Comparing echocardiographic characteristics in genotype positive-phenotype positive hypertrophic cardiomyopathy and hypertensive left ventricular hypertrophy

AIMS

There is little information about hypertrophic cardiomyopathy (HCM) with pathologic genetic mutations and concurrent hypertension (HTN). Hypertensive left ventricular hypertrophy (LVH) does not exclude an underlying genetic aetiology.

METHODS AND RESULTS

This was a single-centre case-control study of 39 adults with pathologic HCM mutations, confirmed by genetic testing, compared to 39 age- and gender-matched patients with hypertensive LVH. The gene-positive HCM cohort was further stratified by the coexisting presence or absence of HTN. Clinical and echocardiographic characteristics were compared. Of 39 gene-positive HCM, 43.6% (17/39) had concurrent HTN. The gene-positive HCM cohort had larger left atrial (LA) area (22.1 cm2 vs. 18.9 cm2, P = 0.002), more diastolic predominant pulmonary vein flow (38.5% vs. 7.7%, P = 0.001), and more moderate diastolic dysfunction (33.3% vs. 12.8%, P = 0.032) when compared with the hypertensive LVH cohort. Greater left ventricular (LV) mass (277.7 g vs. 207.7 g, P = 0.025), increased frequency of severe LVH (58.8% vs. 27.3%, P = 0.047), and more abnormal global longitudinal strain (GLS) (-14.1% vs. -16.9%, P = 0.049) was observed in the gene-positive HCM cohort with concurrent HTN.

CONCLUSION

Gene-positive HCM, compared to hypertensive LVH, is characterized by more advanced diastolic dysfunction and larger LA size. Gene-positive HCM patients with concomitant HTN had greater LV mass, more severe LVH, and more abnormal GLS, suggesting HTN may negatively affect the progression of myocardial dysfunction in genetic HCM. LVH out-of-proportion to pressure burden in HTN patients should raise suspicion of underlying genetic HCM.

The impact of depression on heart transplant outcomes: A retrospective single-center cohort study

BACKGROUND

Depression is prevalent in patients with heart failure and after heart transplant. We identified the prevalence of pre- and post-transplant depression and its association with clinical characteristics and post-transplant outcomes.

METHODS

We reviewed 114 adults transplanted 1/1/2015 to 12/31/2015 and identified patients with pre- and post-transplant depression. Clinical characteristics and outcomes were compared.

RESULTS

Of 114 patients, 35.1% had pre-transplant depression and 26.3% had post-transplant depression. Patients with post-transplant depression within the first year were significantly more likely to have acute rejection (10% vs 0%), longer intensive care unit (11.7 days vs 7.8 days) and hospital stay (31.7 days vs 16.3 days), and discharge to inpatient rehabilitation (26.7% vs 8.3%). Patients with post-transplant depression within the first year had significantly higher 5-year mortality (30% vs 9.5%, p = .009). However, after adjustment for total artificial heart/biventricular assist device, acute rejection, intensive care unit, and hospital length of stay, this relationship was no longer significant (HR 2.11; 95% CI 0.18-25.27; p = .556).

CONCLUSIONS

Depression is common among heart transplant candidates and recipients. While pre-transplant depression did not impact outcomes, patients with post-transplant depression were more likely to have had a complicated course, suggesting the need for increased vigilance regarding depression in such patients.

Anticoagulation Therapy After Transcatheter Aortic Valve Replacement

PURPOSE OF REVIEW

We review the prevalence; natural history; impact of subclinical clinical thrombosis on valve hemodynamics, clinical outcomes, and valve durability; and the role of anticoagulation after transcatheter aortic valve replacement (TAVR).

RECENT FINDINGS

Subclinical leaflet thrombosis is a dynamic finding present in both transcatheter and surgical bioprosthetic aortic valves. This finding is less prevalent in patients on anticoagulation and resolves following initiation of anticoagulation. Routine anticoagulation after TAVR in high-surgical-risk patients was associated with increased mortality and thromboembolic complications. In the absence of a clinical indication for anticoagulation, there is no reason to initiate anticoagulation after TAVR for the prevention of subclinical leaflet thrombosis. In patients with an established indication for anticoagulation, for instance, atrial fibrillation, clinical or symptomatic valve thrombosis, or a clinical event related to valve thrombosis, anticoagulation should be initiated or continued after TAVR to treat the clinical indication.

