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Papers by william miranda

Research paper thumbnail of PO-674-06 Adults with Shone Complex Have High Burden of Atrial and Ventricular Arrhythmias

Research paper thumbnail of Performance of Guideline-Based Algorithms for the Echocardiographic Assessment of Patients with Clinically-Proven Bio Prosthetic Aortic Valve Dysfunction

Journal of the American College of Cardiology

Research paper thumbnail of Hemodynamic Predictors of Survival in Patients Undergoing Transseptal Catheterization for Assessment of Mitral Stenosis Secondary to Mitral Annular Calcification

Journal of the American College of Cardiology, 2021

Research paper thumbnail of Systemic Venous Hypertension and Low Output Are Prevalent at Catheterization in Adults with Pulmonary Atresia and Intact Ventricular Septum Regardless of Repair Strategy

Seminars in Thoracic and Cardiovascular Surgery, 2021

Patients with pulmonary atresia and intact ventricular septum (PA-IVS) require intervention early... more Patients with pulmonary atresia and intact ventricular septum (PA-IVS) require intervention early in life, and most survive to a definitive procedure of either Fontan circulation or right ventricle to pulmonary artery (RV-PA) repair. It remains unknown how surgical strategy impacts hemodynamics and comorbidities in adults. Retrospective analysis of adults (age ≥18 years) with PA-IVS undergoing hemodynamic catheterization at Mayo Clinic, MN between January 2000 through January 2020 was performed. Fourteen patients in the RV-PA group (71% biventricular, 29% 1.5 ventricle repair) and 19 post-Fontan patients [9 lateral tunnel (48%), 6 atriopulmonary (32%), and 4 extracardiac (21%)] were identified. Median age was 29 (21, 34) years. There were no differences in demographics and laboratory data (including MELD-XI) between groups. All patients assessed for liver disease had evidence of hepatic congestion or cirrhosis (14 in the Fontan group and 4 in the RV-PA group). Invasive hemodynamics were comparable between groups with the Fontan and RV-PA groups having similar systemic venous pressure (15.7±4.4 vs. 14.3±6.2, p=0.44) and cardiac output (2.2±0.6 vs. 2.0±0.4 L/min/m2, p=0.23). There was no difference in transplant-free survival (p=0.92; 5-year transplant-free survival RV-PA 84%, Fontan 80%). Hemodynamic derangements, namely elevated systemic venous pressure and low cardiac output, are prevalent in patients with PA-IVS undergoing cardiac catheterization regardless of surgical strategy.

Research paper thumbnail of Outcomes of pericardiectomy for constrictive pericarditis following mediastinal irradiation

Journal of Cardiac Surgery, 2021

Background Pericardiectomy for post-radiation constrictive pericarditis has been reported to gene... more Background Pericardiectomy for post-radiation constrictive pericarditis has been reported to generally have unfavorable outcomes. This study sought to evaluate surgical outcomes in a large cohort of patients undergoing pericardiectomy for radiationassociated pericardial constriction. Methods A retrospective analysis of all patients ([?]18years) who underwent pericardiectomy for a diagnosis of constrictive pericarditis with a prior history of mediastinal irradiation from June 2002 to June 2019 was conducted. There were 100 patients (mean age 57.2±10.1 years, 49% females) who met the inclusion criteria. Records were reviewed to look at surgical approach, extent of resection, early mortality and late survival. Results The overall operative mortality was 10.1% (n=10). The rate of operative mortality decreased over the study period; however, the test of trend was not statistically significant (P=0.062). Hodgkin's disease was the most common malignancy (64%) for which mediastinal radiation had been received. Only 27% patients had an isolated pericardiectomy, and concomitant pericardiectomy and valve surgery was performed in 46% patients. Radical resection was performed in 50% patients, whereas 47% patients underwent a subtotal resection. Prolonged ventilation (26%), atrial fibrillation (21%) and pleural effusion (16%) were the most common post-operative complications. The overall 1,5-and 10-years survival was 73.6%, 53.4% and 32.1% respectively. Increasing age (HR 1.044, 95%CI 1.017-1.073) appeared to have a significant negative effect on overall survival in the univariate model. Conclusion Pericardiectomy performed for radiation associated constrictive pericarditis has poor long-term outcomes. The early mortality, though high (˜10%), has been showing a decreasing trend in the test of time.

