Effect of Race on Echocardiographic Measures of Cardiac Structure and Function.

The relations between race and cardiac structure and function are incompletely understood. We hypothesized that race-specific differences in echocardiography measurements exist. We compared the relation between echocardiography measurements and race among 12,429 nonobese adults without known cardiovascular disease who underwent echocardiography. We compared measurements between whites (n = 10,508), blacks (n = 792), Asians (n = 628), Hispanics (n = 315), Native Americans (n = 34), and multiracial/other (n = 152) cohorts. Multivariate analysis compared measurements indexed to body surface area (BSA) between races and adjusted for variables including age, gender, and mean blood pressure. Mean age was 46.9 ± 17.4 years and 60.5% were women. After multivariable adjustment and using whites as a baseline, there were significant differences (p <0.05) in left ventricular end-diastolic diameter/BSA for blacks (-0.5 mm/m2), Asians (0.4 mm/m2), Hispanics (0.2 mm/m2), and multiracial/others (0.1 mm/m2); septal wall thickness/BSA for blacks (0.4 mm/m2) and Asians (0.1 mm/m2); posterior wall thickness/BSA for blacks (0.4 mm/m2), Asians (0.1 mm/m2), Hispanics (0.04 mm/m2), and multiracial/others (0.03 mm/m2); left atrial diameter/BSA for Asians (0.2 mm/m2), Hispanics (0.3 mm/m2), and multiracial/others (0.1 mm/m2); septal and lateral e' for blacks (-0.7 cm/s; -0.9 cm/s); and peak tricuspid regurgitation gradient for blacks (4.3 mm Hg) and Asians (-0.9 mm Hg). Race is associated with significant differences in left ventricular size, left atrial size, mitral annular velocity, and tricuspid regurgitation gradient. Normal reference ranges for echocardiography measurements should utilize racially diverse cohorts to prevent misclassification of echocardiography findings based on race.

Differences in Echocardiographic Measures of Aortic Dimensions by Race.

It is not clear whether there are differences in aortic dimensions by race. Our hypothesis was that race-specific differences in aortic size exist. We compared the relation between race and aortic dimensions among 15,295 adults without known risk factors for cardiovascular disease or aortic dilatation, who underwent clinically indicated transthoracic echocardiography. We compared inner edge-to-inner edge measurements between whites (n = 12,932), blacks (n = 958), Asians (n = 827), Hispanics (n = 366), Native Americans (n = 38), and others (n = 174). Multivariate analysis compared measurements indexed with body surface area (BSA) between races and adjusted for variables including age, gender, and mean blood pressure. Mean age was 49.9 ± 17.6 years, and 58.7% were female. On gender-specific comparisons, there were significant differences in aortic size between races (p <0.001 for each). Using whites as a baseline, multivariable analysis demonstrated that blacks had smaller BSA-indexed aortic sinus (-0.34 mm/m2, p <0.001) and ascending aorta (-0.43 mm/m2, p <0.001) dimensions; Asians had larger BSA-indexed aortic sinus (0.36 mm/m2, p <0.001), ascending aorta (0.41 mm/m2, p <0.001), and aortic arch (0.20 mm/m2, p = 0.002) dimensions; Hispanics had larger BSA-indexed aortic arch dimensions (0.15 mm/m2, p = 0.01); Native Americans had increased BSA-indexed aortic arch dimensions (0.32 mm/m2, p = 0.01); and other races had increased BSA-indexed aortic arch dimensions (0.11 mm/m2, p = 0.03). In a cohort without known risk factors for aortic dilatation, race is associated with significant differences in aortic dimensions. In conclusion, these findings suggest that reference ranges for aortic size should be established using racially diverse cohorts to prevent misdiagnosis of aortic dilatation based on race.

Indexing left ventricular wall thickness to body surface area improves prognostic value.

