Comparison of balloon-expandable valves versus self-expandable valves in high-risk patients undergoing transcatheter aortic valve replacement for severe aortic stenosis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis (AS) who have a high surgical risk. In Taiwan, this is the first study reporting TAVI outcomes at a single center offering two different transcatheter heart valve technologies via four types of approaches. Our aim was to compare 30-day and 6-month Valve Academic Research Consortium-2 (VARC-2) outcomes of the two valves. METHODS: We reported the procedural, 30-day, and 6-month VARC-2 outcomes of high-risk patients who were consecutively treated with the Medtronic CoreValve (MCV) or with the Edwards SAPIEN valve or SAPIEN XT valve (ESV; Edwards Lifesciences, Irvine, CA, USA) delivered via four types of approaches. RESULTS: From May 2010 to December 2013, 30 consecutive patients with severe AS underwent TAVI: 15 patients were treated with the MCV and 15 patients were treated with the ESV. The transfemoral approach was the most frequently used route (13 MCV and 6 ESV), followed by the transapical approach (9 ESV), trans-subclavian approach (1 MCV), and direct aortic approach (1 MCV). There were no procedural deaths. "Device success" was achieved in 29 (96.7%) patients, and is defined as the absence of procedural mortality, correct positioning of one prosthetic heart valve into the proper anatomical location, and intended performance of the heart valve without moderate or severe regurgitation. The VARC-2-defined combined safety endpoint at 30 days was comparable between patients treated with the ESV and the MCV (33.3% vs. 20%, respectively; group, p = 0.409). At the 6-month follow up, the combined efficacy endpoint was not significantly different between the two groups (13.3% in the ESV group vs. 20% in the MCV group; p = 0.624). There was only one (3.3%) patient who required permanent pacemaker implantation. CONCLUSION: For the first time in Taiwan, we have demonstrated that TAVI using either device is complementary and feasible for treating a wide range of patients by using a careful selection of approaches. Favorable overall procedural success rates and 30-day and 6-month outcomes were achieved with both devices.

Cool seasons are related to poor prognosis in patients with infective endocarditis.

Many cardiac diseases demonstrate seasonal variations in the incidence and mortality. This study was designed to investigate whether the mortality of infective endocarditis (IE) was higher in cool seasons and to evaluate the effects of cool climate for IE. We enrolled 100 IE patients with vegetations in our hospital. The temperatures of the IE episodes were defined as the monthly average temperatures of the admission days. The average temperatures in the cool (fall/winter) and warm seasons (spring/summer) were 19.2°C and 27.6°C, respectively. In addition, patients admitted with the diagnosis of IE were identified from the National Health Insurance Research Database (NHIRD) and the in-hospital mortality rates in cool and warm seasons were compared to validate the findings derived from the data of our hospital. The mortality rate for IE was significantly higher in fall/winter than in spring/summer which presents consistently in the patient population of our hospital (32.7% versus 12.5%, p = 0.017) and from NHIRD (10.4% versus 4.6%, p = 0.019). IE episodes which occurred during cool seasons presented with a higher rate of heart failure (44.2% versus 22.9%, p = 0.025) and D-dimer level (5.5 ± 3.8 versus 2.4 ± 1.8 µg/ml, p = 0.017) at admission than that of warm seasons. These results may reflect the impact of temperatures during the pre-hospitalized period on the disease process. In the multivariate analysis, Staphylococcal infection, left ventricular hypertrophy, left ventricular systolic dysfunction and temperature were the independent predictors of mortalities in IE patients.

A novel finding of the atrial substrate properties and long-term results of catheter ablation in chronic atrial fibrillation patients with left atrial spontaneous echo contrast.

