Abstract Perturbations in cardiac energy metabolism are major contributors to a number of cardiovascular pathologies. In addition, comorbidities associated with cardiovascular disease (CVD) can alter ...systemic and myocardial metabolism, often contributing to the worsening of cardiac function and health outcomes. State-of-the-art metabolomic technologies give us the ability to measure thousands of metabolites in biological fluids or biopsies, providing us with a metabolic fingerprint of individual patients. These metabolic profiles may serve as diagnostic and/or prognostic tools that have the potential to significantly alter the management of CVD. Herein, the authors review how metabolomics can assist in the interpretation of perturbed metabolic processes, and how this has improved our ability to understand the pathology of ischemic heart disease, atherosclerosis, and heart failure. Taken together, the integration of metabolomics with other “omics” platforms will allow us to gain insight into pathophysiological interactions of metabolites, proteins, genes, and disease states, while advancing personalized medicine.
Abstract Transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) has emerged as a less invasive therapeutic option for high surgical risk patients with aortic ...stenosis (AS) and coronary artery disease (CAD). The aim of this study is to determine the outcomes of TAVR when performed with PCI during the same hospitalization. We identified patients using the ICD-9CM procedure codes from the Nationwide Inpatient Sample between the years 2011 and 2013. A total of 22,344 TAVRs were performed between 2011 through 2013. Of these, 21,736 (97.3%) were performed without PCI (TAVR group) while 608 (2.7%) along with PCI (TAVR + PCI group). Amongst the TAVR + PCI group, 69.7% of the patients had single vessel, 22.2% two vessels and 1.6% had three vessels PCI. Drug eluting stents were more commonly used compared to bare metal stents (72% vs 28%). TAVR + PCI group witnessed significantly higher rates of mortality (10.7% vs 4.6%) and complications: vascular injury requiring surgery (8.2% vs. 4.2), cardiac (25.4% vs. 18.6%), respiratory (24.6% vs. 16.1%) and infectious (10.7% vs. 3.3%) ,p<0.001% for all, when compared to the TAVR group. The mean length of hospital stay and cost of hospitalization was also significantly higher in the TAVR + PCI group. The propensity score matched analysis yielded similar results. In conclusion, performing PCI along with TAVR during the same hospital admission is associated with higher mortality, complications and cost when compared with TAVR alone. Patients would perhaps be better served by staged PCI before TAVR.
Abstract Background Ventricular septal defect is a lethal complication after an acute myocardial infarction which have become infrequent with the advent of reperfusion strategies however; they remain ...a major contributor to mortality. Methods We identified patients using the ICD-9CM procedure codes from the Nationwide Inpatient Sample between the years 2001 and 2013. A multivariate hierarchical logistic regression model was used to identify significant predictors of in-hospital mortality. Results We identified 3,373,206 ST-elevation myocardial infarctions, out of which 10,012 (0.3%) were complicated with ventricular septal defect s. Most of the patients (60%) were older than 65, male (55%), and white (63%). Inferior (49.7%) and anterior (41.1%) myocardial infarctions were more commonly implicated with the development of VSDs. The median (IQR) hospitalization length was 7 days (3.0-13.5). Only 7.65% of patients underwent some intervention with 7% surgical and 0.65% minimally invasive. Mechanical support devices were used in 36.5% of patients, with intra-aortic balloon pump (96%) being the most common. In-hospital mortality remained high at 30.5% (downward trending from 41.6% in 2001 to 23.3% in 2013). Age, cardiogenic shock, and in-hospital cardiac arrest were statistically significant predictors of in-hospital mortality. The utilization of corrective procedures significantly declined. The use of mechanical support devices and performing a corrective procedure were associated with higher mortality, length of stay and cost. Conclusion Ventricular septal defects after acute myocardial infarctions remain associated with significantly high mortality rates. Highly specialized regional centers with individual expertise in the management of septal ruptures are required to improve outcomes of these patients.
Background Significant cardiovascular morbidity has been associated with mitral annulus calcification (MAC), but limited data exist regarding its progression. The purpose of this study was to examine ...the natural history of and risk factors for MAC progression. Methods The MESA is a longitudinal cohort study of participants aged 45 to 84 years without clinical cardiovascular disease who underwent serial cardiac computed tomography studies with quantification of MAC. Regression models were used to identify risk factors associated with MAC incidence and progression. Results Prevalent MAC was observed in 534 (9%) of 5,895 participants. Over a median 2.3 years, 280 (5%) developed incident MAC. After adjustment, age was the strongest predictor of incident MAC (adjusted OR, 2.25 per 10 years; 95% CI, 1.97-2.58; P < .0001). Female gender, white ethnicity, body mass index, diabetes, hypertension, hyperlipidemia, serum cholesterol, smoking, and interleukin-6 were also significant predictors of incident MAC. In participants with prevalent MAC, the median rate of change was 10.1 IQR, − 6.7 to 60.7 Agatston units (AU)/year. Baseline MAC severity was the predominant predictor of rate of MAC progression (β-coefficient per 10 AU, 0.88; 95% CI, 0.85-0.91; P < .0001), although ethnicity and smoking status possessed modest influence. Conclusions Several cardiovascular risk factors predicted incident MAC, as did female gender. Severity of baseline MAC was the primary predictor of MAC progression, suggesting that, while atherosclerotic processes may initiate MAC, they are only modestly associated with its progression over these time frames.
