Higher Left Ventricular Pressure Research Articles

Double-layer horizontal cross sutures for intra-atrial mitral valve implantation: An effective surgical method for severe mitral annular calcification

ObjectiveSevere mitral annular calcification (MAC) can make prosthetic implantation extremely difficult. Although intra-atrial mitral valve prosthesis implantation without annular decalcification offers a simpler approach, it poses a potential rupture risk due to high left ventricular pressure. We developed a double-layer (DL) horizontal cross-suture technique, which ensures close proximity of the valve prosthesis to the calcified annulus and segregates the left atrial wall from the left ventricle. The aim of this study was to compare the outcomes of DL suture with conventional single-layer (SL) suture in patients with severe MAC. MethodsThis retrospective cohort study consecutively enrolled patients with severe MAC undergoing mitral valve replacement at Beijing Anzhen Hospital from May 2018 to December 2022. A detailed description of the DL suture method is described. Follow-up medical evaluations, including transthoracic echocardiography measurements, were obtained through outpatient chart reviews. ResultsThe study included 10 patients in the DL suture group and 20 in the SL suture group. All patients in the DL group and all but 3 in the SL group achieved technical success. Compared with the SL group, the DL suture technique was associated with lower rates of perivalvular leakage, stroke, new-onset atrial fibrillation, reoperation, and 30-day mortality. Follow-up was complete, with 1 late mortality in the DL group due to stroke and 4 cardiovascular deaths in the SL group. ConclusionsThe DL horizontal cross-suture technique offers a more effective and safer approach for intra-atrial mitral valve implantation in severe MAC cases than the conventional SL suture method.

Characterization of a robust mouse model of heart failure with preserved ejection fraction.

Heart failure (HF) is a leading cause of morbidity and mortality particularly in older adults and patients with multiple metabolic comorbidities. Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome with multisystem organ dysfunction in which patients develop symptoms of HF as a result of high left ventricular (LV) diastolic pressure in the context of normal or near normal LV ejection fraction (LVEF; ≥50%). Challenges to create and reproduce a robust rodent phenotype that recapitulates the multiple comorbidities that exist in this syndrome explain the presence of various animal models that fail to satisfy all the criteria of HFpEF. Using a continuous infusion of angiotensin II and phenylephrine (ANG II/PE), we demonstrate a strong HFpEF phenotype satisfying major clinically relevant manifestations and criteria of this pathology, including exercise intolerance, pulmonary edema, concentric myocardial hypertrophy, diastolic dysfunction, histological signs of microvascular impairment, and fibrosis. Conventional echocardiographic analysis of diastolic dysfunction identified early stages of HFpEF development and speckle tracking echocardiography analysis including the left atrium (LA) identified strain abnormalities indicative of contraction-relaxation cycle impairment. Diastolic dysfunction was validated by retrograde cardiac catheterization and analysis of LV end-diastolic pressure (LVEDP). Among mice that developed HFpEF, two major subgroups were identified with predominantly perivascular fibrosis and interstitial myocardial fibrosis. In addition to major phenotypic criteria of HFpEF that were evident at early stages of this model (3 and 10 days), accompanying RNAseq data demonstrate activation of pathways associated with myocardial metabolic changes, inflammation, activation of extracellular matrix (ECM) deposition, microvascular rarefaction, and pressure- and volume-related myocardial stress.NEW & NOTEWORTHY Heart failure with preserved ejection fraction (HFpEF) is an emerging epidemic affecting up to half of patients with heart failure. Here we used a chronic angiotensin II/phenylephrine (ANG II/PE) infusion model and instituted an updated algorithm for HFpEF assessment. Given the simplicity in generating this model, it may become a useful tool for investigating pathogenic mechanisms, identification of diagnostic markers, and for drug discovery aimed at both prevention and treatment of HFpEF.

