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Stress (takotsubo) cardiomyopathy (SC) is a recently recognized syndrome with clinical and electrocardiographic (ECG) presentation resembling ST elevation anterior myocardial infarction. As experience with this condition has evolved, a more diverse spectrum of 12-lead ECG patterns has emerged that may affect differential diagnosis. Fifty-nine consecutive patients with SC were prospectively identified at a large community-based cardiology practice. All were women aged 32 to 90 years (mean 66 ± 13) with acute chest pain triggered by emotional or physical incidents and with akinesia of the mid-distal left ventricle; each patient recovered and was discharged within a median of 4 days. On electrocardiography, anterior ST elevation was most common (33 [56%]), with magnitudes less than in controls with left anterior descending coronary artery occlusions (1.4 ± 1.5 vs 2.4 ± 2.2 mm, p <0.001), with considerable overlap. ECG findings in 26 other patients (44%) without ST elevation revealed diffuse T-wave inversion (10 [17%]) and healed anterior infarctions (6 [10%]) or were nonspecific (5 [8.5%]) or normal (5 [8.5%]). Troponin elevations occurred in 56 patients with SC (95%). The mean peak troponin T level was significantly lower in patients with SC (0.64 ± 0.86 ng/ml) than in those with left anterior descending coronary artery occlusions (3.88 ± 4.9 ng/ml) (p <0.0001). Patients with SC with or without ST elevation did not differ with respect to the ejection fraction (29 ± 9% vs 34 ± 9%, respectively, p = NS) or Thrombolysis In Myocardial Infarction (TIMI) frame counts. During recovery, diffuse T-wave inversion evolved in 49 patients with SC (83%). In conclusion, patients with SC present with diverse ECG findings, and no single pattern alone can reliably distinguish this condition from acute coronary syndromes. The diagnosis of SC requires heightened awareness of its unique clinical profile as well as coronary arteriography and left ventriculography. [Copyright &y& Elsevier]

Cardiovascular magnetic resonance (CMR) is a high spatial resolution, 3-dimensional tomographic imaging technique which may identify regions of massive left ventricular hypertrophy (particularly when confined to the anterolateral free wall) in which the extent of wall thickness is underestimated with traditional 2-dimensional echocardiography in patients with hypertrophic cardiomyopathy (HC). This observation may have potential implications on management strategies as extreme left ventricular hypertrophy is a primary risk factor for sudden death in HC and therefore supports an expanding role for CMR in the evaluation of HC patients. [Copyright &y& Elsevier]

Left ventricular apical aneurysms, in absence of coronary artery disease, occur in approximately 1% of patients with hypertrophic cardiomyopathy (HC). Identical twins, age 44 years, are presented with HC and identical LV morphology, including apical aneurysms. These cases demonstrate a genetic predisposition to the development of apical aneurysm, as well as overall LV morphology, in patients with HC. [Copyright &y& Elsevier]

Although tako-tsubo cardiomyopathy (TTC) is regarded as a reversible condition with favorable outcome, a malignant clinical course evolves in some subjects. In this single-institution experience, we describe the clinical profile of patients with adverse TTC outcome. A cohort of 249 consecutive patients with TTC was interrogated for those with acute unstable presentation during the first 24 hours. Forty-seven patients (19%) experienced early complicated clinical course with cardiac arrest in 9 (ventricular fibrillation, n = 4, pulseless electrical activity, n = 3, and asystole, n = 2) or marked hypotension in 38 (systolic blood pressure =90 mm Hg requiring vasopressors and/or balloon pump). Of the 47 patients, Killip class III to IV heart failure was present in 30 (64%). Despite treatment, 8 patients (3%; all women) died inhospital due to respiratory failure, cardiogenic shock, or anoxic brain injury. All 8 inhospital deaths occurred among the 47 patients with unstable presentation, including 2 after cardiac arrest and 6 with marked hypotension. Post-TTC event mortality for a period of 4.7 ± 3.4 years significantly exceeded that in a matched general US population (standardized mortality ratio 1.4; 95% confidence interval 1.1 to 1.9; p = 0.005) largely due to noncardiac co-morbidities. In conclusion, contrary to widespread perception, TTC is not an entirely benign and reversible condition. Among this large cohort, a high-risk subgroup was identified with cardiac arrest or hemodynamic instability, accounting for all hospital deaths. Hospital nonsurvivors had a variety of irreversible co-morbid conditions with the potential to compromise clinical status and adversely affect short-term survival. Long-term survival after hospital discharge was also reduced compared with the general population because of noncardiac co-morbidities [ABSTRACT FROM AUTHOR]

