Trans-Frame Aortic Regurgitation of New-Generation Aortic Bioprosthesis

A widely used aortic valve bioprosthesis is susceptible to regurgitation between the sewing ring and the frame of the valve due to its relatively thin fabric coverage. In some cases this leak has been shown to resolve with administration of protamine, however, tension on this area from annular sutures placed in an asymmetric bicuspid valve annulus may exacerbate the defect.

Foundations of medical decision-making for older adults with cardiovascular disease

为了帮助更老的成年人做好心血管的疾病，遨游复杂决定，临床医生们必须知道医药道德的信条并且有好通讯技巧。决策能力和知情同意的元素被考察，用说明基本概念的相关临床的例子。分享的决策模型，临床医生和病人一起由工作决定照顾的计划，被描述。实现分享的决策的有用通讯技术被建议。

中度至重度一氧化碳中毒后的心肌损伤和长期死亡率

Context: Carbon monoxide (CO) poisoning is a common cause of toxicological morbidity and mortality. Myocardial injury is a frequent consequence of moderate to severe CO poisoning. While the in-hospital mortality for these patients is low, the long-term outcome of myocardial injury in this setting is unknown. Objective: To determine the association between myocardial injury and long-term mortality in patients following moderate to severe CO poisoning. Design, Setting, and Participants: Prospective cohort study of 230 consecutive adult patients treated for moderate to severe CO poisoning with hyperbaric oxygen and admitted to the Hennepin County Medical Center, a regional center for treatment of CO poisoning, between January 1, 1994, and January 1, 2002. Follow-up was through November 11, 2005. Main Outcome Measure: All-cause mortality. Results: Myocardial injury (cardiac troponin I level ≥ 0.7 ng/mL or creatine kinase-MB level ≥ 5.0 ng/mL and/or diagnostic electrocardiogram changes) occurred in 85 (37% ) of 230 patients. At a median follow-up of 7.6 years (range: in-hospital only to 11.8 years), there were 54 deaths (24% ). Twelve of those deaths (5% ) occurred in the hospital as a result of a combination of burn injury and anoxic brain injury (n=8)or cardiac arrest and anoxic brain injury (n=4). Among the 85 patients who sustained myocardial injury from CO poisoning, 32 (38% ) eventually died compared with 22 (15% ) of 145 patients who did not sustain myocardial injury (adjusted hazard ratio, 2.1; 95% confidence interval, 1.2- 3.7; P=.009). Conclusion: Myocardial injury occurs frequently in patients hospitalized for moderate to severe CO poisoning and is a significant predictor of mortality.

动脉粥样硬化血栓形成门诊患者1年内心血管事件的发生率

背景：目前，有关社区中动脉粥样硬化血栓形成稳定患者心血管（cardiovascular，CV）事件发生率的资料比较少，既往也无国际性队列研究对冠状动脉病（coronary artery disease，CAD）、脑血管病（cerebrovascular disease，CVD）、外周动脉病（peripheral arterial disease，PAD）确诊患者以及此类疾病高危患者不同事件的发生率进行评估。 目的：在患有动脉疾病的门诊患者或存在多个动脉粥样硬化血栓形成危险因素的门诊患者中确定当今世界1年内CV事件的发生率。 设计、地点及参试者：“减少动脉粥样硬化血栓形成维系健康（Reduction of Artherotllrombosis for Continued Health，REACH）”注册研究是一项国际前瞻性队列研究。研究人员于2003—2004年从44个国家、5587名医生入选68236例已确诊的动脉粥样硬化性血管病患者（CAD、PAD、CVD；n=55814）以及至少存在3个动脉粥样硬化血栓形成危险因素的患者（n=12422）。 主要观测指标：CV死亡、心肌梗死（myocardial infarction，MI）及卒中的发生率。结果：截至2006年7月，共有95．22％的患者（n=64977）提供了1年内的结局。心血管死亡、MI及卒中的总体发生率为4．24％；动脉粥样硬化性血管病患者为4．69％，仅存在多个危险因素的患者为2．15％。CAD、CVD及PAD患者CV死亡、MI及卒中的总体发生率分别为4．52％、6．47％和5．35％。CAD、CVD及PAD患者发生终点事件（即CV死亡、MI、卒中）以及因动脉粥样硬化血栓形成事件入院的几率分别为15．20％、14．53％和21．14％。上述事件发生率随症状性动脉疾病病变部位数量的增加而增加，仅存在危险因素的患者为5．31％，有1处症状性动脉疾病的患者为12．58％，有2处症状性动脉疾病的患者为21．14％，有3处症状性动脉疾病的患者为26．27％（趋势P〈0．001）。 结论：在这项当代大型国际研究中，患有动脉粥样硬化性血管病的门诊患者以及有动脉粥样硬化血栓形成危险的门诊患者CV事件的年发生率相对较高。存在多部位病变者CV事件的1年发生率升高。