Impact of SGLT2 inhibitors on the evolution of echocardiographic parameters of patients with chronic heart failure

Inhibitors of sodium-glucose cotransporter 2 (SGLT2) have shown, in several prospective studies, their cardiovascular benefit with more particularly a rapid and very significant decrease in hospitalizations for heart failure. The precise mechanisms accounting for the improvement of myocardial function under SGLT2 inhibitors are not yet clarified. The objective of this work is to evaluate the effect of the introduction of SGLT2, in patients with heart failure under optimal treatment, on echocardiographic parameters of left ventricular function. Descriptive analytical study conducted in 40 patients with chronic heart failure with reduced LVEF already receiving optimal treatment, based on angiotensine converting enzyme (ACE), beta-blockers and anti-aldosterone, in which we introduced dapagliflozin at 5–10 mg/day. An echocardiographic evaluation of systolodiastolic left ventricular function and longitudinal function by calculating the GLS was performed before and 3 months after initiation of treatment. Of the 40 patients, 28 of them had type 2 diabetes. On average, 82% of patients had high left ventricular systolic pressure, The mean left ventricular ejection fraction was 40 ± 3.6 before and 41.5 ± 2.5 after treatment, (P = 0.2). Analysis of diastolic function shows an E/E’ ratio at 14.2 ± 3.0 before and 08.1 ± 2.5 after treatment, (P = 0.0001), The index at 0.54 ± 0.03 before and 0.47 ± 0.02 after treatment (P = 0.004), systolic pulmonary blood pressures were 45 ± 5 mmHg before and 34 ± 3 after treatment (P < 0.000), the average GLS was −11.5 ± 2.6 before and −14.5 ± 2.7 after treatment (P < 0.000). SGLT2 inhibitors are agents with pleiotropic effects that, in addition to reducing blood sugar, provide cardiovascular benefits, by lowering preload and postloading. Cardiac fibrosis is recognized as an important pathophysiological factor in the development of heart failure. Several studies indicate an antifibrotic effect of SGLT2 inhibitors. Our modest work confirmed the positive impact of SGLT2 on the improvement of left ventricular function parameters and therefore prognosis.

Lung Ultrasound B-lines as a Surrogate Marker for High Left Ventricular Diastolic Pressures; a bed-side Diagnostic tool

Background: We studied the diagnostic accuracy of B-lines (comet-tail sign) on bedside lung US, NT-proBNP, E/e` on ECHO in differentiation of the causes of acute dyspnea in the emergency setting. Major advantages include bedside availability, no radiation, high feasibility and reproducibility, and cost efficiency. Methods: Our prospective study was performed at the alazhar university hospital, Cairo, Egypt, between July 2019 and March 2020. All patients underwent lung ultrasound examinations, along with TTE, laboratory testing, including rapid NT-proBNP testing. Results: The median E/e’ levels in patients with B-profile were 18, compared with a median of 7.4 in the subjects with A-profile (P =&lt; 0.0001 CI = -9.649 to -7.044). It was found that the sensitivity and the specificity of detecting B-profile on ultrasound is high when E/e’ &gt; 15.5 (95.0% and 83.0% consecutively), which concluded the high correlation between finding B profile on U/S chest and elevated left ventricle filling pressure in a patient presenting with picture of suggestive of heart failure Conclusion: Chest ultrasound can be used as screening test for the evaluation of patients with suspicion of heart failure with excellent sensitivity and good specificity.

The role of regional myocardial topography post-myocardial infarction on infarct extension.

Infarct extension involves necrosis of healthy myocardium in the border zone (BZ), progressively enlarging the infarct zone (IZ) and recruiting the remote zone (RZ) into the BZ, eventually leading to heart failure. The mechanisms underlying infarct extension remain unclear, but myocyte stretching has been suggested as the most likely cause. Using human patient-specific left-ventricular (LV) numerical simulations established from cardiac magnetic resonance imaging (MRI) of myocardial infarction (MI) patients, the correlation between infarct extension and regional mechanics abnormality was investigated by analysing the fibre stress-strain loops (FSSLs). FSSL abnormality was characterised using the directional regional external work (DREW) index, which measures FSSL area and loop direction. Sensitivity studies were also performed to investigate the effect of infarct stiffness on regional myocardial mechanics and potential for infarct extension. We found that infarct extension was correlated to severely abnormal FSSL in the form of counter-clockwise loop at the RZ close to the infarct, as indicated by negative DREW values. In regions demonstrating negative DREW values, we observed substantial fibre stretching in the isovolumic relaxation (IVR) phase accompanied by a reduced rate of systolic shortening. Such stretching in IVR phase in part of the RZ was due to its inability to withstand the high LV pressure that was still present and possibly caused by regional myocardial stiffness inhomogeneity. Further analysis revealed that the occurrence of severely abnormal FSSL due to IVR fibre stretching near the RZ-BZ boundary was due to a large amount of surrounding infarcted tissue, or an excessively stiff IZ.

