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Latent myopathy is more pronounced in patients with low flow versus normal flow aortic stenosis with normal left ventricular ejection fraction who are undergoing surgical aortic valve replacement: Multicenter study with a brief review of the literature

Supariwala, Azhar; Sanchez-Ross, Monica; Suma, Valentin; Seetharam, Karthik; Marrero, Daniel; Swistel, Daniel; Balaram, Sandhya; Chaudhry, Farooq A
BACKGROUND:Midwall fibrosis and low stroke volume are independent predictors of mortality in severe aortic stenosis (AS) with preserved LV ejection fraction (LVEF). The role of speckle tracking echocardiography (STE) to identify latent myopathy pre- and post- aortic valve replacement (AVR) in high risk AS patients with normal LVEF is limited. METHODS:. RESULTS:; P = .01) improved post-AVR. Pre-AVR mid-segments showed a similar myopathy as the basal segments (-9.5 ± 4.3% vs -9.0 ± 4.2%;P = .3). The 16 (43%) LF patients in this study had lower pre- and post-AVR strain compared to NF patients (GLS Pre-AVR:LF vs NF: -5.1 ± 4.1% vs -8.4 ± 4.9% (P = .04) and GLS Post-AVR:LF vs NF: -9.2 ± 3.7% vs -12.5 ± 3.9% (P = .01)). However, there was no difference in absolute and %change improvement in GLS post-AVR (LF vs NF:∆ -4.2 ± 3.5% vs ∆-4.1 ± 5.3% (P = .90) and 193 ± 214% vs 143 ± 230% change (P = .5)). The lowest GLS was seen in LF/HG AS followed by LF/LG, NF/LG and NF/HG AS; P = .03. CONCLUSIONS:Latent myopathy is more pronounced in LF AS both pre- and post-AVR. Our study provides evidence of improvement in myopathy in LF AS despite a persistent worse myopathy compared to NF patients post-AVR.
PMID: 29605969
ISSN: 1540-8175
CID: 3546342

Pulmonary vein isolation alone in patients with persistent atrial fibrillation: an ablation strategy facilitated by antiarrhythmic drug induced reverse remodeling

Khan, Aslam; Mittal, Suneet; Kamath, Ganesh S; Garikipati, Naga Vamsi; Marrero, Daniel; Steinberg, Jonathan S
INTRODUCTION: Pulmonary vein isolation (PVI) alone has been thought to be insufficient in patients with persistent atrial fibrillation (PersAF). We hypothesized that preablation treatment of PersAF with a potent antiarrhythmic drug (AAD) would facilitate reverse atrial remodeling and result in high procedural efficacy after PVI alone. METHODS AND RESULTS: Seventy-one consecutive patients (59.4 +/- 9.8 years) with PersAF and prior AAD failure were treated with oral dofetilide (768 +/- 291 mcg/day) for a median of 85 days pre-PVI. P-wave duration (Pdur) on ECG was used to assess reverse atrial remodeling. Thirty-five patients with paroxysmal (P) AF not treated with an AAD served as controls. All patients underwent PVI alone; dofetilide was discontinued 1-3 mos postablation. In the PersAF patients, the Pdur decreased from 136.3 +/- 21.7 ms (assessed postcardioversion on dofetilide) to 118.6 +/- 20.4 ms (assessed immediately prior to PVI) (P < 0.001). In contrast, no change in Pdur (122.6 +/- 11.5 ms vs. 121.3 +/- 13.7 ms, P = NS) was observed in PAF patients. The 6 and 12 mos AAD-free response to ablation was 76% and 70%, respectively, in PersAF patients, similar to the 80% and 75%, response in PAF patients (P = NS). A decline in Pdur in response to dofetilide was the only predictor of long-term clinical response to PVI in patients with PersAF. CONCLUSIONS: Pre-treatment with AAD resulted in a decrease in Pdur suggesting reverse atrial electrical remodeling in PersAF patients. This may explain the excellent clinical outcomes using PVI alone, and may suggest an alternative ablation strategy for PersAF.
PMID: 20812936
ISSN: 1045-3873
CID: 513232

Prevalence, predictors, and prognosis of atrial fibrillation early after pulmonary vein isolation: findings from 3 months of continuous automatic ECG loop recordings

Joshi, Sandeep; Choi, Andrew D; Kamath, Ganesh S; Raiszadeh, Farbod; Marrero, Daniel; Badheka, Apurva; Mittal, Suneet; Steinberg, Jonathan S
INTRODUCTION: Following pulmonary vein isolation (PVI) for atrial fibrillation (AF), early recurrences are frequent, benign and classified as a part of a "blanking period." This study characterizes early recurrences and determines implications of early AF following PVI. METHODS AND RESULTS: Seventy-two consecutive patients (59.8 +/- 10.7 years, 69% male) were studied following PVI for paroxysmal or persistent AF. Subjects were fitted with an external loop recorder for automatic, continuous detection of AF recurrence for 3 months. AF prevalence was highest 2 weeks after PVI (54%) and declined to an eventual low of 22%. A significant number (488, 34%) of recurrences were asymptomatic; however, all patients with > or =1 AF event had > or =1 symptomatic event. No clear predictor of early recurrence was identified. Forty-seven (65%) patients had at least 1 AF episode, predominantly (39 of 47 patients, 83%) within 2 weeks of PVI. Of the 33 patients who did not experience AF within the first 2 weeks, 85% (28/33) were complete responders (P = 0.03) at 12 months. Recurrence at any time within 3 months was not associated with procedural success or failure. CONCLUSIONS: Early AF recurrence peaks within the first few weeks after PVI, but continues at a lower level until the completion of monitoring. A blanking period of 3 months is justified to identify patients with AF recurrences that do not portend procedure failure. Freedom from AF in the first 2 weeks following ablation significantly predicts long-term AF freedom.
PMID: 19549038
ISSN: 1045-3873
CID: 513242