Research paper thumbnail of Outcomes and periprocedural management of cardiac implantable electronic devices in patients with carcinoid heart disease

Heart Rhythm, 2021

BACKGROUND Carcinoid heart disease (CHD) is a rare complication of hormonally active neuroendocri... more BACKGROUND Carcinoid heart disease (CHD) is a rare complication of hormonally active neuroendocrine tumors that often requires surgical intervention. There are limited data on cardiac implantable electronic device (CIED) implantation in patients with CHD. OBJECTIVES We evaluated the experience of CIED implantation in patients with CHD. METHODS Patients with a diagnosis of CHD and a CIED procedure from January 1, 1995 through June 1, 2020 were identified using a Mayo Clinic proprietary data retrieval tool. Retrospective review was performed to extract relevant data. These included indications for implant, procedural details, complications, and mortality. RESULTS A total of 27 patients (55.6% males, mean age at device implant at 65.6+/- 8.8 years) with a cumulative follow up of 75 patient years (median 1.1, IQR: 0.4-4.6 years) were included for analysis. The majority of implanted devices were dual-chamber permanent pacemakers (63%). Among all CHD patients who underwent any cardiac surgery, the incidence of CIED implantation was 12%. The most common indication for implantation was high-grade heart block (66.7%). Device implant complication rates were modest (14.8%). No patient suffered carcinoid crisis during implantation and there was no peri-implant mortality. The median time from implant to death was 2.5 years, with a one-year mortality of 15%. CONCLUSIONS CHD is a morbid condition and surgical valve intervention carries associated risks, in particular a high requirement for post-operative pacing needs. Our data suggest that CIED implantation can be performed relatively safely. Clinicians must be aware of the relevant carcinoid physiology and take appropriate precautions to mitigate risks.

Research paper thumbnail of Haemodynamic determinants of improved aerobic capacity after tricuspid valve surgery in Ebstein anomaly

Heart, 2020

BackgroundAlthough tricuspid valve surgery improves functional capacity in patients with Ebstein ... more BackgroundAlthough tricuspid valve surgery improves functional capacity in patients with Ebstein anomaly, it is not always associated with improvement in aerobic capacity. The purpose of this study was to identify the determinants of improved aerobic capacity after tricuspid valve surgery in adults with Ebstein anomaly with severe tricuspid regurgitation.MethodsRetrospective study of patients with severe tricuspid regurgitation due to Ebstein anomaly that had tricuspid valve surgery at Mayo Clinic Rochester (2000–2019) and had preoperative and postoperative cardiopulmonary exercise tests and echocardiograms. The patients were divided into aerobic capacity(+) and aerobic capacity(-) groups depending on whether they had postoperative improvement in %-predicted peak oxygen consumption (VO2).ResultsOf 76 patients with severe tricuspid regurgitation due to Ebstein anomaly, 28 (37%) and 48 (63%) were in aerobic capacity(+) and aerobic capacity(-) groups, respectively. The average improvem...

Research paper thumbnail of Diagnosis of Constrictive Pericarditis Using Ejection Times in the Pulmonary Artery and Ascending Aorta

Journal of the American College of Cardiology, 2021

Research paper thumbnail of Comparing Risk Factors and Early Postoperative Outcomes in Adults with Ebstein Anomaly Following Cone Reconstruction Versus Tricuspid Valve Replacement

Journal of the American College of Cardiology, 2021

Research paper thumbnail of Preoperative Imaging Parameters and Early Postoperative Outcomes in Adult Patients with Tetralogy of Fallot

