Recurrent ventricular tachycardia associated with non-compliance with thyroxine treatment for hypothyroidism.

406 Clinical utility of transthoracic echocardiography in patients with atrial fibrillation undergoing evaluation for suspected stroke

Truncating variants in the gene encoding filamin C (FLNCtv) are associated with arrhythmogenic and dilated cardiomyopathies with a reportedly high risk of ventricular arrhythmia. To determine the frequency of and risk factors associated with adverse events among FLNCtv carriers compared with individuals carrying TTN truncating variants (TTNtv). This cohort study recruited 167 consecutive FLNCtv carriers and a control cohort of 244 patients with TTNtv matched for left ventricular ejection fraction (LVEF) from 19 European cardiomyopathy referral units between 1990 and 2018. Data analyses were conducted between June and October, 2020. The primary end point was a composite of malignant ventricular arrhythmia (MVA) (sudden cardiac death, aborted sudden cardiac death, appropriate implantable cardioverter-defibrillator shock, and sustained ventricular tachycardia) and end-stage heart failure (heart transplant or mortality associated with end-stage heart failure). The secondary end point comprised MVA events only. In total, 167 patients with FLNCtv were studied (55 probands [33%]; 89 men [53%]; mean [SD] age at baseline evaluation, 43 [18] years). For a median follow-up of 20 months (interquartile range, 7-60 months), 29 patients (17.4%) reached the primary end point (19 patients with MVA and 10 patients with end-stage heart failure). Eight (44%) arrhythmic events occurred among individuals with baseline mild to moderate left ventricular systolic dysfunction (LVSD) (LVEF = 36%-49%). Univariable risk factors associated with the primary end point included proband status, LVEF decrement per 10%, ventricular ectopy (≥500 in 24 hours) and myocardial fibrosis detected on cardiac magnetic resonance imaging. The LVEF decrement (hazard ratio [HR] per 10%, 1.83 [95% CI, 1.30-2.57]; P < .001) and proband status (HR, 3.18 [95% CI, 1.12-9.04]; P = .03) remained independent risk factors on multivariable analysis (excluding myocardial fibrosis and ventricular ectopy owing to case censoring). There was no difference in freedom from MVA between FLNCtv carriers with mild to moderate or severe (LVEF ≤35%) LVSD (HR, 1.29 [95% CI, 0.45-3.72]; P = .64). Carriers of FLNCtv with impaired LVEF at baseline evaluation (n = 69) had reduced freedom from MVA compared with 244 TTNtv carriers with similar baseline LVEF (for mild to moderate LVSD: HR, 16.41 [95% CI, 3.45-78.11]; P < .001; for severe LVSD: HR, 2.47 [95% CI, 1.04-5.87]; P = .03). The high frequency of MVA among patients with FLNCtv with mild to moderate LVSD suggests that higher LVEF values than those currently recommended should be considered for prophylactic implantable cardioverter-defibrillator therapy in FLNCtv carriers.

Permissive Cardiotoxicity in HER2-Positive Metastatic Breast Cancer With Moderate Left Ventricular Dysfunction.