Efficiency of coronary CT angiography (CCTA) in clinical practice depends on precise reporting and accurate result interpretation.
We sought to assess referring clinicians' understanding of patients' ...coronary artery disease (CAD) severity and to compare satisfactions of the free-form impression (FFI) with satisfactions of the structured impression (SI) section of CCTA reports.
Fifty clinical CCTA reports from May 2011 to April 2012 were retrospectively selected (25 FFI and 25 SI), to include cases with the entire spectrum of CAD (6 categories encompassing normal, minimal, mild, moderate, severe stenosis, and occlusion). A survey containing only randomized blinded impressions was distributed to 4 cardiologists and 2 cardiac imaging specialists. Clinician interpretation was examined regarding (Q1) worst stenosis severity, (Q2) number of vessels with significant stenosis, and (Q3) the presence of nonevaluable segments. Agreement proportions and Cohen's kappa were evaluated between FFI versus SI. Satisfactions were measured with respect to content, clarity, and clinical effectiveness.
Q1 agreement was excellent for both FFI and SI (by 6 categories: 80% versus 85%; P > .05; kappa: 0.87 versus 0.89; by no CAD versus nonsignificant versus significant CAD: 99% versus 97%; P > .05; kappa: 0.99 versus 0.94). Q2 agreement improved from fair to moderate (53% versus 68%; P = .04; kappa 0.31 versus 0.52). Q3 agreement was moderate (90% versus 87%; P > .05; kappa 0.57 versus 0.58). Satisfactions with impressions were high and similar for FFI and SI for clinicians.
Structured impressions were shown to improve result interpretation agreement from fair to moderate with regard to the number of vessels with significant stenosis.
Left Ventricular Remodelling in Aortic Stenosis Rassi, Andrew N., MD; Pibarot, Philippe, DVM, PhD; Elmariah, Sammy, MD, MPH
Canadian journal of cardiology,
09/2014, Letnik:
30, Številka:
9
Journal Article
Recenzirano
Abstract Aortic stenosis (AS) is a progressive condition associated with high mortality if not treated. The hemodynamic effects of AS have serious implications for the left ventricle. In this review, ...we describe the responses of the left ventricle to AS by highlighting the process of adaptive remodelling, which begins as a beneficial compensatory mechanism but ultimately transitions to a maladaptive process with potentially irreversible consequences. We discuss the impact of left ventricular (LV) remodelling on diastolic and systolic function and on the development of symptoms. In addition, we review the adverse consequences of maladaptive LV remodelling on clinical outcomes before and after aortic valve replacement. The relative irreversibility of maladaptive remodelling and the clear relationship between its progression and clinical outcomes suggest a need to incorporate measures of LV performance beyond simply systolic function when deciding on the timing of valve replacement.
Abstract Transcatheter edge-to-edge mitral valve repair (TMVr) with MitraClip has proven to be safe and effective for high-risk surgical patients with severe symptomatic degenerative mitral ...regurgitation. There is paucity of data regarding its use in functional mitral regurgitation (FMR). The objective of this study is to evaluate the use of MitraClip in patients with symptomatic moderate or severe FMR and a high surgical risk. Medical libraries were systematically searched for studies assessing the use of MitraClip for patients with symptomatic moderate or severe FMR and a high surgical risk. Studies reporting safety and efficacy outcomes at 12 months were included in the analysis. A total of 12 studies including 1695 patients (age 73 IQR 70.5-74, 69.8% men, left ventricular ejection fraction 32.5% IQR 29.5-36, NYHA II-IV) undergoing TMVr with MitraClip were included in the analysis. Acute procedural success was 89% (IQR 85.5-92). Ischemic cardiomyopathy was the most common cause of left ventricular dysfunction. Over two-thirds of patients had known coronary artery disease, 35% a previous myocardial infarction, and 38.5% had a prior cardiac surgery. Survival to hospital discharge was 98% (IQR 97-100) and 30-day survival 97% (IQR 96-98). Overall survival at 12-months was 82% (IQR 77-87). Mitral valve re-intervention at 12 months was infrequent (3%; IQR 2-6.5). In conclusion, our pooled analysis suggests that TMVr with MitraClip is feasible, safe, and carries a low rate of mitral valve re-intervention at 12 months in patients with symptomatic moderate or severe FMR and a high surgical risk.
