Percutaneous mitral heart valve repair--MitraClip.

Mitral regurgitation (MR) is the most common cardiac valvular disease in the United States. Approximately 4 million people have severe MR and roughly 250,000 new diagnoses of MR are made each year. Mitral valve surgery is the only treatment that prevents progression of heart failure and provides sustained symptomatic relief. Mitral valve repair is preferred over replacement for the treatment of MR because of freedom from anticoagulation, reduced long-term morbidity, reduced perioperative mortality, improved survival, and better preservation of left ventricular function compared with valve replacement. A large proportion of patients in need of valve repair or replacement do not undergo such procedures because of a perceived unacceptable perioperative risk. Percutaneous catheter-based methods for valvular pathology that parallel surgical principles for valve repair have been developed over the last few years and have been proposed as an alternate measure in high-risk patients. The MitraClip (Abbott Labs) device is one such therapy and is the subject of this review.

Predictors of mortality, rehospitalization for syncope, and cardiac syncope in 352 consecutive elderly patients with syncope.

OBJECTIVES: To investigate the etiologies of syncope and predictors of all-cause mortality, rehospitalization, and cardiac syncope in consecutive elderly patients presenting with syncope to our emergency department. PARTICIPANTS: Participants were 352 consecutive patients aged 65 years or older with syncope admitted to hospital from the emergency department. DESIGN: Observational retrospective study. MEASUREMENTS: Review of medical records for history, physical examination, medications, and tests to determine causes of syncope. Cox stepwise logistic regression analysis was performed to identify significant independent prognostic factors for rehospitalization with syncope, all-cause mortality, and cardiac syncope. RESULTS: Of 352 patients, mean age 78 years, the etiology of syncope was diagnosed in 243 patients (69%). Vasovagal syncope was diagnosed in 12%, volume depletion in 14%, orthostatic hypotension in 5%, cardiac syncope in 29%, carotid sinus hypersensitivity in 2%, and drug overdose/others in 7% of patients. During a mean follow-up of 24 months, 10 patients (3%) were readmitted to the hospital for syncope and 39 (11%) died. Stepwise logistic regression analysis identified history of congestive heart failure (OR 5.18; 95% CI 1.23-21.84, P = .0257) and acute coronary syndrome (OR 5.95; 95% CI 1.11-31.79, P = .037) as independent risk factors for rehospitalization. Significant independent prognostic factors for mortality were diabetes mellitus (OR 2.08; 95% CI 1.09-3.99, P = .0263), history of smoking (OR 2.23; 95% CI 1.10-4.49, P = .0255), and use of statins (OR 0.37; 95% CI 0.19-0.72, P = .0036). Independent risk factors for predicting a cardiac cause of syncope were an abnormal electrocardiogram (OR 2.58; 95% CI 1.46-4.57, P = .0012) and reduced ejection fraction (OR 2.92; 95% CI 1.70-5.02, P < .001). The San Francisco Syncope Rule and Osservatorio Epidemiologico sulla Sincope nel Lazio scores did not predict mortality or rehospitalization in our study population. CONCLUSIONS: Significant independent risk factors for rehospitalization for syncope were congestive heart failure and acute coronary syndrome. Significant independent risk factors for mortality were diabetes mellitus, history of smoking, and use of statins (inverse association).

A rare case of successfully treated cardiac metastasis from transitional cell bladder cancer.

Although it is common to find metastases of transitional cell carcinoma of the bladder to the lymph nodes, lung, bone, and liver, cardiac metastases have only been rarely reported. We report a case of symptomatic metastasis of transitional cell cancer to the right ventricle. A 59-year-old man with a history of transitional cell bladder cancer status post cystectomy and chemotherapy, with neobladder placement, presented with hematuria, shortness of breath, murmur, and evidence of right-sided heart failure. On imaging workup, including transthoracic echocardiography and cardiac computed tomography, we found a large right ventricular mass. A review of the literature showed that there are only 9 cases of cardiac metastasis from transitional cell cancer reported; however, our case is unique because it is the only reported case of symptomatic improvement due to effective treatment with chemotherapy.

Association of corrected QT interval with long-term mortality in patients with syncope.