Patients with ACS and unobstructed coronary arteries represent a clinical dilemma and their diagnosis and management is quite variable in current practice. A 69–year–old man, who underwent valvuloplasty in 2013 for severe mitral regurgitation, presents with troponin–positive typical chest pain and a newly diagnosed RBBB that is identified as suspicious for NSTE–ACS. Coronary angiography reveals a critical ostial stenosis of the intermediate branch of the LCA with preserved TIMI flow. Since there are no other coronary lesions, conservative treatment is chosen. In the following days diarrheal attacks and an increase in inflammation markers is reported. TTE shows a slightly reduced LVEF with hypokinesia of the basal segments of the infero–posterior wall and of the lower IVS. The patient was discharged with a diagnosis of suspected acute myocarditis complicated by mild left ventricular dysfunction. After one month, cardiac MRI is performed with evidence on one hand of akinesia and thinning of mid–basal infero–lateral wall with transmural LGE extended to the posterior papillary muscle (indicating a previous MI); on the other hand of akinesia of the basal septum with transmural LGE and signs of microcirculatory obstruction (MVO) and acute inflammation on T2–weighted sequences (indicating a recent MI) (Figure 1). Moderate left ventricular systolic dysfunction (EF 36%) is highlighted. The MRI performed after 6 months confirms ischemic dilated cardiopathy with moderate left ventricular dysfunction. Following these findings, the coronary angiography is re–evaluated and compared with that of 2013 with evidence in the last study of an occlusion of the first septal branch of the LCA and a distortion in the course of the circumflex branch compared to the previous exam (Figure 2). What about the etiology of these unrecognized myocardial infarctions? Could the previous lateral infarction be the results of distortion in the circumflex branch’s course caused by surgical sutures of mitral valvuloplasty? Could the septal branch closure causing the new septal infarction have occurred due to an extra–coronary embolic event? Accurate diagnosis of the underlying patho–physiological mechanisms leading to the troponin rise is surely important for initiation of appropriate treatment, but may also have long–term implications for the patient. CMR and its unique non–invasive myocardial tissue characterization do not just have a diagnostic role but it has a potential role in risk stratification.Figure 1 Figure 2

IntroductionIncreasing severity of impairment of left ventricular systolic dysfunction (LVSD) in patients with chronic heart failure (CHF) is associated with higher mortality. However, the relation between temporal changes in LVSD...

Background and Objectives: Studies evaluating gender differences and outcomes in heart failure with reduced ejection fraction are limited in Iraq. The aim of this study was to assess the clinical characteristics, risk factors, outcomes and severity of heart failure with reduced ejection fraction in both genders. Patients and Methods: This is a prospective cohort study of 117 patients aged more than 18 years who had been admitted to the Hawler Cardiac Center or medical ward with heart failure with reduced ejection fraction for the period from December 2021 till 30th of October 2022. The clinical characteristics, severity of left ventricular systolic dysfunction and the outcomes over three months were compared between women and men. Results: One hundred seventeen patients were included in the study, 61 (52.1%) patients were male and 56 (47.9%) were female with male to female ration (1.09:1), p-value (0.017). Women presented with higher incidence of moderate left ventricular systolic dysfunction 36(64.2%), obesity 43 (76.8%) p-value=0.017*, dyslipidemia 27 (48.2%) p-value=0.038, pulmonary hypertension 4 (7.1%), atrial fibrillation 15(26.8%) and high cardiac hospitalization 12 (21.4%), while men have high incidence severe left ventricular systolic dysfunction 33(54.1% ) p-value=0.046, smoking 42 (68.9%); p-value &lt;0.001 and ST-segment elevation myocardial infarction 28 (45.9%) p-value &lt;0.001. the p-values off all above findings are less than &lt;0.05 respectively Conclusions: There are major differences in risk factors, clinical presentation and outcomes between both genders. The majority of women presented with moderate left ventricular systolic dysfunction and higher rate of cardiac hospitalization while men presented with severe left systolic dysfunction associated with high incidence of ST-elevation myocardial infarction.

The aim of the study was to evaluate the association between renin - angiotensin - aldosterone system blockers and risk of postoperative atrial fibrillation (AF) development in patients with mild and moderate left ventricular systolic dysfunction. The population of this prospective and observational study consisted of 269 patients with an ejection fraction of < or = 50% undergoing coronary artery bypass and/or valve surgery. Use of renin -angiotensin-aldosterone system blockers (angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) and spironolactone) and their association with postoperative AF (AF episode lasting < or = 5 min) were evaluated. In statistical analysis t test for independent samples, Chi-square test and Mann Whitney U test were used for comparison of variables between groups. Predictors of postoperative AF were determined by multiple logistic regression analysis. During follow-up, 50 patients (13%) developed postoperative AF. With multiple logistic regression analysis, risk factors for postoperative AF were determined: left atrial diameter (OR- 1.09; 95%CI 1.01-1.16, p=0.02), age (OR-1.04; 95%CI 1.002- 1.08, p=0.04), aortic cross-clamp duration (OR- 1.03, 95%CI -1.00-1.05, p=0.01), use of left internal mammarian artery (OR-0.33; 95%CI 0.13-0.88, p=0.03), ACEIs treatment (OR-0.27; 95%CI 0.12-0.62, p=0.002), and ARBs treatment (OR - 0.21, 95%CI 0.07-0.62, p=0.005). Our results indicate that although treatments with ACEIs and ARBs are associated with low incidence of postoperative AF in patients with mild and moderate left ventricular systolic dysfunction, treatment with spironolactone is not.

