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Heart transplantation is the best option for irreversible and critically advanced heart failure. However, limited donor pool, the risk of rejection, infection, and right ventricular dysfunction in short-term post-transplant period, as well as, the development of coronary allograft vasculopathy and malignancy in the long-term post-transplant period limits the utility of heart transplantation for all comers with advanced heart failure. Therefore, selection of appropriate candidates is very important for the best short and long-term prognosis. In this article, we discuss the principles of selection of candidates and compare to the recently updated International Society for Heart and Lung Transplantation (ISHLT) listing criteria with the goal of updating current clinical practice. We found that while most of the recommendations in the new listing criteria are continuous with the previous criteria, updated recommendations are made on the risk stratification models in choosing transplantation candidates. Recommendation on hepatic dysfunction is not directly included in the updated ISHLT listing criteria; however, adoption of the Model for End-stage Liver Disease (MELD) score and modified MELD scores in the evaluation of risk are suggested in recent studies. In conclusion, evaluation of patient selection for heart transplantation should be comprehensive and individualized with respect to indications and the risk of comorbidities of candidates. With the advancement of mechanical circulatory support (MCS), the selection of heart transplantation candidate is continuously evolving and widened. MCS as bridge to candidacy should be considered when the candidate has potentially reversible risk factors for transplantation.

The presence of severe pulmonary arterial hypertension (PAH) in patients with atrial septal defect (ASD) is still thought to preclude shunt closure, although there are several reports of good clinical outcomes after vasodilator therapy. We report the case of a young woman with ASD and severe PAH who was able to successfully undergo percutaneous shunt closure following 1 year use of the oral endothelin receptor antagonist, bosentan.

Background An enlarged left atrium (LA) is a major risk factor for atrial fibrillation (AF) recurrence after a maze operation. Methods Between 2000 and 2009, 35 patients underwent circumferential left atrium resection (CLAR), during mitral valve surgery. All patients had continuous AF. Results Hospital mortalities occurred in two patients (5.7%). Postoperative bleeding occurred in two patients (5.7%). The average follow-up was 64 months. The mean New York Heart Association (NYHA) functional class had significantly decreased to 1.16 ± 0.37 from 2.77 ± 0.65 (p

We aimed to evaluate the diagnostic performance of dual-source computed tomography coronary angiography (DSCT-CA) in the measurement of the ascending aorta (AA) diameter and compare the AA diameter in patients with severe bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) stenosis. Eighty-eight consecutive patients (50 men, mean age 60.3 ± 13 year) with severe aortic stenosis (AS) underwent DSCT-CA before aortic valve surgery. Seventy-four of the 88 patients underwent cardiovascular magnetic resonance (CMR). The internal diameter of AA was measured from early-systole with DSCT-CA and CMR by 2 radiologists independently at 4 levels (aortic annulus, sinuses of Valsalva, sinotubular junction, and tubular portion at the right pulmonary artery). The patients were divided in to 2 groups (BAV [n = 53]; TAV [n = 35]) according to operative findings. Patients with BAV were significantly younger than those with TAV (P = 0.0035). Inter-observer agreement of AA diameters at 4 levels with DSCT-CA and CMR was excellent (intraclass correlation coefficient = 0.89–0.97). Also, the DSCT-CA and CMR measurements of the AA diameter strongly correlated (r = 0.871–0.976). Mean diameter of the AA by DSCT-CA was significantly larger in patients with BAV (34.4 ± 8.2 mm) as compared to those with TAV (30.6 ± 5.5 mm). The diameters at the sinuses of Valsalva, sinotubular junction, and tubular portion were significantly larger in BAV than in TAV. Twenty-two of 53 (41.5%) patients with BAV and 2 of 35 (5.7%) patients with TAV had AA dilatation > 45 mm. DSCT-CA allows accurate assessment of the AA diameters in patients with severe AS. Patients with severe BAV stenosis had larger AA diameters and higher prevalence of AA dilatation > 45 mm as compared to those with severe TAV stenosis.