BACKGROUND: The atrial substrate in chronic atrial fibrillation (AF) patients with a left atrial spontaneous echo contrast (LASEC) has not been previously reported. The aim of this study was to investigate the atrial substrate properties and long-term follow-up results in the patients who received catheter ablation of chronic AF. METHODS: Of 36 consecutive patients with chronic AF who received a stepwise ablation approach, 18 patients with an LASEC (group I) were compared with 18 age-gender-left atrial volume matched patients without an LASEC (group II). The atrial substrate properties including the weighted peak-to-peak voltage, total activation time during sinus rhythm (SR), dominant frequency (DF), and complex fractionated electrograms (CFEs) during AF in the bi-atria were evaluated. RESULT: The left atrial weighted bipolar peak-to-peak voltage (1.0 ± 0.6 vs 1.6 ± 0.7 mV, P = 0.04), total activation time (119 ± 20 vs 103 ± 13 ms, P < 0.001) and DF (7.3 ± 1.3 vs 6.6 ± 0.7 Hz, P < 0.001) differed between group I and group II, respectively. Those parameters did not differ in the right atrium. The bi-atrial CFEs (left atrium: 89 ± 24 vs 92 ± 25, P = 0.8; right atrium: 92 ± 25 vs 102 ± 3, P = 0.9) did not differ between group I and group II, respectively. After a mean follow-up of 30 ± 13 month, there were significant differences in the antiarrhythmic drugs (1.1 ± 0.3 vs 0.7 ± 0.5, P = 0.02) needed after ablation, and recurrence as persistent AF (92% vs 50%, P = 0.03) between group I and group II, respectively. After multiple procedures, there were more group II patients that remained in SR, when compared with group I (78% vs 44%, P = 0.04). CONCLUSION: There was a poorer atrial substrate, lesser SR maintenance after catheter ablation and need for more antiarrhythmic drugs in the chronic AF patients with an LASEC when compared with those without an LASEC.

The impact of diastolic dysfunction on the atrial substrate properties and outcome of catheter ablation in patients with paroxysmal atrial fibrillation.

BACKGROUND: The presence of diastolic dysfunction increases the risk of atrial fibrillation (AF), and might be associated with the left atrial (LA) substrate. The aim of the present study was to investigate the relationships between the diastolic dysfunction, atrial substrate and outcome of the catheter ablation. METHODS AND RESULTS: Eighty-three patients with paroxysmal AF were enrolled. Diastolic dysfunction was defined as a left ventricular ejection fraction (LVEF) of ≥ 50%, and one of the following criteria: (1) a mitral inflow early filling velocity to atrial filling velocity ratio (E/A) of ≤ 0.75; or (2) an E/A ratio of >0.75 and a ratio of the mitral inflow early filling velocity to the velocity of the early medial mitral annular ascent of >10. Patients with diastolic dysfunction were older than those with normal cardiac function. There were no differences in the other baseline characteristics, LA diameter, or LVEF. A decreased LA voltage, and higher recurrence rate were noted in patients with diastolic dysfunction. In the univariate analysis, the patients with recurrence had a lower LA voltage and greater diastolic dysfunction. The multivariate analysis also indicated diastolic dysfunction and LA voltage as independent predictors of recurrence. CONCLUSIONS: The patients with diastolic dysfunction developed a different atrial substrate and had a worse outcome of catheter ablation for atrial fibrillation.

Do the left atrial substrate properties correlate with the left atrial mechanical function? A novel insight from the electromechanical study in patients with atrial fibrillation.

BACKGROUND: The atrial substrate is the determinant of occurrence and maintenance of atrial fibrillation (AF), which can induce remodeling of atrial function and structure. This study investigated the relationship between the left atrial (LA) substrate properties and LA mechanical function. METHODS: Forty-four consecutive patients (50.3 +/- 10.7 years old, 33 men) who presented with sinus rhythm during echocardiographic study before receiving catheter ablation for AF were enrolled. The LA diameter, LA volume, ratio of early and late transmitral filling flow velocities (E/A), LA appendage flow velocity, and transmitral velocity-time integral (VTI) were measured by the echocardiography. The LA empty fraction (LAEF), which was obtained via dividing the difference between maximal and minimal LA volume by maximal LA volume, was calculated as a parameter of the global LA contractile function. The LA global contact voltage mapping (NavX system) was performed before pulmonary vein isolation. RESULTS: Mean LA voltage and LA low voltage zone index (LVZ index, area with voltage < 0.5 mV, divided by total LA surface area) showed significant correlation with LA diameter and volume, but only the LA LVZ index showed significant correlation with A-wave velocity, transmitral A-wave VTI, and LAEF (r =-0.340, -0.411, -0.426; P = 0.024, 0.006, 0.005, respectively). We divided the LA LVZ index into three groups (< 10%, 10-20%, > 20%). The LAEF got worse and the transmitral A-wave VTI percentage (divided by transmitral VTI) decreased as LA LVZ index increased. CONCLUSIONS: The LA substrate properties showed close correlation with LA size, but only the LA LVZ index correlated with the LA mechanical function.

Color M-mode flow propagation velocity: is it really preload independent?

