Faculty Bibliography

BACKGROUND: Heart failure (HF) is the leading cause of hospitalization among US adults, significant increasing mortality and reducing quality of life. Most importantly, prognosis following HF is dismal, being worse than that for most cancers. This population-based observational study evaluates the mortality outcomes for individuals hospitalized for incident heart failure and elucidates the impact of co-existing clinical conditions on mortality. METHODS: We identified participants admitted for heart failure from the NHEFS cohort of 14,407 adults. They were followed from their initial interview (1971-1975) until their last interview in 1992. Information regarding cardiovascular disease risk factors was collected at each interview. Health care facility stay data was used to identify hospitalizations and diagnosis of incident HF. Mortality before last interview was determined using information from the National Death Index-linked mortality file. The relationship between comorbidities and mortality was evaluated using: a) median survival time (with 95% confidence intervals [CI])) from life table analyses for the unadjusted analyses, and b) hazard ratios (with 95% CI) from Cox proportional-hazards models that adjusted for age, sex, race, and education. All analyses incorporated the complex sampling design (strata, cluster, and weight variables) to provide population estimates. RESULTS: Our analysis focused on the sample of 1080 participants who survived their incident CHF-related event. Their median age was 72.2 years (interquartile range 64.6-78.1), 506 (46.8%) participants were male, 89.3% were white, and 37.2% did not complete high school. Median follow-up time was 14.96 years. Diabetes mellitus (DM) was present in 23.5%, hypertension (HTN) in 14.4%, hyperlipidemia in 45.0%, and prior myocardial infarction (MI) in 23.6%. Median survival time (with 95% CI) was lower for individuals with DM [0.73 (0.48-1.07) years with DM vs. 2.04 (1.46-2.58) years without DM, p = 0.002] and prior MI [1.42 (0.79-2.16) with prior MI vs. 1.64 (1.25- 2.30) without MI, p = 0.004]. There was no significant difference in median survival time for hypertension [0.96 (0.69-1.60) with HTN vs. 1.67 (1.39- 2.19) without HTN, p = 0.833] or hyperlipidemia [1.37 (1.00-2.03) with hyperlipidemia vs. 1.62 (1.30-2.41) without hyperlipidemia, p = 0.321]. Participants with DM (HR = 1.82 (1.39-2.37), p < .0001), hypertension (HR = 1.45 (1.05-2.15), p = 0.028) and hyperlipidemia (HR = 1.37 (1.06- 1.77), p = 0.015) were at very high risk for mortality using multivariable Cox models adjusting for age, sex, race, and education. CONCLUSIONS: Participants with diabetes had the highest mortality after incident HF. In both adjusted and unadjusted analyses, patients with diabetes had significantly worse outcomes than those with other conditions. Patients with diabetes should be targeted for HF prevention and if HF develops, they should be the focus of intense monitoring and treatment

BACKGROUND: An independent association between gout and coronary artery disease is well established. The relationship between gout and valvular heart disease, however, is unclear. The aim of this study was to assess the association between gout and aortic stenosis. METHODS: We performed a retrospective case-control study. Aortic stenosis cases were identified through a review of outpatient transthoracic echocardiography (TTE) reports. Age-matched controls were randomly selected from patients who had undergone TTE and did not have aortic stenosis. Charts were reviewed to identify diagnoses of gout and the earliest dates of gout and aortic stenosis diagnosis. RESULTS: Among 1085 patients who underwent TTE, 112 aortic stenosis cases were identified. Cases and non-aortic stenosis controls (n=224) were similar in age and cardiovascular comorbidities. A history of gout was present in 21.4% (n=24) of aortic stenosis subjects compared with 12.5% (n=28) of controls (unadjusted OR 1.90, 95% CI 1.05-3.48, p=0.038). Multivariate analysis retained significance only for gout (adjusted OR 2.08, 95% CI 1.00-4.32, p=0.049). Among subjects with aortic stenosis and gout, gout diagnosis preceded aortic stenosis diagnosis by 5.8 +/- 1.6 years. The age at onset of aortic stenosis was similar among patients with and without gout (78.7 +/- 1.8 vs. 75.8 +/- 1.0 years old, p=0.16). CONCLUSIONS: Aortic stenosis patients had a markedly higher prevalence of precedent gout than age-matched controls. Whether gout is a marker of, or a risk factor for the development of aortic stenosis remains uncertain. Studies investigating the potential role of gout in the pathophysiology of aortic stenosis are warranted and could have therapeutic implications.

