohort had symptom experiences similar to those of the initial cohort, differing in only 5 of 39 symptoms. Conclusions This study identified 6 symptoms relevant to patients across the spectrum of ACHD and remarkable homogeneity of patient experience, suggesting that a single disease-specific patient-reported outcome can be created for quality and outcome assessments.