A previously under-recognized subset of hypertrophic cardiomyopathy (HCM) patients with left ventricular (LV) apical aneurysms is being identified with increasing frequency. However, risks associated ...with this subgroup are unknown.
The authors aimed to clarify clinical course and prognosis of a large cohort of HCM patients with LV apical aneurysms over long-term follow-up.
The authors retrospectively analyzed 1,940 consecutive HCM patients at 2 centers, 93 of which (4.8%) were identified with LV apical aneurysms; mean age was 56 ± 13 years, and 69% were male.
Over 4.4 ± 3.2 years, 3 of the 93 patients with LV apical aneurysms (3%) died suddenly or of heart failure, but 22 (24%) survived with contemporary treatment interventions: 18 experienced appropriate implantable cardioverter-defibrillator discharges, 2 underwent heart transplants, and 2 were resuscitated after cardiac arrest. The sudden death event rate was 4.7%/year. Notably, recurrent monomorphic ventricular tachycardia requiring ≥2 implantable cardioverter-defibrillator shocks occurred in 13 patients, including 6 who underwent successful radiofrequency ablation of the arrhythmic focus without ventricular tachycardia recurrence. Five non-anticoagulated patients experienced nonfatal thromboembolic events (1.1%/year), whereas 13 with apical clots and anticoagulation did not incur embolic events. There was no consistent relationship between aneurysm size and adverse HCM-related events. Rate of HCM-related deaths combined with life-saving aborted disease-related events was 6.4%/year, 3-fold greater than the 2.0%/year event rate in 1,847 HCM patients without aneurysms (p < 0.001).
HCM patients with LV apical aneurysms are at high risk for arrhythmic sudden death and thromboembolic events. Identification of this phenotype expands risk stratification and can lead to effective treatment interventions for potentially life-threatening complications.
In patients with patent foramen ovale (PFO)–associated stroke, the presence of large shunt or atrial septal aneurysm (ASA) has been suggested to convey a high risk of stroke recurrence.
The purpose ...of this study was to assess the respective influence of PFO size and ASA status on stroke recurrence under medical therapy in patients with recent PFO-associated stroke without alternative cause.
The authors pooled individual patient data from 2 prospective observational studies and the medical arms of 2 randomized trials, in which shunt size and ASA status was assessed by independent reading of echocardiographic images. Associations between PFO anatomical features and recurrent ischemic stroke were assessed by mixed effects Cox models.
Of 898 patients (mean age 45.3 years), 178 (19.8%) had ASA with large PFO, 71 (7.9%) ASA with nonlarge PFO, 397 (44.2%) large PFO without ASA, and 252 (28.1%) nonlarge PFO without ASA. Over a median follow-up of 3.8 years (interquartile range: 2.6 to 5.5 years), 47 (5.2%) patients experienced a recurrent stroke. There was a heterogeneity across studies for the association between PFO size and stroke recurrence (pinteraction = 0.01). In a model accounting for age, hypertension, antithrombotic therapy, and PFO anatomy, ASA was independently associated with recurrent stroke (adjusted hazard ratio: 3.27; 95% confidence interval: 1.82 to 5.86; p < 0.0001), whereas large PFO was not (average adjusted hazard ratio across studies: 1.43; 95% confidence interval: 0.50 to 4.03; p = 0.50).
