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1.
Strain Echocardiography to Predict Postoperative Atrial Fibrillation.
Sánchez, FJ, Pueyo, E, Diez, ER
International journal of molecular sciences. 2022;(3)
Abstract
Postoperative atrial fibrillation (POAF) complicates 15% to 40% of cardiovascular surgeries. Its incidence progressively increases with aging, reaching 50% in octogenarians. This arrhythmia is usually transient but it increases the risk of embolic stroke, prolonged hospital stay, and cardiovascular mortality. Though many pathophysiological mechanisms are known, POAF prediction is still a hot topic of discussion. Doppler echocardiogram and, lately, strain echocardiography have shown significant capacity to predict POAF. Alterations in oxidative stress, calcium handling, mitochondrial dysfunction, inflammation, fibrosis, and tissue aging are among the mechanisms that predispose patients to the perfect "atrial storm". Manifestations of these mechanisms have been related to enlarged atria and impaired function, which can be detected prior to surgery. Specific alterations in the atrial reservoir and pump function, as well as atrial dyssynchrony determined by echocardiographic atrial strain, can predict POAF and help to shed light on which patients could benefit from preventive therapy.
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2.
Evaluation of Baseline Cardiac Function by Echocardiography and its Association With Nutritional Status in Pediatric Cancer Patients at The Indus Hospital in Karachi, Pakistan.
Muhammad, S, Belgaumi, AF, Ashraf, MS, Akhtar, S, Iftikhar, S, Raza, MR, Yakoob, MY
Journal of pediatric hematology/oncology. 2019;(6):e388-e394
Abstract
INTRODUCTION Evidence on conducting baseline echocardiogram before starting chemotherapy in pediatric cancer patients is limited from developing countries where malnutrition and infections are common and which may result in cardiac dysfunction. MATERIALS AND METHODS A prospective, observational study was conducted from October 2016 to May 2017 at The Indus Hospital, Karachi, Pakistan, among children 1 to 16 years of age suffering from cancer. Echocardiography was performed before starting chemotherapy. Associations between body mass index and cardiac abnormalities were studied. RESULTS A total of 384 children met the inclusion criteria. The median (interquartile range) age was 8.0 (5.0 to 12.0) years and 62.0% (n=238) were male individuals. Twenty-two of 384 (5.7%) children had systolic dysfunction. Four of 22 had moderate-systolic and one of 22 had mild systolic dysfunction, for whom the therapy was altered, and they were treated without anthracyclines. Four of these 5 patients died, and only 1 of 5 survived through high-risk protocol. Seventeen of 22 children had low-normal systolic dysfunction. We found no evidence of an association between body mass index for age and abnormal left ventricular ejection fraction and abnormal fractional shortening (P-trend=0.587; 0.487, respectively). No associations were found of weight-for-age and height-for-age with these outcomes. CONCLUSIONS In developing countries, echocardiograms should be expeditiously performed and technology made more accessible to rule out cardiac dysfunction and avoid delay in chemotherapy. Malnutrition was not associated with cardiac dysfunction.
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3.
Echocardiographic Features of Patients With Heart Failure and Preserved Left Ventricular Ejection Fraction.