BACKGROUND: Guidelines provide normal ranges of left ventricular (LV) wall thicknesses (WT) without indexing. We hypothesized that indexing WT to body surface area (BSA) improves prognostic value. METHODS: We examined the relationship between WT and BSA in 9737 patients undergoing echocardiography without risk factors for LV hypertrophy other than obesity. We compared WT to BSA and examined the relationship of WT and LV mass index (LVMI) to mortality. RESULTS: There is a linear relationship between BSA and septal and posterior WT (r = 0.38, P < 0.001 for each). Higher quartiles of BSA were associated with increased WT (P < 0.001). After adjusting for age and gender, greater mean WT (MWT) (Hazards Ratio [HR] 1.10 per mm, 95% Confidence Interval [CI] 1.04-1.16, P = 0.001, C-statistic 0.66), LVMI (HR 1.01, 95% CI 1.001-1.01, P = 0.01, C-statistic 0.66), and indexed MWT (HR 1.34 per mm/m2 , 95% CI 1.23-1.47, P < 0.001, C-statistic 0.67) are each associated with increased mortality, with indexed MWT having the highest prognostic value. Each decile of indexed MWT ≥8th decile was associated with increased mortality compared to the 1st decile (P < 0.01 for each). Individuals with indexed MWT ≥8th decile (≥5.0 mm/m2 ) had increased adjusted mortality (HR 1.67, 95% CI 1.43-1.94, P < 0.001, C-statistic 0.67); this had improved prognostic value over guideline definitions of increased MWT (C-statistic 0.66) or LVMI (P = NS). CONCLUSIONS: We observe a linear relationship between BSA and WT. Indexing WT improves mortality prediction over LVMI and nonindexed WT. These findings support indexing WT to BSA.

CT and MRI features of pseudoaneurysms of the mitral-aortic intervalvular fibrosa.

OBJECTIVE: To describe the CT and MR features of pseudoaneurysms of the mitral-aortic intervalvular fibrosa (PMAIVF). MATERIALS AND METHODS: This retrospective study included 9 patients with a diagnosis of PMAIVF who had CT or MRI within 3months of echocardiography. Echocardiography images were reviewed by a cardiologist and CT and MRI images were reviewed by two experienced cardiothoracic radiologists. RESULTS: Recognizable imaging features of PMAIVFs were communication with the Left ventricular outflow tract, location between the anterior leaflet of the mitral valve and the aortic valve, systolic expansion and diastolic collapse. CONCLUSION: CT and MRI show characteristic appearances of PMAIVFs and are complementary to echocardiography.

Usefulness of Echocardiography/Doppler to Reliably Predict Elevated Left Ventricular End-Diastolic Pressure in Patients With Pulmonary Hypertension.

The ability of echocardiography (echo)/Doppler to predict elevated left ventricular (LV) end-diastolic pressure (EDP) specifically among patients with pulmonary hypertension is not well defined. This was a retrospective analysis of 161 patients referred to a specialized pulmonary hypertension clinic. A model based on an American Society of Echocardiography (ASE)/European Association of Echocardiography (EAE) joint statement was evaluated, and a new model was developed using univariate linear regression and multivariable logistic regression for potentially better prediction of elevated LVEDP. The study cohort had a median pulmonary arterial pressure was 34.0 mm Hg and pulmonary vascular resistance was 3.7 Wood units; 81 patients (51%) had LVEDP >15 mm Hg on invasive testing. Doppler E/A, E/e' (septal, lateral, and average), e'/a' (lateral and average), and left atrial volume and diameter all had significant correlation with LVEDP (p <0.05). The ASE/EAE model performed poorly (sensitivity 54% and specificity 66%) for detecting elevated LVEDP. Only echo/Doppler grade 3 diastolic dysfunction had an LVEDP significantly different from other grades (grade 0 to 2, median 15 mm Hg, interquartile range 13 to 22 mm Hg; grade 3, median 22 mm Hg, interquartile range 19 to 32 mm Hg; p <0.01). An experimental model was statistically significant in its prediction of elevated LVEDP (area under the receiver operating characteristic curve 0.7, p <0.001) but demonstrated poor performance (sensitivity 67% and specificity 61%). In conclusion, numerous echo/Doppler measurements correlate with elevated LV filling pressure. However, both the ASE/EAE model and our experimental model had poor test performance that did not permit confident identification of elevated LVEDP.

