Increased mortality from complications of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement.

Aortic stenosis (AS) leads to pulmonary hypertension (PH) and right ventricle (RV) failure. Our goal was to describe mortality related to postoperative complications in PH patients undergoing transcatheter aortic valve replacement (TAVR). Ninety-three TAVR patients were analyzed (controls, sPAP < 50 mmHg; cases, sPAP ≥ 50 mmHg). Significant findings in cases included increased mortality (365 days), post-TAVR atrioventricular block (AVB) and acute kidney injury (AKI), and increased mean length of stay (LOS). This novel study highlights complications of PH as independent risk factors for death and significant morbidity post TAVR. Optimization of preoperative volume status and RV afterload reduction, while addressing AVB and AKI, may play a vital role in reducing mortality and LOS.

Early detection of right ventricular dysfunction using transthoracic echocardiography in ARDS: a more objective approach.

PURPOSE: Right ventricular (RV) dysfunction is an independent predictor of morbidity and mortality in acute respiratory distress syndrome (ARDS). Our goal was to describe morphologic changes in the RV using objective measures on transthoracic echocardiography (TTE) that occur following ARDS. METHODS: We retrospectively measured changes in the following RV parameters from a pre-ARDS TTE to an ARDS TTE: tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), fractional area change (FAC), systolic pulmonary artery pressure (SPAP), peak tricuspid regurgitant (TR) velocity, and septal shift. RESULTS: Over 24 months, 14 patients met inclusion/exclusion criteria. Mean TAPSE decreased from 22.4 mm pre-ARDS to 16.3 mm during ARDS, P<.001. Mean MPI increased from 0.19 to 0.38, P=.001. Mean FAC decreased from 60.8% to 41.2%, P=.003. Peak TR velocity increased from 2.67 m/s pre-ARDS to 3.31 m/s during ARDS, P=.02. SPAP and septal shift demonstrated trends but not statistically different between pre-ARDS and ARDS states. TAPSE correlated with ARDS severity (PaO2 /FiO2 ratios), P=.004, and was lower among 30-day nonsurvivors compared with survivors, P=.002. CONCLUSIONS: Mild RV dysfunction is common after ARDS onset. RV morphologic changes coupled with dysfunction can be detected noninvasively through TTE changes with TAPSE, MPI, and FAC. Mild RV dysfunction by TAPSE is associated with ARDS severity and mortality.

Echocardiographic parameters of right ventricular function predict mortality in acute respiratory distress syndrome: a pilot study.

Right ventricular (RV) dysfunction in acute respiratory distress syndrome (ARDS) contributes to increased mortality. Our aim is to identify reproducible transthoracic echocardiography (TTE) parameters of RV dysfunction that can be used to predict outcomes in ARDS. We performed a retrospective single-center cohort pilot study measuring tricuspid annular plane systolic excursion (TAPSE), Tei index, RV-fractional area change (RV-FAC), pulmonary artery systolic pressure (PASP), and septal shift, reevaluated by an independent blinded cardiologist (JK). Thirty-eight patients were included. Patients were divided on the basis of 30-day survival. Thirty-day mortality was 47%. Survivors were younger than nonsurvivors. Survivors had a higher pH, PaO2∶FiO2 ratio, and TAPSE. Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), and Sequential Organ Failure Assessment (SOFA) scores were lower in survivors. TAPSE has the strongest association with increased 30-day mortality from date of TTE. Accordingly, TAPSE has a strong positive correlation with PaO2∶FiO2 ratios, and Tei index has a strong negative correlation with PaO2∶FiO2 ratios. Septal shift was associated with lower PaO2∶FiO2 ratios. Decrease in TAPSE, increase in Tei index, and septal shift were seen in the severe ARDS group. In multivariate logistic regression models, TAPSE maintained a significant association with mortality independent of age, pH, PaO2∶FiO2 ratios, positive end expiratory pressure, PCO2, serum bicarbonate, plateau pressures, driving pressures, APACHE II, SAPS II, and SOFA scores. In conclusion, TAPSE and other TTE parameters should be used as novel predictive indicators for RV dysfunction in ARDS. These parameters can be used as surrogate noninvasive RV hemodynamic measurements to be manipulated to improve mortality in patients with ARDS and contributory RV dysfunction.

