Abstract The potential for cardiac implantable electronic device leads to interfere with tricuspid valve (TV) function has gained increasing recognition as having hemodynamic and clinical ...consequences associated with incremental morbidity and death. The diagnosis and treatment of lead-related (as distinct from functional) tricuspid regurgitation pose unique challenges. Because of pitfalls in routine diagnostic imaging, a high level of clinical suspicion must be maintained to avoid overlooking the possibility that worsening heart failure is a consequence of mechanical interference with TV leaflet mobility or coaptation and is amenable to lead extraction or valve repair or replacement. The future of cardiac implantable electronic devices includes pacing and perhaps defibrillation without a lead traversing the TV.
Estimates of the prevalence and importance of significant tricuspid regurgitation (STR) related to implantable device leads are based mainly on case reports, small observational studies, or mixed ...samples that include defibrillators. We sought to assess whether patients with permanent pacemaker (PPM) leads have an increased risk of STR and to determine mortality associated with PPM-related TR in a large longitudinal single-center cohort. We examined the prevalence of STR (defined as moderate-severe or ≥3+) among all echocardiograms performed from 2005 to 2011 excluding those with defibrillators. We then examined mortality risk according to the prevalence of PPM and STR after adjusting for cardiac co-morbidities, left ventricular systolic/diastolic function, and pulmonary artery hypertension. We screened 93,592 echocardiograms (1,245 with PPM) in 58,556 individual patients (634 with PPM). The prevalence of STR was higher in patients after PPM placement (mean age 79 ± 3 years; 54% men) compared with those without a PPM (adjusted odds ratio 2.32; 95% confidence interval CI 1.54 to 3.49; p <0.0001). Among patients with a PPM lead, the presence of STR was associated with increased mortality (adjusted hazard ratio 1.40; 95% CI 1.04 to 2.11, p = 0.027, vs no STR). Compared with having neither a PPM lead nor STR, adjusted hazard ratios for death were 2.13 (95% CI 1.93 to 2.34) for STR but no PPM, 1.04 (0.89 to 1.22) for PPM without STR, and 1.55 (1.13 to 2.14) for PPM with STR. In conclusion, in a sample comprising >58,000 individual patients, PPM leads are associated with higher risk of STR after adjustment for left ventricular systolic/diastolic function and pulmonary artery hypertension; similarly to STR from other cardiac pathologies, PPM-related STR is associated with increased mortality.
Transesophageal echocardiography (TEE) is the standard for diagnosis of atrial thrombi and is performed before ablation of atrial arrhythmias. Intracardiac echocardiography (ICE) is routinely used ...during these procedures and may provide an alternative imaging modality.
The purpose of this study was to compare TEE and ICE for right atrial appendage (RAA) and left atrial appendage (LAA) anatomy and thrombus.
This prospective blinded study enrolled 71 patients with atrial arrhythmias who presented for ablation. TEE and ICE were performed simultaneously to assess the RAA and LAA for thrombi, spontaneous echo contrast, and dimensions. ICE images were acquired sequentially from the right atrium, right ventricular outflow tract, and the pulmonary artery.
Imaging of the RAA and LAA was achieved in all 71 patients using ICE but in only in 69 patients using TEE because of inability to intubate the esophagus. A total of 4 thrombi were diagnosed (3 LAA, 1 RAA). All were detected by ICE but only 1 by TEE. Diagnostic imaging of the LAA was achieved in 71 patients (100%) with ICE and in 62 patients (87.3%) with TEE (P < .002). Spontaneous echo contrast was more commonly diagnosed with ICE (P < .01). There was strong correlation between TEE and ICE for length (r = 0.71), width (r = 0.94), and area (r = 0.88) of the LAA. Image quality with ICE was highest from the pulmonary artery and lowest from the right atrium.
ICE imaging is a viable alternative to TEE for visualization of the LAA and RAA during catheter ablation procedures.
Summary Survival in congenital heart disease has steadily improved since 1938, when Dr. Robert Gross successfully ligated for the first time a patent ductus arteriosus in a 7-year-old child. To ...continue the gains made over the past 80 years, transformative changes with broad impact are needed in management of congenital heart disease. Three-dimensional printing is an emerging technology that is fundamentally affecting patient care, research, trainee education, and interactions among medical teams, patients, and caregivers. This paper first reviews key clinical cases where the technology has affected patient care. It then discusses 3-dimensional printing in trainee education. Thereafter, the role of this technology in communication with multidisciplinary teams, patients, and caregivers is described. Finally, the paper reviews translational technologies on the horizon that promise to take this nascent field even further.
