Texas Heart Institute Journal Volume 49: Issue 4

Mitral regurgitation can result from congenital heart disease, rheumatic valve disease, or other congenital malformations of the mitral valve. Faulty valves require surgical repair or replacement. However, echocardiographic and biochemical parameters that inform surgical decision-making for adults may not be appropriate for children. To investigate whether adult parameters can be used in children, we correlated echocardiographic parameters with serum N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in children with chronic mitral regurgitation.

Our sample comprised 45 patients and 38 healthy children. M-mode measurements, left atrial and left ventricular volumes, and Doppler and tissue Doppler echocardiograms were collected. We graded mitral regurgitation according to European Association of Echocardiography recommendations and indexed effective regurgitant area, vena contracta, and regurgitant volume to body surface area. Patients were grouped by regurgitation severity (mild vs moderate or severe) and left ventricular end-systolic dimension (normal vs enlarged).

The NT-proBNP level was higher in patients than in controls (P=0.003), higher in patients with moderate or severe regurgitation (P=0.02), and higher in patients with an enlarged left ventricle (P=0.003). Serum NT-proBNP levels correlated with effective regurgitant area (r=0.47; P=0.002), vena contracta width (r=0.46; P=0.003), regurgitant volume (r=0.32; P=0.04), left ventricular end-systolic diameter (r=0.58; P <0.001), and left atrial diameter (r=0.62; P <0.001). An NT-proBNP value of 66 pg/mL differentiated the mild regurgitation group from the moderate or severe regurgitation group.

Our results correlating NT-proBNP and echocardiographic parameters indexed to body surface area indicate that these adult criteria can be used in children to grade mitral regurgitation and inform surgical decision-making.

Myocardial injury (MI) is not unusual after transcatheter aortic valve replacement (TAVR). To determine precipitating factors and prognostic outcomes of MI after TAVR, we retrospectively investigated relationships between MI after TAVR and aortic root dimensions, baseline patient characteristics, echocardiographic findings, and procedural features.

Of 474 patients who underwent transfemoral TAVR for severe aortic stenosis in our tertiary center from June 2011 through June 2018, 188 (mean age, 77.7 ± 7.7 yr; 96 women [51%]) met the study inclusion criteria. Patients were divided into postprocedural MI (PMI) (n=74) and no-PMI (n=114) groups, in accordance with high-sensitivity troponin T levels.

We found that MI risk was associated with older age (odds ratio [OR]=1.054; 95% CI, 1.013–1.098; P=0.01), transcatheter heart valve type (OR=10.207; 95% CI, 2.861–36.463; P=0.001), distances from the aortic annulus to the right coronary artery ostium (OR=0.853; 95% CI, 0.731–0.995; P=0.04) and the left main coronary artery ostium (OR=0.747; 95% CI, 0.616–0.906; P=0.003), and baseline glomerular filtration rate (OR=0.985; 95% CI, 0.970–1.000; P=0.04). Moreover, the PMI group had a longer time to hospital discharge (P=0.001) and a higher permanent pacemaker implantation rate (P=0.04) than did the no-PMI group.

Our findings may enable better estimation of which patients are at higher risk of MI after TAVR and thus improve the planning and course of clinical care.

von Willebrand factor (vWF) aids coagulation at sites of vessel injury. Elevated vWF levels have been associated with an increased risk of ischemic heart disease (IHD); however, it is unclear whether vWF deficiency, seen in patients with von Willebrand disease (vWD), protects people against IHD. We determined and compared the prevalence and risk of IHD in patients with versus without vWD by using data from the National Inpatient Sample (2009–2014), excluding patients younger than 18 and older than 75 years. The primary outcome was the odds ratio (OR) of IHD in patients with versus without vWD. Secondary outcomes were major medical comorbidities and demographic characteristics in patients with vWD.

Of 224,475,443 weighted hospital-discharge samples, we identified 82,809 patients with a vWD diagnosis. The odds of IHD were lower in patients with vWD than in those without (OR=0.54; 95% CI, 0.52–0.56). After multivariable logistic regression analysis and adjustment for age, sex, and typical IHD risk factors (hypertension, smoking, diabetes, hyperlipidemia, chronic kidney disease, obesity, and family history of IHD), the likelihood of IHD remained lower in patients with vWD than in patients without (OR=0.65; 95% CI, 0.63–0.67). Our study shows that vWF deficiency, as seen in patients with vWD, is associated with a decreased prevalence of IHD. Further investigation may confirm these findings.

