Direct acting oral anticoagulants (DOACs) are increasingly used as off-label alternatives to vitamin K antagonists for the treatment of left ventricular (LV) thrombus. However, efficacy data is ...limited to small case series and one meta-analysis of case reports. We aimed to determine the efficacy and safety of DOACs in treatment of LV thrombus utilizing transthoracic echocardiography (TTE) and clinical outcomes. We identified 52 patients (mean age = 64 years, 71% men) treated with a DOAC for LV thrombus (n = 26 apixaban, n = 24 rivaroxaban, and n = 2 dabigatran). Thirty-five of the 52 patients had a follow-up TTE after DOAC initiation. The primary end point was defined as resolution of LV thrombus (in patients with a subsequent TTE), or death, major bleeding requiring transfusion, intracranial hemorrhage, ischemic stroke, or peripheral embolization. An experienced echocardiographer (M.L.M.) reviewed all TTEs for presence or absence of LV thrombus without knowledge of time point or clinical data. Twenty-nine of the 35 (83%) patients who underwent follow-up TTE had resolution of LV thrombus, with a mean duration of 264 days. Of the total study population, there was 1 cardioembolic event (transient ischemic attack) 52 days after initiating DOAC, 3 gastrointestinal bleeds requiring transfusion, and 1 patient with epistaxis requiring transfusion. All patients with a hemorrhagic complication were receiving concomitant antiplatelet therapy. DOAC therapy appears promising for the treatment of LV thrombus. A larger, prospective study is warranted to confirm these results.
Abstract A routine of regular exercise is highly effective for prevention and treatment of many common chronic diseases and improves cardiovascular (CV) health and longevity. However, long-term ...excessive endurance exercise may induce pathologic structural remodeling of the heart and large arteries. Emerging data suggest that chronic training for and competing in extreme endurance events such as marathons, ultramarathons, ironman distance triathlons, and very long distance bicycle races, can cause transient acute volume overload of the atria and right ventricle, with transient reductions in right ventricular ejection fraction and elevations of cardiac biomarkers, all of which return to normal within 1 week. Over months to years of repetitive injury, this process, in some individuals, may lead to patchy myocardial fibrosis, particularly in the atria, interventricular septum, and right ventricle, creating a substrate for atrial and ventricular arrhythmias. Additionally, long-term excessive sustained exercise may be associated with coronary artery calcification, diastolic dysfunction, and large-artery wall stiffening. However, this concept is still hypothetical and there is some inconsistency in the reported findings. Furthermore, lifelong vigorous exercisers generally have low mortality rates and excellent functional capacity. Notwithstanding, the hypothesis that long-term excessive endurance exercise may induce adverse CV remodeling warrants further investigation to identify at-risk individuals and formulate physical fitness regimens for conferring optimal CV health and longevity.
Abstract Background Current guidelines for preparticipation screening of competitive athletes in the US include a comprehensive history and physical examination. The objective of this study was to ...determine the incremental value of electrocardiography and echocardiography added to a screening program consisting of history and physical examination in college athletes. Methods Competitive collegiate athletes at a single university underwent prospective collection of medical history, physical examination, 12-lead electrocardiography, and 2-dimensional echocardiography. Electrocardiograms (ECGs) were classified as normal, mildly abnormal, or distinctly abnormal according to previously published criteria. Eligibility for competition was determined using criteria from the 36th Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities. Results In 964 consecutive athletes, ECGs were classified as abnormal in 334 (35%), of which 95 (10%) were distinctly abnormal. Distinct ECG abnormalities were more common in men than women (15% vs 6%, P < .001) as well as black compared with white athletes (18% vs 8%, P < .001). Echocardiographic and electrocardiographic findings initially resulted in exclusion of 9 athletes from competition, including 1 for long QT syndrome and 1 for aortic root dilatation; 7 athletes with Wolff-Parkinson-White patterns were ultimately cleared for participation. (Four received further evaluation and treatment, and 3 were determined to not need treatment.) After multivariable adjustment, black race was a statistically significant predictor of distinctly abnormal ECGs (relative risk 1.82, 95% confidence interval, 1.22-2.73; P = .01). Conclusions Distinctly abnormal ECGs were found in 10% of athletes and were most common in black men. Noninvasive screening using both electrocardiography and echocardiography resulted in identification of 9 athletes with important cardiovascular conditions, 2 of whom were excluded from competition. These findings offer a framework for performing preparticipation screening for competitive collegiate athletes.