Transcatheter Mitral Valve Replacement: A Novel Anchor Technology.

Mitral valved stents tend to migrate or to develop paravalvular leakage due to high-left ventricular pressure in this cavity. Thus, this study describes a newly developed mitral valved stent anchoring technology. Based on an existing mitral valved stent, four anchoring units with curved surgical needles were designed and fabricated using three-dimensional (3D) software and print technology. Mitral nitinol stents assembled with four anchoring units were successively fixed on 10 porcine annuli. Mechanical tests were performed with a tensile force test system and recorded the tension forces of the 10 nitinol stents on the annulus. The average maximum force was 28.3 ± 5.21 N, the lowest was 21.7 N, and the highest was 38.6 N until the stent lost contact with the annulus; for the break force (zero movement of stent from annulus), the average value was 18.5 ± 6.7 N with a maximum value of 26.9 N and a minimum value of 6.07 N. It was additionally observed that the puncture needles of the anchoring units passed into the mitral annulus in all 10 hearts and further penetrated the myocardium in only one additional heart. The anchoring units enhanced the tightness of the mitral valved stent and did not destroy the circumflex coronary artery, coronary sinus, right atrium, aortic root, or the left ventricular outflow tract. The new anchoring units for mitral nitinol stents were produced with 3D software and printing technology; with this new type of anchoring technology, the mitral valved stent can be tightly fixed toward the mitral annulus.

58-OR: Diastolic Dysfunction, a Precursor for Heart Failure in Young Adults with Youth-Onset Type 1 and Type 2 Diabetes: The SEARCH for Diabetes in Youth Study

Individuals with diabetes are at high risk for heart failure with preserved ejection fraction due to diabetic cardiomyopathy (DCM), defined as abnormal myocardial structure and function in the absence of overt coronary artery disease. DCM leads to myocardial fibrosis and remodeling with one of the first signs being left ventricular (LV) diastolic dysfunction. The objective was to compare the prevalence of diastolic dysfunction among young adults with type 1 diabetes (T1D) vs. type 2 diabetes (T2D) with diabetes diagnosed in childhood. Participants had T1D or T2D and were enrolled in the SEARCH for Diabetes in Youth Study. Cardiovascular risk factors and diastolic function via echocardiography were measured at an in-person visit, after an average disease duration of 10.9 years (both groups). Unadjusted means were compared between those with T1D and T2D, p &amp;lt;0.05 indicating significance. Diastolic dysfunction was defined as abnormal LV filling volume, LV pressure, or transmitral velocity, based on published norms for age. Of 458 eligible participants, 255 had T1D (mean age 21.2±5.2 years, 60.8% non-Hispanic white, 54.1% female, mean A1c 9.0±1.9%), and 203 had T2D (mean age 24.3±4.3 years, 24.1% non-Hispanic white, 75.4% female, mean A1c 9.6±3.0%). Participants with T2D had a worse cardiovascular risk profile (higher BMI, systolic and diastolic BP, triglycerides, LDL-C, A1c and lower HDL-C) than those with T1D, all p&amp;lt;0.05. Participants with T2D also had lower LV filling volume, transmitral velocity and higher LV pressure, all p&amp;lt;0.05, than those with T1D, suggesting worse diastolic function. The unadjusted prevalence of diastolic dysfunction was high in both groups (57.7% in T2D vs. 47.2% in T1D; p&amp;lt;0.05). Diastolic function is worse in individuals with T2D compared to T1D, but diastolic dysfunction is high in both groups. These findings support monitoring of young adults with diabetes for development of heart-related complications. Disclosure A.S. Shah: None. D. Dabelea: None. L.M. Dolan: None. S. Isom: None. R. Dagostino: Consultant; Self; Amgen, AstraZeneca, Celgene, Daiichi Sankyo. L.E. Wagenknecht: None. G. Imperatore: None. S. Saydah: None. A.D. Liese: None. J.M. Lawrence: None. C. Pihoker: None. E.M. Urbina: None. Funding Centers for Disease Control and Prevention (1U18DP006131, U18DP006133, U18DP006134, U18DP006136, U18DP006138, U18DP006139); National Institutes of Health (1UC4DK108173)

Impact of High Baseline Left Ventricular Filling Pressure on Transcatheter Aortic Valve Replacement Outcomes in Patients with Significant Mitral Annular Calcification