Shah, AM, Cikes, M, Prasad, N, Li, G, Getchevski, S, Claggett, B, Rizkala, A, Lukashevich, I, O'Meara, E, Ryan, JJ, et al
Journal of the American College of Cardiology. 2019;(23):2858-2873
Abstract
BACKGROUND The PARAGON-HF (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction) trial tested the efficacy of sacubitril-valsartan in patients with heart failure with preserved ejection fraction (HFpEF). Existing data on cardiac structure and function in patients with HFpEF suggest significant heterogeneity. OBJECTIVES The aim of this study was to characterize cardiac structure and function, quantify their associations with clinical outcomes, and contextualize these findings with other HFpEF studies. METHODS Echocardiography was performed in 1,097 of 4,822 PARAGON-HF patients within 6 months of enrollment. Associations with incident first heart failure hospitalization or cardiovascular death were assessed using Cox proportional hazards models adjusted for age, sex, region of enrollment, randomized treatment, N-terminal pro-brain natriuretic peptide, and clinical risk factors. RESULTS Average age was 74 ± 8 years, 53% of patients were women, median N-terminal pro-brain natriuretic peptide level was 918 pg/ml (interquartile range: 485 to 1,578 pg/ml), 94% had hypertension, and 35% had atrial fibrillation. The mean left ventricular (LV) ejection fraction was 58.6 ± 9.8%, prevalence of LV hypertrophy was 21%, prevalence of left atrial enlargement was 83%, prevalence of elevated E/e' ratio was 53%, and prevalence of pulmonary hypertension was 31%. Heart failure hospitalization or cardiovascular death occurred in 288 patients at 2.8-year median follow-up. In fully adjusted models, higher LV mass index (hazard ratio [HR]: 1.05 per 10 g/m2; 95% confidence interval [CI]: 1.00 to 1.10; p = 0.03), E/e' ratio (HR: 1.04 per unit; 95% CI: 1.02 to 1.06; p < 0.001), pulmonary artery systolic pressure (HR: 1.51 per 10 mm Hg; 95% CI: 1.29 to 1.76; p < 0.001), and right ventricular end-diastolic area (HR: 1.04 per cm2; 95% CI: 1.01 to 1.07; p = 0.003) were each associated with this composite, while LV ejection fraction and left atrial size were not (p > 0.05 for all). Appreciable differences were observed in cardiac structure compared with other HFpEF clinical trials, despite similar E/e' ratio, pulmonary artery systolic pressure, and event rates. CONCLUSIONS Diastolic dysfunction, left atrial enlargement, and pulmonary hypertension were common in PARAGON-HF. LV hypertrophy, elevated left- and right-sided pressures, and right ventricular enlargement were independently predictive of incident heart failure hospitalization or cardiovascular death. Echocardiographic differences among HFpEF trials despite similar clinical event rates highlight the heterogeneity of this syndrome. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
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4.
Comparison of intranasal midazolam, intranasal ketamine, and oral chloral hydrate for conscious sedation during paediatric echocardiography: results of a prospective randomised study.
Alp, H, Elmacı, AM, Alp, EK, Say, B
Cardiology in the young. 2019;(9):1189-1195
Abstract
OBJECTIVE There are several agents used for conscious sedation by various routes in children. The aim of this prospective randomised study is to compare the effectiveness of three commonly used sedatives: intranasal ketamine, intranasal midazolam, and oral chloral hydrate for children undergoing transthoracic echocardiography. METHODS Children who were referred to paediatric cardiology due to a heart murmur for transthoracic echocardiography were prospectively randomised into three groups. Seventy-three children received intranasal midazolam (0.2 mg/kg), 72 children received intranasal ketamine (4 mg/kg), and 72 children received oral chloral hydrate (50 mg/kg) for conscious sedation. The effects of three agents were evaluated in terms of intensity, onset, and duration of sedation. Obtaining high-quality transthoracic echocardiography images (i.e. absence of artefacts) were regarded as successful sedation. Side effects due to medications were also noted. RESULTS There was no statistical difference in terms of sedation success rates between three groups (95.9, 95.9, and 94.5%, respectively). The median onset of sedation in the midazolam, ketamine, and chloral hydrate was 14 minutes (range 7-65), 34 minutes (range 12-56), and 40 minutes (range 25-57), respectively (p < 0.001 for all). However, the median duration of sedation in study groups was 68 minutes (range 20-75), 55 minutes (range 25-75), and 61 minutes (range 34-78), respectively (p = 0.023, 0.712, and 0.045). Gastrointestinal side effects such as nausea and vomiting were significantly higher in the chloral hydrate group (11.7 versus 0% for midazolam and 2.8% for ketamine, respectively, p = 0.002). CONCLUSION Results of our prospectively randomised study indicate that all three agents provide adequate sedation for successful transthoracic echocardiography. When compared the three sedatives, intranasal midazolam has a more rapid onset of sedation while intranasal ketamine has a shorter duration of sedation. Intranasal ketamine can be used safely with fewer side effects in children undergoing transthoracic echocardiography.
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5.
Low-Value Transthoracic Echocardiography, Healthcare Utilization, and Clinical Outcomes in Patients With Coronary Artery Disease.