Heart disease is the leading cause of pregnancy-related mortality in the United States and has led to the development of combined cardio-obstetrics (COB) clinics as a model for prenatal care. In ...other areas of medicine, these types of collaborative care models have shown improvement in morbidity, mortality, and patient satisfaction. There is some data to suggest that a combined COB clinic improves maternal outcomes but there is no data to suggest patients prefer this type of care model. This study aims to evaluate patient satisfaction in a combined COB clinic and whether this type of model enhances perceived communication and knowledge uptake. A quality questionnaire was developed to assess patient perceptions regarding communication, satisfaction, and perceived knowledge. Patients who attended the clinic (
= 960) from 2014-2020 were contacted by email, with a response received from 119 (12.5%). Participants completed a questionnaire assessing satisfaction and perceived knowledge uptake with answers based on a Likert scale (7 representing very satisfied and 1 representing very unsatisfied). Safe and effective contraceptive use was evaluated by multiple choice options. Knowledge was also assessed by comparing contraceptive use before and after the clinic. Participants reported high levels of satisfaction with the clinic (6.2 ± 1.5), provider-to-patient communication (6.1 ± 1.6), and with the multidisciplinary appointment approach (6.3 ± 1.5). As well, participants reported an increase in knowledge about heart disease a result of collaborative counseling. In summary, a multidisciplinary approach to cardio-obstetrics not only improves outcomes but is a patient satisfier.
Transesophageal echocardiography (TEE) is frequently performed in patients with acute ischemic cerebrovascular events to exclude a cardioembolic source. We aimed to determine the clinical impact of ...TEE on management. This is a retrospective single-center study of 1,458 consecutive patients hospitalized with acute ischemic stroke or transient ischemic attack who underwent TEE for evaluation of a suspected cardioembolic cause. Significant TEE findings were determined for each patient as recorded on the TEE report. The medical record was reviewed for baseline, clinical, and demographic variables and to determine whether significant management changes occurred as a result of the TEE findings. Potential significant changes in management included initiation of anticoagulation, placement of a patent foramen ovale (PFO) closure device, initiation of antibiotic therapy for endocarditis, surgical PFO closure, other cardiac surgery, and coil embolization of a pulmonary arteriovenous malformation. A significant change in management occurred in 243 patients (16.7%); 173 (71%) underwent treatment for PFO with a percutaneous PFO closure device (n = 100), initiation of chronic systemic anticoagulation (n = 68), or surgical PFO closure (n = 5). Additional findings leading to a change in management included endocarditis (n = 20), aortic arch atheroma (n = 14), intracardiac thrombus (n = 13), pulmonary arteriovenous malformation (n = 2), aortic valve fibroelastoma (n = 2), other valve masses (n = 4), and miscellaneous causes (n = 15). In conclusion, in patients with suspected cardioembolic stroke, TEE findings led to a change in management in 16.7% of patients. Of these, most (71%) were directed at prevention of subsequent paradoxical emboli in patients with PFO.
Left atrial appendage closure with the WATCHMAN device is an alternative to chronic oral anticoagulation for thromboembolic prophylaxis in atrial fibrillation patients. Left atrial device‐related ...thrombus (DRT) has been described in the first year after implant with an incidence of ~6%. A 79‐year‐old man underwent WATCHMAN device placement in 2006. Routine protocol specified follow‐up transesophageal echocardiograms (TEE) at 6 weeks, 6 months, and 1 year following implant showed no evidence for DRT or peri‐device flow. A decade after device implant, the patient presented with severe symptomatic aortic stenosis and underwent repeat TEE, which revealed a 21 mm × 18 mm DRT on the LA aspect of the WATCHMAN device. He was prescribed apixaban 5 mg po BID. A TEE performed 111 days later demonstrated marked diminution in the DRT (9 mm in diameter). This case demonstrates that WATCHMAN DRT may occur late following implantation.
A 48-year-old woman presented with heart failure and bioprosthetic pulmonary valve regurgitation 2 years after pulmonary valve replacement. Intracardiac echocardiography demonstrated uniform ...thickening of a single prosthetic valve leaflet suggesting leaflet thrombosis rather than bioprosthetic valve degeneration. After 3 months of anticoagulation, valve regurgitation and symptoms improved. (Level of Difficulty: Intermediate.)
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Apical hypertrophic cardiomyopathy (ApHCM) is a rare variant of HCM which predominantly involves the left ventricular apex, and therefore does not typically result in obstructive physiology. It has ...been infrequently reported in general, with a rarity in heart transplant patients, mostly due to a modest or delayed presentation with symptoms. We present a case of a heart transplant patient with a stable postoperative course who was incidentally found to have ApHCM during follow up non-invasive testing.
