Citations

Background: In right heart failure, Doppler-derived indices such as RV performance index (RIMP) and tricuspid regurgitant duration (TRD) have been linked to clinical outcomes, but variably. We tested the hypothesis that this variability is based on varying timing and predictive value of the onset of diastolic phase, according to right atrial pressure (RAP) and to whether tissue or flow Doppler is used. Methods: We reviewed echocardiograms and catheter examinations for 151 consecutive patients with pulmonary arterial hypertension. Te’ and TE were defined as the time from QRS onset to the onset of early diastolic velocity on tissue Doppler imaging at the tricuspid valve annulus and to TRD terminal indicating the onset of tricuspid inflow. All measurements were corrected for heart rate. The patients were grouped into low (RAP < 10mmHg, n = 84) and high RAP groups (RAP ≧ 10mmHg, n = 67). Results: Over 3 years, there were 62 total deaths and 8 lung transplantations. In low RAP group, Te’ was prolonged in association with an increase in Tau (R = 0.51, p = 0.0001) and prolonged Te’ predicted higher mortality (HR = 1.20 / 10ms, p = 0.02). In high RAP group, Te’ was still prolonged as Tau increased (R = 0.43, p = 0.008) independently of RAP, while TE was reversely shortened as RAP rose (R = 0.41, p = 0.0006) and shortened TE predicted higher mortality (HR = 0.86 / 10ms, p = 0.008). An increase in RIMP using tissue Doppler only in low RAP group and shortened TRD only in high RAP group predicted higher mortality (HR = 2.09 / 0.1, p = 0.002 and HR = 0.89 / 10ms, p = 0.02, respectively), keeping in line with Te’ and TE, respectively. Conclusions: Both the onset of diastolic tricuspid annular movement and the onset of tricuspid inflow relate to relaxation disorder. As RAP elevates, only the tricuspid inflow onsets early. These observations should be considered when interpreting Doppler-derived indices: they predict clinical outcomes in a limited group of patients according to RAP and to whether tissue or flow is focused on.

Limited information exists regarding the echocardiographic and clinical predictors of exercise capacity and their effects on exercise with advancing age or by sex. We hypothesized that LV diastolic function (DF) impacts exercise capacity to a greater degree with advancing age. This was a prospective cohort study of consecutive patients undergoing routine exercise echocardiography with the Bruce protocol (n=2955). DF assessments at rest and exercise were performed. Those with echocardiographic exercise-induced ischemia and significant valvular disease were excluded. Univariate and multivariate analyses were conducted to determine the strongest echocardiographic and clinical predictors of exercise capacity (METs). Results were reported as unstandardized β coefficient (Standard Error) as outlined beside each variable. Age and sex interactions of these predictors with exercise capacity were determined. The strongest independent multivariate predictors of exercise capacity were female vs. male sex [−1.98 (0.07), p<0.0001], body mass index >30 kg/m 2 [−1.24 (0.08), p<0.0001], age per 10 year increment [−0.85 (0.01), p<0.0001], mild resting diastolic dysfunction vs. normal [−0.70 (0.10), p<0.0001], and moderate/severe resting diastolic dysfunction vs. normal [−1.3 (0.13), p<0.0001]. LV filling pressures measured by a resting E/e’ ≥ 15 [−0.42 (0.14), p=0.004] or exercise E/e’≥ 15 [−0.31 (0.14), p<0.0001] similarly predicted a reduction in exercise capacity, each in separate multivariate analyses. The impact of impaired relaxation and left ventricular filling pressures on exercise capacity increased with advancing age (p<0.001 and p=0.02 respectively), and was most marked after age 50. These predictors had a similar negative effect on exercise capacity among men and women (p=NS). In conclusion, in this large population referred for exercise echocardiography and not limited by ischemia, resting DF and resting/exercise LV filling pressures independently predicted exercise capacity. The increasingly potent effect of impaired relaxation and exercise LV filling pressures with advancing age suggest that DF plays an important role in the development of exercise intolerance in the elderly.