Left ventricular filling pressure (LVFP) has been demonstrated to be a major predictor of poor cardiovascular outcomes. However, estimation of LVFP in patients with aortic stenosis is limited by the high prevalence of significant mitral annular calcification. The aim of this study was to investigate the effect of transcatheter aortic valve replacement on LVFP and the relationship of LVFP to mortality and hospitalization. This was a single-center, retrospective study of 140 consecutive patients in sinus rhythm with significant mitral annular calcification who underwent transcatheter aortic valve replacement for severe aortic stenosis from May 2011 to June 2015. Mean follow-up duration was 3.06±1.48years (minimum, 2.4years; maximum, 6.5years). Diastolic function was assessed using recently proposed criteria for those with significant mitral annular calcification. High LVFP was defined as a mitral E/A ratio > 1.8 or a ratio of 0.8 to 1.8 and isovolumic relaxation time < 80 msec. At baseline, the proportion of patients with high LVFP was 40.7%, similar to 1month (39.7%) (P=.86). However, the proportion of patients with high LVFP was significantly decreased at 1year compared with those at baseline (26.9% vs 40.7%, P=.02). Multivariate analysis showed that high LVFP at baseline significantly increased risk for all-cause mortality compared with patients with normal LVFP (hazard ratio, 2.84; 95% confidence interval, 1.33-6.05; P=.007). High baseline LVFP was associated with a significantly increased all-cause mortality, and LVFP does not improve in the short term but only at 1year after transcatheter aortic valve replacement.

High Left Ventricular Filling Pressure on Doppler Echocardiography Is Associated With Graft Failure and Overall Mortality Following Kidney Transplantation.

Although E/e´ is prognostic of mortality in patients with end-stage renal disease (ESED), little is known about the prognostic implications of E/e´ following kidney transplant (KT). The objective of this study was to evaluate whether an elevated E/e´ is associated with graft function, postoperative hemodialysis, and overall mortality in end-stage renal disease patients following KT. A retrospective observational study. Tertiary teaching hospital. In total, 1,045 patients underwent KT at the authors' hospital between January 2006 and December 2013. None. Patients were divided into groups with an E/e´<15 or≥15, as assessed by preoperative echocardiography (median time from preoperative assessment of echocardiography to surgery: 37 days [IQR: 16-68 days]). Of 1,045 patients, 821 patients (78.6%) had an E/e´<15, and 224 patients (21.4%) had an E/e´≥15. Multivariate analysis indicated that age (odds ratio [OR]: 1.03; 95% confidence interval [CI]: 1.01-1.04, p = 0.001), diabetes mellitus (OR: 2.7; CI: 1.94-3.83, p<0.001), β-blocker (OR: 1.4; CI: 1.03-1.95, p = 0.034), left atrial dimension (OR: 1.07; CI: 1.04-1.11, p<0.001), and left ventricular mass index (OR: 1.02; CI: 1.01-1.03, p<0.001) are predictive of E/e´≥15. After adjustment using inverse probability of treatment weighting, E/e´≥15 also was associated independently with postoperative hemodialysis (OR: 2.0; 95% CI: 1.5-2.6, p<0.001), graft failure (OR: 1.7; 95% CI: 1.4-2.2; p<0.001), and overall mortality (hazard ratio [HR]: 3.2; 95% CI: 2.1-4.8, p<0.001). Preoperative E/e´ is a prognostic indicator of overall mortality in ESRD patients undergoing KT.

Aortic stiffness as a predictor of high-sensitivity cardiac troponin T levels at a chronic stage after ST-segment elevation myocardial infarction

Background Aortic stiffness is associated with early pulse wave reflection resulting in an increase of cardiac afterload and impairment of coronary perfusion. Experimental data show that high left ventricular pressure due to increased aortic stiffness is associated with enhanced myocardial cell death. We investigated whether aortic stiffness is related to high-sensitivity cardiac troponin T (hs-TnT) concentrations at a chronic stage 1 year after ST-segment elevation myocardial infarction (STEMI).

