Prior Structural Heart Disease Research Articles

EP News: Case Reports

Complete heart block at the time of pregnancy has been rarely observed and previously attributed to autoimmune disorders, metabolic derangements, prior structural heart disease (congenital, valvular, and surgical), or inflammation. Less is known about patients in whom complete heart block is felt to be idiopathic. Young et al (https://doi.org/10.1016/j.hrcr.2021.07.002) shared a case of a 37-year-old woman at 30 weeks of gestation who presented with 1 week of dyspnea, fatigue, and palpitations and was diagnosed with complete heart block (heart rate in the 40s).

Impact of a predefined pacemapping protocol for ablation of infrequent premature ventricular complexes: a prospective, multicenter study

Abstract Funding Acknowledgements Type of funding sources: None. Background Pacemapping (PM) is a useful maneuver for aiding PVC ablation procedures, but its stand-alone clinical value when activation mapping is precluded is still to be defined. Objectives To analyze the clinical efficacy of a predefined PM protocol to be applied during low-burden premature ventricular complex (PVC) ablation procedures, regardless of their site of origin (SOO) and the presence of prior structural heart disease (SHD). Methods Prospective, non-randomized, multicenter study including 185 consecutive patients referred for a first PVC ablation. A predefined PM protocol was performed to guide ablation whenever a burden < 1 PVC/min was found after a 15-min waiting period, which precluded activation mapping. PM was performed using the PASO module of CARTO3 navigation system, obtaining a correlation grading, color-coded map. A minimum correlation of 94% was required for classifying an area as the PVC-SOO. After identifying the SOO, a high-density PM map with a fill threshold set to 6 was performed and ablation was delivered to the ‘target area’, defined as the area delimited by the 3 best matching points above the minimum correlation of 94%. Three RF applications were systematically applied in the target area with appropriate parameters: 40 W for the RVOT and aortic root, 50 W for the subvalvular LVOT, 20-30 W in the distal coronary sinus, at operator’s discretion in other locations. Clinical success was defined as a PVC-burden reduction of ≥ 80% in the 24-h Holter after 6 months. Results 105/185 patients (57%) could undergo activation mapping, while 60/185 (32%) had to be PM-guided. Only 20 patients (11%) had to be canceled due to complete absence of PVCs. Baseline QRS, PVC burden and an OT origin were independent predictors of the need to undergo a PM-guided ablation. The most frequent SOO locations were RVOT (44%), LV (23%), and LVOT (16%), with a significantly higher proportion of RVOT-SOO in the PM group (52% vs. 40%, p = 0.03). The mean target area was 0.6 ± 0.9 cm2, with a mean smallest PM correlation within that area of 95 ± 4%. The mean 10-ms isochronal area in LAT-guided procedures was significantly higher than the PM target area (1.7 ± 2.3 cm2; p < 0.001). The mean number of PM matching points acquired was 39 ± 21 (range 6 – 98). Mean mapping (29 ± 22 min) and RF (135 ± 124 sec) times were similar both for LAT and PM-guided procedures, with significantly shorter procedure times in the PM group (53 ± 24 vs. 61 ± 26 min; p = 0.04). Clinical success after a 6-month follow-up reached 87% for the PM approach, similar to that of LAT mapping-based ablation procedures (90%; p = 0.58). Conclusions When LAT mapping is precluded by a very low PVC burden in unselected patients referred for PVC ablation procedures, a first-line, stepwise PM and ablation protocol directed to a target area with > 94% matching correlation is a feasible alternative, reaching comparable clinical results regardless of the PVC-SOO and the presence of SHD. Abstract Figure. Example of a predefined PM protocol

Gram-negative infective endocarditis: a retrospective analysis of 10 years data on clinical spectrum, risk factor and outcome.

Infective endocarditis (IE) is a significant cause of morbidity and mortality. Underlying congenital heart disease and acquired valvular disease significantly increases the IE risk, which is still prevalent in developing countries. Gram-negative organism related IE prevalence appears to be rising with limited data on their presentation and outcomes. This study hopes to shed further light on this subject. This retrospective cross-sectional study occurred in a tertiary care center in South India. A retrospective cross-sectional study performed in a single tertiary care center in South India. All patients with IE from 2006 to 2016 were included in this study. The details of clinical presentation, laboratory investigations, clinical course, microbiology, and outcomes were obtained. Patients fulfilling the modified Duke's criteria and a culture-proven diagnosis of gram-negative IE were eligible for inclusion. A total of 27 patients were enrolled from Jan 2006 to Dec 2016, among whom 78% were male. Prior structural heart disease was common in our cohort (41%) with renal (55%) and embolic (51%) complications being the most common systemic complications. A comparison of mortality with survivors found that congenital and acquired structural heart disease had a higher risk of mortality. Non-fermenting GNB accounted for 52% of the cohort, with Pseudomonas accounting for 19%. E. coli was the most common bacilli isolated, constituting 37% of the cohort. Assessment of risk factors for adverse outcomes found that renal dysfunction and intravascular device were significant with multivariate-logarithmic analysis showing renal dysfunction as an independent risk factor. In-hospital mortality in this series was 30%. In conclusion, gram-negative IE was more prevalent among males. Underlying structural heart disease was the most common risk factor associated with the disease. Renal dysfunction and embolic complications were the most common complications in this cohort. E. coli and NFGNB accounted for 70% of the offending organisms. In-hospital mortality was similar to patients with IE secondary to common organisms. The presence of renal dysfunction was an independent risk factor for an adverse outcome.