Background: Increased reflective wave from pulmonary artery (PA) causes mid-systolic deceleration (MSD) and notching in Doppler flow velocity envelope of RV ejection flow. Our aim is to test whether profile of MSD and notching provides insight into hemodynamics and patient outcomes in pulmonary artery hypertension (PAH), using quantitative measurements. We hypothesized that the deceleration time of the MSD slope (DTMSD), meaning the steepness of the slope, reflects interaction between RV ejection and reflective wave, and that peak velocity of post-notching flow (Vpost) reflects RV function. Methods: We reviewed RV ejection flow envelope recordings by pulsed wave Doppler for 157 consecutive patients with PAH between 1/2008 and 3/2013 (age 57 ± 14) with an estimated RV systolic pressure of 79 ± 23 mmHg. DTMSD was measured as the time between the first peak acceleration wave and MSD slope extrapolated to zero line. We also reviewed right heart catheterization performed within one month from echocardiography in 78 of the 157 patients. Results: We identified MSD and notching in 148 patients. On multivariate regression analyses, PA capacitance was the key determinant of DTMSD (beta = -0.49, p <0.0001). Vpost was determined by cardiac index (beta = -0.36, p = 0.0014). During a median follow-up period of 30 months, there were 47 deaths from all causes and 7 lung transplantations. On Cox hazard analyses, shorter DTMSD and smaller Vpost are significant predictors of higher mortality independently of each other (HR 0.92 / 10ms, p = 0.045 and HR 0.97, p = 0.028, respectively). Conclusion: Mid-systolic deceleration of RV ejection flow became steeper in the setting of lower PA compliance causing a greater reflectance wave. Reduced peak velocity of post-notching flow reflected impaired RV with reduced cardiac output. Quantitative assessment of profile of mid-systolic deceleration and notching in RV ejection flow envelope is useful in predicting hemodynamics and patient outcomes in PAH.

Introduction: Pericardial decompression syndrome (PDS) has been reported as a spectrum of cardiac decompensation following pericardiocentesis including ventricular failure, cardiogenic shock and pulmonary edema. PDS has been reported in patients undergoing drainage ≥450 mL of pericardial fluid. Hence judicious drainage of large volume effusions to avoid complication has been recommended Hypothesis: PDS complicating undergoing transthoracic echocardiography (TTE) guided pericardiocentesis is uncommen Methods: Consecutive patients undergoing TTE guided pericardiocentesis at our center from 1/2007 to 12/2016 were reviewed. Procedures were performed in a standard fashion under moderate conscious sedation with TTE determining the location of aspiration and determining adequate resolution of pericardial fluid post procedure. All fluid was removed at time of centesis regardless of the size of effusion, except for patients with severe pulmonary hypertension (n=9), who had staged removal of 100cc every 10 minutes. Post procedure, a pigtail catheter was left in the pericardial space for ongoing intermittent drainage and removed after the total net output was <50 mL/24 hours. Patients were monitored in an intermediate level care unit. All patients underwent repeat TTE at the time of catheter removal. Large volume was defined as ≥450 mL of fluid. Patients in whom pericardiocentesis was technically unsuccessful were excluded Results: Over a 10-year period a total of 1067 patients (57% male, mean age 62±16 years) underwent 1164 technically successful pericardiocentesis procedures. Of these, 561 patients had large volume (≥450 mL) aspirated (mean 750±345 mL aspirated, range 450 - 4300 mL). Patients had a pericardial catheter in place for a mean 2.9±2 days. One patient with pre-existing severe biventricular dysfunction after aspiration of 400cc developed hypotension that improved with reversal of sedation, but proceeded to have PEA arrest and die. No other patient developed clinical events of acute left or right heart failure, ventricular dysfunction, unexplained hypotension, cardiogenic shock or other clinical events that could relate to PDS Conclusions: At most one episode of PDS was observed after technically successful percutaneous pericardiocentesis in 1164 cases (561 were large volume), although whether this case was PDS is unclear. PDS appears to be very rare, and staging pericardial decompression over time may be unnecessary, other than, perhaps, in patients with severe ventricular dysfunction or severe pulmonary hypertension

LINKED CONTENT This article is linked to Meserve et al paper. To view this article, visit https://doi.org/10.1111/apt.16217

INTRODUCTION: Significant variability between colonoscopy operators contributes to postcolonoscopy colorectal cancers (CRCs). We aimed to estimate postcolonoscopy colorectal neoplasia (CRN) detection by multi-target stool DNA (mt-sDNA), which has not previously been studied for this purpose. METHODS: In a retrospective cohort of patients with +mt-sDNA and completed follow-up colonoscopy, positive predictive value (PPV) for endpoints of any CRN, advanced adenoma, right-sided neoplasia, sessile serrated polyps (SSP), and CRC were stratified by the time since previous colonoscopy (0–9, 10, and ≥11 years). mt-sDNA PPV at ≤9 years from previous average-risk screening colonoscopy was used to estimate CRN missed at previous screening colonoscopy. RESULTS: Among the 850 studied patients with +mt-sDNA after a previous negative screening colonoscopy, any CRN was found in 535 (PPV 63%). Among 107 average-risk patients having +mt-sDNA ≤9 years after last negative colonoscopy, any CRN was found in 67 (PPV 63%), advanced neoplasia in 16 (PPV 15%), right-sided CRN in 48 (PPV 46%), and SSP in 20 (PPV 19%). These rates were similar to those in 47 additional average risk persons with previous incomplete colonoscopy and in an additional 68 persons at increased CRC risk. One CRC (stage I) was found in an average risk patient who was mt-sDNA positive 6 years after negative screening colonoscopy. DISCUSSION: The high PPV of mt-sDNA 0–9 years after a negative screening colonoscopy suggests that lesions were likely missed on previous examination or may have arisen de novo . mt-sDNA as an interval test after negative screening colonoscopy warrants further study.