ICD预防肥厚型心肌病患者发生心脏性猝死的研究

背景:ICD最近被用于预防肥厚型心肌病(HCM)患者发生心脏性猝死,但是,对其疗效以及患者的选择仍未完全明确。目的:研究HCM患者的临床危险因素状况与ICD植入的发生率及有效性。设计、地点和患者:1986—2003年,入选506例相互无关的HCM患者。

心脏磁共振成像在肥厚型心肌病诊断中的应用

Background-Two-dimensional echocardiography is currently the standard test for the clinical diagnosis of hypertrophic cardiomyopathy(HCM). The present study was undertaken to determine whether cardiac MRI(CMR) affords greater accuracy than echocardiography in establishing the diagnosis and assessing the magnitude of left ventricular(LV) hypertrophy in HCM. Methods and Results-Forty-eight patients(age 34±16 years) suspected of having HCM(or with a confirmed diagnosis) were imaged by both echocardiography and CMR to assess LV wall thickness in 8 anatomic segments(total n=384 segments) and compared in a blinded fashion. Maximum LV thickness was similar by echocardiography(21.7±9.1 mm) and CMR(22.5±9.6 mm; P=0.21). However, in 3(6%) of the 48 patients, echocardiography did not demonstrate LV hypertrophy, and CMR identified otherwise undetected areas of wall thickening in the anterolateral LV free wall(17 to 20 mm), which resulted in a new diagnosis of HCM. In the overall study group, compared with CMR, echocardiography also underestimated the magnitude of hypertrophy in the basal anterolateral free wall(by 20±6%; P=0001), as well as the presence of extreme LV wall thickness(≥30 mm) in 10%of patients(P< 0.05). Conclusions-CMR is capable of identifying regions of LV hypertrophy not readily recognized by echocardiography and was solely responsible for diagnosis of the HCM phenotype in an important minority of patients. CMR enhances the assessment of LV hypertrophy, particularly in the anterolateral LV free wall, and represents a powerful supplemental imaging test with distinct diagnostic advantages for selected HCM patients.

Reintervention with Transcatheter and Surgical Aortic Valves: A Systematic Review and Meta-Analysis

Background: Despite expanding indications, data regarding the long-term durability of transcatheter heart valves (THV) are limited. Methods: We performed a systematic review and meta-analysis of all published studies with ≥5years of follow-up reporting aortic valve reintervention rates of transcatheter (TAVR) and surgical aortic valve replacement (SAVR). Randomized controlled trials (n = 4) and propensity-matched observational studies (n = 1) involving all surgical risk categories were included. The primary endpoint was the composite of aortic valve reintervention and death. Results: The meta- analysis included 4145 patients: 2101 underwent TAVR (mean age 81.7 ± 6.7 years, 54% male) and 2044 SAVR (mean age 81.8 ± 6.6 years, 54% male). All TAVR procedures were performed with early generations of THV. At a median follow-up of 5 years (range 5 - 6 years), TAVR had higher reintervention rates (odds ratio (OR) 3.33;95% CI: [1.78, 6.24], p < 0.001, I2 = 0%), all-cause mortality (OR 1.45;95% CI: [1.22, 1.75], p < 0.001, I2 = 44%) and the composite of reintervention and death (OR 1.47;95% CI: [1.14, 1.91], p < 0.001, I2 = 64%). Rates of myocardial infarction, transient ischemic attack, stroke, endocarditis, and the composite of endocarditis and thrombosis were similar between the groups. Conclusion: Despite comparable short and medium-term results, TAVR with early-generation THV has higher rates of reintervention and the composite of reintervention and death. Further studies employing newer definitions of structural valve deterioration and bioprosthetic valve failure are needed to assess whether technological enhancements in THV technology will improve long-term outcomes.

