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Papers by John Lesser

Circulation, Oct 28, 2008

<jats:p>Stress cardiomyopathy (SC) is a newly reported condition of older women, triggered ... more <jats:p>Stress cardiomyopathy (SC) is a newly reported condition of older women, triggered by emotionally and physically stressful events, characterized by acute heart failure with a distinctive angiographic profile, and regarded as a reversible process. To date, extended follow-up of SC patients is largely unavailable. We have assembled a substantial consecutive group of patients with SC to assess short and long-term clinical consequences of this condition. Between 2001–2008, we prospectively identified and followed (mean 2.0 years, range 0–6.7) 113 consecutive women with SC at a tertiary care United States hospital. Patients were female, aged 32–92 years (mean 68±13), and 16 (14%) were < 55 years. In 105 (93%) a triggering stressful event (emotional in 50, acute illness in 55) was identified; however, in 8 patients (7%) no such event preceded SC. The ECG showed ST-segment elevation in 58(51%) patients and ejection fraction (EF) was 31±11%. Troponin was elevated in 109 (96%); peak troponin (T) was 0.64±0.76 ng/ml. Of the 113 patients, 110(97%) survived the acute event: 3 patients (3%) died in-hospital (cardiogenic shock in 2; subarachnoid hemorrhage in 1). Other complications included: cardiac arrest 2 (2%), hypotension requiring inotropic drug and/or intra-aortic balloon pump in 22 (19%), pulmonary or cerebral embolism in 3 (3%), left ventricular (LV) or right ventricular thrombus in 7 (6%) and LV outflow obstruction in 13 (12%). CMR findings included absent delayed hyperenhancement (gadolinium) in 82/83 (99%), normal LV apical contraction in 46%, RV akinesia in 22%, and pleural effusions due to heart failure in 46%. At follow-up, EF returned to normal in all patients, but one or more SC events recurred in 7 (6%) patients (complicated by non-fatal cardiac arrest in 1), of whom 3 were taking beta-blockers. Post-hospital death occurred in 15 (13%) patients of which 14 were noncardiac and 1 of unknown cause. Among this large cohort of women, some SC events occurred atypically either without a stress trigger or in younger premenopausal patients. SC also led to death in the acute phase or to later non-fatal recurrences of SC or cardiac arrest in about 10%. Therefore, the clinical profile of SC is much broader than previously regarded.</jats:p>

Journal of the American College of Cardiology, Mar 1, 2015

Journal of the American College of Cardiology, Oct 1, 2019

Circulation, Nov 26, 2013

Background: Hypertrophic cardiomyopathy (HCM) has traditionally been regarded as a high risk dise... more Background: Hypertrophic cardiomyopathy (HCM) has traditionally been regarded as a high risk disease, and the most common cause of sudden cardiac death (SCD) in the young. However, the overall mort...

American Journal of Cardiology, Jun 1, 2016

Journal of the American College of Cardiology, Mar 1, 2011

American Journal of Cardiology, Apr 1, 2014

Journal of the American College of Cardiology, Mar 1, 2018

Journal of Cardiovascular Computed Tomography, May 1, 2015

American Journal of Cardiology, May 1, 2012

Hypertrophic cardiomyopathy (HC) is the most common cause of sudden death in the young, but survi... more 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.

American Journal of Cardiology, Jun 1, 2008

Stress (takotsubo) cardiomyopathy (SC) is a recently recognized syndrome with clinical and electr... more 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&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;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&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;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.

Journal of the American College of Cardiology, May 1, 2015

BACKGROUND Hypertrophic cardiomyopathy (HCM) has been prominently associated with adverse disease... more BACKGROUND Hypertrophic cardiomyopathy (HCM) has been prominently associated with adverse disease complications, including sudden death or heart failure death and a generally adverse prognosis, with annual mortality rates of up to 6%. OBJECTIVES This study determined whether recent advances in management strategy, including implantable cardioverter-defibrillators (ICDs), heart transplantation, or other therapeutic measures have significantly improved survival and the clinical course of adult HCM patients. METHODS We addressed long-term outcomes in 1,000 consecutive adult HCM patients presenting at 30 to 59 years of age (mean 45 AE 8 years) over 7.2 AE 5.2 years of follow-up. RESULTS Of 1,000 patients, 918 (92%) survived to 53 AE 9.2 years of age (range 32 to 80 years) with 91% experiencing no or only mild symptoms at last evaluation. HCM-related death occurred in 40 patients (4% [0.53%/year]) at 50 AE 10 years from the following events: progressive heart failure (n ¼ 17); arrhythmic sudden death (SD) (n ¼ 17); and embolic stroke (n ¼ 2). In contrast, 56 other high-risk patients (5.6%) survived life-threatening events, most commonly with ICD interventions for ventricular tachyarrhythmias (n ¼ 33) or heart transplantation for advanced heart failure (n ¼ 18 [0.79%/year]). SD occurred in patients who declined ICD recommendations, had evaluations before application of prophylactic ICDs to HCM, or were without conventional risk factors. The 5-and 10-year survival rates (confined to HCM deaths) were 98% and 94%, respectively, not different from the expected all-cause mortality in the general U.S. population (p ¼ 0.25). Multivariate independent predictors of adverse outcome were younger age at diagnosis, female sex, and increased left atrial dimension. CONCLUSIONS In a large longitudinally assessed adult HCM cohort, we have demonstrated that contemporary management strategies and treatment interventions, including ICDs for SD prevention, have significantly altered the clinical course, now resulting in a low disease-related mortality rate of 0.5%/year and an opportunity for extended longevity.