Background Increasing severity of impairment of left ventricular systolic dysfunction (LVSD) in patients with chronic heart failure (CHF) is associated with higher mortality. However, the relation between temporal changes in LVSD severity and long-term clinical outcome is unknown. Purpose We therefore investigated the effects of change of LVSD as measured by serial echocardiography on all-cause mortality in patients with CHF. Methods Patients with CHF defined as the presence of compatible symptoms and either at least moderate LVSD or NTproBNP &amp;gt;125 ng/L were enrolled. LVSD was qualitatively assessed as: none, mild, moderate, and severe. Echocardiography was performed at baseline and 12 months. The primary endpoint was all-cause mortality. Cox proportional hazard models were used to assess the relation between changes in LVSD and outcome. Hazard ratios (HR) are reported with 95% confidence intervals (CI). Results At baseline, 170 (11%) had no, 231 (16%) mild, 633 (43%) moderate and 453 (30%) severe LVSD. Amongst patients with either moderate or severe LVSD at baseline, 40% had improvement in function at 12 months (figure 1). Amongst patients with no LVSD at baseline, only 14% had deterioration of function. During subsequent median follow up of 2773 days, 868 patients died. Worsening of LVSD was associated with increasing all-cause mortality in patients with moderate LVSD and severe LVSD at baseline, but this was not significant after adjustment for covariables (table 1). Improvement of LVSD was independently associated with better survival in patients with moderate LVSD at baseline (HR 0.72 (95% CI: 0.53–0.98, p=0.04). Conclusion Greater severity of LVSD at baseline is associated with increasing likelihood of improvement. Amongst patients with moderate LVSD, improvement in LVSD is independently associated with survival. Funding Acknowledgement Type of funding sources: Public Institution(s).

BackgroundAdvantages of multiple arterial conduits for coronary artery bypass grafting (CABG) have been reported previously. We aimed to evaluate the mid-term outcomes of multiple arterial CABG (MABG) among patients with mild to moderate left ventricular systolic dysfunction (LVSD).MethodsThis multicenter study using propensity score matching took place from January 2013 to June 2019 in Jiangsu Province and Shanghai, China, with a mean and maximum follow-up of 3.3 and 6.8 years, respectively. We included patients with mild to moderate LVSD, undergoing primary, isolated multi-vessel CABG with left internal thoracic artery. The in-hospital and mid-term outcomes of MABG versus conventional left internal thoracic artery supplemented by saphenous vein grafts (single arterial CABG) were compared. The primary end points were death from all causes and death from cardiovascular causes. The secondary end points were stroke, myocardial infarction, repeat revascularization, and a composite of all mentioned outcomes, including death from all causes (major adverse events). Sternal wound infection was included with 6 months of follow-up after surgery.Results243 and 676 patients were formed in MABG and single arterial CABG cohorts after matching in a 1:3 ratio. In-hospital death was not significantly different (MABG 1.6% versus single arterial CABG 2.2%, p = 0.78). After a mean (±SD) follow-up time of 3.3 ± 1.8 years, MABG was associated with lower rates of major adverse events (HR, 0.64; 95% CI, 0.44–0.94; p = 0.019), myocardial infarction (HR, 0.39; 95% CI, 0.16–0.99; p = 0.045) and repeat revascularization (HR, 0.42; 95% CI, 0.18–0.97; p = 0.034). There was no difference in the rates of death, stroke, and sternal wound infection.ConclusionsMABG was associated with reduced mid-term rates of major adverse events and cardiovascular events and may be the procedure of choice for patients with mild to moderate LVSD requiring CABG.