Uniqueness of laryngeal nerve injury following heart transplantation

BACKGROUND

The incidence of recurrent laryngeal nerve injury (RLNI) after heart transplantation has not been well studied. This can manifest as vocal cord dysfunction causing dysphonia. Previous research is limited to aortic, coronary bypass, and valvular surgery. Identifying RLNI after heart transplantation is important in order to more accurately detail complications associated with this major surgery.

METHODS

This is a retrospective study assessing 972 adult patients who underwent orthotopic heart transplantation between 2010-2019. Primary outcome was incidence of RLNI. Secondary outcomes were 1-year mortality and length of stay. Cardiology and otolaryngology notes were examined. Key word searches were used to identify possible RLNI in patients' health care record.

RESULTS

2.9% (29/972) of patients developed new RLNI confirmed by laryngoscopy during hospitalization. Patients with RLNI had a significantly increased risk of 1-year mortality (P = .015) and length of stay (P = .006) compared to those without RLNI. 68.9% (20/29) of RLNI was left-sided (68.9%).

CONCLUSIONS

Recurrent laryngeal nerve injury is a recognizable adverse outcome following heart transplantation. This study supports that RLNI is associated with increased 1-year mortality and length of stay. Early otolaryngology evaluation may be warranted to evaluate vocal cord mobility and address potential management.

Abstract 212: Left Ventricular Hypertrophy by Electrocardiogram Criteria is Associated With Post-Transcatheter Aortic Valve Replacement High-Degree Atrioventricular Block and Left Bundle Branch Block

Background and Hypothesis: Severe aortic valve stenosis is associated with LVH, which has been shown to increase all-cause mortality and lead to conduction abnormalities. Patients undergoing trans-catheter aortic valve replacement (TAVR) have an increased risk for conduction abnormalities and subsequent permanent pacemaker (PPM) implantation. We investigated an association between pre-TAVR LVH by ECG criteria and post-TAVR conduction abnormalities and need for a permanent pacemaker. This relationship has not been studied before.

Methods: A retrospective chart review was conducted in 388 consecutive TAVR patients (57.7% females, transfemoral approach in 59.3%, 77.9% with Sapien valve) without pre-TAVR pacemaker. Analyses of variation, chi-square, multi-variate, and logistic regression were used. The study was approved by the institutional IRB.

Results: Post-TAVR pacemaker was more commonly needed in patients with baseline QRS >120 msec (35 vs. 11%, p<0.003), baseline RBBB (35 vs. 20%, p<0.02), post-TAVR LBBB (39 vs. 17%, p<0.0001), or post-TAVR high-degree AV block (69 vs. 12%, p<0.0001). All 388 patients had LVH by echocardiographic criteria, but only 50% of the patients had LVH by ECG criteria. Patients with LVH by ECG criteria were more likely to develop post-TAVR LBBB (27 vs. 13%, p=0.001) or high grade AV block (26% vs. 14%, p=0.005). Overall, there was a trend for increased pacemaker need in patients with pre-TAVR LVH by ECG criteria (20% vs. 17%, p=0.385).

Conclusion: LVH by voltage criteria in TAVR patients is associated with post-TAVR LBBB and post-TAVR high degree AV blocks, which lead to post-TAVR pacemaker placement. Pre-TAVR LVH by ECG criteria may be used to identify high-risk patients in whom extended telemetry monitoring may be warranted. Additional studies investigating this important subject are needed.

Abstract 213: Prevalence and Regression of Left Ventricular Hypertrophy by Sokolow-lyon and Cornell Electrocardiogram Voltage Criteria After Transcatheter Aortic Valve Replacement

Background and Hypothesis: Left Ventricular Hypertrophy (LVH) due to critical aortic stenosis is expected in TAVR patients. ECG markers of LVH were associated with a significant increase in all-cause mortality in a large prospective study (ARIC) of the general, middle-aged population. However, the sensitivity of LVH by ECG voltage criteria in patients with severe aortic valve stenosis undergoing trans-catheter aortic valve replacement (TAVR) has not yet been studied. The regression of LVH by ECG voltage criteria after TAVR also has not been evaluated.