Aortic valve myxoma at the extreme age: a review of literature.

Primary cardiac tumours are a rare finding, with cardiac myxoma and fibroelastoma representing the majority of these tumours. Cardiac myxomas are most commonly found in the left atrium but are rarely found with attachment to the cardiac valves. The authors describe a case of aortic myxoma found in an 81-year-old man presented with peripheral arterial disease. CT angiogram of the thorax was performed to find the source of emboli and it showed a mass attached to the aortic valve and protruding into the aorta. Details of the location and texture were studied on transoesophageal echocardiography. Preoperative coronary angiography showed coronary artery disease and the patient underwent successful coronary artery bypass grafting and simultaneous resection of the mass. Histopathology revealed the mass as a myxoma.

Arrhythmias and sudden death among older children and young adults following tetralogy of Fallot repair in the current era: are previously reported risk factors still applicable?

BACKGROUND: Young adult patients (pts) with repaired tetralogy of Fallot (TOF) remain at risk for arrhythmias (Ar) and sudden cardiac death (SCD). Based on past studies with earlier pt subsets, Ar/SCD events were associated with right ventricular (RV) systolic pressures >60 mm Hg, outflow tract gradients >20 mm Hg, and QRS duration >180 ms. However, there are limited recent studies to evaluate these risk factors in the current patient generation. METHODS: Patients with TOF followed over the past 50 years were grouped by presence of any arrhythmias (group 1), absence of arrhythmias (group 2), and presence of SCD or significant ventricular arrhythmias (group 3) and correlated with current pt age, gender, age at repair, repair types, echocardiogram, cardiac magnetic resonance imaging, electrocardiogram/Holter, hemodynamics, and electrophysiology findings. RESULTS: Of 109 pts, 52 were male aged 17-58 years. Of these, 59 (54%) had Ar, two of whom had SCD. These 59 pts were chronologically older at the time of analysis, with repair at an older age and wider QRS duration (78-240, mean 158 ms) when compared with those without Ar. However, there was no correlation with surgical era, surgical repair, gender, RV pressure >60 mm Hg, right ventricular outflow tract gradient >20 mm Hg, or RV end-diastolic volume on CMRI. CONCLUSIONS: Ar/SCD risk continues to correlate with repair age and advancing pt age. QRS duration is longer in these patients but at a shorter interval (mean 158 ms) and less RV pressure (mean 43 mm Hg) than previously reported. In the current TOF patient generation, neither surgical era, type of repair, RV outflow gradient nor RV volume correlate with Ar/SCD. Electrophysiologic testing to verify and identify arrhythmias remains clinically effective.

Remodeling and thrombosis following closure of coronary artery fistula with review of management: large distal coronary artery fistula--to close or not to close?

BACKGROUND: To evaluate postdiscovery outcome of coronary artery fistulae (CAF). CAF treatment sequelae and risk factors for coronary thrombosis have not been adequately evaluated. METHODS: Outcome on follow-up of 16 patients with CAF was reviewed. Risk factors for adverse coronary events were assessed based on type, size, and treatment of CAF. RESULTS: Median age was 10 years (0.01-56). Seven patients had large, four medium, and five small sizes CAF. Eight had proximal and 8 distal type CAF. There were 7 in the intervention group (IG) and 9 in nonintervention (NIG). In the IG, 1 had myocardial infarction (MI) <24 hr with distal thrombosis following large distal type CAF closure. Follow-up angiograms in 6 pts showed; decrease in conduit coronary artery size towards normal in 4, 1 had discrete intimal stenosis, persistent coronary dilatation in 1, thrombosis of residual proximal fistula segment without MI in 2, evidence of revascularization in 2 and neovascularization in 1 patient. In the NIG, 6 of the 9 pts available for follow-up were asymptomatic. Angiogram available in 1 patient showed persistent coronary dilatation with partial closure. CONCLUSION: Post-CAF treatment sequelae include thrombosis and MI, revascularization, persistent coronary dilatation, remodeling, and decrease in conduit coronary artery size towards normal. The large size distal type of CAF may be at highest risk for coronary thrombosis post closure. The optimal treatment approach to various morphologies of CAF at various ages remains to be determined.