COVID-19 and venous thromboembolism: Known and unknown for imaging decisions

As we continue to fight against the current coronavirus disease-2019(COVID-19)pandemic,healthcare professionals across the globe are trying to answer questions surrounding how to best help patients with the up-to-date available science while awaiting the development of new therapies and mass vaccination.Since early in the pandemic,studies indicated a heightened risk of venous thromboembolism(VTE)in COVID-19 infected patients.There have been differing expert opinions about how to assess pretest probability of VTE in this patient population.This has been partly due to the high prevalence of respiratory failure in this patient population and the use of D-dimer as a prognostic test which is also frequently elevated in patients with COVID-19 in absence of VTE.Some experts have argued for an approach similar to usual care with testing if clinical suspicion is high enough.Some have argued for more routine screening at different points of care.Others have even suggested empiric therapeutic anticoagulation in moderate to severely ill COVID-19 patients.In the following article,we review and summarize the most current literature in hopes of assisting clinicians in decision making and guidance for when to be concerned for VTE in COVID-19 patients.We also discuss research gaps and share pathways currently being used within our institution.

肥厚型心肌病患者心电图形态与表型表现及临床预后的关系

Twelve-lead electrocardiography, a traditional component in evaluations of patients with hypertrophic cardiomyopathy (HC), is often regarded as a marker for the magnitude of left ventricular(LV) hypertrophy, which in turn has been linked to sudden death risk. To determine whether electrocardiographic(ECG) patterns have clinical utility by accurately reflecting phenotypic expression or predicting clinical outcome, voltages and patterns were compared with LV wall thicknesses assessed by echocardiography and with clinical outcomes in 448 consecutive patients with HC. Significant but relatively weak correlations were evident between maximum LV wall thickness and ECG voltage: r=0.295(p< 0.01) for the sum of R-and S-wave voltages in all 12 leads, r=0.254(p< 0.01)for the maximum R or S wave in any lead, and r=0.210(p< 0.01) for the sum of SV1(or SV2) and RV5(or RV6). Of 55 patients with extreme LV hypertrophy(LV wall thickness ≥30 mm), only 24(44%) showed greatly increased ECG voltage≥30 mm in any lead. Of 102 patients with outflow gradients≥30 mm Hg at rest, only 43(42%) had ECG voltage ≥30 mm in any lead. Normal ECG results were uncommonly associated with HC-related death(1 of 40 patients, 2.5%) but had similar prevalence in surviving patients(17 of 376 patients, 4.5%; p=NS). In conclusion, in HC, 12-lead ECG voltages are not a reliable clinical marker for the magnitude of LV hypertrophy or outflow obstruction. Diverse ECG patterns, consistent with heterogenous expression of this disease, did not predict HC-related death. Scalar electrocardiography has selective but limited power in routine clinical assessments of patients with HC.

中、重度一氧化碳中毒后的心肌损伤与远期死亡率

Context: Carbon monoxide(CO) poisoning is a common cause of toxicological morbidity and mortality. Myocardial injury is a frequent consequence of moderate to severe CO poisoning. While the in- hospital mortality for these patients is low, the long- term outcome of myocardial injury in this setting is unknown. Objective: To determine the association between myocardial injury and long- term mortality in patients following moderate to severe CO poisoning. Design, Setting, and Participants: Prospective cohort study of 230 consecutive adult patients treated for moderate to severe CO poisoning with hyperbaric oxygen and admitted to the Hennepin County Medical Center, a regional center for treatment of CO poisoning, between January 1, 1994, and January 1, 2002. Follow- up was through November 11, 2005. Main Outcome Measure: All- cause mortality. Results: Myocardial injury(cardiac troponin I level ≥ 0.7 ng/mL or creatine kinase- MB level ≥ 5.0 ng/mL and/or diagnostic electrocardiogram changes) occurred in 85(37% ) of 230 patients. At a median follow- up of 7.6 years(range: in- hospital only to 11.8 years), there were 54 deaths(24% ). Twelve of those deaths(5% ) occurred in the hospital as a result of a combination of burn injury and anoxic brain injury(n=8) or cardiac arrest and anoxic brain injury(n=4). Among the 85 patients who sustained myocardial injury from CO poisoning, 32(38% ) eventually died compared with 22(15% ) of 145 patients who did not sustain myocardial injury(adjusted hazard ratio, 2.1; 95% confidence interval, 1.2- 3.7; P=.009). Conclusion: Myocardial injury occurs frequently in patients hospitalized for moderate to severe CO poisoning and is a significant predictor of mortality.

