Left ventricular regional shape dynamics analysis by three-dimensional cardiac magnetic resonance imaging associated with left ventricular function in first-time myocardial infarction patients.

Geometric remodelling of the left ventricle (LV) following myocardial infarction reflects on the geometric characteristics directly. This study focuses on a potential index based on curvedness. Nine consecutive normal volunteers and thirty consecutive myocardial infarction patients underwent MRI scan (twenty-seven patients had follow-up scan). Short-axis cine images of all cases were delineated. Three dimensional LV models were reconstructed and restored for possible motion distortion. The curvedness values were computed over 16-segments nomenclature. The curvedness signal for each segment over twenty-two time frames were fitted using a second order Fourier Series. Fourier coefficients were extracted and unsupervised learning was conducted between normal and patient data. An accuracy of 89% and adjusted Rand Index of 0.5374 suggest that these Fourier Series and curvedness based features can be an useful index for prognosis and diagnosis in clinical practice.

What is the best surgical treatment for obstructive hypertrophic cardiomyopathy and degenerative mitral regurgitation?

BACKGROUND: Many prefer mitral valve replacement (MVR) for patients with obstructive hypertrophic cardiomyopathy (HCM) and concomitant degenerative mitral regurgitation (MR). We reviewed our results of septal myectomy combined with mitral valve repair (MVrep) and MVR when these problems coexist. METHODS: Between 1990 and 2006, 32 patients (56% men; mean age, 60.7 +/- 16.7 years) underwent extended septal myectomy for HCM with concomitant MVrep or MVR for degenerative MR (4% of myectomies and 3% of isolated MVrep during the same period). Preoperatively, 63% were in New York Heart Association (NHYA) functional class III/IV. Preoperative peak left ventricular outflow tract (LVOT) gradient was 63.7 +/- 37.6 mm Hg. Systolic anterior motion (SAM) was present in 94%, with severe MR in 88%. RESULTS: Extended septal myectomy included concomitant MVrep in 28 (88%) or mechanical MVR in 4 (12%). MVrep included leaflet resection in 10 (36%), edge-to-edge stitch in 6 (21%), and leaflet plication in 8 (29%). An annuloplasty ring/band was used in 19 (68%) and commissural annuloplasty in 2 (7%). There was one early death (3%). At discharge, resting LVOT gradient was reduced to 10.2 +/- 19.0 mm Hg (p < 0.005). Dismissal echocardiography in MVrep patients demonstrated chordal SAM in 6 (21%, p < 0.005). MR was absent or mild in 21 (75%) and moderate in 6 (21%; p < 0.005 vs preoperatively). At late follow-up, LVOT gradient was 2.5 +/- 5.8 mm Hg, SAM resolved in all patients, and 2 had moderate MR; 24 (83%) were in NYHA class I/II (p < 0.005). CONCLUSIONS: Concomitant MVrep with myectomy for HCM and degenerative MR can be performed with low early mortality with satisfactory relief of LVOT obstruction and MR. Most patients have significant relief of symptoms. MVR can be avoided in most patients with degenerative MR and HCM.

Management of moderate functional mitral regurgitation at the time of aortic valve replacement: is concomitant mitral valve repair necessary?

OBJECTIVE: The optimal management of moderate functional mitral regurgitation at the time of aortic valve replacement remains undefined. METHODS: We retrospectively identified 686 consecutive patients undergoing aortic valve replacement between 1993 and 2006 with at least moderate (grade 2 or more) functional mitral regurgitation. Patients with structural valve abnormalities or significant coronary artery disease were excluded, leaving 190 in the study. Analyses for predictors of residual mitral regurgitation and survival were performed. The impact of mitral regurgitation on survival was further analyzed among 91 patients case matched for age, gender, and left ventricular ejection fraction to individuals without mitral regurgitation undergoing isolated aortic valve replacement. RESULTS: The mean age of the study group was 74 +/- 11years, 45% were male, and 78% had New York Heart Association III or IV Class classification. The mean preoperative ejection fraction was 48% +/- 17%. Operative mortality was 5% (n = 9). Follow-up echocardiographic data were available for 88% of patients at discharge and 57% of patients at midterm. Mitral regurgitation was improved at discharge in 76% of patients and at mid-term follow-up in 67% of patients. Independent predictors of improved mitral regurgitation were lesser degrees of preoperative tricuspid regurgitation or prebypass mitral regurgitation, absence of cerebrovascular disease, and lower left ventricular ejection fraction. Postoperatively, 89% of patients were New York Heart Association Class I or II Symptom; No reoperations for mitral regurgitation were performed. Survival was 68% at 5 years and 42% at 10 years. Independent predictors of late mortality were increasing age, diabetes, dialysis-dependent renal failure, and increased tricuspid regurgitation severity. The survival of 91 patients from this cohort did not differ from case-matched patients without mitral regurgitation undergoing aortic valve replacement (P = .33). CONCLUSION: Moderate functional mitral regurgitation improved in most patients after aortic valve replacement. Residual mitral regurgitation did not affect survival independently of left ventricular function.