Journal of the American College of Cardiology, 2020

Background: Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart diseas... more Background: Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease with the majority of patients requiring additional surgical interventions in adulthood. We examined preoperative imaging in adult TOF patients to identify factors impacting early postoperative morbidity and mortality. Methods: We performed a single institution, retrospective review of patients ≥18 years with TOF who underwent cardiac surgery between 1/8/2008-6/21/2018. Data were analyzed using 2-tail Fisher's exact test and logistic regression. Results: There were 219 patients included (median age 40, range 18-83 yrs, 60% male) with TOF who underwent cardiac surgery. Surgical interventions included repair or replacement of the pulmonary valve (n=200), tricuspid valve (n=70), mitral valve (n=13), and aortic valve (n=8). Early postoperative complications included arrhythmias (n=46, 21%), mechanical circulatory support (n=7, 3%), dialysis (n=7, 3%), reoperation (n=5, 2%), cardiac arrest (n=3, 1%) and 30-day mortality (n=3, 1%). Low right ventricular ejection fraction (EF) on MRI, right ventricular systolic pressure >1/3 systemic, left ventricular (LV) enlargement and low LV EF conferred the greatest relative risk for complications (Table). Conclusion: Surgical interventions for adult TOF patients can be performed with low early morbidity and mortality. Preoperative imaging parameters can predict patients at higher risk for complications in the early postoperative period.

Research paper thumbnail of Cardiac Intensive Care Unit Outcomes After Cone Repair in Adults with Ebstein Anomaly

Journal of the American College of Cardiology, 2020

Background: Adults with Ebstein anomaly (EA) have excellent mid and late outcomes following cone ... more Background: Adults with Ebstein anomaly (EA) have excellent mid and late outcomes following cone repair (CR); however, early morbidity and mortality are not well described. We examined the impact of perioperative comorbid conditions on early postoperative outcomes in adults with EA following CR. Methods: This is a single institution, retrospective review of 153 patients ≥18 years that had CR for EA from 6/2007-12/2018. Data were analyzed using t-test or chi-squared test as appropriate. Univariate and multivariate analyses were applied for significant variables. Results: We included 153 adults (mean age 36.2±13.7 years; 40% males) that had CR for EA. Of these, 55 (36%) had previous cardiac surgery. Preoperative echocardiography demonstrated ≥ moderate tricuspid valve (TV) regurgitation in 151 (99%); 70 (46%) had ≥ moderately decreased right ventricular (RV) function. Baseline comorbidities include arrhythmia in 78 (51%), body mass index >30 kg/m 2 in 37 (24%), and smoking history in 38 (25%). Concomitant procedures at time of CR included atrial septal defect/patent foramen ovale closure (n=88), bidirectional cavopulmonary anastomosis (n=5), RV plication (n=70), and Maze procedure (n=57). Mean cardiopulmonary bypass and aortic cross clamp times were 88±22 and 73±19 minutes respectively. Median duration of mechanical ventilation was 1 (1, 1) days, cardiac intensive care unit length of stay (LOS) 2 (1, 2) days and hospital LOS 4 (4, 5) days. Mean peak serum lactate was 6.2±3.4 mmol/L; 80% of patients were on vasoactive support >24 hours. Postoperative morbidities include new arrhythmia (62, 41%), reoperation for valve re-repair/replacement (6, 4%), delayed sternal closure (2, 1%), readmission <30 days (4, 3%) and mortality <30 days (1, 0.7%). Degree of TV regurgitation, RV dilation and left ventricular ejection fraction improved postoperatively (p<0.01 for all). On multivariate analyses, hospital LOS increased with older age (p<0.01), higher peak lactate (p=0.02) and occurrence of new arrhythmia (p=0.02). Conclusion: Adults with EA following CR have excellent early postoperative outcomes. Older age, higher peak lactate level and onset of new arrhythmia could predict longer hospital LOS.

Research paper thumbnail of Low Flow, Low Gradient Severe Mitral Stenosis: Hemodynamics, Clinical Characteristics and Outcomes