INTRODUCTION: The electrocardiographic parameters QRS duration, QRS-T angle and QTc can predict mortality in patients with cardiovascular disease. The prgnostic value of these parameters in hospitalized patients with syncope needs investigation. MATERIAL AND METHODS: We retrospectively studied 590 consecutive patients hospitalized with syncope. After excluding patients with baseline abnormal rhythm, QT- prolonging medications, and missing data, 459 patients were analyzed. Baseline demographic characteristics, co-morbidities, medication use, San Francisco Syncope Rule (SFSR) and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score and data on mortality were collected. The categorical variables and continuous variables of the 2 groups of patients with prolonged QTc and normal QTc interval were analyzed by Fischer's exact test and Mann-Whitney Test. A stepwise Cox regression model was used for time to death analysis. RESULTS: Of 459 patients, prolonged QTc interval was observed in 122 (27%). Mean follow-up was 41 months. Patients with prolonged QTc interval had higher prevalence of cardiovascular disease, OESIL score, high risk SFSR, hypertension, dyslipidemia, coronary artery disease, congestive heart failure, and increased mortality. Stepwise Cox regression analysis showed that significant independent prognostic factors for time to death were prolonged QTc interval (p = 0.005), age (p = 0.001), diabetes mellitus (p = 0.001) and history of malignancy (p = 0.006). QRS duration and QRS-T angle were not independent predictors of mortality. CONCLUSIONS: A prolonged QTc interval is an independent predictor of long-term mortality in hospitalized patients with syncope.

Dual-source versus single-source cardiac CT angiography: comparison of diagnostic image quality.

OBJECTIVE: Dual-source CT improves temporal resolution, and theoretically improves the diagnostic image quality of coronary artery examinations without requiring preexamination beta-blockade. The purpose of our study was to show the improved diagnostic image quality of dual-source CT compared with single-source CT despite the absence of preexamination beta-blockade in the dual-source CT group. MATERIALS AND METHODS: We performed a retrospective analysis of consecutive patients who underwent coronary artery evaluation with either single-source CT or dual-source CT at our institution between February 2005 and October 2006. Examination reports were analyzed for the presence of image artifacts, and image quality was graded on a 3-point scale (no, mild, or severe artifact). Type of artifact (motion, calcium, quantum mottle) was also noted. RESULTS: Examinations (339 single-source CT and 126 dual-source CT) of 465 patients were analyzed. Artifact was reported in 39.8% of examinations using single-source CT and in 29.4% of examinations using dual-source CT (p < 0.05). The number of examinations with motion artifact was significantly higher with single-source CT than with dual-source CT (15.9% vs 4.8%; p < 0.001) despite significantly higher heart rates in the dual-source CT group (59.4 +/- 8.4 vs 68.6 +/- 14.6 beats per minute; p < 0.001). No patients in the dual-source CT group received preexamination beta-blockade compared with 81% of patients in the single-source CT group. The presence of severe (nondiagnostic) calcium artifact was also significantly reduced in the dual-source CT group (13.0% vs 3.2%; p < 0.001). CONCLUSION: Dual-source CT provides significantly better diagnostic image quality than single-source CT despite higher heart rates in the dual-source CT group. These findings support the use of dual-source CT for coronary artery imaging without the need for preexamination beta-blockade.

Enhancing the utility of prostascint SPECT scans for patient management.

This project investigated reducing the artifact content of In-ill ProstaScint SPECT scans for use in treatment planning and management. Forty-one patients who had undergone CT or MRI scans and simultaneous Tc-99m RBC/In-111 ProstaScint SPECT scans were included. SPECT volume sets, reconstructed using Ordered Set-Expectation Maximum (OS-EM) were compared against those reconstructed with standard Filtered Back projection (FBP). Bladder activity in Tc-99m scans was suppressed within an ellipsoidal volume. Tc-99m voxel values were subtracted from the corresponding In-111 after scaling based on peak activity within the descending aorta. The SPECT volume data sets were merged with the CT or MRI scans before and after processing. Volume merging, based both on visual assessment and statistical evaluation, was not affected. Thus iterative reconstruction together with bladder suppression and blood pool subtraction may improve the interpretation and utility of ProstaScint SPECT scans for patient management.