Randomized comparison of exercise haemodynamics of Freestyle, Magna Ease and Trifecta bioprostheses after aortic valve replacement for severe aortic stenosis.

OBJECTIVES: The purpose of this study was to compare haemodynamics at rest and during exercise after clinically indicated aortic valve replacement (AVR) for aortic stenosis among patients randomly assigned to one of three haemodynamically excellent bioprostheses. METHODS: In a single-centre, prospective trial, 60 patients undergoing clinically indicated AVR were randomly assigned to Freestyle, Magna Ease or Trifecta bioprostheses. Six months after surgery, patients underwent supine bicycle stress echocardiography for the assessment of aortic valve haemodynamics. RESULTS: There were 5 protocol deviations from random valve assignments, and 4 patients did not return for follow-up stress echo, yielding a study group of 56 patients {17 Freestyle, 21 Magna Ease, 18 Trifecta; median age 70 [interquartile range (IQR) 63-78 years], 37 (66%) men}. There were no statistically significant differences between groups in valve size, concomitant procedures or exercise variables. Resting haemodynamics revealed significant differences between groups in mean gradient [Freestyle 7 (IQR 5-9) mmHg, Magna Ease 9 (IQR 7-11) mmHg, Trifecta 5 (IQR 4-8) mmHg; P = 0.04], effective orifice area (EOA) [2.5 (IQR 2.2-2.7), 2.1 (IQR 1.7-2.3) and 2.6 (IQR 2.3-2.8), respectively; P = 0.02] and EOA index [1.22 (IQR 1.11-1.32), 1.02 (IQR 0.89-1.14) and 1.31 (IQR 1.00-1.42), respectively; P = 0.03]; in each case, Trifecta had better haemodynamics compared with Magna Ease. With exercise, significant differences between groups were evident in peak velocity at 50 watts and peak exercise; mean gradient at 25 watts, 50 watts and maximal exercise; and EOA at 25 watts and at peak exercise; all with haemodynamic superiority of Trifecta compared with Magna Ease. There were no statistically significant differences between Trifecta and Freestyle haemodynamics at rest or with exercise. CONCLUSIONS: In a prospective, randomized study comparing haemodynamics after Freestyle, Magna Ease and Trifecta, all three valves exhibited good haemodynamics at rest and with exercise. There were small but significant differences between groups, with favourable haemodynamics associated with Trifecta compared to Magna Ease, and no significant differences between Trifecta and Freestyle. The Trifecta valve appears to offer haemodynamics similar to a stentless valve without the technical complexity of stentless valve implantation. CLINICALTRIALSGOV IDENTIFIER: NCT01635244.

Regression of Paravalvular Aortic Regurgitation and Remodeling of Self-Expanding Transcatheter Aortic Valve: An Observation From the CoreValve U.S. Pivotal Trial.

OBJECTIVES: The aim of this study was to describe the natural history and clinical importance of paravalvular aortic regurgitation (PVAR) after CoreValve transcatheter aortic valve replacement (TAVR) and to relate these findings to the structural and hemodynamic changes documented by serial echocardiographic analysis. BACKGROUND: PVAR after TAVR with the self-expanding CoreValve bioprosthesis has been shown to regress over time, but the time course and the mechanism of PVAR regression has not been completely characterized. METHODS: Patients with severe aortic stenosis who underwent CoreValve TAVR and followed up to 1 year in the multicenter CoreValve U.S. Pivotal Trial (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement) were studied. Serial echocardiography studies were analyzed by an echocardiographic core laboratory. Annular sizing ratio was calculated from computed tomography measurements. Paired, as well as total, data were compared. RESULTS: The CoreValve was implanted in 634 patients with a mean age of 82.7 ± 8.4 years. After a marked improvement noted at discharge, aortic valve velocity, mean gradient, and effective orifice area further improved significantly at 1 month (2.08 ± 0.45 m/s vs. 1.99 ± 0.46 m/s, p < 0.0001, 9.7 ± 4.4 mm Hg vs. 8.9 ± 4.6 mm Hg, p < 0.0001, and 1.78 ± 0.51 cm(2) vs. 1.85 ± 0.58 cm(2), p = 0.03, respectively). The improvement was sustained through 1 year. PVAR was moderate or severe in 9.9%, and of 36 patients with moderate PVAR at discharge and paired data, 30 (83%) improved at least 1 grade of regurgitation at 1 year. Annular sizing ratio was significantly associated with the degree of PVAR. CONCLUSIONS: There was further improvement in aortic prosthetic valve hemodynamics and regression of PVAR up to 1 year compared with discharge after TAVR with CoreValve. These changes are possibly due to remodeling and outward expansion of the self-expandable CoreValve with nitinol frame. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement [Medtronic CoreValve U.S. Pivotal Trial]; NCT01240902).

