Prevalence and Clinical Correlates of Aortic Dilation in Hypertrophic Cardiomyopathy.

BACKGROUND: Aortic dilation has been associated with various cardiac conditions, although its prevalence and clinical correlates in hypertrophic cardiomyopathy (HCM) remain unclear. OBJECTIVES: The purposes of this study were to define the prevalence of ascending aortic dilation in a large referral population of patients with HCM and to determine clinical and echocardiographic correlates of aortic dilation. METHODS: A total of 1,698 patients with HCM underwent echocardiographic measurement of the tubular ascending aorta (proximal and midlevel) during index evaluation at a tertiary HCM referral center. End-diastolic ascending aorta dimension was indexed to body surface area, with dilation defined for the tubular ascending aorta as 2 SD above the mean (>19 mm/m2) and independently as greater than published age-, sex-, and body surface area- adjusted norms (for the sinus of Valsalva and midlevel). Aortic size and presence of aortic enlargement were correlated with clinical and echocardiographic parameters. RESULTS: Tubular ascending aortic dilation >19 mm/m2 was present in 303 patients with HCM (18%), and dilation above adjusted norms was present in 210 patients with HCM (13%). The median indexed tubular ascending thoracic aortic dimension was 16.5 (interquartile range, 14.8-18.2) mm/m2. Indexed dimension increased linearly with age (R = 0.53, P < .0001). Women and patients with a history of systemic hypertension were more likely to have tubular aortic enlargement >19 mm/m2 (29.8% vs 9.9% and 24.1% vs 10.5%, respectively, P < .0001 for both). Patients with obstructive physiology were more likely to have tubular aortic enlargement >19 mm/m2 than those without resting or provocable obstruction (19.6% vs 14.4%, P = .007). Using adjusted norms, aortic enlargement was more frequent at the midlevel compared with the sinus of Valsalva (71% vs 29%), more common in patients with hypertension (15.4% vs 10.6%, P = .009), and more common in patients with paroxysmal atrial fibrillation (16.3% vs 11.5%, P = .036), but no other relationships remained statistically significant. CONCLUSIONS: In this large cohort of patients with HCM, aortic dilation was common. The key correlate of tubular aortic enlargement >19 mm/m2, and aortic enlargement greater than adjusted norms included a history of systemic hypertension. Given an increased prevalence of aortic dilation in HCM, further study is needed on the clinical impact of aortic dilation.

Occupational musculoskeletal pain in cardiac sonographers compared to peer employees: a multisite cross-sectional study.

OBJECTIVES: The purpose of this study was to compare the prevalence and impact of work-related musculoskeletal pain in cardiac sonographers to a large control group of peer employees with similar demographics. BACKGROUND: Cardiac sonographers are known to have high levels of occupational musculoskeletal pain. Comparative studies with other employees within cardiology/radiology departments have never been performed. METHODS: An electronic survey was administered to Mayo Clinic employees at six major patient care facilities in four different states. RESULTS: There were 2682 employees within the departments of cardiology and radiology who were contacted, and 1532 (57%) completed the survey. After excluding those who wore protective lead aprons, 517 employees comprised the control group and 66 cardiac sonographers made up the study group. Cardiac sonographers reported work-related musculoskeletal pain more frequently than the control group (88% vs 40%; P<.001). This association persisted after multivariable adjustment for age, sex, body mass index, length of current employment, and history of preexisting musculoskeletal pain (OR 11.6; [95% CI 5.32, 25.5]; P<.001). Cardiac sonographers sought medical care for their work-related pain more often (55% vs 21%; P<.001) and missed more work due to pain (35% vs 12%, P<.001). In a secondary analysis, cardiac sonographers also experienced more work-related musculoskeletal pain than nurses, technicians, and physicians working in the interventional laboratory who regularly wear a protective lead apron (P<.001). CONCLUSIONS: In this multisite cross-sectional study, cardiac sonographers experienced significantly more work-related pain and missed more work due to pain than peer employees within cardiology/radiology departments.

Occupational health hazards of working in the interventional laboratory: a multisite case control study of physicians and allied staff.