Two patients with hypertrophic cardiomyopathy are reported from the recent experience of the Hypertrophic Cardiomyopathy Center of the Minneapolis Heart Institute Foundation, demonstrating limitations in the risk stratification algorithm currently used for this disease. One patient, an asymptomatic 21-year-old male college student, was prophylactically implanted with a cardioverter-defibrillator. This decision was based largely on the presence of apparent extensive myocardial fibrosis identified by contrast-enhanced cardiovascular magnetic resonance imaging, currently not considered a risk factor in this disease. Fifteen months later, ventricular fibrillation was interrupted by an appropriate defibrillator shock. The other patient, an asymptomatic 15-year-old male subject without any apparent high-risk markers, died suddenly at home. Necropsy examination of the heart identified scarring confined to portions of both left ventricular papillary muscles, possibly representing a substrate for ventricular tachyarrhythmias. In conclusion, these 2 cases demonstrate that present strategies for assessing high-risk status in hypertrophic cardiomyopathy are inadequate to identify all such patients. However, while the anecdotal nature of these observations cannot yet justify altering the general guidelines for implantation of defibrillators for the primary prevention of sudden death related to hypertrophic cardiomyopathy, 1 of our 2 cases suggests a future role for contrast-enhanced cardiovascular magnetic resonance in the risk stratification of this complex disease. [Copyright &y& Elsevier]

This case presents an uncommon but important mechanism of muscular left ventricular outflow obstruction in hypertrophic cardiomyopathy due to anomalous and direct papillary muscle insertion into the anterior mitral leaflet, a finding reliably identified clinically by cardiac magnetic resonance imaging. The identification of this left ventricular outflow tract morphology is important before invasive ventricular septal reduction therapy because it dictates a specific surgical strategy. These findings further support the role of cardiac magnetic resonance imaging in the early evaluation of hypertrophic cardiomyopathy patients. [ABSTRACT FROM AUTHOR]

Cardiovascular magnetic resonance (CMR) with extensive late gadolinium enhancement (LGE) is a novel marker for increased risk for sudden death (SD) in patients with hypertrophic cardiomyopathy (HC). Small focal areas of LGE confined to the region of right ventricular (RV) insertion to ventricular septum (VS) have emerged as a frequent and highly visible CMR imaging pattern of uncertain significance. The aim of this study was to evaluate the prognostic significance of LGE confined to the RV insertion area in patients with HC. CMR was performed in 1,293 consecutive patients with HC from 7 HC centers, followed for 3.4 ± 1.7 years. Of 1,293 patients (47 ± 14 years), 134 (10%) had LGE present only in the anterior and/or inferior areas of the RV insertion to VS, occupying 3.7 ± 2.9% of left ventricular myocardium. Neither the presence nor extent of LGE in these isolated areas was a predictor of adverse HC-related risk, including SD (adjusted hazard ratio 0.82, 95% confidence interval 0.45 to 1.50, p = 0.53; adjusted hazard ratio 1.16/10% increase in LGE, 95% confidence interval 0.29 to 4.65, p = 0.83, respectively). Histopathology in 20 HC hearts show the insertion areas of RV attachment to be composed of a greatly expanded extracellular space characterized predominantly by interstitial-type fibrosis and interspersed disorganized myocyte patterns and architecture. In conclusion, LGE confined to the insertion areas of RV to VS was associated with low risk of adverse events (including SD). Gadolinium pooling in this region of the left ventricle does not reflect myocyte death and repair with replacement fibrosis or scarring. [ABSTRACT FROM AUTHOR]