Methods: A retrospective chart review was conducted in 388 consecutive TAVR patients (57.7% females, transfemoral approach in 59.3%, 77.9% with Sapien valve) without ventricular-paced rhythm. ECG data was collected and analyzed by Sokolow-Lyon and Cornell Voltage criteria. Results were compared to transthoracic echocardiogram. Analyses of variation, correlation, chi-square, and logistic regression were used. The study was approved by the institutional IRB.

Results: Pre-TAVR LVH by echocardiographic criteria was present in all patients. Sokolow-Lyon and Cornell criteria for LVH were present and concordant in 15% of patients; and in 53% of patients, neither ECG criteria was suggestive for LVH. Concordance between these two citeria was poor, with 37% of patients had LVH only by Cornell and 25% only by Sokolow-Lyon criteria (p<0.0001). One hundred forty one of 388 patients had follow up ECG’s at least 6 months (9.0+/-12.8 months) post-TAVR, with 13% no longer indicating LVH by Sokolow-Lyon criteria (p=0.005). Post-TAVR LVH by SL criteria was more likely in women (83 vs. 17%, p=0.015). Other co-morbidities and demographic variables were not predictive of LVH regression by ECG criteria.

Conclusion: The presence of LVH by Sokolow-Lyon and Cornell ECG voltage criteria poorly correlates with the presence of LVH in critical aortic stenosis patients undergoing TAVR. Despite significant variability in pre-TAVR LVH manifestation by traditional ECG criteria, LVH regression by ECG criteria may be observed fairly soon after TAVR. Additional research is needed to clarify clinical implications and long-term outcomes associated with post-TAVR LVH regression.

Abstract 052: Improved Hospital Outcomes With Hypokalemia on Admission in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Purpose: We hypothesized that advanced circulatory compromise, as manifested by acidosis and hyperkalemia should be associated with worsened clinical outcomes in cardiac arrest patients treated with therapeutic hypothermia.

Methods: Results of initial admission laboratory studies, medical history, and echocardiogram in 203 consecutive cardiac arrest patients (59 females, 59+/- 15 years old) undergoing therapeutic hypothermia were reviewed. Mortality was ascertained through hospital records. ANOVA, chi-square, Kaplan-Meier, and logistic regression analyses were used. The study was approved by the institutional IRB.

Results: Increased mortality was noted with older age, decreased admission pH, elevated admission lactate, lower admission hemoglobin, and pulseless electrical activity or asystole as presenting rhythms (Table). Admission hypokalemia and ventricular fibrillation/tachycardia were associated with improved hospital mortality (Table). Potassium was significantly lower in patients admitted with ventricular fibrillation/tachycardia (3.897+/-0.92) as compared to patients with asystole (4.674+/-1.377) or pulseless electrical activity (4.491+/-1.055 mEq/dL, p<0.0001). In multivariate logistic regression analysis, independent predictors of increased hospital mortality included increased admission potassium (OR 2.0, 95%CI 1.291-3.170, p=0.002)), older age (OR 1.04, 95%CI 1.007-1.071, p=0.017), admission PEA (OR 3.7, 95%CI 1.358-10.282, p=0.011 when compared to ventricular fibrillation/tachycardia) or asystole (OR 17.2, 95%CI 4.423-66.810, p<0.001 when compared to ventricular fibrillation/tachycardia); while decreased mortality was associated with higher hemoglobin (OR 0.8, 95%CI 0.665-0.997, p=0.047).

Conclusions: Hyperkalemia, pulseless electrical activity, and asystole are predictive of increased hospital mortality in survivors of cardiac arrest. An association between low or low-normal potassium, observed VT-VF, and better outcomes is unexpected and may be used for prognostic purposes. More prospective investigations of mortality predictors in these critically ill patients are needed.