In patients with PFO-associated stroke, ASA is a more important predictor of recurrent stroke than shunt size. These results can help to better identify those patients with a high risk of stroke recurrence under medical therapy who may derive the most benefit from PFO closure. (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence CLOSE; NCT00562289) (Device Closure versus Medical Therapy in Patients with Cryptogenic Stroke and High-Risk Patent Foramen Ovale DEFENSE-PFO; NCT01550588)
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Abstract Background Congenital left ventricular aneurysm (LVA) or diverticulum (LVD) is rare cardiac anomalies. We aimed to analyse the clinical characteristics and outcome in all ever published ...patients. Methods MEDLINE, Web of science, Google and EMBASE, and reference lists of relevant articles were searched for publications reporting on LVA or LVD patients. Results We identified 809 patients published since 1816 354 (49.1%) LVA, 453 (50.6%) LVD, 2 (0.3%) both. Mean age at diagnosis was 34.1 ± 27 (LVA) and 29.7 ± 27.6 years (LVD; p = 0.05). 48.9% were male. LVA was larger (38.7 ± 22.5 mm versus 31.4 ± 21.2 mm; p = 0.002) and frequently found in submitral location (33% versus 4.9%; p < 0.001), LVD was frequently located at the LV-apex (61.2% versus 28.7%; p < 0.001). LVD was often associated with cardiac (34.2% versus 11%; p < 0.001) or extracardiac anomalies (32.7% versus 3%; p < 0.001). LVA patients presented more frequently with ventricular tachycardia/fibrillation (18.1% versus 13.1%; p = 0.01), the incidences of rupture (4% versus 4.5%; p = 0.9), syncope (8.3% versus 5.1%; p = 0.1), and embolic events (4.9% versus 3.6%; p = 0.4) at presentation were not different between LVA and LVD. Mean follow-up was 56.3 ± 43 months. Cardiac death occurred more frequently in the LVA group (11.5% versus 5.0%; p = 0.05) at a median age of 0.8 LVA and 2.5 LVD years. The leading cause of cardiac death was congestive heart failure in the LVA-group (50.0% versus 0.0%; p = 0.01), and rupture in the LVD-group (75.0% versus 27.3%; p = 0.04). Conclusions LVA and LVD are distinct congenital anomalies with different clinical and morphological characteristics. The prognosis of LVA is significantly worse during long-term follow-up.
Left atrial appendage aneurysms (LAAA) are rare. Patients with LAAA are often diagnosed incidentally or after cardiac tachyarrhythmia or systemic thromboembolism happen. Early diagnosis and surgical ...resection is of utmost importance to prevent hazardous adverse events.
We present a case of 46-year-old man with congenital LAAA. The individual in this manuscript has given written informed consent to publish these case details.
Imaging studies, such as echocardiography, cardiovascular computed tomography (CT) and magnetic resonance imaging (MRI), demonstrated the large cavity arising from the left atrial appendage. The diagnosis of LAAA was confirmed.
The patient underwent an aneurysmectomy without any complications.
TTE confirmed the disappearance of the LAAA from the left parasternal short-axis view of the aortic root postoperatively. The patient remained asymptomatic without any adverse events at his 3-month follow-up visits.
The associated high risk of life-threatening complications and the relative ease of surgical removal suggest that prompt evaluation should be considered in patients with lesions adjacent to the left heart border.
Left ventricular aneurysms may be repaired by the linear technique or endoventricular circular patch plasty technique. Choice of technique should be based on the individual patient, including cavity ...and aneurysm geometry. In this article, we describe the principles underlying decision making with 2 illustrative cases.
We present the exceedingly rare case of an 18-year-old boy with recurrent syncope attacks and dyspnea at rest for 3 weeks. Transthoracic echocardiography showed a giant aneurysm dilatation occupying ...the left ventricular outflow tract. The intraoperative finding was a giant thick-walled unruptured aneurysm of the sinus of Valsalva from the right coronary cusp. The roof of the aneurysm was excised and the defect was repaired, sparing the aortic valve. Histopathology analysis from the roof of the wall of the aneurysm revealed features of endarteritis obliterans of the vasa vasora in keeping with syphilitic infection with aneurysmal dilation. A rapid plasma reagin test was reactive.
The most common mechanical complications of acute myocardial infarction include free-wall rupture, ventricular septal rupture (VSR), papillary muscle rupture and pseudoaneurysm. It is rare for a ...patient to experience more than one mechanical complication simultaneously. Here, we present a case of ST-segment elevation myocardial infarction (STEMI) complicated with three mechanical complications, including ventricular apical wall rupture, ventricular aneurysm formation and ventricular septal dissection (VSD) with VSR. Cardiac auscultation revealed rhythmic S1 and S2 with a grade 3 holosystolic murmur at the left sternal border. Electrocardiogram indicated anterior ventricular STEMI. Serological tests showed a significant elevated troponin I. Bedside echocardiography revealed ventricular apical wall rupture, apical left ventricle aneurysm and VSD with VSR near the apex. This case demonstrates that several rare mechanical complications can occur simultaneously secondary to STEMI and highlights the importance of bedside echocardiography in the early diagnosis of mechanical complications.
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