OBJECTIVE: This study investigates the change in flow propagation velocity (FPV) in uremic patients who undergo regular hemodialysis (H/D). MATERIALS AND METHODS: We studied 93 uremic patients (44 men and 49 women; 59 +/- 14-years-old) receiving regular hemodialysis. Patients were separated by baseline left ventricular ejection fraction (LVEF): 71 patients with LVEF > 50% (group 1), 13 patients with LVEF 35-50% (group 2), 7 patients with LVEF < 35% (group 3). All patients were in sinus rhythm before H/D. They received complete transthoracic echocardiographic examinations. Flow propagation velocity was measured by color M-mode echocardiography in apical four chambers view. All these parameters were obtained before and after H/D. Paired data were compared. According to different H/D amounts, we viewed the FPV response after H/D in variant baseline LVEF groups. RESULT: The baseline FPV became lower in patients with low LVEF. After H/D, obvious decrement of FPV occurred in group 1, but there were no obvious changes in groups 2 and 3. In fact, a slight increment of FPV was found in group 3. In patients with baseline LVEF > 50%, FPV after H/D was almost always lower, regardless of H/D amount. But there was different response in patients with baseline LVEF < 50%. CONCLUSION: Flow propagation velocity is preload independent in patients with LVEF < 50%, but it is preload-dependent in patients with LVEF > 50%.

Efficacy and safety of slow-release fluvastatin 80 mg daily in Chinese patients with hypercholesterolemia.

BACKGROUND: Before this study, the efficacy and safety of doubling the dosage of fluvastatin from 40 mg/day to 80 mg/day in Chinese patients with primary hypercholesterolemia remained to be determined. METHODS: In this open-label, active-controlled randomized 2-center study, patients with primary hypercholesterolemia were randomized to treatment with immediate-release fluvastatin 40 mg/day (n = 30) or slow-release fluvastatin 80 mg/day (n = 31) for 12 weeks. The primary efficacy variable was percent change in low-density lipoprotein (LDL) cholesterol level from baseline. Secondary efficacy variables were percent changes in total cholesterol, triglyceride, and high-density lipoprotein (HDL) cholesterol levels, and the percent of patients achieving LDL cholesterol goals of the US National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) II. RESULTS: Both fluvastatin dosages (40 mg/day vs 80 mg/day) effectively reduced LDL cholesterol (-22.5% vs -29.9%; p = 0.087), total cholesterol (-17.3% vs -22.5%; p = 0.140), and triglyceride levels (-14.0% vs -12.3%; p = 0.813) (all p < 0.0001 for comparison with baseline), and slightly increased HDL cholesterol levels (+5.2% vs +5.6%; p = 0.917), after 12 weeks of treatment. The percent of patients achieving LDL cholesterol goals of the NCEP ATP II was 37% versus 65% (p < 0.05). The adverse event profiles for the 2 fluvastatin dosages were similar. CONCLUSION: In Chinese patients with primary hypercholesterolemia, doubling the dosage of fluvastatin from 40 to 80 mg once daily was effective and safe regarding reduction of LDL cholesterol level, and allowed more patients to achieve LDL cholesterol goals of the NCEP ATP II.

Catheter ablation of atrial fibrillation versus atrioventricular junction ablation plus pacing therapy for elderly patients with medically refractory paroxysmal atrial fibrillation.

BACKGROUND: Catheter ablation of atrial fibrillation (AF) has become another nonpharmacologic therapeutic option for medically refractory paroxysmal AF. Whether this method is better than atrioventricular (AV) junction ablation plus pacing therapy is unknown. The purpose of this study was to compare the very long-term (longer than 4 years) clinical outcomes of the 2 methods in elderly patients (>65 years old) with medically refractory paroxysmal AF. METHODS: From January 1995 to December 2001, 71 elderly patients with medically refractory paroxysmal AF were included; group 1 included 32 patients with successful AV junction ablation plus pacing therapy and group 2, 37 patients with successful catheter ablation of AF. RESULTS: After a mean follow-up of more than 52 months, the AF was better controlled in the group 1 patients than group 2 (100% vs 81%, P = 0.013), however, they had a significantly higher incidence of persistent AF (69% vs 8%, P < 0.001) and heart failure (53% vs 24%, P = 0.001). Furthermore, the incidence of ischemic stroke and cardiac death was similar between the 2 groups. Compared with the preablation values, a significant increase in the NYHA functional class (1.7 +/- 0.9 vs 1.4 +/- 0.7, P = 0.01) and significant decrease in the left ventricular ejection fraction (44 +/- 8% vs 51 +/- 10%, P = 0.01) were noted in the group 1 patients, but not in the group 2 patients. CONCLUSIONS: Although AV junction ablation plus pacing therapy better controlled the AF in elderly patients with medically refractory paroxysmal AF, that method was associated with a higher incidence of persistent AF and heart failure than catheter ablation of AF in the very long-term follow-up.