An 80-year-old man with syncope was admitted for evaluation. His clinical examination revealed nothing remarkable. He had no history of heart disease, his blood pressure and electrolyte levels were normal, and he was taking no medications known to cause bradyarrhythmia. Overnight telemetry revealed the electrocardiogram displayed below (Fig. 1).

The rhythm strip suggests which diagnosis?

A)
Isorhythmic atrioventricular dissociation
B)
Mobitz type I atrioventricular block
C)
Premature ventricular contractions in trigeminy
D)
Junctional escape and intermittently captured beats
E)
Premature atrial complexes in trigeminy

FOCUS on ECGs: Answer #30

D) Junctional escape and intermittent capture beats

Lyme Carditis and Inflammation-Driven Plaque Erosion Presenting as Sudden Cardiac Arrest

Marco KaldasMD,

Moneal ShahMD,

Diana PashaievaBDS,

Georgios LygourisMD, and

Anita RadhakrishnanMD

Double Interatrial Septum and Patent Foramen Ovale in Woman With Transient Ischemic Attack

Thrombotic Left Main Coronary Artery Occlusion Treated With Bioresorbable Scaffold

Percutaneous Coronary Intervention for Acute Coronary Syndrome in a 44-Year-Old Man With Hemophilia A

Mitral Regurgitation and Serum N-Terminal Pro-Brain Natriuretic Peptide Levels in Children: A Modification of Adult Criteria

Predictors and Prognostic Implications of Myocardial Injury After Transcatheter Aortic Valve Replacement

The Cardioprotective Potential of von Willebrand Disease in Ischemic Heart Disease

Decongestion Models and Metrics in Acute Heart Failure: ESCAPE Data in the Age of the Implantable Cardiac Pressure Monitor

Percutaneous Intervention With GuideLiner Catheter in 4 Patients With Anomalous Coronary Artery Originating From Opposite Sinus of Valsalva

Fetal Left Ventricular Apical Aneurysm Progressing to Dilated Cardiomyopathy Due to Glycogen Storage Disease

Myocardial Scintigraphy in Diagnosing Cardiac Transthyretin Amyloidosis

Right Atrial Thrombus Mimicking a Myxoma: Synergism of Hormonal Contraceptives and Antiphospholipid Antibodies

Thoracic Endovascular Aortic Repair With Subclavian Revascularization for Symptomatic Nonaneurysmal Aberrant Right Subclavian Artery

Nontuberculous Mycobacterial Infections Associated With Left Ventricular Assist Devices in 3 Patients

Papillary Fibroelastoma Incidentally Found on Left Atrial Wall During Minimally Invasive Aortic Valve Replacement

Distal Aortic Malperfusion Exacerbated by Antegrade Stent-Graft Placement During Hybrid Repair of Acute DeBakey Type I Aortic Dissection

A Gnostic Understanding of Coping for the Cardiothoracic Surgeon

What Is the Mechanism of This Cardiac Rhythm?

FOCUS on ECGs: Answer #30

Using the Apple Watch to Record Multiple-Lead Electrocardiograms in Detecting Myocardial Infarction: Where Are We Now?

Lyme Carditis and Inflammation-Driven Plaque Erosion Presenting as Sudden Cardiac Arrest

Risk Factors for Development of Stroke in Patients With Continuous-Flow Left Ventricular Assist Device Support as Destination Therapy

Navigating the Complexities of Mitral Valve Clipping: Early Severe Mitral Valve Stenosis After Mitral Valve Clipping

Midterm Outcomes of Pediatric Mitral Valvuloplasty for Moderate to Severe Mitral Valve Regurgitation and Associated Risk Factors for Postoperative Deterioration

The Department of Cardiovascular Anesthesia of The Texas Heart Institute: An Informal History

Iliac Artery Aneurysm Repair with Preservation of a Single Ectopic Pelvic Kidney

Restoration of Renal Allograft Function via Reduced-Contrast Percutaneous Revascularization of Transplant Renal Artery Stenosis

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Ectopic Right Renal Artery Originating from Anomalous Common Celio-Mesenteric Trunk: Multifaceted Imaging Approach

Good Doctors and the State of Missouri: A Connection Worth Remembering