Cardiovascular Magnetic Resonance Characterization of Mitral Valve Prolapse Yuchi Han, Dana C. Peters, Carol J. Salton, Dorota Bzymek, Reza Nezafat, Beth Goddu, Kraig V. Kissinger, Peter J. ...Zimetbaum, Warren J. Manning, Susan B. Yeon Cardiovascular magnetic resonance (CMR) has not been previously used to characterize mitral valve prolapse (MVP). Cardiovascular magnetic resonance was compared to transthoracic echocardiography in 25 MVP patients and 25 controls. A 2-mm leaflet excursion into the left atrium on the left ventricular outflow view was 100% sensitive and specific for MVP. Leaflet thickness, length, and mitral annular diameters correlated well between CMR and transthoracic echocardiography. Of 16 MVP patients, 10 (63%) demonstrated late gadolinium enhancement of the papillary muscles consistent with fibrosis whereas no controls did. This is the first study to demonstrate fibrosis in vivo in the subvalvular apparatus in MVP patients.
Current guidelines recommend an implantable cardioverter-defibrillator (ICD) according to the left ventricular ejection fraction (LVEF). However, they do not mandate volumetric LVEF assessment. We ...sought to determine whether volumetric LVEF measurement using cardiovascular magnetic resonance imaging (CMR-LVEF) is superior to conventional LVEF measurement using 2-dimensional transthoracic echocardiography (Echo-LVEF) for risk stratifying patients referred for primary prevention ICD. Patients who underwent primary prevention ICD implantation at our institution and had undergone preimplantation CMR-LVEF from November 2001 to February 2011 were identified. Volumetric CMR-LVEF was determined from cine short-axis data sets. CMR-LVEF and Echo-LVEF were extracted from the clinical reports. The end point was appropriate ICD discharge (shock and/or antitachycardia pacing). Of 48 patients, appropriate ICD discharge occurred in 9 (19%) within 29 ± 25 months (range 1 to 99, median 20). All patients met the Echo-LVEF criteria for ICD implantation; however 25% (95% confidence interval 13% to 37%) did not meet the CMR-LVEF criteria. None (0%) of these latter patients had received an appropriate ICD discharge. Using CMR-LVEF ≤30% as a threshold for ICD eligibility, 19 patients (40%) with a qualifying Echo-LVEF would not have been referred for ICD, and none (0%) received an ICD discharge.For primary prevention ICD implantation, volumetric CMR-LVEF might be superior to clinical Echo-LVEF for risk stratification and can identify a large minority of subjects in whom ICD implantation can be safely avoided. In conclusion, if confirmed by larger prospective series, volumetric methods such as CMR should be considered a superior “gatekeeper” for the identification of patients likely to benefit from primary prevention ICD implantation.
Objectives This study describes results of tracheal reconstruction in children with slide tracheoplasty with cardiopulmonary bypass and identifies predictors for adverse outcomes. Methods ...Preoperative characteristics, operative variables, and outcome measures were collected for children undergoing slide tracheoplasty with cardiopulmonary bypass between April 2001 and October 2009. Predictors of worse outcomes were identified by bivariate analysis. Multiple regression analysis was performed for predictors of prolonged hospital stay. Results Cohort included 80 patients (median age, 8.7 months; 7 days–21 years). Forty-eight patients had associated cardiac or great vessel anomalies; 24 had simultaneous repair of cardiovascular anomaly at tracheal reconstruction. Fifty (63%) were extubated within 48 hours after operation. Median stay was 18.5 days (range, 7–119 days). Twenty-three patients (29%) required significant airway reintervention during median follow-up of 12 months (range, 4 months–7.8 years). There were 4 deaths, 2 early and 2 late. In bivariate analysis, age ( P = .017), cardiopulmonary bypass duration ( P = .025), and duration of mechanical ventilation ( P < .05) were associated with mortality; duration of postoperative mechanical ventilation was associated with need for significant airway reintervention ( P = .009). Multiple regression analysis indicated preoperative ventilatory support ( P < .001), longer cardiopulmonary bypass ( P = .002), previous airway operation ( P = .01), and need for significant airway reintervention ( P < .001) as predictors of longer hospital stay. Conclusions Slide tracheoplasty with cardiopulmonary bypass can be performed with low mortality in a diverse pediatric population. This technique minimizes need for early significant airway reintervention in most cases.
PDF