Tharmaratnam, T, Bouck, Z, Sivaswamy, A, Wijeysundera, HC, Chu, C, Yin, CX, Nesbitt, GC, Edwards, J, Yared, K, Wong, B, et al
Circulation. Cardiovascular quality and outcomes. 2019;(11):e006123
Abstract
BACKGROUND The relationship between ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not known. Our objective was to investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with CAD and whether practice behavior influences patient outcomes. METHODS AND RESULTS A retrospective cohort of outpatient CAD patients was accrued by identifying patients with at least 1 visit to 1 of 35 Ontario-based cardiologists in the EchoWISELY randomized clinical trial (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) control group. The main outcomes of interest were patient-level receipt of diagnostic tests, physician visits, medication prescriptions, and clinical outcomes at 1 year. Our cohort consisted of 3966 patients with CAD (mean [SD] age, 67.8 [12.0] years; 72% men), with an outpatient visit to 1 of 35 eligible cardiologists, stratified into 3 ordering tertiles. Patients of cardiologists in the top ordering tertile of rarely appropriate transthoracic echocardiograms had significantly lower odds of receiving the following services at 1 year compared with patients in the low ordering group: cholesterol assessment (odds ratio [OR], 0.77 [95% CI, 0.65-0.91]); hemoglobin A1c assessment (OR, 0.79 [95% CI, 0.66-0.94]); β-blocker prescription (OR, 0.70 [95% CI, 0.55-0.90]); and aldosterone receptor antagonist prescription (OR, 0.46 [95% CI, 0.22-0.98]). Patients of high ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54 [95% CI, 1.04-2.28]), although all other outcomes were similar. CONCLUSIONS Patients with CAD seen by cardiologist who ordered a high rate of rarely appropriate transthoracic echocardiograms were less likely to receive potentially high-value screening tests and evidence-based medications than low ordering cardiologists. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02038101.
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6.
The Interplay between Fasting Glucose, Echocardiography, and Biomarkers: Pathophysiological Considerations and Prognostic Implications.
Pareek, M
Danish medical journal. 2017;(9)
Abstract
BACKGROUND Traditional cardiovascular risk stratification tools that employ clinical risk factors are limited by their modest discriminative abilities. As such, robust cardiovascular risk assessment, including our understanding of the complex interplay between risk factors, in the primary preventive setting, remains incomplete. Phenotypical heterogeneity may be even greater among subjects with hyperglycemic conditions, i.e., prediabetes and diabetes, which is worrisome, given the dramatic global rise in mean fasting glucose levels, and the strong association with adverse cardiovascular outcomes. The unmet need for refinement or restratification of risk based on these conventional prediction models is only emphasized by our entrance into the era of precision medicine. Potential tools for closing these gaps and increasing our understanding of the pathways from risk factors through subclinical changes to manifest disease include echocardiography and circulating biomarkers. OBJECTIVES 1) To examine whether greater fasting plasma glucose (FPG) levels were associated with left ventricular mass (LVM), geometric pattern, diastolic function, and concentrations of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-TnT) in apparently healthy, elderly subjects with a preserved LV ejection fraction ± 50%; 2) To examine whether FPG levels modified the prognostic role of abnormal LVM, geometric pattern, diastolic dysfunction, NT-proBNP, and hs-TnT, in predicting cardiovascular morbidity and mortality; 3) To define the incremental prognostic value of NT-proBNP and hs-TnT for predicting incident cardiovascular outcomes, beyond traditional risk factors, glycemic status, and subclinical echocardiographic abnormalities; 4) To explore the associations of NT-proBNP and hs-TnT with key echocardiographic measures of LV structure and function, including the effects of FPG levels. METHODS The thesis was based on a series of cross-sectional and prospective observational studies. The study population was derived from the echocardiography subsample (n=1,792) of the Malmö Preventive Project Re-Examination Study (MPP-RES) (2002-2006, n=18,238), a population-based screening program that included inhabitants from Malmö, Sweden, who belonged to prespecified birth cohorts between 1921-1949. Subjects, who underwent echocardiography, were randomly chosen from the three categories defined by base-line FPG, i.e., normal fasting glucose, impaired fasting glucose, and diabetes, including use of anti-diabetic medication. Blood samples for cardiovascular biomarker assessments were drawn at the time of echocardiography and kept frozen until analysis. Outcome data were obtained through national and local registries. The original echocardiography subsample was stratified into patients and apparently healthy subjects, the latter being the focus of this thesis. RESULTS 1) Subjects with diabetes had a greater prevalence of concentric LV hypertrophy (LVH), grade 2 or 3 diastolic dysfunction, and higher hs-TnT concentrations. Subjects with impaired fasting glucose had the lowest NT-proBNP