Journal of the American College of Cardiology, 2018

Background: In aortic stenosis, it is well accepted that severe valvular stenosis can coexist wit... more Background: In aortic stenosis, it is well accepted that severe valvular stenosis can coexist with low stroke volume and low transvalvular gradient in the setting of factors such as left ventricular dysfunction or increased arterial elastance. This concept has not been established in patients with severe mitral valve stenosis. We sought to describe the hemodynamics, clinical characteristics and outcome after valvuloplasty of patients with low flow (LF), low gradient (LG) severe MS. Methods: We examined 101 consecutive patients with severe rheumatic MS (mitral valve area ≤ 1.5 cm 2) who underwent balloon valvuloplasty. LF was defined as stroke volume index ≤ 35 mL/m 2 and LG as mean mitral valve gradient < 10 mmHg by echocardiography. To characterize systolic, diastolic, and arterial function, global and segmental strain, left ventricular end systolic elastance (Ees), diastolic capacitance (volume at end diastolic pressure 30 mmHg, V 30), and effective arterial elastance (Ea) were measured. Results: LF/LG severe MS was present in 11 %, LF/high gradient (HG) in 13%, normal flow (NF)/LG in 44%, and NF/HG in 32%. Compared to other groups, patients in the LF/LG group were older (p<0.0001) with a higher prevalence of permanent atrial fibrillation (64%) (p=0.0002). LF/LG was associated with a decreased preload (LV diastolic dimension), higher afterload (Ea), lower ejection fraction (EF), and lower global longitudinal strain (p<0.05 for all). All LF/LG patients had severe subvalvular thickening associated with their decreased LV compliance and basal systolic strain suggesting subvalvular tethering of myocardium. All 4 groups had significant improvement in valve area following valvuloplasty but the LF/LG group demonstrated the least hemodynamic improvement. Conclusion: LF/LG severe MS is a distinct entity characterized by a high prevalence of atrial fibrillation, ventricular-vascular uncoupling, and diastolic left ventricular stiffening. These distinct features may contribute to the lesser benefit from valvuloplasty.

Research paper thumbnail of Impact of Left Ventricular Ejection Fraction Between 50 and 60% Versus ≥60% on Mortality After Aortic Valve Replacement for Severe Aortic Stenosis

Journal of the American College of Cardiology, 2018

Background: Left ventricular ejection fraction (LVEF) is a major prognostic indicator for the out... more Background: Left ventricular ejection fraction (LVEF) is a major prognostic indicator for the outcome of patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS). Currently, LVEF of 50% is defined as low normal for AS. However, a clear cut off value of LVEF related to the best outcome after AVR remains undetermined. Methods: Clinical outcome based on LVEF was assessed in 621 consecutive patients with severe AS [aortic valve area (AVA) ≤1 cm 2 ]. Results: Mean AVA was 0.83±0.13 cm 2 and LVEF was 59±14%. LVEF≥60% was present in 419 (67%), 80 (13%) had 50≤ LVEF<60%, and 122 (20%) had an LVEF<50%. During the median follow-up of 2.7 years, the mortality was worse for patients with an LVEF <50% and also worse for patients with 50% ≤ LVEF <60% compared to patients with an LVEF ≥60% (P<.001, Fig 1.). Even after AVR, patients with a 50%≤ LVEF<60% had a worse outcome compared to patients with an LVEF≥60% (P<.001, Fig 1.). In the Cox model, LVEF <60% was associated with worse survival outcomes (hazard ratio [HR]: 1.94; 95%CI: 1.45-2.58; P <.001) after adjusting for age, sex, AVA, symptoms, ischemic heart disease, diabetes mellitus and atrial fibrillation. The risk remained higher in patients with 50% ≤ LVEF <60% compared with patients with LVEF ≥60% (HR: 1.61; 95%CI: 1.09-2.32). Conclusion: In patients with severe AS, LVEF <60% is abnormal and predicts a poor outcome even after AVR compared to the patients with LVEF >60%. AVR may be considered when LVEF is < 60% (not 50%) even in asymptomatic patients with severe AS.

Research paper thumbnail of Hemodynamic Impact of Isolated Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Mitral Stenosis: A Doppler Echocardiographic Study