In hypertrophic cardiomyopathy (HC), atrial fibrillation (AF) is an important determinant of clinical deterioration due to heart failure or embolic stroke. This study characterizes left atrial (LA) structural and functional parameters to establish markers predictive of AF risk, using cardiovascular magnetic resonance (CMR) imaging. We studied 427 consecutive patients with HC in sinus rhythm with CMR (age 44 ± 18 years), including 41 who developed clinically overt AF after study entry (2.6 ± 2.1 years), 49 patients with AF before CMR, 337 patients with HC but without AF, and 244 normal controls. LA chamber was assessed for absolute and indexed end-diastolic volume (LAEDV), end-systolic volume, and percent ejection fraction (LAEF). In the 41 prospectively studied patients with HC who developed AF during follow-up, LAEDV was significantly greater than in patients without AF (146 ± 48 vs 107 ± 37 ml) or in normal controls (81 ± 24 ml, p <0.001). Percent LAEF was lower in patients developing AF (36 ± 10%) than without AF (46 ± 12%) or controls (55 ± 9%, p <0.001). Multivariate analysis identified LAEF (<38%), LAEDV (≥118 ml), and age (≥40 years) as independently associated with AF occurrence. In conclusion, CMR measures of LA remodeling and dysfunction reliably identified patients with HC at risk for future development of AF. Decrease in LAEF represents a strong novel marker of susceptibility to AF in this disease. [ABSTRACT FROM AUTHOR]

Preparticipation screening of athletes with 12-lead electrocardiography has been promoted for the detection of asymptomatic cardiovascular disease, particularly hypertrophic cardiomyopathy (HC). Although false-positive electrocardiographic (ECG) results for HC are well recognized in athlete screening, expected false-negative rates are unknown. The aim of this study was to characterize the rate of false-negative ECG findings in a cohort of young asymptomatic patients with phenotypically expressed HC, defined by cardiovascular magnetic resonance, using the 2010 European Society of Cardiology recommended ECG criteria for the identification of suspected heart disease in trained athletes. Cardiac magnetic resonance studies and 12-lead electrocardiography were performed in 114 consecutive asymptomatic patients with HC aged ≤35 years (mean age 22 ± 8 years; 77% male patients). Electrocardiograms were analyzed to distinguish pathologic ECG patterns from alterations considered nonpathologic and physiologic consequences of athletic training. Among the 114 patients with HC, 103 (90%) demonstrated ≥1 pathologic ECG abnormality, while the remaining 11 patients (10%) had normal or nonpathologic ECG patterns and therefore defined a subgroup in whom ECG screening would not be expected to raise suspicion of heart disease (i.e., false-negative results). In this false-negative ECG results group, maximal left ventricular wall thickness was 17 ± 2 mm (range 15 to 21), compared to patients with pathologic ECG patterns, in whom maximal left ventricular wall thickness was 22 ± 5 mm (p = 0.003). In conclusion, a substantial minority of young asymptomatic patients with HC with phenotypically expressed left ventricular hypertrophy have nonpathologic ECG findings on the basis of the 2010 European Society of Cardiology guidelines. In principle, this high false-negative rate of 10% represents an important limitation in applying 12-lead electrocardiography to large, apparently healthy athletic populations for the detection of HC. [Copyright &y& Elsevier]

Hypertrophic cardiomyopathy (HC) is the most common cause of sudden death in the young, but survival to particularly advanced age is less well appreciated. The investigators report the prevalence, clinical features, and demographics of patients with HC surviving to ≥90 years of age. Of 1,297 patients with HC in the Hypertrophic Cardiomyopathy Center database (Minneapolis Heart Institute Foundation), 26 (2.0%) were identified who had achieved the age of ≥90 years; 18 (69%) were women. HC diagnosis came late in life, at 61 to 92 years (mean 80 ± 8; ≥75 years in 21 patients), recognized fortuitously by the detection of a heart murmur or during family screening (n = 6) or after onset of new symptoms (n = 20). At most recent evaluation (or death) patients were aged 90 to 96.7 years (mean 92.2 ± 2), with 6 presently alive at 91 to 96 years of age; HC did not appear to be the primary cause of death in any patient. Left ventricular wall thicknesses were 15 to 31 mm (mean 20 ± 3); 8 patients (31%) had obstruction to left ventricular outflow at rest (peak instantaneous gradients, 38 to 135 mm Hg). Significant HC-related complications occurred in 13 patients (50%), including progressive heart failure symptoms, atrial fibrillation, and nonfatal embolic stroke. Although no patient died suddenly, 13 (50%) nevertheless carried conventional HC risk markers. A greater proportion of cohort patients reached ≥90 years of age (2.0%) than expected in the general population (0.8%) (p <0.001). In conclusion, HC may be unrecognized until late in life and is consistent with survival to particularly advanced age into the 10th decade of life without the need for major HC-related treatment interventions, and with demise ultimately largely unrelated to this disease. This principle regarding the natural history of HC can afford a measure of reassurance to many patients. [ABSTRACT FROM AUTHOR]