The detection of a thrombus at the left atrial appendage (LAA) is an important step for management in a patient with a suspected embolic infarction. However, spontaneous echocardiographic contrast (SEC), which can mimic thrombus, can confuse clinicians in many cases. We examined electrocardiographic-gated 64-slice multidetector computed tomography with a 2-phase scan and transesophageal echocardiography in 314 patients with suspected embolic stroke. The transesophageal echocardiographic findings were classified using a 5-grade scale and the multidetector computed tomographic findings were categorized as no filling defect, an early filling defect (a filling defect seen on early-phase images without considering the late-phase images), and a persistent filling defect (a filling defect seen on added late-phase images, as well as on early-phase images). For quantitative analysis, the ratio of Hounsfield units in the LAA to the ascending aorta (AA) was calculated for each early-phase and late-phase image (LAA/AA(L)). Using transesophageal echocardiography as the reference standard, for no filling defect seen on early-phase images, the presence of a thrombus, including severe SEC, could be ruled out with 100% sensitivity and a 100% negative predictive value. When considering the addition of late-phase images, all persistent filling defects had resulted from the presence of a thrombus and severe SEC. However, using the optimal cutoff value of 0.5 for the LAA/AA(L) ratio, thrombi could be distinguished from severe SEC where all thrombi had a LAA/AA(L) ratio0.5. In conclusion, our findings suggest that 2-phase multidector computed tomography is useful for the detection and differentiation of a thrombus from SEC at the LAA in patients with suspected embolic stroke.

Metabolic syndrome (MS) is associated with faster progression of degenerative aortic stenosis (AS). However, the influence of MS on AS progression and clinical outcomes in patients with bicuspid aortic valve (BAV) has not been studied. A total of 1,640 patients with BAVs were identified at two

Background and Purpose: Cardiac multidetector computed tomography (MDCT) is less dependent upon the patient’s condition and may be valuable in the diagnosis of embolic sources when the patient’s cooperation is limited due to a neurologic deficit. However, its role has never been validated in acute stroke patients whose stroke mechanism is assumed to be embolic. Methods: Consecutive patients who were admitted with acute ischemic stroke from May 1, 2007 to November 30, 2007 were included in this study. Inclusion criteria were (1) any cardiac evidence of high-risk embolic sources for cerebral embolism, or (2) radiological or (3) clinical evidence of embolic stroke. All patients underwent transthoracic echocardiography first, and then cardiac MDCT or transesophageal echocardiography (TEE) was attempted, if possible. The results and feasibility of cardiac MDCT and TEE were compared. Results: One hundred and forty-three patients met the inclusion criteria. Cardiac MDCT was performed in 124 patients (86.7%), TEE in 83 patients (57.3%), whereas 75 patients (52.4%) underwent both studies. Renal insufficiency for cardiac MDCT and lack of cooperation for TEE were found to be the most impeding factors. Among the patients with both evaluations, cardiac MDCT identified a high-risk intracardiac embolic source in 8 and an extracardiac source in 20, while TEE found an intracardiac source in 1 and an extracardiac source in 7. Statistically significant differences were found with respect to detecting cardioembolic sources and high-risk aortic atheroma. Conclusions: Cardiac MDCT is a feasible and accurate diagnostic tool for embolic sources in an acute stroke setting.

Purposes: We assessed the association between arterial stiffness, as determined by brachial ankle pulse wave velocity (baPWV), and the extent of coronary artery disease (CAD) by conventional coronary angiography (CAG) in patients who visited outpatient clinic for angina without any previous history of heart disease. Method: We retrospectively analyzed the data of 583 consecutive patients who had undergone baPWVand elective CAG for suspected CAD between January 2012 and November 2013 in single cardiovascular center. Results: The baPWV was one of the statistically meaningful predictors of significant CAD (diameter of stenosis >50%) in addition to male gender, age, the level of HDL-cholesterol and HbA1c in multivariate analysis. However, baPWV was not the significant predictor of revascularization. When the extent of CAD was classified into following 4 groups; no significant CAD, 1-, 2and 3-vessel disease, there was significant difference of baPWV between the significant and non significant CAD group, but there was no difference of baPWV among the three significant CAD groups, although there was trend toward the positive correlation. Conclusion: Although baPWV was an independent predictor of significant CAD, it was not significantly associated with the extent of CAD.

For evaluation of post-operative stent associated cardiac events after drug-eluting stent (DES) implantation we analyzed data of 138 patients who underwent non-cardiac surgery after DES implantation and compared the data with those of 101 patients who underwent non-cardiac surgery after bare metal stent (BMS) implantation. Three patients (2.2%) in DES group developed post-operative cardiac events and none in BMS group (p=0.2). One patient died due to suspected stent thrombosis and the other two had myocardial infarction due to angiographically proven stent thrombosis. The time interval between stent implantation and surgery in those with cardiac events was 6, 264, and 367 days, respectively. Our data shows that peri-operative stent-related thrombotic complications can occur long after DES implantation and careful peri-operative monitoring for cardiac events is needed in patients receiving non-cardiac surgery after DES implantation.