Journal of the American College of Cardiology, 2019

Background: Mitral stenosis (MS) frequently coexists in patients with severe aortic stenosis (sAS... more Background: Mitral stenosis (MS) frequently coexists in patients with severe aortic stenosis (sAS). However, the impact of aortic valve replacement (AVR) on MS is unknown. Methods: We retrospectively investigated patients who underwent AVR or transcatheter AVR (TAVR) for sAS from 2008 to 2015. Transmitral gradient by Doppler echocardiography ≥ 4 mmHg was identified as MS; patients were stratified according to mitral valve area (MVA, by continuity equation) as > or ≤ 2.0 cm 2. We compared MVA before and after AVR in patients with MS. We investigated the clinical outcomes of patients with vs. without MS using 1:2 matching for age, sex, LVEF, percent with TAVR and year of AVR. Results: Of 204 patients with sAS and MS (age 76 ± 9 years), 198 could be matched with 390 with sAS without MS. In those with MS, MVA increased after AVR in 126 (62%). Among all MS patients, the mean MVA increased after AVR (2.0 ± 0.5 to 2.3 ± 0.7 cm 2 , p < 0.01). Increase in stroke volume (SV) was a predictor for increase of MVA (odds ratio 7.1, 95% CI 3.3-15, p<0.01). Of 109 (55%) patients with MVA≤2 cm 2 , MVA increased to > 2.0 cm 2 after AVR in 53 and remained ≤ 2.0 cm 2 in 56. Patients with MS had poorer prognosis compared with those without MS (Figure). MVA ≤ 2.0 cm 2 after AVR was an independent predictor of overall mortality (hazard ratio 1.6, 95% CI 1.1-2.4, p=0.024). Conclusion: MVA by CE improved with increase of SV after AVR in two-thirds patients with sAS and MS. Patients with MS, especially MVA ≤ 2.0 cm 2 after AVR had higher mortality compared with those without MS.

Research paper thumbnail of Yes, You Can Use the Tricuspid Regurgitation Signal for the Right Ventricular to Right Atrial Gradient, No Matter How Severe the Tricuspid Regurgitation: A Simultaneous Echocardiography: Catheterization Study

Journal of the American College of Cardiology, 2019

Background: The performance of the modified Bernoulli equation to estimate the RV-RA pressure gra... more Background: The performance of the modified Bernoulli equation to estimate the RV-RA pressure gradient by continuous wave Doppler in severe tricuspid regurgitation (TR) is not known. Methods: Simultaneous continuous wave (CW) Doppler of the TR jet was prospectively obtained at time of cardiac catheterization in seven patients with a diagnosis of severe TR by transthoracic echocardiography. Simultaneous right ventricle (RV) and right atrial (RA) pressures were measured for the calculation of RV-RA gradients. CW Doppler data was digitized and the gradient was calculated according to the modified Bernoulli equation. Correlation between Doppler-derived and invasively measured RV-RA gradients was performed by simple linear regression (Pearson's correlation) and the Bland-Altman method. Results: Seven patients (mean age 62 years, 43% female) had 27 cardiac cycles analyzed (range 3-5 per patient) (see Figure). The mechanism of severe TR was thickened restricted leaflets in one patient, mixed device lead and annular dilation in 4, and isolated annular dilatation in 2. Mean RA pressure by cardiac catheterization was 16±6.7 mmHg and RV systolic pressure was 41±17.6. The peak RV-RA gradient was on average 17.8±8.1 mmHg by catheterization and 20.8±8.4 by Doppler. The correlation coefficient was r=0.93 with a mean difference of 3.7±3.1 mmHg (p<0.0001). Conclusion: In patients with severe TR, the modified Bernoulli equation can be used to accurately determine the peak RV-RA pressure gradient.

Research paper thumbnail of Outcomes of Pregnancy in Women with Left Ventricular Noncompaction

Journal of the American College of Cardiology, 2019

Background: Left ventricular noncompaction (LVNC) is an inherited cardiomyopathy characterized by... more Background: Left ventricular noncompaction (LVNC) is an inherited cardiomyopathy characterized by prominent left ventricular trabeculations and deep intertrabecular recesses. LVNC is associated with an increased risk of arrhythmia, embolic events, and heart failure. There is limited information regarding pregnancy outcomes in women with LVNC. Methods: Echocardiography and radiology databases were queried from 2000-2017 to identify female patients with LVNC between the ages of 18 and 40. LVNC was defined on transthoracic echo (TTE) based on an end systolic noncompacted:compacted ratio >2, and end diastolic epicardium to trough:epicardium to peak of trabeculation (X:Y) ratio <0.5. Results: Sixty-one patients with LVNC were identified. Obstetric data was not available for 16 patients. Of the remaining 45, 29 patients had 72 documented pregnancies (range, 1 to 5), of which 55 culminated in a live born neonate. Mean maternal age at first pregnancy was 27 years ± 4.6. Three women (10%) delivered by cesarean section, all performed for obstetric indications. Only two women were diagnosed with LVNC prior to pregnancy, and nine women (31%) were diagnosed with LVNC peripartum, after presenting with heart failure symptoms. Those diagnosed in the peripartum period had a mean ejection fraction (EF) of 33% ± 15.1. Significant peripartum cardiovascular events included new-onset atrial fibrillation with rapid ventricular rates in a patient 35 weeks pregnant with no prior diagnosis of cardiomyopathy. Cesarean section was performed at 37 weeks, and she was diagnosed with LVNC and a reduced EF (41%) postpartum. Another patient, with no prior diagnosis, suffered a resuscitated ventricular fibrillation arrest at five weeks postpartum. TTE at that time illustrated LVNC with an EF of 40%. Conclusion: Pregnancy with LVNC was well-tolerated for the majority of women in this series. However, LVNC may first present as heart failure in the peripartum period and should be considered in the differential diagnosis of peripartum cardiomyopathy. LVNC can cause cardiovascular events with hemodynamic instability in the peripartum period, including atrial fibrillation and ventricular fibrillation arrest.

