Naqvi, Tasneem Z.

AbstractWe present a case of a 60‐year‐old male who was found to be in atrial fibrillation during routine evaluation. Anticoagulation was initiated for 36 h and he was referred for TEE‐guided electrical cardioversion. There was no thrombus identified in the left atrial appendage, however, the appendage was large and had a tongue‐like accessory lobe along with spontaneous contrast in the left atrium and its appendage. TEE probe was not withdrawn, patient underwent successful cardioversion with 200 joules and developed a marked increase in left atrial and left atrial appendage spontaneous contrast along with the development of tear drop shaped thrombus in the left atrial appendage immediately after cardioversion, which rapidly became more dense. There was an associated marked decrease in appendage velocities. Patient was hospitalized to initiate low molecular weight heparin. This case highlights the need for vigilance in patients with an unknown duration of atrial fibrillation, who have received a short duration of anticoagulant therapy and who have adverse appendage anatomy as thrombus may develop immediately after cardioversion despite anticoagulation.

Echocardiography (Echo) has a primary role in the evaluation of cardiac valve regurgitation. Echo valve regurgitation assessment includes multiple qualitative and quantitative methods which require adequate image quality, comprehensive echocardiographic images and precise measurements to obtain accurate assessment. For patient management, it is also important to investigate the mechanism of valve regurgitation. Severity and mechanism of valve regurgitation determine whether continued medical follow up is optimal or surgical or percutaneous valve repair, or replacement option should be necessary. Transthoracic Echo (TTE) is the gold standard most commonly used for the assessment of valve leaflet anatomy, valve motion and regurgitation severity to determine primary versus secondary causes of valve regurgitation, however transesophageal echo (TEE) provides high resolution imaging of valve leaflets and supporting apparatus and oftentimes determines mechanism of valve regurgitation particularly for mitral and tricuspid valves when TTE is unable to determine the mechanism. By providing surgical type views in a moving heart under normal hemodynamic conditions, 3D TEE has greatly improved assessment of mechanism and etiology of valve regurgitation. Besides, TEE also allows quantitation of valve regurgitation severity by Doppler methods as well as direct 3D planimetry of valve area and regurgitant orifice area. Doppler methods are pre and afterload dependent whereas direct 3D planimetry allows assessment of location and severity of valve regurgitation irrespective of ventricular loading conditions. Pre or intraoperative 3D TEE assessment can provide valuable information for surgical planning of valve repair or replacement. This review discusses various valvular pathologies causing regurgitation and the role of TTE and TEE in improving this assessment as shown by several case examples.

We present a case of a 60 year old male who found to be in atrial fibrillation during routine evaluation. Anticoagulation was initiated for 36 hours and he was referred for TEE guided electrical cardioversion. There was no thrombus identified in the left atrial appendage, however the appendage was large and had a tongue like accessory lobe along with spontanous contrast on the left atrium and its appendage. TEE probe was not withdrawn, patient underwent successful cardioversion with 200 joules and developed a thrombus in the left atrial appendage immediately after cardioversion, which rapidly became more dense. There was an associated marked decrease in appendage velocities. Patient was hospitalized to initiate low molecular weight heparin. This case highlights the need for vigilance in patients with unknown duration of atrial fibrillation, who have received a short duration of anticoagulant therapy and who have adverse appendage anatomy as thrombus may develop immediately after cardioversion despite anticoagulation.

Importance In patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited. Objective To report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial. Design, Setting, and Participants SURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021. Intervention Patients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis. Main Outcomes and Measures The prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years. Results A total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm 2 vs 1.8 [0.6] cm 2 ; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention. Conclusions and Relevance Among intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

