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Stepanek J, Farina JM, Mahmoud AK, Chao CJ, Alsidawi S, Ayoub C, Barry T, Pereyra M, Scalia IG, Abbas MT, Wraith RE, Brown LS, Radavich MS, Curtisi PJ, Hartzendorf PC, Lasota EM, Umetsu KN, Peterson JM, Karlson KE, Breznak K, Fortuin DF, Lester SJ, Arsanjani R. Identifying the Causes of Unexplained Dyspnea at High Altitude Using Normobaric Hypoxia with Echocardiography. J Imaging 2024; 10:38. [PMID: 38392086 PMCID: PMC10889907 DOI: 10.3390/jimaging10020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Exposure to high altitude results in hypobaric hypoxia, leading to physiological changes in the cardiovascular system that may result in limiting symptoms, including dyspnea, fatigue, and exercise intolerance. However, it is still unclear why some patients are more susceptible to high-altitude symptoms than others. Hypoxic simulation testing (HST) simulates changes in physiology that occur at a specific altitude by asking the patients to breathe a mixture of gases with decreased oxygen content. This study aimed to determine whether the use of transthoracic echocardiography (TTE) during HST can detect the rise in right-sided pressures and the impact of hypoxia on right ventricle (RV) hemodynamics and right to left shunts, thus revealing the underlying causes of high-altitude signs and symptoms. A retrospective study was performed including consecutive patients with unexplained dyspnea at high altitude. HSTs were performed by administrating reduced FiO2 to simulate altitude levels specific to patients' history. Echocardiography images were obtained at baseline and during hypoxia. The study included 27 patients, with a mean age of 65 years, 14 patients (51.9%) were female. RV systolic pressure increased at peak hypoxia, while RV systolic function declined as shown by a significant decrease in the tricuspid annular plane systolic excursion (TAPSE), the maximum velocity achieved by the lateral tricuspid annulus during systole (S' wave), and the RV free wall longitudinal strain. Additionally, right-to-left shunt was present in 19 (70.4%) patients as identified by bubble contrast injections. Among these, the severity of the shunt increased at peak hypoxia in eight cases (42.1%), and the shunt was only evident during hypoxia in seven patients (36.8%). In conclusion, the use of TTE during HST provides valuable information by revealing the presence of symptomatic, sustained shunts and confirming the decline in RV hemodynamics, thus potentially explaining dyspnea at high altitude. Further studies are needed to establish the optimal clinical role of this physiologic method.
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Affiliation(s)
- Jan Stepanek
- Aerospace Medicine Program, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Juan M Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Ahmed K Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Said Alsidawi
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Isabel G Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | | | - Rachel E Wraith
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Lisa S Brown
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Michael S Radavich
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Pamela J Curtisi
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | | | - Elizabeth M Lasota
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Kyley N Umetsu
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Jill M Peterson
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Kristin E Karlson
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Karen Breznak
- Aerospace Medicine Program, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - David F Fortuin
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Steven J Lester
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
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Farina JM, Chao CJ, Pereyra M, Roarke M, Said EF, Barry T, Alsidawi S, Sell-Dottin K, Sweeney JP, Fortuin DF, Ayoub C, Lester SJ, Oh JK, Arsanjani R, Marcotte F. Role of lipoprotein(a) concentrations in bioprosthetic aortic valve degeneration. Heart 2024; 110:299-305. [PMID: 37643771 DOI: 10.1136/heartjnl-2023-322987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES Lipoprotein(a) (Lp(a)) is associated with an increased incidence of native aortic stenosis, which shares similar pathological mechanisms with bioprosthetic aortic valve (bAV) degeneration. However, evidence regarding the role of Lp(a) concentrations in bAV degeneration is lacking. This study aims to evaluate the association between Lp(a) concentrations and bAV degeneration. METHODS In this retrospective multicentre study, patients who underwent a bAV replacement between 1 January 2010 and 31 December 2020 and had a Lp(a) measurement were included. Echocardiography follow-up was performed to determine the presence of bioprosthetic valve degeneration, which was defined as an increase >10 mm Hg in mean gradient from baseline with concomitant decrease in effective orifice area and Doppler Velocity Index, or new moderate/severe prosthetic regurgitation. Levels of Lp(a) were compared between patients with and without degeneration and Cox regression analysis was performed to investigate the association between Lp(a) levels and bioprosthetic valve degeneration. RESULTS In total, 210 cases were included (mean age 74.1±9.4 years, 72.4% males). Median time between baseline and follow-up echocardiography was 4.4 (IQR 3.7) years. Bioprostheses degeneration was observed in 33 (15.7%) patients at follow-up. Median serum levels of Lp(a) were significantly higher in patients affected by degeneration versus non-affected cases: 50.0 (IQR 72.0) vs 15.6 (IQR 48.6) mg/dL, p=0.002. In the regression analysis, high Lp(a) levels (≥30 mg/dL) were associated with degeneration both in a univariable analysis (HR 3.6, 95% CI 1.7 to 7.6, p=0.001) and multivariable analysis adjusted by other risk factors for bioprostheses degeneration (HR 4.4, 95% CI 1.9 to 10.4, p=0.001). CONCLUSIONS High serum Lp(a) is associated with bAV degeneration. Prospective studies are needed to confirm these findings and to investigate whether lowering Lp(a) levels could slow bioprostheses degradation.
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Affiliation(s)
- Juan M Farina
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Michael Roarke
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Ebram F Said
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Said Alsidawi
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Kristen Sell-Dottin
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - John P Sweeney
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - David F Fortuin
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Steven J Lester
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Francois Marcotte
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Abudiab MM, Hakim FA, Fortuin DF, Scott RL. Anomalous coronary artery in a transplanted heart: a rare incidental diagnosis. J Saudi Heart Assoc 2016; 28:46-8. [PMID: 26778904 PMCID: PMC4685202 DOI: 10.1016/j.jsha.2015.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/09/2015] [Accepted: 06/10/2015] [Indexed: 11/05/2022] Open
Abstract
Coronary artery anomaly is a rare postoperative coronary angiographic finding in heart transplant recipients. We report a case of anomalous origin of the right coronary artery in an asymptomatic 70-year-old heart transplant patient. Most coronary artery anomalies are benign, but surgical treatment may be necessary in major coronary artery anomalies that are known to have adverse outcomes.
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Affiliation(s)
- Muaz M Abudiab
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ United States
| | - Fayaz A Hakim
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ United States
| | - David F Fortuin
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ United States
| | - Robert L Scott
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ United States
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