A Pharmacy Blueprint for Electronic Medical Record Implementation Success.

OBJECTIVE: Implementation of an integrated, electronic medical record (EMR) has been promoted as a means of improving patient safety and quality. While there are a few reports of such processes that incorporate computerized prescriber order entry, pharmacy verification, an electronic medication administration record (eMAR), point-of-care barcode scanning, and clinical decision support, there are no published reports on how a pharmacy department can best participate in implementing such a process across a multihospital health care system. METHOD: This article relates the experience of the design, build, deployment, and maintenance of an integrated EMR solution from the pharmacy perspective. It describes a 9-month planning and build phase and the subsequent rollout at 8 hospitals over the following 13 months. RESULTS: Key components to success are identified, as well as a set of guiding principles that proved invaluable in decision making and dispute resolution. Labor/personnel requirements for the various stages of the process are discussed, as are issues involving medication workflow analysis, drug database considerations, the development of clinical order sets, and incorporation of bar-code scanning of medications. Recommended implementation and maintenance strategies are presented, and the impact of EMR implementation on the pharmacy practice model and revenue analysis are examined. CONCLUSION: Adherence to the principles and practices outlined in this article can assist pharmacy administrators and clinicians during all medication-related phases of the development, implementation, and maintenance of an EMR solution. Furthermore, review and incorporation of some or all of practices presented may help ease the process and ensure its success.

Mortality Predictors in Patients Referred for but Not Undergoing Transcatheter Aortic Valve Replacement.

Although transcatheter aortic valve replacement (TAVR) has expanded the proportion of patients with aortic stenosis (AS) who are candidates for valve replacement, some patients remain untreated, and their outcomes are not clear. We evaluated 172 consecutive patients with severe symptomatic AS referred for TAVR who declined (n = 55) or were not candidates for (n = 117) intervention. We examined clinical and echocardiographic variables associated with mortality. There were 77 deaths, and mean follow-up was 17.9 ± 10.9 months for survivors. Mortality rate at 1 and 2 years was 39.2% and 52.6%, respectively. There was a significant difference in mortality rate between patients who declined the procedure and those who were not candidates (p = 0.001), with 1-year mortality rates of 20.6% and 48.4%, respectively. On multivariate analysis, 4 variables were independently associated with all-cause mortality: New York Heart Association Class IV heart failure (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.6 to 4.2, p <0.001), glomerular filtration rate <48 ml/min (HR 2.1, 95% CI 1.3 to 3.4, p = 0.002), albumin <3.9 g/dl (HR 1.9, 95% CI 1.2 to 3.1, p = 0.007), and ejection fraction <50% (HR 1.9, 95% CI 1.4 to 3.0, p = 0.01). In this new era with expanded treatment options, patients with severe symptomatic AS who remain untreated after referral for TAVR experience a mortality rate of 39% at 1 year. The presence of advanced heart failure, renal dysfunction, low albumin, and/or left ventricular dysfunction identifies patients at higher risk of mortality.

Cor triatriatum: a reversible cause of severe pulmonary hypertension.

Cor triatriatum sinister is a congenital heart disorder that can lead to progressive dyspnea, pulmonary hypertension, and ultimately right ventricular (RV) failure. We report a case in which symptoms of progressive pulmonary hypertension were initially attributed to asthma, leading to a delayed diagnosis that resulted in suprasystemic pulmonary pressures and RV dysfunction. Rapid symptomatic and hemodynamic improvement was observed after surgical repair, with normalization of pulmonary artery pressures and RV function.