肥厚型心肌病猝死危险因素分层

肥厚型心肌病（HCM）是最常见的遗传性心脏病。普通人群患病率1／500，以自然病史差异极大为特征。很多患者终生无症状，寿命与常人并无不同。有些患者有心力衰竭（心衰）或心房颤动（房颤）的症状，某些患者猝死。猝死者常常先前没有症状，年龄较轻。HCM是青年人和运动员最常见的猝死原因。因此对猝死危险进行分层，预防猝死是一个重要的临床问题。

肥厚型心肌病猝死预防：肥厚型心肌病患者除颤器置入

从50年前认识到肥厚型心肌病（HCM）起，对HCM患者猝死危险已有了充分的认识和足够的重视。HCM是青年人（包括受训运动员）猝死最常见的原因。置入性心脏除颤器（ICD）起初用于治疗缺血性心脏病，近几年用于HCM心原性猝死的预防。临床ICD置人增加很快，是改变HCM青年患者病程的主要治疗手段。

肥厚型心肌病心房颤动：决定因素、临床进程与处理

心房颤动（房颤）是一个全球性健康问题，东西方患病率相同，反映人群老化，心血管病负担加重。在肥厚型心肌病（HCM）患者中，房颤是最常见的持续性心律不齐，最常见的并发症之一，对临床病程与预后影响很大。房颤成为HCM治疗的棘手问题，特别年轻患者，需要一致的循证治疗策略。尽管HCM房颤的循证依据不多，近期证据提示，新的治疗方法给某些患者带来了希望。

正电子发射断层成像术在肥厚型心肌病中的应用：发现微血管功能异常所致的心肌低灌注

肥厚型心肌病是最常见的遗传性心脏疾病，其在人群中患病率约为2／1000，以表型表达和临床表现差异极大为特点——从完全无症状到猝死、疾病进展和心力衰竭相关并发症等。微血管水平的心肌缺血与疾病表达和临床后果密切相关，是一些致命性并发症，如室性心律失常、猝死、左心室重构和收缩功能障碍的直接原因。至今，肥厚型心肌病患者心肌缺血的评估还存在一定技术和实际的困难，尚没有纳入到规范的临床实践中，亦没有列入肥厚型心肌病的诊疗指南。

"Commissural drop"wiring technique facilitates catheter crossing of severely stenotic aortic valve

To the Editor:An 82-year-old man with symptomatic severe calcific aortic valve stenosis(peak velocity:5.19 m/s;mean gradient:78.0 mmHg;aortic valve area:0.48 cm2)underwent transfemoral transcatheter aortic valve replacement.During the procedure,a 0.035-inch straight-tip glide wire(Terumo,Somerset,NJ,USA)supported by a 6 Fr Judkins Right 4(JR4)coronary catheter(Medtronic,Minneapolis,MN,USA)were used to cross the severely stenotic aortic valve.However,the JR4 catheter could not pass the aortic valve because the wire crossed the aortic valve in the left/right coronary commissure creating an unfavorable angle and limited pushability for the catheter.Instead of switching to a differently shaped catheter(eg,an Amplatz left 1 catheter),we advanced the glide wire and therefore the more supportive portion of the wire further through the aortic valve.Subsequently,both wire and JR4 catheter dropped into the non/left coronary commissure,allowing the JR4 catheter to cross the valve easily.Eventually,a 34 mm self-expanding Evolut R valve(Medtronic)was implanted,and the patient was discharged uneventfully(Figure 1A-E and Supplementary Video 1,http://links.lww.com/CM9/A353["Commissural drop"wiring technique.]).