Effect of obstructive sleep apnea on mitral valve tenting.

Obstructive apneas produce high negative intrathoracic pressure that imposes an afterload burden on the left ventricle. Such episodes might produce structural changes in the left ventricle over time. Doppler echocardiograms were obtained within 2 months of attended polysomnography. Patients were grouped according to apnea-hypopnea index (AHI): mild/no obstructive sleep apnea (OSA; AHI <15) and moderate/severe OSA (AHI ≥15). Mitral valve tenting height and area, left ventricular (LV) long and short axes, and LV end-diastolic volume were measured in addition to tissue Doppler parameters. Comparisons of measurements at baseline and follow-up between and within groups were obtained; correlations between absolute changes (Δ) in echocardiographic parameters were also performed. After a mean follow-up of 240 days mitral valve tenting height increased significantly (1.17 ± 0.12 to 1.28 ± 0.17 cm, p = 0.001) in moderate/severe OSA as did tenting area (2.30 ± 0.41 to 2.66 ± 0.60 cm(2), p = 0.0002); Δtenting height correlated with ΔLV end-diastolic volume (rho 0.43, p = 0.01) and Δtenting area (rho 0.35, p = 0.04). In patients with mild/no OSA there was no significant change in tenting height; there was a borderline significant increase in tenting area (2.20 ± 0.44 to 2.31 ± 0.43 cm(2), p = 0.05). Septal tissue Doppler early diastolic wave decreased (8.04 ± 2.49 to 7.10 ± 1.83 cm/s, p = 0.005) in subjects with moderate/severe OSA but not in in those with mild/no OSA. In conclusion, in patients with moderate/severe OSA, mitral valve tenting height and tenting area increase significantly over time. This appears to be related, at least in part, to changes in LV geometry.

Saddle pulmonary embolism: is it as bad as it looks? A community hospital experience.

BACKGROUND: Saddle pulmonary embolism represents a large clot and a risk for sudden hemodynamic collapse. However, the clinical presentation and outcomes vary widely. On the basis of the findings of right heart dysfunction on echocardiograms, computed tomography angiography, or cardiac enzyme elevation, some argue for the use of thrombolytics or catheter thrombectomy even for hemodynamically stable patients. OBJECTIVE: To investigate the outcomes and management of patients with saddle pulmonary embolism, including radiographic appearance (estimate of clot burden) and echocardiographic features. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: This study is a retrospective evaluation of all patients with computed tomography angiography positive for pulmonary embolism from June 1, 2004, to February 28, 2009. Two radiologists selected those with saddle pulmonary embolism and evaluated the clot burden score. The clinical information, echocardiography, treatments, and outcomes of these patients were extracted via chart review. Saddle pulmonary embolism was found in 37 of 680 patients (5.4%, 95% confidence interval 4% to 7%) with documented pulmonary embolism on computed tomography angiography. For patients with saddle pulmonary embolism, the median age was 60 yrs and 41% were males. Major comorbidities were neurologic (24%), recent surgery (24%), and malignancy (22%). Transient hypotension occurred in 14% and persistent shock in 8%. One patient required mechanical ventilation. Echocardiography was performed in 27 patients (73%). Right ventricle enlargement and dysfunction were found in 78% and elevated pulmonary artery systolic pressure in 67%. Computed tomography angiography demonstrated a high median pulmonary artery clot burden score of 31 points. The median right ventricle to left ventricle diameter ratio was 1.39. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 33 (87%) and thrombolytics in four (11%). The median hospital length of stay was 9 days. Two of 37 saddle pulmonary embolism patients (5.4%) died in the hospital (95% confidence interval 0.7% to 18%). CONCLUSIONS: Most patients with saddle pulmonary embolism found on computed tomography angiography responded to the standard management for pulmonary embolism with unfractionated heparin. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.

Diverticular and aneurysmal structures of the left ventricle in adults: report of a case within the context of a literature review.

Left ventricular outpouchings are increasingly detected on cardiovascular imaging. Herein, we describe the case of a 45-year-old man who underwent noncardiac preoperative imaging and was found to have an asymptomatic left ventricular outpouching. The patient underwent successful surgical repair of the structure. When left ventricular outpouchings are detected, the main differential diagnoses are pseudoaneurysm, aneurysm, and diverticulum. The outcomes for these conditions differ substantially, and accurate diagnosis can be crucial in making clinical decisions. We review the relevant medical literature, outline the natural history of these left ventricular abnormalities, and discuss options in regard to their management.

The correlation of left ventricular hypertrophy with the severity of atherosclerosis and embolic events.