Diagnosis of an isolated persistent left side superior vena cava by contrast echocardiography compared with invasive angiographic study.

BACKGROUND: The prevalence of left side superior vena cava (LSVC) is low and usually invasive angiography is necessary to validate its presence. Non-invasive echocardiographic study is important for the diagnosis and definition of associated lesions. The aim of this study is to demonstrate the clinical feasibility and accuracy of diagnosing LSVC by contrast echocardiography. METHODS: Four cases were included in this study. They were aged from 41 to 75 years old, 1 male and 3 female, all in sinus rhythm, with mean heart rate 83 +/- 14 beat per minute. They all received transthoracic echocardiography and transesophageal echocardiography. Contrast material was rapidly infused from both left arm vein and right arm vein to evaluate the diagnostic value of contrast enhancement for LSVC. They also received invasive angiographic study as the diagnostic golden standard. An isolated persistent left side superior vena cava with drainage into the right atrium was considered to be present, supposing the following diagnostic criteria were met: (1) the presence of a dilated coronary sinus in parasternal long axis view of two-dimensional echocardiography; (2) earlier enhancement of the dilated coronary sinus than the right cardiac chambers after contrast material infusion into a left arm vein; (3) right cardiac chambers were enhanced earlier than the dilated coronary sinus after contrast material infusion into a right arm vein. RESULTS: All 4 patients received the complete studies without any complications during the study procedures. Correct diagnostic yields could be obtained even with or without other associated cardiac lesions. CONCLUSIONS: According to the experiences obtained from this study, contrast echocardiography is safe and highly informative for the definite diagnosis of left superior vena cava with drainage into coronary sinus. Correct diagnosis could be obtained by contrast echocardiography in all four cases within this study. The accuracy was 100%, if the above three echocardiographic diagnostic criteria were adopted.

Left ventricular 4D echocardiogram motion and shape analysis.

The article describes the methodology and the processes of modeling the function and the motion of left ventricle using transesophageal echocardiograph. The parameters can be used in studying the functionality of left ventricle, the status of abnormality of myocardial, and the geometric and morphological of left ventricle in shape analysis. The parameters describes the motion of left ventricle are the left ventricular (LV) floating long axis, the morphological parameters. The LV morphological parameters describe the wall motion, the LV chamber cavity variation, the effective R-ratio of endomyocardial chamber of LV, the area surface curvature, and the global surface curvature circularity. The parameters such as stroke volume, ejection fraction used in evaluation of LV functions are also extracted.

Visualization of Secundum Atrial Septal Defect Using Transthoracic Three-Dimensional Echocardiography in Children: Implications for Transcatheter Closure.

BACKGROUND: The objective of this study was to evaluate the efficacy of quantitative measurements of secundum atrial septal defect (ASD) with dynamic transthoracic three-dimensional (3-D) echocardiography. METHODS: Twenty-six patients (age, 13 months to 14 years; mean age, 37 months) with secundum ASDs underwent 3-D echocardiographic imaging generated from transthoracic echocardiographic interrogation before surgery. Four specific cut planes were defined: four-chamber view, transverse view, en face view from right and left atrial side. The images obtained from 16 patients clearly demonstrated all four defined cut planes for the quantitative measurement. RESULTS: The defect sizing determined by the 3-D images correlated well with surgical findings. These images may be interactively manipulated to optimize visualization of the defect to allow the cardiologist to perform transcatheter occlusion. A significant correlation was demonstrated to the limbic band tissue assessment by four-chamber and transverse views. Unusual atrial structures such as muscle bands and the fore-shortening of the en face view might induce biased measurements. CONCLUSIONS: The transthoracic approach was successful in capturing sufficient data to create 3-D images, which can provide an accurate assessment of secundum ASD. The possibility of underestimation should always be taken into account with the en face view. Multiple cut planes were essential to ensure correct sizing for adequate selection of the occluder.