Influence of Mitral Valve Anterior Leaflet in vivo Shape on Left Ventricular Ejection

Recent studies have demonstrated that, due to the active involvement of leaflet contractile elements, the anterior mitral leaflet (AML) is very stiff and maintains a compound curvature during ventricular systole. Studies based on structural mechanics have shown that both leaflet stiffness and compound curvature are key factors limiting AML deformation in the presence of high left ventricular (LV) systolic pressures. In the present study, we tested the hypothesis that maintenance of this physiological AML compound curvature also plays a role in the optimization of LV outflow during ejection. The LV cavity, mitral valve and aortic root of a healthy human were reconstructed from cardiac magnetic resonance images on 18 evenly rotated long-axis cut-planes at peak systole. Computational fluid dynamics was used to assess hemodynamics within the ventricular outflow tract in the presence of three different AML profiles: (i) physiologically compound as measured in vivo, (ii) flat, (iii) concave (i.e., prolapsed) towards the ventricle. Relative to the physiologic profile, AML flat and concave profiles induced progressively increasing hemodynamic alterations at the LV outflow and immediately downstream to the aortic valve, characterized at peak systole by flow detachment, a mean vorticity increase of 15.6 and 53.1% and an instantaneous power loss increase of 12 and 46%, respectively. These results support the hypothesis that the physiological AML shape plays an important role in optimizing LV ejection. This implies that AML profile alterations associated with valvular disease or surgical repair procedures can significantly reduce LV ejection efficiency.

Mitral leaflet modeling: Importance of in vivo shape and material properties

The anterior mitral leaflet (AML) is a thin membrane that withstands high left ventricular (LV) pressure pulses 100,000 times per day. The presence of contractile cells determines AML in vivo stiffness and complex geometry. Until recently, mitral valve finite element (FE) models have neglected both of these aspects. In this study we assess their effect on AML strains and stresses, hypothesizing that these will differ significantly from those reported in literature.Radiopaque markers were sewn on the LV, the mitral annulus, and AML in sheep hearts, and their four-dimensional coordinates obtained with biplane video fluoroscopy. Employing in vivo data from three representative hearts, AML FE models were created from the marker coordinates at the end of isovolumic relaxation assumed as the unloaded reference state. AML function was simulated backward through systole, applying the measured trans-mitral pressure on AML LV surface and marker displacements on AML boundaries.Simulated AML displacements and curvatures were consistent with in vivo measurements, confirming model accuracy. AML circumferential strains were mostly tensile (1–3%), despite being compressive (−1%) near the commissures. Radial strains were compressive in the belly (−1 to −0.2%), and tensile (2–8%) near the free edge.These results differ significantly from those of previous FE models. They reflect the synergy of high tissue stiffness, which limits tensile circumferential strains, and initial compound curvature, which forces LV pressure to compress AML radially. The obtained AML shape may play a role not only in preventing mitral regurgitation, but also in optimizing LV outflow fluid dynamics.

Facteurs associés au syndrome d’apnées du sommeil dans l’insuffisance cardiaque

Objective Genesis of sleep apnoea syndrome (SAS) in chronic heart failure (CHF) is not well known. The aim of our study was to find associated factors to SAS in heart failure (HF) and to look for differences between central sleep apnea (CSA) and obstructive sleep apnea (OSA). Patients and methods We realised a cross-sectional and retrospective study. Thirty patients with stable heart failure under medical optimal therapy were included. Polygraphy, echocardiography and cardiopulmonary exercise were systematically performed. Results Men were predominant (80%) in the group. Mean age, left ventricular ejection fraction (LVEF) were respectively 64.1 ± 13.8 years and 40 ± 9.8%. SAS was present in 60% of patients (33.3% were classified as central sleep apnoea [CSA] and 26.7% as obstructive sleep apnoea [OSA]). Body mass index, blood pressure and left ventricular pressures estimated by the E/Ea ratio were significantly higher in the group with SAS ( P < 0.05) compared to the non SAS group. New York Heart Association class was significantly higher ( P = 0.04) and the predicted peak VO 2 was significantly lower in CSA patients compared to OSA patients. Conclusion High left ventricular pressures estimated by the E/Ea are significantly associated with SAS in heart failure. CSA patients tend to have a worse functional state than OSA patients.