The development of the hypertrophic cardiomyopathy (HC) phenotype with left ventricular (LV) hypertrophy usually occurs in adolescence, and documentation of patients with later onset of wall thickening during adulthood is rare. We report 4 patients with asymptomatic, nonobstructive HC (3 women and 1 man) who were studied with serial cardiovascular magnetic resonance imaging or echocardiography. In these patients, LV wall thickening, confined to the apex and the contiguous distal portions of the ventricular septum and free wall, appeared in midlife and beyond. These patients were >40, >50, or >70 years old when the hypertrophy became evident. The maximum LV wall thickness was 14 to 25 mm (mean 18), with a “spade” deformity of the distal chamber, associated with a nondilated cavity and normal ejection fraction (65% to 80%), in the absence of mitral valve systolic anterior motion. In each patient, similar electrocardiographic patterns with similar diffuse and marked T-wave inversion (with or without increased precordial voltages) preceded the appearance of the HC phenotype on the imaging studies. In conclusion, the recognition that the onset of LV hypertrophy in HC can be delayed well into adulthood (and even to advanced age) has important implications regarding the clinical screening practices for families, and suggests the potential value of extending prospective serial imaging beyond adolescence in some relatives. Electrocardiographic repolarization abnormalities can predict the future development of apical LV hypertrophy in adults with HC. [Copyright &y& Elsevier]

Multidetector computed tomographic angiography defines anatomy in complex congenital heart disease, but radiation exposure and general anesthesia requirements limit its application. The aim of this study was to compare radiation exposure, anesthesia use, and diagnostic accuracy between standard-pitch, single-source computed tomography and high-pitch, dual-source computed tomography for image quality and risk in a clinical pediatric population. Consecutive computed tomographic scans were evaluated in patients aged <2 years with complex congenital heart disease. Two groups were compared on the basis of standard- versus high-pitch scans. High-pitch scans were further divided into variable pitch (2.25 to 3.0) and highest pitch (3.4) groups. Image quality, radiation exposure, anesthesia use, and diagnostic confidence and accuracy were determined. Sixty-one scans were reviewed (29 at standard pitch, 32 at high pitch). Body surface area, scan length, and indications were similar. The median dose-length product for standard-pitch scans was 66 mGy · cm (range 29 to 372) compared to 7 mGy · cm (range 3 to 50) in all high-pitch scans. The median dose-length product was 28 mGy · cm (range 8 to 50) for variable high-pitch scans and 5 mGy · cm (range 3 to 12) for the highest fixed-pitch scans. Diagnostic confidence was similar, although high-pitch scans had higher image noise and lower contrast-to-noise ratios. All high-pitch scans were performed under sedation with free breathing, and all standard-pitch scans required general anesthesia. Diagnostic accuracy was 100% in the 2 groups, with 17 standard-pitch and 16 high-pitch patients undergoing procedural validation. In conclusion, high-pitch, dual-source computed tomography provides excellent diagnostic accuracy and markedly reduces radiation dose, although image quality is mildly reduced. [Copyright &y& Elsevier]