BACKGROUND: The occupational hazards of working in the interventional laboratory have been inadequately studied for physicians and remain unaddressed for nonphysician personnel. OBJECTIVES: This study sought to determine whether the prevalence of work-related musculoskeletal pain, cancer, and other medical conditions is higher among physicians and allied staff who work in interventional laboratories compared with employees who do not. METHODS: Mayo Clinic employees who work in affiliated hospitals with interventional cardiology or interventional radiology laboratories took an electronic survey. Results were stratified on the basis of self-reported occupational exposure to procedures that involve radiation. RESULTS: There were 1,543 employees (mean age 43 ± 11.3 years, 33% male) who responded to the survey (response rate of 57%), and 1,042 (67.5%) reported being involved with procedures utilizing radiation. These employees reported experiencing work-related pain more often than the control group before (54.7% vs. 44.7%; p < 0.001) and after adjustment for age, sex, body mass index, pre-existing musculoskeletal conditions, years in profession, and job description (odds ratio: 1.67; 95% confidence interval: 1.32 to 2.11; p < 0.001). Musculoskeletal pain varied significantly by job description, with the highest incidence reported by technicians (62%) and nurses (60%) followed by attending physicians (44%) and trainees (19%; p < 0.001). There was no difference in cancer prevalence between groups (9% vs. 9%; p = 0.96). CONCLUSIONS: Musculoskeletal pain is more common among healthcare workers who participate in interventional procedures and is highest in nonphysician employees. The diagnosis of cancer in employees who participate in procedures that utilize radiation was not elevated when compared to controls within the same departments, although any conclusion regarding causality is limited by the cross-sectional nature of the study, as well as the low overall prevalence of malignancy in our study group.

Imaging Pandora's Box: incidental findings in elderly patients evaluated for transcatheter aortic valve replacement.

OBJECTIVE: To determine the frequency and clinical impact of noncardiovascular incidental findings (IFs) detected on preoperative computed tomographic angiography (CTA) of the chest/abdomen/pelvis performed in elderly patients with severe aortic stenosis being considered for transcatheter aortic valve replacement (TAVR). PATIENTS AND METHODS: The CTA studies for 424 consecutive patients being evaluated for TAVR between January 1, 2009, through January 24, 2012, were reviewed for noncardiovascular IFs (62.0% male; median ± SD age, 82 ± 8.3 years). The electronic medical record was reviewed to assess for subsequent clinical management and survival. RESULTS: Potentially pathologic IFs (PPIFs) were present in 285 patients (67.2%). The mean ± SD number of PPIFs per patient was 1.1 ± 1.0 (range, 0-4). Factors associated with higher numbers of PPIFs were reduced ejection fraction (P=.02) and history of smoking (P=.06). Potentially pathologic incidental findings prompted clinical work-up in 39 patients (9.2%) and delayed or canceled treatment plans for aortic stenosis in 7 patients (1.7%). The number needed to image to diagnose a new malignancy or medical condition was 19. The number of PPIFs was predictive of poor overall survival before (hazard ratio, 1.58; 95% CI, 1.31-1.88) and after (hazard ratio, 1.45; 95% CI, 1.19-1.76) adjustment for baseline clinical variables (P<.001 for both). CONCLUSION: This investigation found that PPIFs are common in elderly patients undergoing TAVR-CTA scans and, once discovered, commonly generate further clinical evaluation. Higher numbers of PPIFs may be predictive of poorer survival, but further study is required to guide the appropriateness of pursuing diagnostic evaluations for asymptomatic PPIFs in this elderly population.

Histologically proven, low-grade brainstem gliomas in children: 30-year experience with long-term follow-up at Mayo Clinic.

INTRODUCTION: To evaluate long-term overall survival (OS), progression-free survival (PFS), and outcomes in pathologically proven brainstem low-grade gliomas (BS-LGG) in children. METHODS: The Mayo Clinic tumor registry identified 48 consecutive children (≤20 y, 52% female) with biopsy-proven BS-LGG treated at Mayo Clinic between January 1971 and December 2004. Medical records were retrospectively reviewed. For analysis, patients were censored at the time of recurrence, death, or last follow-up. RESULTS: The median age at diagnosis was 12 years with a median follow-up of 6.0 years. The majority of tumors were grade I (69%) and pathology was consistent with an astrocytoma in the majority of patients (98%). Gross total resection was obtained in 4, subtotal in 17, and 27 patients were biopsied only. Postoperative radiotherapy (RT) was used in 29 patients. Median OS for the entire group was 14.8 years with a 1-, 5-, and 10-year OS of 85%, 67% and 59%, respectively. Median PFS for the entire group was 7.3 years. Improved survival was associated with undergoing resection versus biopsy-only with 5-year OS rates of 85% and 50% (P=0.002), respectively. A high proportion of patients (42%) had diffuse tumors and 13 patients (27%) had diffuse pontine gliomas (DPGs). DPGs had an OS of 1.8 years with a worse median PFS than non-DPGs (1.8 vs. 11.1 y; P=0.009). RT was used preferentially in patients with poor prognosis such as those who had a biopsy-only procedure (19/27) and DPGs (9/13). CONCLUSIONS: OS in this single institution retrospective study in pathologically proven BS-LGG with extensive follow-up displayed favorable long-term outcomes. Improved outcomes were associated with nondiffuse classification.

