Faculty Bibliography

Background: Patients with severe aortic stenosis in the setting of low gradient and preserved left ventricular ejection fraction (LVEF) remain an area of clinical uncertainty. Methods: Retrospective chart review identified 209 patients who underwent transcatheter aortic valve replacement (TAVR) between September 2014 and September 2015. Of these patients, 3 (1.4%) were excluded due to procedural indication other than severe aortic stenosis and 41 (20%) were excluded due to reduced LVEF (<50%). Of the remaining 165 patients with aortic valve area <1 cm2, 77 (47%) had either a peak velocity <4.0 m2 or mean gradient <40 mmHg (LG group) and 88 (53%) had both peak velocity >4.0 m2 and mean gradient >40 mmHg (HG group) across the AV. Outcomes were defined by the valve academic research consortium 2 criteria when applicable and compared between the LG and HG groups via Fisher's exact test. Median follow-up was 367 days. Continuous data are shown as median [interquartile range] and categorical data are shown as proportions. Results: The 30-day mortality risk as assessed by Society of Thoracic Surgery score was not significantly different between the LG and HG groups (5.9% [3.5-8.1] vs 6.2% [4.4-7.6], p=0.45). There were no significant differences in outcomes (Table). Conclusion: In a high-volume center, patients undergoing TAVR for severe AS with LG preserved LVEF have no significant difference in adverse outcomes, both in-hospital and on 1-year follow-up, when compared to patients with HG preserved LVEF. (Figure Presented)

Pectus excavatum is one of the most common congenital chest wall deformities. The degree of sternal depression, which may result in compression of the right heart by the chest wall, is variable. While typically asymptomatic, there are various symptoms that can result from severe pectus excavatum. We report on a patient with severe pectus excavatum leading to dynamic obstruction of the right ventricular outflow tract in the seated position.

Aortic root thrombus is an uncommon complication of continuous-flow left ventricular assist devices (LVAD). We present the case of a 71-year-old man with ischemic cardiomyopathy who underwent destination therapy HeartMate II LVAD placement. Eighteen months later, he presented with a cerebrovascular accident followed by myocardial infarction. Transesophageal echocardiography revealed an aortic root thrombus spanning the left and noncoronary cusps and obliterating the left main coronary artery. We discuss the incidence, risk factors, and management of aortic root thrombus in LVAD patients. To our knowledge, this is the first report of three-dimensional echocardiography used to characterize an LVAD-associated aortic root thrombus.

We report a rare case of progressive left ventricular outflow tract (LVOT) obstruction after percutaneous device closure of a mechanical prosthetic mitral valve (MV) paravalvular leak (PVL) in the region of aortomitral curtain in a patient who also had small mechanical aortic valve prosthesis with patient-prosthesis mismatch.

PURPOSE OF REVIEW: Functional mitral regurgitation (FMR) is a common complication of left ventricular dysfunction. It is now recognized as an important clinical entity and an independent predictor of poor prognosis in cardiomyopathy patients. In this review, we provide a comprehensive summary of the pathophysiology, latest imaging modalities, and diagnostic criteria for FMR. Additionally, we discuss the recent literature on the continuously evolving surgical and percutaneous treatment options. RECENT FINDINGS: The criteria for quantification of FMR on echocardiography were updated and are distinct from organic mitral regurgitation in the most recent American College of Cardiology/American Heart Association 2014 valve guidelines. Furthermore, the evolving role of MitraClip for potential treatment of FMR offers exciting prospects to treat high-risk symptomatic patients. SUMMARY: Our review serves to consolidate the current diagnostic and treatment modalities for FMR and provide a contemporary resource for clinicians while treating patients. Additionally, we identify the gaps present in our knowledge of FMR to guide further clinical investigation.

Lipomatous atrial septal hypertrophy (LASH) is a histologically benign cardiac lesion characterized by excessive fat deposition in the region of the interatrial septum that spares the fossa ovalis. The etiology of LASH remains unclear, though it may be associated with advanced age and obesity. Because of the sparing of the fossa ovalis, LASH has a pathognomonic dumbbell shape. LASH may be mistaken for various tumors of the interatrial septum. Histologically, LASH is composed of both mature and brown (fetal) adipose tissue, but the role of brown adipose tissue remains unclear. In interventional procedures requiring access to the left atrium, LASH may interfere with transseptal puncture, as traversing the thickened area can reduce the maneuverability of catheters and devices. This may cause the needle to enter the epicardial space, causing dangerous pericardial effusions. LASH was once considered a contraindication to percutaneous device closure of atrial septal defects because of an associated increased risk for incorrect device deployment. However, careful attention to preprocedural imaging and procedural intracardiac echocardiography enable interventional cardiologists to perform procedures in patients with LASH without serious complications. In this review article, the authors describe anatomic and functional aspects of LASH, with emphasis on their roles in percutaneous interventions.

AIM: Left ventricular (LV) transient ischemic dilatation (TID) is not clear how it relates to inducible myocardial ischemia during stress echocardiography (SE). METHODS AND RESULTS: Eighty-eight SEs were examined from the site certification phase of the ISCHEMIA Trial. LV end-diastolic volume (EDV) and end-systolic volume (ESV) were measured at rest and peak stages and the percent change calculated. Moderate or greater ischemia was defined as >/=3 segments with stress-induced severe hypokinesis or akinesis. Optimum cut points in stress-induced percent EDV and ESV change that identified moderate or greater myocardial ischemia were analyzed. Analysis from percentage distribution identified a > 13% LV volume increase in EDV or a > 9% LV volume increase in ESV as the optimum cutoff points for moderate or greater ischemia. Using these definitions for TID, there were 27 (31%) with TIDESV and 12 (14%) with TIDEDV . By logistic regression analysis and receiver operating characteristic curves, the percent change in ESV had a stronger association with moderate or greater myocardial ischemia than that of EDV change. Compared to those without TIDESV , cases with TIDESV had larger extent of inducible wall-motion abnormalities, lower peak stress LVEF, and higher likelihood of moderate or grater ischemia. For moderate or greater myocardial ischemia detection, TIDESV had a sensitivity of 46%, specificity of 83%, positive predictive value of 70%, and negative predictive value of 64%. CONCLUSION: Transient ischemic dilatation by SE is a marker of extensive myocardial ischemia and can be used as an additional marker of higher risk.