In hypertrophic cardiomyopathy (HCM), the clinical significance attributable to the broad range of left ventricular (LV) systolic function, assessed as the ejection fraction (EF), is incompletely resolved. We evaluated the EF using cardiovascular magnetic resonance (CMR) imaging in a large cohort of patients with HCM with respect to the clinical status and evidence of left ventricular remodeling with late gadolinium enhancement (LGE). CMR imaging was performed in 310 consecutive patients, aged 42 ± 17 years. The EF in patients with HCM was 71 ± 10% (range 28% to 89%), exceeding that of 606 healthy controls without cardiovascular disease (66 ± 5%, p <0.001). LGE reflecting LV remodeling showed an independent, inverse relation to the EF (B-0.69, 95% confidence interval −0.86 to −0.52; p <0.001) and was greatest in patients with an EF <50%, in whom it constituted a median value of 29% of the LV volume (interquartile range 16% to 40%). However, the substantial subgroup with low-normal EF values of 50% to 65% (n = 45; 15% of the whole cohort), who were mostly asymptomatic or mildly symptomatic (37 or 82% with New York Heart Association functional class I to II), showed substantial LGE (median 5% of LV volume, interquartile range 2% to 10%). This overlapped with the subgroup with systolic dysfunction and significantly exceeded that of patients with an EF of 66% to 75% and >75% (median 2% of the LV volume, interquartile range 1.5% to 4%; p <0.01). In conclusion, in a large cohort of patients with HCM, a subset of patients with low-normal EF values (50% to 65%) was identified by contrast-enhanced CMR imaging as having substantial degrees of LGE, suggesting a transition phase, potentially heralding advanced LV remodeling and systolic dysfunction, with implications for clinical surveillance and management. [Copyright &y& Elsevier]

Increased thickness of the left ventricular (LV) wall is the predominant feature of the hypertrophic cardiomyopathy (HC) phenotype. The structural characteristics of the LV papillary muscles (PMs) have received little attention. In this study, cardiovascular magnetic resonance (CMR) was used to characterize PM morphology in a large HC population. Cine and delayed enhancement (DE) CMR images were obtained in 201 patients with HC and 43 control subjects. PM number and mass index were greater in patients with HC compared with controls (2.5 vs 2.1, p <0.001, and 6 ± 2 vs 3 ± 2 g/m2, p <0.001, respectively), including 109 (54%) with PM mass ≥7 g/m2 (≥2 SDs above the mean for controls). Greater LV wall mass index was associated with more substantial PM mass (r = 0.09, p <0.001). Furthermore, 12 patients with HC (19%) had normal LV mass with localized wall thickness but increased PM mass. In patients with HC with LV outflow obstruction at rest, PMs were positioned closer to the ventricular septum (displaced anteriorly: 58% vs 42% for subjects without obstruction, p = 0.02), with more marked hypertrophy (9 ± 5 vs 6 ± 4 g/m2, p <0.001). Preoperative CMR identified 3 patients with accessory, anteriorly displaced PMs judged to contribute to outflow obstruction, which were resected during septal myectomy. DE of the PMs was identified in 13 patients with HC (6%), including 3 with DE confined to PMs. In conclusion, CMR demonstrates LV PMs to be part of the cardiomyopathic process in HC, with increases in number and mass, and not uncommonly associated with remodeling with DE. The identification of accessory PMs may be useful in planning preoperative strategy. [Copyright &y& Elsevier]

Few other diseases show the degree of phenotypic heterogeneity expressed by HC. The two novel patients reported here with isolated posterobasal LV free wall hypertrophy (and mitral valve prolapse) extend this morphologic diversity even farther, now 3 decades after the introduction of contemporary 2-dimensional imaging. [ABSTRACT FROM AUTHOR]

Patients with left ventricular apical aneurysms represent a unique patient subgroup in the broad clinical spectrum of hypertrophic cardiomyopathy (HC) associated with the risk for sudden death, heart failure, and peripheral thromboembolism. Routine chronic anticoagulation has not been a standard recommendation for these patients. We present a 36-year-old patient with HC with features of acute coronary syndrome, likely secondary to coronary thromboembolism as a complication of left ventricular apical aneurysm. Our experience with this patient raises consideration for prophylactic anticoagulant therapy for this unusual subset of patients with HC. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Comparison of circadian rhythm patterns in tako-tsubo cardiomyopathy versus ST-segment elevation myocardial infarction" by Scott W. Sharkey and colleagues in a 2012 issue and also presents a response from the authors of the article.