Three-dimensional volumetric computed tomographic scoring as an objective outcome measure for chronic rhinosinusitis: clinical correlations and comparison to Lund-Mackay scoring.

BACKGROUND: We aimed to test the hypothesis that three-dimensional (3D) volume-based scoring of computed tomography (CT) images of the paranasal sinuses was superior to Lund-Mackay CT scoring of disease severity in chronic rhinosinusitis (CRS). We determined correlation between changes in CT scores (using each scoring system) with changes in other measures of disease severity (symptoms, endoscopic scoring, and quality of life) in patients with CRS treated with triamcinolone. METHODS: The study group comprised 48 adult subjects with CRS. Baseline symptoms and quality of life were assessed. Endoscopy and CT scans were performed. Patients received a single systemic dose of intramuscular triamcinolone and were reevaluated 1 month later. Strengths of the correlations between changes in CT scores and changes in CRS signs and symptoms and quality of life were determined. RESULTS: We observed some variability in degree of improvement for the different symptom, endoscopic, and quality-of-life parameters after treatment. Improvement of parameters was significantly correlated with improvement in CT disease score using both CT scoring methods. However, volumetric CT scoring had greater correlation with these parameters than Lund-Mackay scoring. CONCLUSION: Volumetric scoring exhibited higher degree of correlation than Lund-Mackay scoring when comparing improvement in CT score with improvement in score for symptoms, endoscopic exam, and quality of life in this group of patients who received beneficial medical treatment for CRS.

Comparison of surgical septal myectomy to medical therapy alone in patients with hypertrophic cardiomyopathy and syncope.

The presence of syncope despite medical therapy in patients with hypertrophic cardiomyopathy (HC) is considered an indication for surgical myectomy; however, no study has examined the long-term effects on recurrent syncope and survival after surgery in these patients. We examined 239 patients with HC and a history of syncope who had undergone surgical myectomy (mean age 48 ± 17 years; 56% men). The patients were age- and gender-matched to patients with HC and syncope who were treated medically without myectomy (mean age 51 ± 16 years; 59% men). The median follow-up period was 4.7 years (0.8, 11.3). The recurrence rate of syncope was 11% in the myectomy patients and 40% in the medical group (p <0.0001). Multiple episodes of syncope, left ventricular outflow tract obstruction, and recent syncope were identified as baseline predictors of recurrent syncope. Survival free of all-cause mortality was greater for patients who had undergone surgical myectomy than for the medically treated patients (10-year estimate 82 ± 4% vs 69 ± 4%; p = 0.01). In conclusion, surgical myectomy in patients with HC and a history of syncope was associated with a reduction in recurrent syncope and increased survival.

Incidental findings in imaging research: evaluating incidence, benefit, and burden.