Research paper thumbnail of The Prognosis of Patients with Moderate Aortic Stenosis

Journal of the American College of Cardiology, 2019

Background: The natural history of moderate aortic stenosis (mod AS) requires clarification to pr... more Background: The natural history of moderate aortic stenosis (mod AS) requires clarification to provide optimal management strategy. Methods: Patients with aortic valve area > 1 and ≤1.5cm 2 in 2012 were identified and stratified by stroke volume index (SVI) and left ventricular ejection fraction (LVEF). All-cause death was compared to age-and sex-matched Minnesota population. Results: Table shows patient characteristics. Mod AS mortality was higher than expected (P<.001, Fig A). When stratified by LVEF (Fig B, C) or SVI (Fig D, E), mortality was significantly higher in patients with low LVEF and/or SVI (P<.001 for all) Conclusion: Mod AS patients showed poor survival. A clinical trial examining role of aortic valve replacement in all patients with mod AS would be beneficial especially in those with low LVEF or SVI.

Research paper thumbnail of Flow dynamics in the false lumen in distal aorta following surgery for type A aortic dissection

European Heart Journal, 2018

Research paper thumbnail of Echo-Doppler assessment of ventricular filling pressures in adult Fontan patients

International Journal of Cardiology, 2018

Background: Diastolic dysfunction is felt to be part of the natural history of patients with prio... more Background: Diastolic dysfunction is felt to be part of the natural history of patients with prior Fontan operation. Despite that, data on noninvasive assessment of diastolic function and ventricular filling pressures in Fontan patients are limited. Methods: We included 48 adult Fontan patients who underwent right heart catheterization with pulmonary artery wedge pressure measurement (PAWP) and transthoracic echo-Doppler assessment within 7 days. Offline measurement of systemic atrioventricular valve pulsed-wave (PW) and medial/lateral tissue Doppler velocities were performed and correlated to PAWP. Results: Median age was 31.4 years (IQR 25-37.4); 52% of patients were females. Median ventricular ejection fraction was 55% (IQR 50.3-57.5) and median PAWP was 10 mmHg (IQR 8-11.3). PW Doppler E velocity (r=0.65, p=<.0001), deceleration time (r=-0.40, p=0.006), and isovolumic relaxation time (IVRT) (r=-0.40, p=0.005) correlated with PAWP, whereas E/A ratio did not (p=0.10). Median medial and lateral E/e' ratios also correlated to PAWP (r=0.59; p=0.009 and r=0.75, p<.0001, respectively). An E velocity >75 cm/s had a sensitivity of 89% and specificity 85% for predicting a PAWP>12 mmHg (97% negative predictive value) whereas a deceleration time <135 ms has a sensitivity of 89% and a specificity of 84% (97% negative predictive value). Positive predictive values were 55% and 50%, respectively. Conclusion: Our data suggest that PW Doppler atrioventricular E velocity and deceleration time could be used to identify adult Fontan patients with normal and elevated filling pressures. However, positive predictive values for PAWP>12 mmHg were poor. Further studies, particularly prospective, simultaneous echo-catheterization correlation, are critically needed.