We found a highly inconsistent relation between the granular and reflective ultrasound ("speckling") pattern frequently observed in the ventricular septum of patients with hypertrophic cardiomyopathy and evidence of myocardial fibrosis by contrast-enhanced cardiovascular magnetic resonance imaging. Therefore, this distinctive echocardiographic appearance of the myocardium does not accurately characterize left ventricular scarring and is most likely explained as an extraneous ultrasound signal pattern. In conclusion, myocardial fibrosis in patients with hypertrophic cardiomyopathy is most reliably identified using contrast-enhanced cardiovascular magnetic resonance imaging. [ABSTRACT FROM AUTHOR]

Current guidelines empirically recommend serial clinical evaluations for asymptomatic patients with severe mitral regurgitation (MR). However, there is a paucity of data on the effectiveness of such monitoring. This study sought to examine the potential benefit of guideline adherence among asymptomatic patients with severe primary MR. Asymptomatic patients with severe primary MR who had been evaluated in the Allina Health system between January 1, 2012 and May 30, 2018 were examined. The medical records were manually reviewed for demographics, comorbidities, echocardiographic data, subsequent interventions, and clinical outcomes. Patients were grouped according to occurrence of guideline adherence, which was defined as a serial clinical evaluation with echocardiography every 12 ± 1 month until mitral valve surgery, or death. Over the study period, 246 patients (67.3 ± 15.5 years, 61.4% men) with severe, asymptomatic primary MR were identified, including 154 patients (62.6%) with and 92 patients (37.4%) without guideline adherence. Overall, there were no differences in demographics, morbidities, MR severity, or left ventricular function between patient adherence groups. During follow-up (40.9; 21.2, 58.3 months), patients with adherence more frequently had surgery or transcatheter therapy performed (64.3% vs 18.5%; p <0.001) and the time to intervention was earlier (13.6 [3.9-22.7] vs 44.2[25.6-57.3] months; p <0.001). Compared to non-adherent patients, those with guideline adherence had a significantly higher five-year survival free from all-cause mortality (92.0% vs 74.3%, p = 0.002), and freedom from death or hospitalization for heart failure (90.1% vs 69.3%, p = 0.001). Adherent patients also had a significantly better survival free from combined endpoint of death, re-hospitalization for heart failure, myocardial infarction, and stroke (84.5% vs 63.2%, p = 0.002). In patients with asymptomatic severe primary MR, guideline adherence with serial evaluations every 12 months or less is associated with earlier therapy and improved long-term outcomes. These data support educational efforts to promote guideline adherence., Competing Interests: Disclosures The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Transfemoral aortic valve implantation (TAVI) has become a viable alternative to surgical valve implantation, particularly for higher risk patients; however, vascular complications (VCs) remain a concern in transfemoral TAVI. We aimed to determine clinical and computed tomographic angiography-derived risk factors associated with Valve Academic Research Consortium (VARC)-2 criteria VCs in patients who underwent TAVI. From 2011 to 2017, 481 patients underwent percutaneous transfemoral TAVI at the Minneapolis Heart Institute and were screened for procedural and postprocedural access-related VC according to VARC-2 criteria. Clinical and clinical and computed tomographic angiography-derived data were collected to establish risk factors for VC. A total of 99 (21%) patients had VARC-2 VCs. Closure device failure (CDF) occurred in 56 of 99 (57%), minor VCs in 37 of 99 (37%), and major VCs occurred in 6 of 99 (6%). Access site-related VCs were preceded by CDF in 18 of 43 (42%) patients and the risk of major/minor VCs was 14 times greater in patients who experienced closure complications. The incidence of CDF was higher in common femoral artery (CFA) access sites with circumferential vessel wall calcification of more than 90° (p = 0.02) and when skin-surface to CFA access-site distance at an optimal access angle of 45° exceeded 80 mm (p = 0.03). In conclusion, both the degree of circumferential CFA access site calcification and distance to skin surface at an optimal access angle may improve risk stratification of access planning in patients who underwent percutaneous transfemoral TAVI., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Prospective investigations for the frequency of hypoattenuated leaflet thickening (HALT) and its clinical implications in transcatheter aortic valve implantation (TAVI) patients are limited. We initiated a prospective screening program of TAVI patients for HALT beginning in July 2015. Eligible patients were evaluated with gated, contrast-enhanced multidetector computed tomography within 30 days of TAVI, and examined for HALT and clinical outcomes. During the study period, 287 patients (81 ± 8 years; 53% men) who underwent TAVI with commercially approved devices were examined. Overall, 26 patients (9.1%) had occurrence of HALT, and only one of these patients had detectable hemodynamic changes on echocardiography at diagnosis. Notably, 9 of 26 HALT patients had been receiving warfarin, however, the HALT patients more often had subtherapeutic international normalized ratio whereas using warfarin than patients without HALT on index multidetector computed tomography imaging (p = 0.01). Patients who developed HALT had lower baseline aortic gradient, valvuloarterial impedance, and peak aortic velocity, and more commonly had been treated with balloon-expandable valves (73% of all HALT cases) with a higher incidence among those who received larger prostheses. All patients with HALT were placed on anticoagulation at diagnosis, and valvular function remained unchanged at follow-up. Two patients with HALT (7.7%) experienced ischemic stroke. A statistical trend for more major adverse clinical events was present in HALT patients. In conclusion, HALT was detected in 9% of TAVI cases in this prospective observational cohort, with a greater frequency in patients with large, balloon-expandable prostheses. Prospective screening may be considered as early HALT is reversible by timely therapeutic anticoagulation., (Copyright © 2018. Published by Elsevier Inc.)

