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Ashrith G.,Houston Methodist key Heart and Vascular Center | Gupta D.,Sloan Kettering Cancer Center | Hanmer J.,University of Pittsburgh | Weiss R.M.,University of Iowa
Journal of cardiovascular magnetic resonance : official journal of the Society for Cardiovascular Magnetic Resonance | Year: 2014

BACKGROUND: With recent advances in imaging methods, detection of LVNC is increasingly common. Concomitantly, the prognostic importance of LVNC is less clear.METHODS: We followed 42 patients (63% male, age 44 ± 15 years) with incident heart failure or suspected cardiomyopathy, in whom cardiovascular magnetic resonance (CMR) yielded a diagnosis of LVNC, for 27 ± 16 months.RESULTS: LVNC was preferentially distributed among posterolateral segments, with apical predominance. Patients with maximum non-compacted-to-compacted thickness ratio (NC:C) < 3 improved by 0.9 ± 0.7 NYHA Class, compared to 0.3 ± 0.8 for patients with NC:C > 3 (p = 0.001). In 29 patients with baseline LVEF < 0.40, there was an inverse correlation between NC:C ratio, and the change in LVEF during follow-up. Tachyarrhythmias were observed in 42% of patients with LGE, and in 0% of patients without LGE (p = 0.02). In multivariate analysis, arrhythmia incidence was significantly higher in patients with LGE, even when adjusted for LVEF and RVEF.CONCLUSIONS: CMR assessments of myocardial morphology provide important prognostic information for patients with LVNC who present with incident heart failure or suspected cardiomyopathy.

Hakeem A.,University of Arkansas for Medical Sciences | Hakeem A.,Central Arkansas Medical Center | Bhatti S.,University of Arkansas for Medical Sciences | Chang S.M.,Houston Methodist key Heart and Vascular Center
JACC: Cardiovascular Imaging | Year: 2014

End-stage renal disease (ESRD) is a growing global health problem with major health and economic implications. Cardiovascular complication is the major cause of morbidity and mortality in this population. Clustering of traditional atherosclerotic risk factors, such as diabetes, systemic inflammation, and altered mineral metabolism, contributes to enhanced systemic atherosclerosis in patients with ESRD. Prevalence of obstructive coronary artery disease (CAD) on coronary angiography exceeds 50% in this population. Despite having extensive CAD and vascular disease, patients with ESRD often do not present with classic symptoms because of impaired exercise capacity and diabetes. Furthermore, clinical trial data are exceedingly lacking in this population, resulting in considerable clinical equipoise regarding the optimal approach to the identification and subsequent management of CAD in these patients. Traditional clinical screening tools, including conventional risk prediction models, are significantly limited in their predictive accuracy for cardiovascular events in patients with ESRD. Noninvasive cardiac stress imaging modalities, such as nuclear perfusion and echocardiography, have been shown to improve the traditional clinical model in identifying the presence of CAD. Furthermore, they add incremental prognostic information to angiographic data. Novel imaging techniques and biomarker assays hold significant promise in further improving the ability to identify and risk-stratify for CAD. This review focuses on the current understanding of the clinical risk profile of asymptomatic patients with ESRD with an emphasis on the strengths and limitations of various noninvasive cardiovascular imaging modalities, including the role of novel methods in refining risk prediction. In addition, issues and challenges pertaining to the optimal timing of initial risk assessment ("screening") and possible repeat screening ("surveillance") are addressed. We also summarize the current data on the approach to the patient with ESRD being evaluated for transplantation in the context of recent guidelines and position statements by various professional societies. © 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.

Estep J.D.,Houston Methodist key Heart and Vascular Center
Current Opinion in Cardiology | Year: 2015

Purpose of review This review highlights the most recent developments in the field of heart failure with reduced and preserved ejection fraction (HFrEF and HFpEF). Recent findings The largest trial to date in patients with HFrEF demonstrated that LCZ696, a novel combination drug of valsartan and a neprilysin inhibitor, as compared with enalapril, significantly reduced the death rates from any cause and from cardiovascular causes and the rates of hospitalizations for worsening heart failure. Both ivabradine, a novel heart rate lowering therapy, currently approved by the Food and Drug Administration (FDA), and coenzyme Q10, a powerful antioxidant, when used as adjunctive treatment in HFrEF have also been shown to be efficacious in reducing important heart failure-related cardiovascular adverse events. In contrast, clinical trials in HFpEF remain disappointing; however, the recent FDA approval of a novel pulmonary artery pressure monitoring device has the potential to reduce heart failure readmissions in patients with HFpEF or HFrEF. Summary Novel therapies including LCZ696 and ivabradine have the potential to help curb the burden of heart failure in patients with HFrEF. For now, there continues to remains no clear evidence that novel therapeutic interventions modify the natural history of HFpEF. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Barker C.M.,Houston Methodist key Heart and Vascular Center
Current Opinion in Cardiology | Year: 2016

Purpose of review: Clinical trials in transcatheter aortic valve replacement (TAVR) have been essential in establishing the effectiveness as well as the limitations of this exciting and disruptive technology. This review will focus on clinical trials related to TAVR that have been presented in the past year or are currently enrolling, as well as future trials that are in the planning stages. Recent findings: The currently available devices have gone through iterations to improve safety and outcomes, including lower profiles to reduce bleeding complications as well as adding a sealing skirt or allowing for repositioning in order to decrease para-valvular regurgitation and need for a permanent pacemaker. The intermediate-risk clinical trials will be finishing soon and will be followed by low-risk trials. Ancillary devices will likely continue to expand the access to this therapy. One of the main challenges moving forward will be the post-TAVR pharmacotherapy. Summary: Recently, improvements in first-generation devices have led to improved outcomes. Current trials evaluating novel TAVR platforms and lower risk patients as well as ancillary devices will likely continue to expand the access to this therapy. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Hahn R.T.,Columbia University | Gillam L.D.,United Medical Systems | Little S.H.,Houston Methodist key Heart and Vascular Center
JACC: Cardiovascular Imaging | Year: 2015

Transcatheter aortic valve replacement (TAVR) with the use of the self-expandable Revalving system is an accepted alternative to surgical replacement for severe, symptomatic aortic stenosis in high-risk or inoperable patients. Intraprocedural imaging relies on fluoroscopic guidance, with echocardiographic imaging used as a supportive imaging modality. Intraprocedural transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) offer real-time imaging guidance throughout the procedure and may contribute to improving procedural results. Registries suggest that TAVR may be performed in lower-surgical-risk patients with equal outcomes to high-risk patients with ongoing randomized trials comparing these results with surgical outcomes. Understanding the utility of echocardiographic imaging in diagnosing or preventing complications may be particularly important as we move toward these lower-risk patient populations. This imaging compendium is intended to be a comprehensive compilation of intraprocedural complications imaged by intraprocedural echocardiography. © 2015 American College of Cardiology Foundation.

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