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...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.展开更多
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 t...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.展开更多
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...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.展开更多
<strong>Background:</strong><span style="font-family:;" "=""><span style="font-family:Verdana;"> Despite expanding indications, data regarding the long-term d...<strong>Background:</strong><span style="font-family:;" "=""><span style="font-family:Verdana;"> Despite expanding indications, data regarding the long-term durability of transcatheter heart valves (THV) are limited. </span><b><span style="font-family:Verdana;">Methods:</span></b><span style="font-family:Verdana;"> We performed a systematic review and meta-analysis of all published studies with ≥5</span></span><span style="font-family:;" "=""></span><span style="font-family:;" "=""><span style="font-family:Verdana;">years of follow-up reporting aortic valve reintervention rates of transcatheter (TAVR) and surgical aortic valve replacement (SAVR). </span><span style="font-family:Verdana;">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. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> The meta-</span></span><span style="font-family:Verdana;"> </span><span style="font-family:;" "=""><span style="font-family:Verdana;">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)</span><span style="font-family:Verdana;">. All TAVR procedures were performed with early</span></span><span style="font-family:Verdana;"> </span><span style="font-family:Verdana;">generations of THV. At</span><span style="font-family:;" "=""><span style="font-family:Verdana;"> 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, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 0%), all-cause mortality (OR 1.45;95% CI: [1.22, 1.75], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 44%) and the composite of reintervention and death (OR 1.47;95% CI: [1.14, 1.91], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 64%). Rates of myocardial infarction, transient ischemic attack, stroke, endocarditis, and the composite of endocarditis and thrombosis were similar between the groups. </span><b><span style="font-family:Verdana;">Conclusion</span></b><span style="font-family:Verdana;">: 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.</span></span>展开更多
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...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.展开更多
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 ...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.展开更多
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 t...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.展开更多
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 repla...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.]).展开更多
文摘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.
文摘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.
文摘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.
文摘<strong>Background:</strong><span style="font-family:;" "=""><span style="font-family:Verdana;"> Despite expanding indications, data regarding the long-term durability of transcatheter heart valves (THV) are limited. </span><b><span style="font-family:Verdana;">Methods:</span></b><span style="font-family:Verdana;"> We performed a systematic review and meta-analysis of all published studies with ≥5</span></span><span style="font-family:;" "=""></span><span style="font-family:;" "=""><span style="font-family:Verdana;">years of follow-up reporting aortic valve reintervention rates of transcatheter (TAVR) and surgical aortic valve replacement (SAVR). </span><span style="font-family:Verdana;">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. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> The meta-</span></span><span style="font-family:Verdana;"> </span><span style="font-family:;" "=""><span style="font-family:Verdana;">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)</span><span style="font-family:Verdana;">. All TAVR procedures were performed with early</span></span><span style="font-family:Verdana;"> </span><span style="font-family:Verdana;">generations of THV. At</span><span style="font-family:;" "=""><span style="font-family:Verdana;"> 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, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 0%), all-cause mortality (OR 1.45;95% CI: [1.22, 1.75], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 44%) and the composite of reintervention and death (OR 1.47;95% CI: [1.14, 1.91], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 64%). Rates of myocardial infarction, transient ischemic attack, stroke, endocarditis, and the composite of endocarditis and thrombosis were similar between the groups. </span><b><span style="font-family:Verdana;">Conclusion</span></b><span style="font-family:Verdana;">: 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.</span></span>
文摘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.
文摘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.
文摘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.
文摘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.]).