Refractory progressive heart failure (HF) is becoming the predominant cause of mortality in nonobstructive hypertrophic cardiomyopathy (HC). To anticipate development of this important and often unpredictable clinical course, we investigated whether left ventricular diastolic dysfunction, assessed by echocardiographic Doppler parameters, could identify a subset of patients with HC without obstruction at rest who would experience progression of HF. Diastolic function parameters, assessed by Doppler tissue imaging (DTI), mitral inflow, and pulmonary venous flow were measured in 274 consecutive adult patients with HC evaluated from 2003 to 2007. DTI and other diastolic and clinical/demographic parameters were measured against the composite end point of HF/death, heart transplantation, or progression to advanced New York Heart Association functional class III/IV symptoms and sudden death (SD)/implantable defibrillator (ICD) interventions. HF end points were reached in 19 of 274 patients (7%) over a follow-up period of 4.0 ± 2.3 years. Variables significantly associated with HF outcome by univariate analysis included male gender, initial New York Heart Association class II, lower ejection fraction, and reduced septal and lateral e' mitral annular tissue velocities. Multivariable analysis showed only a reduced lateral e' mitral annular tissue velocity to be independently associated with the composite HF end points (HR 0.77; 95% CI 0.65 to 0.91; p = 0.003). In addition, estimated pulmonary arterial systolic pressure and extensive late gadolinium enhancement by magnetic resonance were also associated with HF outcome (p = 0.04 and p <0.001, respectively). No Doppler (or clinical) variable was associated with SD/appropriate ICD interventions. In conclusion, in HC without outflow obstruction at rest, diastolic dysfunction, evidenced by DTI-reduced lateral e' mitral annular tissue velocity, was associated with adverse long-term HF outcome but was unrelated to SD. This echocardiographic marker provides a potential noninvasive strategy for anticipating progressive HF in this HC patient group., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Tako-tsubo cardiomyopathy (TTC) is an acute reversible cardiac condition usually triggered by stressful events, with a predilection for older women and clinical presentation often confused with acute coronary syndrome. Definition of the diurnal hourly pattern of TTC events may contribute to understanding the pathogenesis of this complex entity. We prospectively enrolled 186 consecutive patients with TTC (68 ± 14 years old, 95% women) and, for comparison, 2,975 patients with ST-segment elevation myocardial infarction (STEMI) at the Minneapolis Heart Institute over the same period. Circadian periodicity was analyzed for hourly occurrence of events throughout the day and for days of the week and months of the year. Occurrence of TTC showed a nonuniform distribution with a distinctive afternoon peak from 12:00 (noon) to 4:00 p.m., comprising 28% (n = 52) of all events, and with the nadir at 12 to 4 a.m. (chi-square 25.6, p <0.001). Patients with events within the peak were older (73 ± 13 years) than other patients (66 ± 13 years, p = 0.0025). Events were uniformly distributed over days of the week and months (p = 0.2 and 0.47, respectively). In contrast, patients with STEMI showed peak occurrence in the early morning hours, 8:00 a.m. to 12:00 p.m., comprising 24% of all events (chi-square 248, p <0.001). In conclusion, TTC events occurred in a circadian pattern with a peak in the afternoon hours, distinctive from the predilection of STEMI for morning hours. This timing of TTC events is most consistent with mechanisms underlying stressful life situations that usually trigger this condition., (Copyright © 2012 Elsevier Inc. All rights reserved.)