Abstract Introduction: Individuals with cancer may be at higher risk of atrial fibrillation (AF). However, sufficient data are lacking in AF risk among breast cancer survivors, especially for the mid-to long-term risk of AF and the impact of cancer treatment on this association. We aimed to investigate the risk of incident AF in women diagnosed with breast cancer and evaluate the association by length of follow-up and breast cancer treatment. Methods: Using the Korean Health Insurance Service database, we studied 96,476 women who were diagnosed with breast cancer (aged≥20 years) without prior history of AF and breast cancer and underwent breast cancer surgery between January 2007 and December 2013. They were matched 1:3 to a cancer-free population (n=289,428) based on birth year and sex and were followed to the end of 2018. Using ICD-10 codes (I48.0 to I48.4, I.48.9), AF was defined when it was a discharge diagnosis or was verified more than twice in an outpatient clinic. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of AF associated with breast cancer relative to the cancer-free population, adjusting for age, income, and comorbidities including diabetes, hypertension and hyperlipidemia. Results: During a median follow-up of 6.8 years, AF developed in 2,105 women with breast cancer (3.2 per 1,000 person-years). Mean age at baseline among participants was 49.6 years. Having breast cancer was associated with increased risk of AF (HR, 2.04; 95% CI, 1.93-2.15). This association was stronger for women aged <50 years (HR, 3.98; 95% CI, 3.59-4.40). When we repeated analyses with lag periods of two years to explore the possibility of reverse causation and mid-to long-term risk of AF (n=91,370), the association was largely attenuated but remained significant (HR, 1.18; 95% CI, 1.09-1.28 for total women and HR, 1.60; 95% CI, 1.38-1.86 for women aged <50 years). However, no increased risk of AF was observed in women with breast cancer aged >65 years. Compared with no use of anthracyclines and taxanes, respectively, ever use of anthracyclines and taxanes was associated with increased risk of AF after further adjusting for other cancer treatment modalities including use of trastuzumab, radiotherapy, and endocrine treatment (HR, 1.25; 95% CI, 1.12-1.40 and HR, 1.37; 95% CI, 1.23-1.53, respectively). This association persisted only among women with breast cancer ever treated with anthracyclines when analysis was limited to those with two year-lag periods (HR, 1.23; 95% CI, 1.04-1.45). Conclusions: In this large-scale nationwide cohort study in South Korea, women with breast cancer had an elevated risk of incident AF, especially for women with breast cancer younger than 50 years, regardless of the length of follow-up. Our findings also suggest that cardiotoxic side effects of cancer treatment such as use of anthracyclines might increase both short-term and mid-to long-term risk of AF among women with breast cancer. Citation Format: Yong-Moon ("Mark") Park, Wonyoung Jung, Yohwan Yeo, Sang Hyun Park, Ronda Henry-Tillman, Hong Seok Lee, Tasneem Z. Naqvi, Kyungdo Han, Dong Wook Shin. Risk of atrial fibrillation among women diagnosed with breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3214.

Background: Goal directed point of care echo (POCE) has emerged as a quick, bedside tool to assess cardiac structure and function. However, impact of physician performed POCE during cardiac consultation on immediate patient diagnosis, downstream testing and management has not been assessed. Purpose: To study the impact of POCE performed by consulting cardiologist (CC) during initial cardiology consult. Methods: 69 study patients (pts) underwent examination by an expert imaging CC from Jan 2014-May 2016. During 1-hour consultation, medical records were reviewed, medical history and physical exam was performed followed by cardiologist-performed POCE (Philips CX50). We included a matched control group of 65 pts seen by 3 different CCs during the same time period who underwent standard echo (Secho) up to 3 months after the initial visit. Results: Baseline characteristics were comparable between the two groups for age (mean of 62 ) , cardiac risk factors, and referral diagnoses. POCE findings and Secho (mean delay of 17.2 days after visit) are shown in Table1 and diagnostic tests ordered following initial visit in both groups in Figure 1. POCE had greater yield of echo abnormalities and led to less referral for noninvasive stress testing, more cardiovascular medication changes (15.3 vs 5.7% pts) and more advanced cardiac testing (21 vs 9% pts) compared to the control group after the initial visit. Conclusion: Focused echo at time of consultation leads to more medication adjustments, less referral for noninvasive stress testing, earlier referral for advanced cardiac diagnostic imaging and shortens time to advanced diagnostic workup by about two weeks.

AbstractTakotsubo cardiomyopathy is a transient cardiac condition commonly triggered by a stressor, presenting with clinical features mimicking acute coronary syndromes. We report an unusual case of Takotsubo cardiomyopathy in a man with severe three‐vessel coronary artery disease awaiting coronary bypass surgery who developed rapid spontaneous recovery of cardiac function before revascularization.

Background: Pectus excavatum (PE) deformity involves posterior depression of the sternum and adjacent costal cartilages. The relationship of CT/MRI chest cardiac compression indices used as indications for surgical repair of PE with echocardiographic findings and with improvement in cardiac chamber compression and function post PE repair is unknown. Methods: We evaluated right atrial (RA) size, tricuspid annulus (TA size, right ventricular (RV) outflow tract size as well as RV 2D strain on intra-operative trans-esophageal echocardiography (TEE) immediately pre and post surgical PE repair. Inspiratory and expiratory Haller Index (HI) and cardiac compression indices (CCI) were measured on pre op CT/MR scans (Figure). Offline measurement of chamber dimensions on TEE images was performed and Speckle tracking strain measurements were made using Syngo US Workplace software (Siemens). P<0.05 was considered significant. Results: 60 patients, 73% male, 27% female, age 33.6±10.3 yrs underwent PE repair following CT/MRI from 2010-2014 (Figure). There was a strong correlation between expiratory CT/MRI chest AP diameter and pre-op RA size (panel A). Pre op RA and TA compression on TEE inversely correlated with pre op RV global longitudinal strain rate(RVGLSR) (panels B & C). CCI predicted improvement in RA size post PE repair (panels D & E). In addition pre op RA size on TEE correlated with improvement in RVGLSR post PE repair surgery (panel F). Conclusion: In patients with PE deformity, pre surgical CCI correlated with right-sided cardiac chamber compression on pre op TEE. Severity of chest and cardiac compression also predicted magnitude of improvement in right-sided chamber size and RV longitudinal deformation post PE repair. Our findings provide insight regarding the beneficial effects of PE surgery on right heart chamber compression and improvement in RV function and the important role of intraoperative TEE for patients undergoing PE repair surgery.