AbstractSeveral environmental factors have been implicated in the pathogenesis of inflammatory bowel diseases (IBD); however, the evidence for alcohol is sparse, as is its implications on disease activity and overall management. Here, we examine the available evidence for the effect of alcohol on IBD, including its association with the development of IBD, role in exacerbations, and potential medication interactions. Several mechanisms have been demonstrated to mediate the effects of ethanol in the gastrointestinal tract. Alcohol has been shown to alter the gut microbiome, disrupt intestinal barrier, and increase intestinal permeability, directly and indirectly promoting immune activation. Conversely, specific alcoholic beverages, notably red wine, may have anti-inflammatory properties capable of assisting in disease control and affecting disease monitoring. Nonetheless, most alcohol-mediated effects seem to facilitate intestinal inflammation and consequently impact disease onset, recurrence, and symptom control. Furthermore, alcohol use interferes with the metabolism of several medications leading to increased side effect profiles or even loss of effect. Notably, mesalamine, azathioprine, methotrexate, and biologic medications can all be affected by concomitant alcohol intake via a variety of mechanisms.

Abstract Hypertrophic cardiomyopathy (HCM) is a heritable, phenotypically diverse, and often asymptomatic heart muscle disease which is a major cause of sudden cardiac death (SCD) in young adults. The gold-standard for the diagnosis of HCM is echocardiography (echo), which is an ultrasound-based cardiac imaging modality. Across all sites of the Mayo Clinic enterprise, echo images and measurement data are reviewed, interpreted, and reported via the Echo Information Management System (EIMS). The objective of this paper is to develop a machine learning model for the identification of HCM from cardiac measurements obtained by the echo. We developed a novel machine learning model on patient demographic information and echo measurements that were retrieved from the EIMS digital data registry and selected by cardiologists. Random forest (RF) was utilized to investigate the predictive performance of these features on the identification of HCM patients. The HCM cohort consists of 3,548 patients with at least one HCM diagnostic billing code (ICD-9 or ICD-10), from 2014 to 2019. The class labels “HCM yes” and “HCM no” were assigned by manual review of medical records as well as the outcomes of the gold standard imaging tests for HCM diagnosis. The developed model performed well in finding HCM patients with an accuracy of 95%, recall of 99%, and precision of 97%. The F1 score was 98 %, while 4% of patients were misclassified. This model will be translated into clinical practice for a clinical decision support system in EIMS to assist providers in the accurate diagnosis of HCM from echo data automatically while ensuring high-quality echo interpretation.

Introduction: Diastolic dysfunction impairs exercise capacity and has prognostic value in exercise echocardiography. We aimed to assess whether left atrial strain (LAS), which is reduced with worsening in diastolic function, is associated with all-cause death or heart failure hospitalization in patients undergoing treadmill echocardiography. Methods: We performed 2D-speckle tracking analysis of LAS in 1636 consecutive patients (mean age 64±13 and 59% men) who underwent treadmill echocardiography between 1/2013 and 1/2014. We used the 2016 ASE recommendation to define diastolic function and elevated LV filling pressure. Results: Of 1636 study subjects, 95% had LV ejection fraction ≥ 50%. Diastolic function was normal in 44% of patients and abnormal in the remaining (23% grade I, 9% grade II, 1% grade III, and 23% indeterminate). During a mean follow-up of 5.5±1.8 years, 210 patients (12.8%) experienced the composite outcome (157 death and 88 heart failure hospitalization). Lower LASreseroivr, LASbooster and LA emptying fraction (LAEF) were all associated with increased risk for the adverse outcome independent of age, sex, clinical and echocardiographic parameters, and after further adjustment for diastolic function (abnormal vs. normal) (all p≤0.001). The association of LASbooster with the outcome attenuated in a model with LASreservoir or LAEF (both p>0.1). Adding LASreservoir to clinical and echocardiographic parameters provided incremental prognostic value (continuous net reclassification improvement=0.09, p=0.04), but not LAEF or LASbooster. Patients with LASreservoir <34.2% (lowest tertile) had more than doubled risk for death or heart failure hospitalization than those with LASreservoir ≥34.2% after multivariable adjustment in the entire cohort (adjusted hazard ratio 2.2, 95%CI: 1.53 - 3.23), as well as in those with normal stress test (n=1217, adjusted HR, 3.53, 95%CI: 2.29 - 5.53) or those without elevated resting LV filling pressure (n=1466, adjusted HR: 2.08, 95%CI: 1.46 - 2.96). Conclusions: LASreservoir provides independent prognostic information in patients undergoing exercise echocardiography.