Faculty Bibliography

This paper provides a comprehensive overview of 3D transesophageal echocardiography still images and movies of mechanical mitral valves, mitral bioprostheses, and mitral valve repairs. Alongside these visual descriptions, the historical overview of surgical and percutaneous mitral valve intervention is described with the special emphasis on the incremental value of 3D transesophageal echocardiography (3DTEE). For each mitral valve intervention, 2D echocardiography, chest x-ray, and fluoroscopy images corresponding to 3DTEE are given. In addition, key references on echocardiographic imaging of individual valves and procedures are enumerated in accompanying figures and tables.

BACKGROUND: Ischemic heart disease (IHD) is the most potent risk factor for heart failure (HF). Our study aims to evaluate the incremental impact of diabetes on the incidence of HF in individuals with IHD. METHODS: Data from the NHANES Epidemiologic Follow-Up Study (Baseline: 1971 to 1974) were linked to the facility and mortality files up to 1992. Our analyses were restricted to patients with IHD without prevalent HF at baseline. The cumulative incidence of HF in patients with diabetes and IHD versus those with IHD alone was assessed using failure curves. Cox proportional hazards models were used to control for important covariates. All analyses incorporated the complex sample design by including the weights and clustering variables. RESULTS: Out of the 14,407 participants, 497 had IHD without prevalent HF and had information about diabetes status. Among these participants, the cumulative incidence of HF was 38.1% for those with diabetes (n=63) and 26.5% in those without diabetes (n=434) (log-rank p-value<0.005). The multivariate hazard ratio (adjusted for age, BMI, alcohol consumption, hypertension, high cholesterol, and smoking) for incident HF for people who had myocardial infarction (MI) and diabetes compared to people who had MI alone was 2.98 (95% CI 1.51, 5.88). CONCLUSION: Among participants with MI, those with diabetes had a substantially higher incidence of HF than those without diabetes. Based on these findings, practitioners should focus greater attention on patients with diabetes and previous MI in order to potentially prevent incident HF.

BACKGROUND: Coronary artery calcification as assessed by computed tomography (CT) is a validated predictor of cardiovascular risk, whether identified on a dedicated cardiac study or on a routine non-gated chest CT. The prevalence of incidentally detected coronary artery calcification on non-gated chest CT imaging and consistency of reporting have not been well characterized. HYPOTHESIS: Coronary calcification is present on chest CT in some patients not taking statin therapy and may be under-reported. METHODS: Non-gated chest CT images dated 1/1/2012 to 1/1/2013 were retrospectively reviewed. Demographics and medical history were obtained from charts. Patients with known history of coronary revascularization and/or pacemaker/defibrillator were excluded. Two independent readers with cardiac CT expertise evaluated images for the presence and anatomical distribution of any coronary calcification, blinded to all clinical information including CT reports. Original clinical CT reports were subsequently reviewed. RESULTS: Coronary calcification was identified in 204/304 (68%) chest CTs. Patients with calcification were older and had more hyperlipidemia, smoking history, and known coronary artery disease. Of patients with calcification, 43% were on aspirin and 62% were on statin medication at the time of CT. Coronary calcification was identified in 69% of reports when present. CONCLUSIONS: A high prevalence of coronary calcification was found in non-gated chest CT scans performed for non-cardiac indications. In one-third, coronary calcification was not mentioned in the clinical report when actually present. In this population of patients with cardiac risk factors, standard reporting of the presence of coronary calcification may provide an opportunity for risk factor modification.

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)

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.