Clinical presentation, temporal relationship, and outcome in thirty-three patients with type 2 heparin-induced thrombocytopenia after cardiotomy.

BACKGROUND: Type 2 heparin-induced thrombocytopenia is an uncommon but often fatal complication of heparin, frequently difficult to diagnose after cardiac surgery. In this series, we record the clinical presentation, temporal relationship, and treatment outcome of patients diagnosed with heparin-induced thrombocytopenia postoperatively. METHODS: Thirty-three consecutive patients (1.1%) with a diagnosis of heparin-induced thrombocytopenia established by a greater than 50% drop in platelet count with or without a thrombotic event and a positive platelet factor-4 assay were reviewed. We recorded the clinical presentation, the time to presentation, treatment, and outcome (thrombosis, mortality). Univariate analysis was performed on 13 preoperative, operative, and postoperative variables. RESULTS: The cohort was at increased mortality risk as a result of age (69.4 years), reduced cardiac function (46.8%), nonbypass operations (57.6%), emergency surgery (21.2%), and implantation of three assist devices. The mean time to suspect heparin-induced thrombocytopenia postoperatively was 5.4 days, with 22 cases (66.6%) occurring within 5 days. All patients had previous (within 3 months) exposure to heparin, and 66.6% had ongoing treatment with heparin before surgery. Overall mortality was 33%; thrombotic complications occurred in 15 patients (45.5%), with a mortality of 7 (46.6%) despite immediate cessation of heparin and treatment with a nonheparin analog. Thrombocytopenia without thrombosis occurred in 18 patients (54.5%), but a subgroup of 5 patients with nonthrombotic complications accounted for the 4 (22.2%) deaths. CONCLUSIONS: Heparin-induced thrombocytopenia after cardiac surgery is uncommon but may occur within 5 days of surgery, further complicating diagnosis and treatment. Thrombotic complications result in a high mortality despite treatment with a nonheparin analog, and a subgroup of patients with thrombocytopenia fared poorly.

The combined use of extracorporeal life support and the Berlin Heart pulsatile pediatric ventricular assist device as a bridge to transplant in a toddler.

There is a very limited published material about experience with long-term pediatric mechanical circulatory support as a bridge to heart transplant. We report on a 2-year-old, 12 kg boy admitted with 2-week history of low-grade fever, ear pain, pulmonary edema, and congestive heart failure. Trans-thoracic echocardiography confirmed severe myocardial dysfunction with a left ventricular ejection fraction of 0.20 and percentage shortening of 13. After 2 days of ventilatory and inotropic support, the patient continued to deteriorate and subsequently required femoro-femoral extracorporeal life support (ECLS). This was later complicated by a progressive coagulopathy and massive bleeding. On day 17, a pulsatile pediatric paracorporeal biventricular assist device (VAD) (Berlin Heart) was implanted. The patient's condition improved significantly with all coagulopathies corrected, and the patient was extubated 21 days later. After 109 days of bi-VAD support, the patient was successfully transplanted and discharged home 45 days post transplant. Our early experience with initial ECLS bridge to VAD and subsequently to transplant was encouraging. It allowed for additional time to select the ideal organ donor and optimize the recipient's comorbid condition and multiorgan failure. VAD provides an additional armamentarium of circulatory support in pediatric patients with severe heart failure.