BACKGROUND: Little information exists concerning the frequency and medical significance of incidental findings (IFs) in imaging research. METHODS: Medical records of research participants undergoing a research imaging examination interpreted by a radiologist during January through March 2004 were reviewed, with 3-year clinical follow-up. An expert panel reviewed all IFs generating clinical action to determine medical benefit/burden on the basis of predefined criteria. The frequency of IFs that generated further clinical action was estimated by modality, body part, age, and sex, along with net medical benefit or burden. RESULTS: Of 1426 research imaging examinations, 567 (39.8%) had at least 1 IF (1055 total). Risk of an IF increased significantly by age (odds ratio [OR], 1.5; 95% confidence interval, 1.4-1.7 per decade increase). Abdominopelvic computed tomography generated more IFs than other examinations (OR, 18.9 vs ultrasonography; 9.2% with subsequent clinical action), with computed tomography of the thorax and magnetic resonance imaging of the head next (OR, 11.9 and 5.9; 2.8% and 2.2% with action, respectively). Of the 567 examinations with an IF, 35 (6.2%) generated clinical action, resulting in clear medical benefit in 1.1% (6 of 567) and clear medical burden in 0.5% (3 of 567). Medical benefit/burden was usually unclear (26 of 567 [4.6%]). CONCLUSIONS: Frequency of IFs in imaging research examinations varies significantly by imaging modality, body region, and age. Research imaging studies at high risk for generating IFs can be identified. Routine evaluation of research images by radiologists may result in identification of IFs in a high number of cases and subsequent clinical action to address them in a small but significant minority. Such clinical action can result in medical benefit to a small number of patients.

Aborted myocardial infarction: is it real in the troponin era?

BACKGROUND: Cardiac troponins are the markers of choice for the diagnosis of acute myocardial infarction. The objective of this study was to compare the frequency of "aborted myocardial infarction" (no detectable myocardial injury) determined by measurement of troponin versus that determined by creatine kinase (CK) and creatine kinase-muscle brain (CK-MB) measurement criteria among patients with ST-elevation myocardial infarction (STEMI) who received reperfusion therapy. METHODS: Since 2004, the Mayo Clinic (Rochester, MN) has had a standard reperfusion protocol for the treatment of patients with STEMI. During the study period, 767 patients presented with new or presumed new ST elevation or left bundle block. RESULTS: The diagnosis of STEMI was confirmed in 765 (99.7%) patients. Using the 99th percentile cutoff value, troponin T elevations occurred in 765 (100%) of 765 patients when serial samples were available. Creatine kinase-MB levels of twice or more the upper limit of normal occurred in 681 (90.1%) of 749 patients with serial samples for CK-MB, and CK equal or greater than twice the gender-specific upper limits of normal occurred in 521 (78.8%) of 661 patients with serial samples for CK available. CONCLUSION: The frequency of aborted myocardial infarction is 0% when using troponin at the 99th percentile cutoff as recommended by contemporary guidelines from the European Society of Cardiology (Nice, France) and American College of Cardiology (Washington, DC).

Age-related changes among 25 patients with congenital cardiac left-to-right shunts and irreversible plexogenic pulmonary arteriopathy.

BACKGROUND: Some patients with congenital heart disease and irreversible plexogenic pulmonary arteriopathy survive into adulthood. The purpose of this study was to compare histopathological and antigen expression patterns in adults and children with congenital heart disease and plexogenic pulmonary arteriopathy. METHODS: Autopsy/explant lung tissues from 25 patients with congenital heart disease and plexogenic pulmonary arteriopathy were reviewed for 24 histopathological parameters associated with plexogenic pulmonary arteriopathy, including the prevalence and character of plexiform lesions. Immunohistochemistry using antibodies against CD31, C-kit, smooth muscle actin, CD68, and Fli-1 was performed to evaluate plexiform lesions. RESULTS: Group 1 consisted of 14 patients aged <20 years, and Group 2 included 11 patients aged >or=20 years (range, 20-69 years). Cellular plexiform lesions trended toward greater prevalence in Group 1 than in Group 2 (P=.081), whereas involuted plexiform lesions more frequently affected Group 2 than Group 1 (P=.0037). In addition, recent platelet-fibrin thrombi within plexiform lesions occurred more often in Group 1 than in Group 2 (P=.0419). Intimal proliferation/fibrosis of elastic arteries and pulmonary vein dilation were more common in Group 2 (P=.0172 and P=.0048, respectively). CD31 and C-kit staining in non-lumen-lining cells of plexiform lesions was more frequent in Group 2 than in Group 1 (P=.0858 and P=.0173, respectively). No statistically significant differences in expression patterns between cellular and involuted plexiform lesions existed. CONCLUSIONS: Among patients with congenital heart disease and plexogenic pulmonary arteriopathy, histopathological differences were observed between those surviving into adulthood and those dying in childhood/adolescence. Plexiform lesions in adults undergo remodeling from a cellular morphology to an involuted morphology. It is unclear whether this simply represents the natural progression of plexiform lesions or also confers a survival advantage.