concentrations. LVMI was primarily associated with diastolic function in subjects with hyperglycemia; 2) LV diastolic dysfunction was associated with an increased risk of incident cardiovascular events, but did not provide discriminative im-provement. Concentric LVH and diastolic dysfunction were more strongly associated with adverse prognosis in subjects with hyper-glycemia. High concentrations of NT-proBNP and hs-TnT predicted incident cardiovascular events, with no effect modification by FPG; 3) NT-proBNP, but not hs-TnT, provided discriminative improvement beyond traditional risk factors, FPG, and LVH and/or diastolic dysfunction; 4) NT-proBNP and hs-TnT were associated with several echocardiographic parameters, but effect sizes were generally modest. Associations between biomarkers and echocardiographic measures were affected by hyperglycemia. CONCLUSIONS FPG influenced the interplay between subclinical echocardiographic abnormalities, circulating biomarkers, and cardiovascular outcomes at multiple stages, in this cohort of apparently healthy, elderly subjects. Newly diagnosed diabetes, but not impaired fasting glucose, was associated with adverse subclinical changes. The associations between structural echocardiographic abnormalities and biomarker concentrations were stronger in subjects with hyperglycemia. NT-proBNP, but not echocardiographic measures or hs-TnT, provided discriminative improvement on top of traditional cardiovascular risk factors. FPG further modified the prognosis re-lated to echocardiographic alterations, but not that predicted by biomarkers. Therefore, FPG should be considered when assessing markers of subclinical cardiovascular alterations.
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7.
Image-guidance for transcatheter aortic valve implantation (TAVI) and cerebral embolic protection.
Vernikouskaya, I, Rottbauer, W, Gonska, B, Rodewald, C, Seeger, J, Rasche, V, Wöhrle, J
International journal of cardiology. 2017;:90-95
Abstract
UNLABELLED The study was aimed at evaluation of the feasibility and potential benefit of image fusion (IF) of pre-procedural CT angiography (CTA) and x-ray (XR) fluoroscopy for image-guided navigation in transfemoral transcatheter aortic valve implantation (TAVI) with the strong focus on guiding the double-filter cerebral embolic protection device and valve prosthesis placement. METHODS In 31 patients undergoing TAVI, image registration of CTA-derived 3D anatomical models of the relevant cardiac anatomy and vasculature, and live XR was performed applying a commercially available navigation tool. The approach was evaluated in terms of the accuracy of the overlay. In 27 TAVI patients with IF receiving double-filter cerebral embolic protection device overall procedure time, fluoroscopy time, radiation dose, and total volume of intra-procedural iodinated contrast agent (CA) were registered and compared to those of a control group of prospectively enrolled during the same period of time N=27 patients receiving the same protection system but without IF. RESULTS AND CONCLUSIONS Image co-registration and model-based guidance is feasible in TAVI procedures. The overlay facilitates placement of the embolic protection device, placement of the guide wire in the left ventricle and initial alignment of the valve prosthesis prior to final deployment, thus improving the confidence level of the operators during the procedure without compromising CA or XR dose.
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8.
Left Ventricular global longitudinal strain predicts heart failure readmission in acute decompensated heart failure.
Romano, S, Mansour, IN, Kansal, M, Gheith, H, Dowdy, Z, Dickens, CA, Buto-Colletti, C, Chae, JM, Saleh, HH, Stamos, TD
Cardiovascular ultrasound. 2017;(1):6
Abstract
BACKGROUND The goal of this study was to determine if left ventricular (LV) global longitudinal strain (GLS) predicts heart failure (HF) readmission in patients with acute decompensated heart failure. METHODS AND RESULTS Two hundred ninety one patients were enrolled at the time of admission for acute decompensated heart failure between January 2011 and September 2013. Left ventricle global longitudinal strain (LV GLS) by velocity vector imaging averaged from 2, 3 and 4-chamber views could be assessed in 204 out of 291 (70%) patients. Mean age was 63.8 ± 15.2 years, 42% of the patients were males and 78% were African American or Hispanic. Patients were followed until the first HF hospital readmission up to 44 months. Patients were grouped into quartiles on the basis of LV GLS. Kaplan-Meier curves showed significantly higher readmission rates in patients with worse LV GLS (log-rank p < 0.001). After adjusting for age, sex, history of ischemic heart disease, dementia, New York Heart Association class, LV ejection fraction, use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers, systolic and diastolic blood pressure on admission and sodium level on admission, worse LV GLS was the strongest predictor of recurrent HF readmission (p < 0.001). The ejection fraction was predictive of readmission in univariate, but not in multivariate analysis. CONCLUSION LV GLS is an independent predictor of HF readmission after acute decompensated heart failure with a higher risk of readmission in case of progressive worsening of LV GLS, independent of the ejection fraction.