Objectives Patients with congenital bicuspid aortic valves have aortic valve stenosis at a relatively young age compared with patients with tricuspid aortic valves. We hypothesize that aortic valve ...stenosis evolves from a more aggressive inflammatory process, with increased macrophage/T-cell and neovessel content in congenital bicuspid aortic valveswhen compared with that seen in tricuspid valves. Methods Fifty-one severely stenotic aortic valves were obtained at the time of aortic valve replacement. A total of 17 bicuspid and 34 tricuspid aortic valves were evaluated. Macrophage/T-cell infiltration (CD68 plus CD3) and neovessel density (CD34) were evaluated with immunohistochemical staining. Leaflet calcification and ossification were also quantified. Real-time polymerase chain reaction was used to assess expression of chondromodulin 1 and vascular endothelial growth factor. Results The density of macrophages/T cells was greater in congenital bicuspid aortic valves than in tricuspid valves (51 ± 31 vs 23 ± 13 cells/mm2 , P = .002). Neovascularization was more frequently noted in congenital bicuspid aortic valves when compared with tricuspid valves (31 ± 10 vs 21 ± 9 vessels/mm2 , P = .0005), and calcification was more severe ( P = .03). Expression of chondromodulin 1 demonstrated a 6-fold downregulation ( P = .0003) and expression of vascular endothelial growth factor demonstrated a 2-fold increase ( P = .02) in congenital bicuspid aortic valves compared with that seen in tricuspid valves. Multivariable analyses demonstrated significant associations between bicuspid aortic valve anatomy and increased inflammatory cell infiltration (β = 25.8, P = .0007) and neovascularization (β = 9.4, P = .001), despite adjusting for measured covariates. Conclusions The pathogenesis of aortic valve stenosis in bicuspid aortic valves is associated with a more aggressive inflammatory process with increased macrophage infiltration and neovascularization when compared with that seen in tricuspid valves.
Abstract Objectives This study sought to identify predictors of recurrent ischemic neurologic events within the CLOSURE I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke ...and/or Transient Ischemic Attack Due to Presumed Paradoxical Embolism Through a Patent Foramen Ovale) trial. Background The CLOSURE I trial found that transcatheter patent foramen ovale (PFO) closure using the STARFlex device was not superior to medical therapy in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO. Methods The CLOSURE I trial is a multicenter, randomized trial of transcatheter PFO closure compared with medical therapy in patients who presented with cryptogenic stroke or TIA and had a PFO. We identified clinical predictors of recurrent ischemic stroke or TIA during 2 years of follow-up using Cox proportional hazards regression within the pooled intention-to-treat cohort. Results In 909 patients, the incidence of recurrent events was 5.7% with 25 patients suffering a recurrent stroke and 30 a TIA. Patients who had a recurrent event had higher body mass index (30.2 ± 6.2 vs. 28.3 ± 5.8%; p = 0.03) and more frequently had diabetes (19.2% vs. 7.1%; p = 0.0016), hypertension (46.2% vs. 30.1%; p = 0.015), and ischemic heart disease (3.8% vs. 0.9%; p = 0.05). Diabetes (hazard ratio HR: 3.39; 95% confidence interval CI: 1.69 to 6.84; p = 0.0007), index TIA (HR vs. stroke: 2.13; 95% CI: 1.20 to 3.80; p = 0.01), and the detection of atrial fibrillation after study enrollment (HR: 4.85; 95% CI: 2.05 to 11.47; p = 0.0003) independently predicted recurrent ischemic neurologic events. Recurrent neurologic events were more frequent in subjects with RoPE (Risk of Paradoxical Embolism) score ≤5 than those with >5 (14.5% vs. 4.2%; p < 0.0001). Conclusions These findings suggest an alternative etiology to paradoxical embolism was frequently responsible for recurrent events within the CLOSURE I trial. (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke or TIA Due to the Possible Passage of a Clot of Unknown Origin Through a Patent Foramen Ovale (PFO) CLOSURE I; NCT00201461 )
Objectives This study sought to examine the frequency of indications for and the immediate and long-term clinical outcomes of transcatheter closure of patent foramen ovale (PFO). Background ...Transcatheter PFO closure is commonly performed for several indications, including cryptogenic stroke, despite conflicting data regarding the efficacy of this intervention. Methods We report the outcomes of 800 consecutive patients (52% male, 50 ± 14 years of age) who underwent PFO closure at our institution after multidisciplinary evaluation over a 16-year period. Results Indications for closure included cryptogenic cerebrovascular event (94%), hypoxemia (2%), peripheral embolism (3%), and migraine headaches (2%). Procedural success was 99% with effective closure obtained in 93% of patients. At a mean follow-up of 42.7 ± 33.4 months, 21 patients suffered a recurrent ischemic neurologic event (12 strokes, and 9 transient ischemic attacks) for an incidence rate of 0.79 events per 100 person-years and freedom from recurrent events of 91.6% at 10 years. There was no device-based difference in the rate of recurrent ischemic neurologic events (p = 0.82). Only Eustachian valve prominence (hazard ratio: 9.04; 95% confidence interval: 2.07 to 39.44; p = 0.0034) was associated with recurrent neurologic events. Conclusions Transcatheter PFO closure is safe and feasible in patients with several clinical indications. The long-term efficacy of this intervention in patients with paradoxical embolism appears superb in this observational study. Carefully selected patients with features suggestive of paradoxical embolism are the most likely to benefit from PFO closure and should be the focus of future investigation.
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