OBJECTIVE: The study was undertaken to assess the correlation between the presence and degree of aortic atheroma with degree of Left ventricular (LV) mass index and subsequent clinical outcomes. MATERIAL AND METHOD: The authors studied the clinical profiles of 87 patients with aortic atherosclerosis and controls, who had undergone TEE between 1995 and 2000. RESULTS: Mean LV mass index was 116 gram/m2 in atherosclerosis group compared to 81 gram/m2 in the control group (p < 0.009). In the atherosclerotic group, there was a close correlation between LV mass index score and severity of the plaque in the aortic arch and descending aorta (p < 0.001, 0.001). The presence of large ulcerated plaque had a significant correlation with stroke (p < 0.002). CONCLUSION: 1) LV mass index correlates with the severity of aortic atheroma. 2) Smoking, elevated mean arterial blood pressure and a high LV mass index score are significantly correlated with large ulcerated plaque and stroke. 3) These findings may in part explain the higher cardiovascular risk in patients with increased left ventricular mass.

Inducible left ventricular outflow tract gradient during dobutamine stress echocardiography: an association with intraoperative hypotension but not a contraindication to liver transplantation.

BACKGROUND: Dobutamine stress echocardiography (DSE) is frequently used in the evaluation of cardiac risk prior to orthotopic liver transplantation (OLT). In the general cardiac population, an inducible left ventricular outflow tract gradient (LVOT Delta) during DSE has variable prognostic importance. The purpose of this study was to determine the prevalence and clinical significance of LVOT Delta in patients undergoing OLT during DSE. METHODS: Consecutive medical records of 106 patients who had undergone OLT at our institution from January 1997 until January 2002 were retrospectively analyzed and divided into two groups based on the presence (Group I, LVOT Delta >36 mmHg) or absence (Group II, LVOT Delta< or = 36 mmHg) of a significant LVOT Delta measured during DSE. We determined any outcome differences between these two groups with regard to intraoperative hypotension, cardiac mortality, length of hospital stay, graft function, and renal function post-OLT. RESULTS: Forty-six patients had an LVOT Delta > 36 mmHg (Group I) and 60 patients had LVOT Delta< or = 36 mmHg (Group II). Baseline demographics were similar in both groups. There was no significant overall difference in cardiac mortality between Group I versus Group II patients (0 versus 1 patient, respectively, P=0.57). Intraoperative hypotension occurred in 4 patients in Group I versus 0 patient in Group II (P=0.03). Length of stay, graft function, and postoperative renal function were similar in both groups. CONCLUSION: A significant LVOT Delta >36 mmHg is a frequent finding occurring in 46/106 (43%) of patients who have DSE pre-OLT. Intraoperative hypotension is associated with patients having an LVOT Delta. However, post-OLT patients with significant LVOT Delta have a similar in-hospital outcome compared to patients without significant LVOT Delta.

Bacteremia and infective endocarditis in patients on hemodialysis.

The number of patients with end-stage renal disease (ESRD) has risen dramatically over the last decade. There are 300,000 patients in the United States with ESRD who are receiving hemodialysis (HD), and the incidence is increasing at a rate of 6% to 8% per year. Bacteremia, a prerequisite for infective endocarditis (IE), occurs at a rate of 0.7 to 1.4 episodes per 100 patient-care months. Few other medical conditions, except for chemotherapy-induced neutropenia, immunosuppression, and intravenous drug abuse, are associated with higher rates of bacteremia. IE occurs in approximately 2% to 6% of patients receiving HD. The aim of this article is to review the pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE in patients receiving HD.

Undefined hypercoaguable state associated with massive right ventricular thrombus and embolism in a previously healthy 17-year-old male.

A right ventricular thrombus (RVT) is an unusual finding on echocardiography. We describe a healthy young male patient who developed RVT with subsequent pulmonary embolism (PE), the etiology of which remains uncertain.

Penetrating aortic atherosclerotic ulcer complicated by periesophageal hematoma.

Penetrating aortic atherosclerotic ulcers have been recently recognized as an entity among the acute aortic syndromes with a potentially fatal outcome. We describe the case of a patient presenting with severe chest pain who died as a result of a thoracic-aorta penetrating atherosclerotic ulcer complicated by a intramural hematoma of the esophagus and stomach, leading to exsanguination. To our knowledge this is the first case reported in the literature of such a complication from penetrating aortic atherosclerotic ulcers.

Epidemiology and outcome of infective endocarditis in hemodialysis patients.