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9.
Echocardiographic evaluation of patients presenting with acutely decompensated heart failure in the setting of dietary or medication noncompliance-Is there a role?
Goyfman, M, Kort, S
Echocardiography (Mount Kisco, N.Y.). 2017;(10):1426-1431
Abstract
BACKGROUND Reevaluating patients who are admitted with heart failure (HF) exacerbation using echocardiogram is a common and appropriate indication. However, it is unknown whether it is appropriate to reevaluate such patients when the exacerbation is attributed to patients' noncompliance with self-care behaviors, where the presumption is that the underlying HF biology is stable. METHODS Echocardiograms on all patients hospitalized for HF exacerbation attributed to dietary or medication noncompliance were retrospectively assessed for the presence of significant changes from prior echocardiogram. RESULTS A total of 559 charts of patients admitted with heart failure exacerbation were reviewed, of which 125 patients (22%) were thought to have dietary or medication noncompliance as the etiology. Fifty-three patients (42%) had a follow-up echocardiogram performed during the index admission. The likelihood of being reevaluated by an echocardiogram during admission was not affected by the clinical service that the patient was admitted to, the patient's gender, or age. Eighty percent of echocardiograms performed within a year of prior study and 78% of echocardiograms performed >1 year revealed at least one significant change. The most common changes identified were an increase in left atrium diameter, worsening of pulmonary artery systolic pressure and worsening ejection fraction. There was no correlation between the time interval of between echocardiograms and the likelihood of a significant change. CONCLUSIONS Repeat echocardiograms in patients admitted with HF exacerbation due to noncompliance revealed significant changes in the majority of patients studied. The changes may reflect worsening in cardiac function in addition to the presumed etiology of noncompliance.
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10.
In-hospital measurement of left ventricular ejection fraction and one-year outcomes in acute coronary syndromes: results from the IMMEDIATE Trial.
Mukherjee, JT, Beshansky, JR, Ruthazer, R, Alkofide, H, Ray, M, Kent, D, Manning, WJ, Huggins, GS, Selker, HP
Cardiovascular ultrasound. 2016;(1):29
Abstract
BACKGROUND In patients with acute coronary syndrome (ACS), reduced left ventricular ejection fraction (LVEF) is a known marker for increased mortality. However, the relationship between LVEF measured during index ACS hospitalization and mortality and heart failure (HF) within 1 year are less well-defined. METHODS We performed a retrospective analysis of 445 participants in the IMMEDIATE Trial who had LVEF measured by left ventriculography or echocardiogram during hospitalization. RESULTS Adjusting for age and coronary artery disease (CAD) history, lower LVEF was significantly associated with 1-year mortality or hospitalization for HF. For every 5 % LVEF reduction, the hazard ratio [HR] was 1.26 (95 % CI 1.15, 1.38, P < 0.001). Participants with LVEF < 40 % had higher hazard of 1-year mortality or HF hospitalization than those with LVEF > 40 (HR 3.59; 95 % CI 2.05, 6.27, P < 0.001). The HRs for the association of LVEF with the study outcomes were similar whether measured by left ventriculography or by echocardiography, (respectively, HR 1.32; 95 % CI 1.15, 1.51 and 1.21; 95 % CI 1.106, 1.35, interaction P = 0.32) and whether done within 24 h or not within 24 h (respectively, HR 1.28; 95 % CI 1.10, 1.50 and 1.23; 95 % CI 1.10, 1.38, interaction P = 0.67). CONCLUSIONS Among patients with ACS, lower in-hospital LVEF is associated with increased 1-year mortality or hospitalization for HF, regardless of the method or timing of the LVEF assessment. This has prognostic implications for clinical practice and suggests the possibility of using various methods of LVEF determination in clinical research.