Journal of Cardiovascular Magnetic Resonance, Oct 1, 2008

Circulation, Feb 1, 2005

Background-A clinical entity characterized by acute but rapidly reversible left ventricular (LV) ... more Background-A clinical entity characterized by acute but rapidly reversible left ventricular (LV) systolic dysfunction and triggered by psychological stress is emerging, with reports largely confined to Japan. Methods and Results-Over a 32-month period, 22 consecutive patients with this novel cardiomyopathy were prospectively identified within a community-based practice in the Minneapolis-St. Paul, Minn, area. All patients were women aged 32 to 89 years old (mean 65Ϯ13 years); 21 (96%) were Ն50 years of age. The syndrome is characterized by (1) acute substernal chest pain with ST-segment elevation and/or T-wave inversion; (2) absence of significant coronary arterial narrowing by angiography; (3) systolic dysfunction (ejection fraction 29Ϯ9%), with abnormal wall motion of the mid and distal LV, ie, "apical ballooning"; and (4) profound psychological stress (eg, death of relatives, domestic abuse, arguments, catastrophic medical diagnoses, devastating financial or gambling losses) immediately preceding and triggering the cardiac events. A significant proportion of patients (37%) had hemodynamic compromise and required vasopressor agents and intra-aortic balloon counterpulsation. Each patient survived with normalized ejection fraction (63Ϯ6%; PϽ0.001) and rapid restoration to previous functional cardiovascular status within 6Ϯ3 days. In 95%, MRI identified diffusely distributed segmental wall-motion abnormalities that encompassed LV myocardium in multiple coronary arterial vascular territories. Conclusions-A reversible cardiomyopathy triggered by psychologically stressful events occurs in older women and may mimic evolving acute myocardial infarction or coronary syndrome. This condition is characterized by a distinctive form of systolic dysfunction that predominantly affects the distal LV chamber and a favorable outcome with appropriate medical therapy. (Circulation. 2005;111:472-479.) Key Words: cardiomyopathy Ⅲ magnetic resonance imaging Ⅲ angiography Ⅲ heart failure Ⅲ women A cute and rapidly reversible left ventricular (LV) dysfunction triggered by profound psychological stress is a recently recognized clinical scenario. Prior reports have largely been confined to Japanese patients, which raises the possibility of a geographically restricted cardiovascular syndrome. 1-6 This clinical entity is of substantial general medical interest owing to its presentation, which mimics myocardial infarction and acute coronary syndrome, potentially unfavorable consequences, and a high likelihood of survival with appropriate medical therapy. Therefore, it is timely to report the present sizable and prospectively assembled patient cohort from the United States that demonstrates the clinical profile of this cardiomyopathy.

Journal of the American College of Cardiology, Apr 1, 2011

International Journal of Cardiovascular Imaging, Oct 16, 2015

Ventricular volumes and ejection fraction are often used in clinical decision making in patients ... more Ventricular volumes and ejection fraction are often used in clinical decision making in patients with congenital heart disease (CHD). The referral diagnosis, radiation exposure and image quality of functional cardiac computed tomography (CT) in a relatively large cohort of patients of CHD has not been reported. This is a retrospective evaluation of functional CT studies performed in CHD patients from three institutions (1/2007-3/2013). Patient and scanner characteristics, radiation dose estimates and image quality were compared. Two hundred ninety-eight functional CT studies were evaluated. The most common referral diagnosis were tetralogy of Fallot (33 %), transposition complexes (24 %) single ventricle heart disease (15 %), and left sided obstruction (15 %). The reason for cardiac CT was presence of pacemaker (60 %), need for detailed coronary artery imaging (18 %), metallic artifact in CMR (12 %), evaluation of prosthetic valve function (4 %), and claustrophobia or BMI too large for the available MR scanner (6 %). 266 (89.3 %) scans allowed quantification of ventricular function, 25 (8.4 %) scans allowed qualitative assessment of function, and 7 (2.3 %) of the scans were non-diagnostic for functional analysis. Median DLP was 399 mGy cm (186, 614), and median effective dose was 5.5 mSv (2.6, 8.5). Radiation dose and image quality varied across institutions. Cardiac CT function imaging can be performed in patients with congenital heart disease when CMR is contraindicated or has poor image quality. Radiation dose and image quality varies across institutions.

Current Cardiovascular Imaging Reports, Jul 21, 2012

ABSTRACT Therapeutic electrophysiology procedures have rapidly evolved to help improve the qualit... more ABSTRACT Therapeutic electrophysiology procedures have rapidly evolved to help improve the quality of life in patients with heart rhythm disturbances. Cardiac CT angiography is a robust, high-resolution imaging tool that is commonly utilized for electrophysiology procedural planning and to improve intraprocedural efficiency. While cardiac CT is most often used to support radiofrequency ablation for atrial fibrillation, it also helps in assessing cardiac veins for cardiac resynchronization therapy, the left atrial appendage for thrombus, and post-procedural complications such as pulmonary vein stenosis. In this article, we will discuss the utility of cardiac CT for electrophysiology procedural related indications.