The beneficial effects of implanted cardioverter defibrillator (ICD) therapy in patients with malignant ventricular tachyarrhythmias and variable degrees of left ventricular (LV) dysfunction are debated. ICD use and patient survival were examined in 128 patients with malignant ventricular arrhythmias and moderate or severe LV dysfunction. Group I included 64 patients with moderate LV dysfunction (LV ejection fraction of > 30%) and group II, 64 patients with severe LV dysfunction (LV ejection fraction of < or = 30%). Follow-up period ranged from 1 to 78 months. The two groups were similar in age, incidence of coronary artery disease and presenting arrhythmia. The mean LV ejection fraction in group I was 44% +/- 8% and group II was 22% +/- 5% (P < 0.0001). At 4 years of follow-up, 66% of patients from group I and 62% from group II (P = NS) had ICD activation for presumed ventricular tachyarrhythmia. Survival was calculated using actuarial analysis. Arrhythmic or sudden death mortality at 4 years of follow-up was 4% in group I and 7% in group II (P = NS). Cardiac mortality was for group I, 7% (P < 0.05), 12% (P < 0.01), 15% (P < 0.01), and 15% (P < 0.01) for follow-up years 1, 2, 3, and 4, respectively. For group II, cardiac mortality was 27%, 36%, 41%, and 41% for follow-up years for 1, 2, 3, and 4, respectively. The majority of cardiac deaths in both groups was observed in the first 2 years of follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Bedside Assessment of Left Ventricular Emptying Using Contrast-Enhanced Handheld Ultrasound: A Pilot Study

Cardiac surgery is higher risk in the elderly. It has been suggested that preoperative left ventricular systolic dysfunction (LVSD) and cardiopulmonary bypass (CPB) affect elderly and young patients differently. This study investigates the predictive risk of preoperative LVSD and CPB time for operative mortality in the two groups of patients. We reviewed the data for 2616 consecutive patients aged >/=70 years and 4078 young patients who had coronary artery bypass grafting (CABG) and/or valve surgery between March 1998 and January 2007. Subgroups defined by severity of LVSD (ejection fraction >0.50 [mild], 0.31-0.50 [moderate] and </=0.30 [severe]) were analysed. Logistic regression models were constructed to identify risk factors among elderly and young patients. Elderly patients were higher risk and more often underwent valve operation. Moderate and severe LVSD were present in 22% (n=566) and 6% (n=155) of elderly compared to 18% (n=739) and 5% (n=215) of young patients (p=0.001). Operative mortality for CABG was higher in elderly patients with mild (2.3% vs 0.7%, p<0.0001), moderate (4.7% vs 2.3%, p=0.04) and severe LVSD (13.5% vs 8.8%, p=0.01). Although CPB times for similar procedures were equivalent for the two groups, procedure-specific mortality rates were higher among elderly patients for all operations. Whereas age (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03-1.15, p=0.002) and CPB time (OR 1.01, 95% CI 1.0-1.02, p<0.0001) were predictors for operative mortality for the elderly, they (age [OR 1.0, 95% CI 0.96-1.05, p=0.87], CPB time [OR 1.0, 95% CI 1.0-1.01, p=0.17]) were not for young patients. Moderate LVSD was a risk factor for young patients (OR 3.01, 95% CI 1.45-6.26, p=0.003) but not for the elderly (OR 1.33, 95% CI 0.77-2.29, p=0.30). Differences in the significance of risk factors between elderly and young patients contribute to the disproportionate operative mortalities. Our data showed that age and CPB duration increased the risk of operative mortality only in the elderly, but the impact of moderate, unlike severe, LVSD was tempered. Further studies are warranted to investigate more biocompatible bypass systems in elderly patients, and if current risk stratification should, perhaps, be revised for elderly patients.

This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty. All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed. Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws. Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting.