Arrhythmias in viral myocarditis and pericarditis.

Acute viral myocarditis and acute pericarditis are self-limiting conditions that run a benign course and that may not involve symptoms that lead to medical assessment. However, ventricular arrhythmia is frequent in viral myocarditis. Myocarditis is thought to account for a large proportion of sudden cardiac deaths in young people without prior structural heart disease. Identification of acute myocarditis either with or without pericarditis is therefore important. However, therapeutic interventions are limited and nonspecific. Identifying those at greatest risk of a life-threatening arrhythmia is critical to reducing the mortality. This review summarizes current understanding of this challenging area in which many questions remain.

ACS-like acute myocarditis vs. acute myocardial infarction: continuous clinical challenge

Background: Myocarditis with an acute coronary syndrome (ACS)-like presentation poses an important clinical challenge in the differential diagnosis of acute myocardial infarction (AMI). Comparing ACS-like myocarditis with AMI patients can shed a light on the similarities and the important differences between the two clinical syndromes. Objective: To compare the clinical, laboratory and echocardiographic characteristics of patients with ACS-like myocarditis and acute myocardial infarction. Methods: We conducted a retrospective analysis comparing consecutive patients, hospitalized at the Sheba Heart Center, with cardiac magnetic resonance (CMR)-proven ACS-like acute myocarditis and non-ST elevation MI (NSTEMI) between February 2002 and May 2012. The AMI group included patients with NSTEMI, without prior structural heart disease (SHD). Elderly NSTEMI patients (age>65) were excluded to achieve a minimal degree of matching between the cohort populations. Results: One hundred and one consecutive patients with CMR confirmed myocarditis were included along with 124 patients with first NSTEMI, average age of 33.9±12.5 vs. 52.4±7.6 respectively (p<0.001). Cardiac risk factors were significantly more prevalent in the AMI group (p<0.01). The average ejection fraction was 54.0% and 54.6% (NS) respectively, with similar prevalence of localized regional wall motion abnormality (WMA) and average WM score index of 1.2 in both study groups. The cardiac biomarkers were markedly higher in the myocarditis group including troponin I (14.5 vs. 5.9, p<0.001) and peak CPK (648.5 vs. 447.5, p=0.008). In-hospital clinical outcome parameters like hemodynamic instability and pulmonary congestion were similar while we found a trend towards more tachyarrhythmia in patients with myocarditis (8 vs. 4, p=0.07). Conclusions: Localized regional WMA is as prevalent in ACS-like myocarditis as in AMI patients, emphasizing the diagnostic dilemma between the two entities. Interestingly, we show significantly higher cardiac biomarkers elevation for the same extent of myocardial dysfunction in patients with acute myocarditis compared to myocardial infarction.

Lactobacillus isolated pulmonic valve endocarditis with ventricular septal defect detected by transesophageal echocardiography

Endocarditis resulting from Lactobacillus species, an anaerobic, nonsporulating, gram-positive bacilli, is rare. Forty-two cases have been reported in the literature.l, 2 Lactobacillus species are generally considered nonpathogenie flora of the mouth, gut, and female genital tract.l They have been mostly reported in patients with prior structural heart disease (83 % ), congenital (bicuspid aortic valve, ventricular septal defect [VSD]) or acquired (prior endocarditis, rheumatic heart disease, prosthetic valves).3 The aortic, mitral, and tricuspid valves have been infected by Lactobacillus species. From our review of the literature isolated Lactobacillus pulmonary valve endocarditis has not been previously reported. We present such a case in a young woman with subarterial VSD and emphasize the role of transesophageal echocardiography (TEE) in establishing the diagnosis. A 21-year-old white woman arrived at the University of Rochester Medical Center with a l-week history of chills, fever, and dry cough. One day before admission, she noted the onset of a pleuritic left-sided chest pain and dyspnea. She denied recent weight loss or genitourinary or gastrointestinal symptoms. Her medical history was significant for congenital supracristal VSD and clinically insignificant pulmonary stenosis diagnosed by cardiac catheterization at the age of 6. Surgical correction was not required. She had no history of diabetes or hypertension. She denied intravenous drug or alcohol abuse. She had no recent dental work or teeth cleaning. She reported a broken molar 1 month before admission. Physical examination on admission was notable for a temperature of 40.2” C, blood pressure of 130/75 mm Hg, heart rate of 150 beats/ mm, and a respiratory rate of 36 breaths/min. Fundoscopic examination revealed no Roth spots or retinal hemorrhages. The oral cavity had teeth with multiple caries. There was no lymphadenopathy. No skin lesions were noted. The jugular venous pressure was estimated at 6 cm water above the right atrium. The lungs had decreased breath sounds and rales over the left lower lobe but were