Assessment of Left Ventricular Endocardial Fibroelastosis in Fetuses With Aortic Stenosis and Evolving Hypoplastic Left Heart Syndrome

Systematic evaluation of left ventricular (LV) endocardial fibroelastosis (EFE) in the fetus has not been reported. The role of EFE in the pre- and postnatal evolution of hypoplastic left heart disease, and the implications of EFE for outcomes after prenatal intervention for fetal aortic stenosis with evolving hypoplastic left heart syndrome have also not been determined. A 4-point grading system (0-3) was devised for the assessment of fetal LV echogenicity, which was presumed to be due to EFE. Two reviewers independently graded EFE on the preintervention echocardiograms of fetuses treated with in utero aortic valvuloplasty for evolving hypoplastic left heart syndrome from 2000 to 2008. Intra- and interobserver reproducibility was determined for the EFE grade and characterization of related echocardiographic features. The relations among EFE severity, other left heart anatomic and physiologic variables, and postintervention outcomes were analyzed. The assessment and grading of EFE was possible for both observers in all 74 fetuses studied. By consensus, the EFE severity was grade 1 in 31 patients, grade 2 in 32, and grade 3 in 11. Fetuses with mild (grade 1) EFE had significantly greater maximum instantaneous aortic stenosis gradients (e.g., higher LV pressures) and less globular LV geometry than patients with grade 2 or 3 EFE on preintervention echocardiogram. The severity of EFE was not associated with the size of the aortic valve or LV. From preintervention to late gestation, the time-indexed change in LV end-diastolic volume was significantly greater in fetuses with grade 1 EFE than those with more severe EFE. Incorporation of EFE severity into our previously published threshold score improved the sensitivity and positive predictive value for the postnatal biventricular outcomes. In conclusion, echocardiographic grading of EFE is possible, with reasonable intra- and interobserver reliability in midgestation fetuses with evolving hypoplastic left heart syndrome. EFE severity corresponded to some indexes of left heart size, geometry, and function and with the probability of a biventricular outcome postnatally. Additional experience and external validation of the EFE grading scoring system are necessary.

Left thoracotomy surgical approach for chronic instrumentation in dogs providing high quality left ventricular pressure, aortic pressure and cardiac electrocardiogram signals

Left thoracotomy surgical approach for chronic instrumentation in dogs providing high quality left ventricular pressure, aortic pressure and cardiac electrocardiogram signals

Early and late effects of iron deficiency on heart and baroreflex function

Iron deficiency (ID) induces cardiac and neural alterations, such as cardiac hypertrophy and apoptosis, electron transport dysfunction, and brain mitochondrial disruption. Cardiac norepinephrine (NE) depletion suggests chronically high sympathetic nervous system (SNS) traffic to the heart. Thus, ID would be expected to affect heart function and blood pressure, and our previous experiments have shown baroreflex alterations after 4 weeks of ID.HYPOTHESES(1) Chronic high SNS output initially leads to a hyperfunctional heart with higher left ventricular pressure (LVP) and heart rates (HR) at each mean arterial pressure (MAP), and (2) eventual depletion of NE, along with heart apoptosis and debility, is coincident with reduced LVP and HR at all MAP.METHODSRats were fed control (CN) or ID diets for 2 or 4 weeks. Baroreflex experiments were conducted using ramp (before and after atropine) and steady state protocols. Hearts were excised for Langendorff experiments to obtain LVP at set flow rates.RESULTSHematocrit verified ID (p ≤ 0.05); heart mass verified hypertrophy. Baroreflex preliminary data suggests higher HR at all MAP at 2 weeks, but lower HR after 4 weeks; experiments continue at time of writing. Langendorff data indicates higher LVP with ID at 2 weeks, but lower LVP after 4 weeks.CONCLUSIONChanges with ID are adaptive at 2 weeks but pathological after 4 weeks. Supported by WY INBRE (LC4090).

Predictors of Technical Success and Postnatal Biventricular Outcome After In Utero Aortic Valvuloplasty for Aortic Stenosis With Evolving Hypoplastic Left Heart Syndrome

Aortic stenosis in the midgestation fetus with a normal-sized or dilated left ventricle predictably progresses to hypoplastic left heart syndrome when associated with certain physiological findings. Prenatal balloon aortic valvuloplasty may improve left heart growth and function, possibly preventing evolution to hypoplastic left heart syndrome. Between March 2000 and October 2008, 70 fetuses underwent attempted aortic valvuloplasty for critical aortic stenosis with evolving hypoplastic left heart syndrome. We analyzed this experience to determine factors associated with procedural and postnatal outcome. The median gestational age at intervention was 23 weeks. The procedure was technically successful in 52 fetuses (74%). Relative to 21 untreated comparison fetuses, subsequent prenatal growth of the aortic and mitral valves, but not the left ventricle, was improved after intervention. Nine pregnancies (13%) did not reach a viable term or preterm birth. Seventeen patients had a biventricular circulation postnatally, 15 from birth. Larger left heart structures and higher left ventricular pressure at the time of intervention were associated with biventricular outcome. A multivariable threshold scoring system was able to discriminate fetuses with a biventricular outcome with 100% sensitivity and modest positive predictive value. Technically successful aortic valvuloplasty alters left heart valvar growth in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome and, in a subset of cases, appeared to contribute to a biventricular outcome after birth. Fetal aortic valvuloplasty carries a risk of fetal demise. Fetuses undergoing in utero aortic valvuloplasty with an unfavorable multivariable threshold score at the time of intervention are very unlikely to achieve a biventricular circulation postnatally.