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.

OBJECTIVE: This study aims to provide the first description of the computed tomographic (CT) appearances of intracardiac embolized brachytherapy seeds in patients undergoing electrocardiogram (ECG)-gated cardiac CT. METHODS: The institutional Picture Archive and Communication System was searched for male patients who underwent enhanced ECG-gated cardiac CT, and reports were searched for the key words "metallic," "prostate," "brachytherapy," "radiation," "embolized," and "radioactive." Each study was identified and examined for an intracardiac metallic object conforming to the size of a prostate seed. RESULTS: Between January 01, 2005, and June 30, 2014, a total of 3206 male patients underwent ECG-gated cardiac CT. Five patients (0.15%) had a history of prostate cancer and an intracardiac metallic object with CT imaging characteristics consistent with an embolized prostate seed. In all 5 patients, the seeds were embedded in the trabeculations of the inferior aspect of the basal right ventricular free wall. CONCLUSIONS: Intracardiac embolized brachytherapy seeds appear as small objects with surrounding metallic artifact characteristically embedded in the inferior aspect of the basal right ventricular free wall.

Contraindications to transesophageal echocardiography (TEE) include various esophageal pathologies, but compression of the esophagus by vertebral osteophytes is not listed in the current American Society of Echocardiography guidelines. We report a case of diffuse idiopathic skeletal hyperostosis (DISH) in an 81-year-old man who had incidentally been found to have extrinsic esophageal compression by cervical osteophytes prior to a proposed TEE. The incidence of esophageal perforation in patients with DISH and vertebral osteophytes is not well documented. We believe these patients are at increased risk of esophageal perforation during TEE, and thus, TEE may be relatively contraindicated in patients with DISH.

RATIONALE: Obesity is characterized by increased systemic and pulmonary blood volumes (pulmonary vascular congestion). Concomitant abnormal alveolar membrane diffusion suggests subclinical interstitial edema. In this setting, functional abnormalities should encompass the entire distal lung including the airways. OBJECTIVES: We hypothesize that in obesity: 1) pulmonary vascular congestion will affect the distal lung unit with concordant alveolar membrane and distal airway abnormalities; and 2) the degree of pulmonary congestion and membrane dysfunction will relate to the cardiac response. METHODS: 54 non-smoking obese subjects underwent spirometry, impulse oscillometry (IOS), diffusion capacity (DLCO) with partition into membrane diffusion (DM) and capillary blood volume (VC), and cardiac MRI (n = 24). Alveolar-capillary membrane efficiency was assessed by calculation of DM/VC. MEASUREMENTS AND MAIN RESULTS: Mean age was 45+/-12 years; mean BMI was 44.8+/-7 kg/m2. Vital capacity was 88+/-13% predicted with reduction in functional residual capacity (58+/-12% predicted). Despite normal DLCO (98+/-18% predicted), VC was elevated (135+/-31% predicted) while DM averaged 94+/-22% predicted. DM/VC varied from 0.4 to 1.4 with high values reflecting recruitment of alveolar membrane and low values indicating alveolar membrane dysfunction. The most abnormal IOS (R5 and X5) occurred in subjects with lowest DM/VC (r2 = 0.31, p<0.001; r2 = 0.34, p<0.001). Cardiac output and index (cardiac output / body surface area) were directly related to DM/VC (r2 = 0.41, p<0.001; r2 = 0.19, p = 0.03). Subjects with lower DM/VC demonstrated a cardiac output that remained in the normal range despite presence of obesity. CONCLUSIONS: Global dysfunction of the distal lung (alveolar membrane and distal airway) is associated with pulmonary vascular congestion and failure to achieve the high output state of obesity. Pulmonary vascular congestion and consequent fluid transudation and/or alterations in the structure of the alveolar capillary membrane may be considered often unrecognized causes of airway dysfunction in obesity.

The aim of this study was to determine the diagnostic value of cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE), cine imaging, and resting first-pass perfusion (FPP) in the evaluation for ischemic (IC) versus nonischemic (NIC) cardiomyopathy in new-onset heart failure with reduced (