Funding Acknowledgements Type of funding sources: None. Background The coronavirus disease 2019 (COVID-19) is mainly a respiratory disease potentially leading to acute respiratory distress syndrome but can have multiple system involvement. Data pertaining to cardiac sequalae is of urgent importance to define subsequent cardiac surveillance. Purpose To describe the short-term impact of COVID-19 pneumonia in patients with reduced Left ventricular ejection fraction (LVEF). Methods This single center, prospective observational study included 141 RT-PCR confirmed COVID-19 patients who had reduced ejection fraction on echocardiography quantitively assessed by modified Simpson’s method. The study group were divided into three groups based on the ejection fraction: 34 patients had mild left ventricular (LV) dysfunction (LVEF&amp;gt;41-50%), 50 patients had moderate left ventricular dysfunction (LVEF=31-40%) and 57 patients had severe left ventricular dysfunction (LVEF &amp;lt;30%). Demographics, clinical characteristics, in hospital events and clinical sequelae of survivors during 6 months follow up period were analyzed. Results Mean age of the study population was 60.22± 12.53 years.71.6% were males and 28.3% were females. Average length of hospital stay in the study group was 10.93±6.9 days. Patients with mild LV dysfunction had longer hospital stay (13.65± 7.09 days) than patients with moderate LV dysfunction (10.90±6.05 days) and patients with severe LV dysfunction (9.33±6.83 days) (p=0.01). Patients with severe LV dysfunction had higher Interleukin-6 levels (IL-6) and BNP levels in comparison to other groups.50% of patients with severe LV dysfunction required invasive ventilation during the course of hospital stay, while it was 20.6% in patients with mild LV dysfunction and 32% in patients with moderate LV dysfunction. 63% of patients with severe left ventricular dysfunction expired in the study period compared to 26.4% of patients with mild LV dysfunction and 40% of patients with moderate LV dysfunction (P=0.001). Patients with severe LV dysfunction had increased major adverse cardiac events in 6 months follow up compared to patients with mild and moderate LV dysfunction. Patients with severe LV dysfunction had increased in hospital mortality (40%) compared to patients with mild LV dysfunction (20%) and patients with moderate LV dysfunction (32%). Patients with higher levels of IL-6 (OR: 1.004, 95% CI: 1.002-1.01, P&amp;lt;0.001), procalcitonin (OR: 1.24, 95% CI: 1.07-1.44, P=0.004) and CT severity score (OR1.21, 95% CI: 1.13-1.28, P&amp;lt;0.01) are independent predictors of mortality in the study population. Conclusion Patient with reduced ejection fraction (LVEF &amp;lt;30%) have a poor 6 month outcome after COVID 19 pneumonia.

Description of Case: A 14-year-old male with a Haller Index of 6.1 was referred to cardiology clinic for evaluation of severe pectus excavatum (PE). He was asymptomatic but was incidentally found to have incessant atrial tachycardia (AT) with a left atrial focus predicted based on p wave morphology analysis on electrocardiogram. On echocardiogram, he had evidence of left atrial compression and moderate left ventricular systolic dysfunction, consistent with tachycardia induced cardiomyopathy. Initial medical therapy with ivabradine, flecainide, and atenolol led to rate control and subsequent improvement in left ventricular function but failed to terminate the arrhythmia. He underwent surgical repair of the PE. Postoperatively, left ventricular function normalized, but AT persisted despite continued escalation to ivabradine, sotalol, and flecainide. An electrophysiology study performed 8 weeks from surgical repair identified a focal AT arising from the left atrial posterior wall. The focus was successfully eliminated with radiofrequency ablation. He has since remained in sinus rhythm and off antiarrhythmic therapy with full recovery of ventricular function. Discussion: Pectus excavatum is the most common anterior chest wall deformity. Though often a benign, asymptomatic, cosmetic anomaly, PE has been associated with several cardiac effects including hemodynamic compromise and arrhythmias secondary to cardiac compression. To our knowledge, this is the first pediatric case of persistent, drug refractory AT requiring catheter ablation, despite surgical correction of the PE. The p wave morphology on electrocardiogram, left atrial deformity on echocardiogram, and intracardiac activation map of the AT focus in this case, support cardiac compression as the mechanism for AT. These findings suggest the potential for sustained atrial remodeling with subsequent arrhythmia in the context of PE and underscores the importance of cardiac screening in asymptomatic adolescents with severe chest wall deformities.