Precordial thump for cardiac arrest is effective for asystole but not for ventricular fibrillation

Precordial thump for cardiac arrest remains controversial. Although precordial blows can trigger ventricular fibrillation (VF) (i.e., commotio cordis), they paradoxically have been regarded as potential therapy for cardiac arrest. In commotio cordis, impact energy and resultant peak left ventricular (LV) pressure are important variables in VF initiation. The purpose of this study was to assess the relationship between LV pressures generated by thumps and their effectiveness in defibrillation of VF or resuscitation of asystole after defibrillation. After induction of VF, 10 swine each received 18 chest thumps; two sets of three thumps each with a clenched fist, a 30-mph lacrosse ball, and a 40-mph lacrosse ball. If asystole followed defibrillation, manual thumps were given to induce ventricular depolarizations until resumption of spontaneous rhythm. During VF, generated LV pressure (mmHg) was 263 +/- 52 with manual thumps, 392 +/- 179 with 30-mph ball thumps, and 616 +/- 182 with 40-mph ball thumps (P <.001). None of the 180 thumps terminated VF. All episodes required electrical defibrillation. During asystole, generated LV pressures were greater for thumps that induced ventricular depolarizations than for those that did not (111 +/- 27 mmHg vs 73 +/- 23 mmHg, P <.001). A significant association was observed between induction of ventricular depolarizations and thump-generated LV pressures (odds ratio 2.0 per 10 mmHg rise in LV pressure, 95% confidence interval 1.8-2.1). Despite generating high LV pressures, precordial thumps were not effective in terminating VF. Based on these data, precordial thump for VF in cardiac arrest victims cannot be recommended but for asystolic victims might be beneficial.

Coronary heart disease in women: Less extensive disease and improved long-term survival compared to men

Objectives. The aim of the study was to compare extent of coronary disease and subsequent long-term survival in women compared to men adjusted for baseline differences in demographics and morbidity. Design. In the database at Feiring Heart Clinic 18 767 patients had a coronary angiographic examination in the period from March 1999 to December 31, 2006. Their survival status as of May 31, 2007 was ascertained through the Norwegian National Registry. Survival was compared using age stratified analyses and Cox regression adjusting for baseline differences. Results. Significantly more women than men had no coronary disease (28.7 vs. 10.5%, p <0.001), while three vessel disease was more frequently present in men (38.7 vs. 21.8%, p <0.001), as judged by coronary angiography. Covariate adjusted survival was significantly better in women compared to men with an overall hazard ratio of 1.29 (p <0.001), but with no significant difference in the subgroup with high left ventricular end diastolic pressure. Conclusions. At the time of referral to invasive examination women had less extensive coronary artery disease than men as judged by coronary angiography and improved long-term survival when baseline differences were accounted for.

Innovative, Replaceable Heart Valve: Concept, In Vitro Study, and Acute In Vivo Study

The purpose of this study was to evaluate the feasibility of our innovative, replaceable heart valves that can be easily detached from the sewing ring at the time of repeat replacement. The prototype devices consist of the base magnet ring assembly and the valve magnet ring assembly that utilize magnetic coupling force for the locking mechanism. Magnetic coupling strength was evaluated in vitro. Prototype bioprosthetic valves were implanted acutely in three sheep to confirm the feasibility of the replaceable mitral valve. The static separation force of prototype size #25 was 12.5 lb, meeting the design goal. In situ attachment and detachment of the valve magnet ring assembly from the base magnet ring assembly were very easily accomplished in all animals. The magnetic coupling did not decouple even under extremely high left ventricular pressures. We have demonstrated the feasibility of this innovative concept of a replaceable mitral valve.