Reliable exclusion of acute coronary syndrome among hospitalized patients with elevated troponin.

BACKGROUND: Elevated cardiac troponin I (cTnI) occurs in acute coronary syndrome (ACS) as well as various scenarios not associated with ACS. HYPOTHESIS: Simple clinical criteria can reliably exclude ACS among hospitalized patients with elevated cTnI. METHODS: Records for patients hospitalized from January to April 2011 with elevated cTnI (>0.29 ng/dL) and an available echocardiogram were retrospectively reviewed. Patients with ST-segment elevation myocardial infarction were excluded. Based on available clinical data, patients were classified as having ACS or elevation of cTnI unrelated to ACS (non-ACS). Median follow-up was 365 days. RESULTS: Of 265 records meeting inclusion criteria, 82 (31%) had ACS and 183 (69%) had non-ACS. In multivariable analysis, odds ratios for non-ACS were 7.6 (95% confidence interval [CI]: 3.8-15.3) for peak cTnI <2 ng/dL, 6.3 (95% CI: 3.1-13.0) for absent wall-motion abnormality, and 4.4 (95% CI: 2.2-8.6) for no prior coronary artery disease history. The area under the receiver operating curve for amodel using these 3 variables was 0.86, with a 98% negative predictive value for excluding ACS. Patients who met these 3 criteria had no ACS-related deaths over 1-year follow-up. CONCLUSIONS: Hospitalized patients with peak Tn level<2 ng/dL, no prior history of coronary artery disease, and no new echocardiographic wall-motion abnormality appear to have a very low likelihood of ACS. Prospective validation of these results is needed to determine whether additional diagnostic testing could be safely avoided in hospitalized patients meeting these simple clinical criteria.

Long-term clinical outcomes 15 years after aortic valve replacement with the Freestyle stentless aortic bioprosthesis.

BACKGROUND: The Freestyle stentless aortic root bioprosthesis has excellent hemodynamics and durability through 10 years. The purpose of this report is to present clinical outcomes in a large multicenter cohort through 15 years. METHODS: The multicenter evaluation of the Freestyle valve began in 1992 at 21 centers in North America and Europe. In 1997, a long-term study continued, including 725 patients from 8 of the original centers; clinical outcomes data after 10 years have continued to be collected at 6 of 8 centers. RESULTS: Patient age was 71.7±7.9 years. There were 402 (55.4%) men and 323 (44.6%) women. Total follow-up was 5,491.2 patient-years. There were 52 late reoperations, with explant of the bioprosthesis in 47 cases. Respective 10- and 15-year survival was 46.2%±2.3% and 25.9%±3.2%; freedom from valve-related death was 94.9%±1.5% and 92.7%±3.5%; freedom from reoperation was 92.3%±1.8% and 80.7%±5.0%; and freedom from explant owing to structural valve deterioration was 96.5%±1.3% and 83.3%±4.8%. Increased age was associated with higher risks of all-cause mortality and valve-related mortality and lower risks of reoperation and explant caused by structural valve deterioration. CONCLUSIONS: In this long-term, multicenter, observational study, the Freestyle stentless aortic root bioprosthesis offered good clinical outcomes in terms of survival, freedom from valve-related mortality, freedom from reoperation, and freedom from structural valve deterioration. The Freestyle valve is a viable option for use in patients undergoing bioprosthetic aortic valve replacement and for anticipated desire for long-term durability.

Antireflective surface structures in glass by self-assembly of SiO2 nanoparticles and wet etching.

We describe the fabrication of an antireflective surface structure with sub-wavelength dimensions on a glass surface using scalable low-cost techniques involving sol-gel coating, thermal annealing, and wet chemical etching. The glass surface structure consists of sand dune like protrusions with 250 nm periodicity and a maximum peak-to-valley height of 120 nm. The antireflective structure increases the transmission of the glass up to 0.9% at 700 nm, and the transmission remains enhanced over a wide spectral range and for a wide range of incident angles. Our measurements reveal a strong polarization dependence of the transmission change.