Patient is a 45-year-old gentleman with a history of cardiac transplantation in March 2013 for heart failure in the setting of arrhythmogenic right ventricular cardiomyopathy, on chronic dual immunosuppression therapy. He has maintained preserved allograft function with no treatable rejection. Mild donor-derived atherosclerotic disease was found on the first surveillance coronary angiogram with no progression over subsequent years. He has remained asymptomatic and extremely active. In September 2020, he underwent surveillance myocardial perfusion imaging, which showed a large area of moderately severe ischemia laterally extending from the mid ventricle to the apex, prompting coronary angiography which did not show significant epicardial coronary disease. A subsequent echocardiogram with contrast demonstrated normal biventricular function, with evidence of hypertrophy with classic spading of the apical myocardium, along with a corresponding reduction in longitudinal straining, consistent with ApHCM. Upon retrospective evaluation of prior echocardiograms, the finding was likely also present though less evident. Holter monitor detected no arrhythmia and treadmill exercise testing confirmed normal functional capacity, normal blood pressure response to exercise, and no arrhythmias.. Review of the details of the donor's death did not suggest cardiac etiology or arrhythmia.
In our literature search, we found only one similar presentation in a cardiac transplant patient with apical HCM. In general, familial ApHCM is known to follow an autosomal dominant inheritance, whereas sporadic forms are caused by acquired mutations of various sarcomeric and nonsarcomeric protein genes. Other associated factors include long-standing high-pressure states, as well as medications, with one case report suggesting a possible relation with tacrolimus. One literature review suggested a possible increase in mortality in ApHCM patients. Therefore, although it is usually a rare condition, pre and post transplant monitoring must take into account that this condition may clinically manifest post transplantation.
Abstract Background We evaluated the prevalence of isolated T-wave inversions (TWI) in American athletes using contemporary ECG criteria. Ethnic and gender disparities including the association of ...isolated TWI with underlying abnormal cardiac structure are evaluated. Methods From 2004 to 2014, 1755 collegiate athletes at a single American university underwent prospective collection of medical history, physical examination, 12-lead ECG, and 2-dimensional echocardiography. ECG analysis was performed to evaluate for isolated TWI as per contemporary ECG criteria. Results The overall prevalence of isolated TWI is 1.3%. Ethnic and gender disparities are not observed in American athletes (black vs. white: 1.7% vs. 1.1%; p=0.41) (women vs. men: 1.5% vs. 1.1; p=0.52). No association was found with underlying cardiomyopathy. Conclusion A lower prevalence of isolated TWI in American athletes than previously reported. Isolated TWI was not associated with an abnormal echocardiogram. No ethnic or gender disparity is seen in American college athletes.
We sought to determine the relationship between clinical risk factors for systemic thromboembolism in patients with atrial fibrillation and the prevalence of left atrial (LA) spontaneous echocontrast ...(SEC) and LA thrombus (LAT).
Atrial fibrillation is associated with an increased risk of systemic thromboembolism. LA SEC and LAT also predict thromboembolic events. The relationship between clinical risk factors for systemic thromboembolism and prevalence of LA SEC and LAT is unknown.
In all, 524 patients with atrial fibrillation underwent transesophageal echocardiography between August 2000 and March 2005. Clinical risk factors for systemic thromboembolism were determined for each patient. A CHADS(2) score ranging from 0 to 6 was calculated for each patient as: congestive heart failure = 1 point; hypertension = 1 point; age 75 years or older = 1 point; diabetes mellitus = 1 point; and history of stroke including transient ischemic attack or systemic embolism = 2 points. Transesophageal echocardiography reports were reviewed for the presence of LA SEC and LAT. Univariate and multivariable models were structured to assess which clinical risk factors predicted the presence of LA SEC or LAT.
In a multivariable model, age 75 years or older, previous thromboembolic event, and left ventricular ejection fraction (LVEF) less than 40% predicted LA SEC, whereas LVEF less than 40% was the only predictor of LAT. LA SEC was present in 24% of patients with a CHADS(2) score of 0, but was present in 58% with a CHADS(2) score of 5 or 6 (P < .0001). LAT was present in 3% percent of patients with a CHADS(2) score of 0, but in 17% of patients with a CHADS(2) score of 5 or 6 (P = .0026).
Age 75 years or older, previous thromboembolic event, and LVEF less than 40% predict presence of LA SEC. LVEF less than 40% is the only multivariate predictor of LAT. The prevalence of LA SEC and LAT increases with increasing CHADS(2) score.
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