BACKGROUND: Survival in patients with infective endocarditis (IE) ranges from 4 to 50% depending on the type of organism, the type of valve involvement and the type of treatment. METHODS: We conducted a retrospective analysis of data in hemodialysis (HD) patients at our center from 1990 to 2000. Demographics, risk factors, and outcome data were extracted in the subgroup of patients with first-episode IE diagnosed primarily by echocardiography. RESULTS: A total of 2239 patients underwent HD at our center. Thirty-two (1.4%) had IE defined using the Duke Criteria. Permanent and temporary venous dialysis catheters, arteriovenous (AV) grafts, and AV fistulae were used in 19 (59%), 12 (38%), and 1 (3%) patient respectively. Mean access duration was 7.6 +/- 7.9 months. Thirty (94%) patients had positive blood cultures, with the majority having Staphylococcus aureus bacteremia. Two (7%) patients had positive echocardiographic findings but negative blood cultures due to the commencement of empiric antibiotic therapy prior to blood cultures. The mitral valve was mainly affected. Transesophageal echocardiography was performed in 23 (72%) patients and detected an intracardiac mass in all 23 patients. One-year mortality was 56.3%. A poor 1-year prognosis was associated with presenting features of low hemoglobin, elevated leukocyte count, hypoalbuminemia, severe aortic and mitral regurgitation, and annular calcification in mitral valve IE. CONCLUSION: The prevalence of IE in HD patients is 1.4%. One-year mortality was 56.3%. Close observation is required during the first year when patients with severe valvular regurgitation and hematological abnormalities have a high mortality.

Rapid Development of a Papillary Fibroelastoma with Associated Thrombus: The Role of Transthoracic and Transesophageal Echocardiography.

Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are frequently utilized in patient's with suspected cerebral vascular ischemia. We describe a patient with suspected cerebral vascular ischemic event whom was found to have a mobile valvular mass by TTE and TEE. The lesion was unusual due to its rapid development over a period 6 months, which was documented on serial echocardiography. The mass was excised surgically and pathology showed a papillary fibroelastoma with extensive thrombus. The differential diagnosis of a cardiac valvular mass and the treatment of cardiac fibroelastomas are reviewed. In this case, both TTE and TEE were valuable in diagnosis and facilitating surgical management of a cardiac fibroelastoma.

Mediastinal Tumor Presenting as Expanding Aortic Aneurysm Diagnosed by Transesophageal Echocardiography.

This article describes a patient with suspected expanding ascending aortic aneurysm in whom transesophageal echocardiography appropriately determined the presence of a mediastinal soft tissue mass and visualized compression of the superior vena cava. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Coronary Angioplasty of an Anomalous Coronary Artery in the Elderly: Case Report and Review of the Literature.

Newer developments in biotechnology and increasing operator experience have broadened the clinical applicability of percutaneous transluminal coronary angioplasty. These advances have allowed the treatment of patients with variant and anomalous coronary arteries and the treatment of an increasingly elderly population. A case of successful percutaneous transluminal coronary angioplasty in a 90-year-old man with unstable angina and an anomalous origin of the left main coronary artery is reported.

Atrial Fibrillation in the Elderly: A Review.

Atrial fibrillation is the most common cardiac arrhythmia in the elderly. It is associated with significant morbidity and mortality due to hemodynamic and cardioembolic complications. The incidence of stroke in elderly patients is 5 times higher than in patients in sinus rhythm. Atrial fibrillation should be actively treated in the elderly. Treatment should be directed toward the correction of reversible factors, control of ventricular response rate, restoration and maintenance of sinus rhythm, and prevention of cardioembolic events. Treatment of atrial fibrillation in the elderly should be individualized with careful regard for risk-benefit ratio.

Cardiac Surgery in Patients At or Above 75 Years Old: Analysis of Perioperative and Long-term Outcome.

BACKGROUND: The peri-operative and long-term outcome of 211 consecutive patients at or above 75 years of age undergoing cardiac surgery between 1987-1990, was assessed. 79.6% of patients underwent CABG, 8.5% underwent both CABG and valvular surgery, 8.1% underwent only valvular surgery and 3.8% underwent other procedures. RESULTS: Survival curve analysis revealed no intra-operative deaths and a 30 day, 1,3, and 5 year overall survival rate of 93.3%, 89.2%, 77.8% and 64.6% respectively. 30.8% of patients had major peri-operative complications. Transient post-operative atrial fibrillation occurred in 47% of patients. There was a non-statistical trend towards increased risk of post-operative stroke in patients with transient post-operative atrial fibrillation. Early cardiothoracic re-operation was required in 8.5%. 91.9% of patients were followed up at a mean of 36.5Â+/-18.2 months post-operatively. 94.1% lived at home, 96.3% were ambulant, 96.3% were NYHA class I or II. Previously undetected malignancy was he cause of mortality in 10/45 (22%) patients who died after the thirtieth post-operative day, during the follow-up period. CONCLUSIONS: Chronologic age alone is not a contra-indication to cardiac surgery. Standard selection criteria with careful consideration of risk-benefit ratio, quality of life, presence of comorbid disease and health care costs should be factored in the decision process regarding cardiac surgery in the elderly. Particular attention should be paid to screening for malignancy and to management of transient post-operative atrial fibrillation.