Research paper thumbnail of E/E’ < 15 Performs Poorly in Patients with Elevated Left Filling Pressures and Atrial Fibrillation/Flutter: A Simultaneous Doppler-Catheterization Study

Journal of the American College of Cardiology, 2017

Background: As reinforced by the 2016 American Society of Echocardiography (ASE) diastology guide... more Background: As reinforced by the 2016 American Society of Echocardiography (ASE) diastology guidelines, early mitral inflow velocity (E) to medial mitral early diastolic tissue Doppler velocity (e') ratio is a key component in the noninvasive assessment of left-sided filling pressures. However, the

Research paper thumbnail of PO-674-06 Adults with Shone Complex Have High Burden of Atrial and Ventricular Arrhythmias

Research paper thumbnail of Performance of Guideline-Based Algorithms for the Echocardiographic Assessment of Patients with Clinically-Proven Bio Prosthetic Aortic Valve Dysfunction

Journal of the American College of Cardiology

Research paper thumbnail of Hemodynamic Predictors of Survival in Patients Undergoing Transseptal Catheterization for Assessment of Mitral Stenosis Secondary to Mitral Annular Calcification

Journal of the American College of Cardiology, 2021

Research paper thumbnail of Systemic Venous Hypertension and Low Output Are Prevalent at Catheterization in Adults with Pulmonary Atresia and Intact Ventricular Septum Regardless of Repair Strategy

Seminars in Thoracic and Cardiovascular Surgery, 2021

Patients with pulmonary atresia and intact ventricular septum (PA-IVS) require intervention early... more Patients with pulmonary atresia and intact ventricular septum (PA-IVS) require intervention early in life, and most survive to a definitive procedure of either Fontan circulation or right ventricle to pulmonary artery (RV-PA) repair. It remains unknown how surgical strategy impacts hemodynamics and comorbidities in adults. Retrospective analysis of adults (age ≥18 years) with PA-IVS undergoing hemodynamic catheterization at Mayo Clinic, MN between January 2000 through January 2020 was performed. Fourteen patients in the RV-PA group (71% biventricular, 29% 1.5 ventricle repair) and 19 post-Fontan patients [9 lateral tunnel (48%), 6 atriopulmonary (32%), and 4 extracardiac (21%)] were identified. Median age was 29 (21, 34) years. There were no differences in demographics and laboratory data (including MELD-XI) between groups. All patients assessed for liver disease had evidence of hepatic congestion or cirrhosis (14 in the Fontan group and 4 in the RV-PA group). Invasive hemodynamics were comparable between groups with the Fontan and RV-PA groups having similar systemic venous pressure (15.7±4.4 vs. 14.3±6.2, p=0.44) and cardiac output (2.2±0.6 vs. 2.0±0.4 L/min/m2, p=0.23). There was no difference in transplant-free survival (p=0.92; 5-year transplant-free survival RV-PA 84%, Fontan 80%). Hemodynamic derangements, namely elevated systemic venous pressure and low cardiac output, are prevalent in patients with PA-IVS undergoing cardiac catheterization regardless of surgical strategy.

Research paper thumbnail of Outcomes of pericardiectomy for constrictive pericarditis following mediastinal irradiation

Journal of Cardiac Surgery, 2021

Background Pericardiectomy for post-radiation constrictive pericarditis has been reported to gene... more Background Pericardiectomy for post-radiation constrictive pericarditis has been reported to generally have unfavorable outcomes. This study sought to evaluate surgical outcomes in a large cohort of patients undergoing pericardiectomy for radiationassociated pericardial constriction. Methods A retrospective analysis of all patients ([?]18years) who underwent pericardiectomy for a diagnosis of constrictive pericarditis with a prior history of mediastinal irradiation from June 2002 to June 2019 was conducted. There were 100 patients (mean age 57.2±10.1 years, 49% females) who met the inclusion criteria. Records were reviewed to look at surgical approach, extent of resection, early mortality and late survival. Results The overall operative mortality was 10.1% (n=10). The rate of operative mortality decreased over the study period; however, the test of trend was not statistically significant (P=0.062). Hodgkin's disease was the most common malignancy (64%) for which mediastinal radiation had been received. Only 27% patients had an isolated pericardiectomy, and concomitant pericardiectomy and valve surgery was performed in 46% patients. Radical resection was performed in 50% patients, whereas 47% patients underwent a subtotal resection. Prolonged ventilation (26%), atrial fibrillation (21%) and pleural effusion (16%) were the most common post-operative complications. The overall 1,5-and 10-years survival was 73.6%, 53.4% and 32.1% respectively. Increasing age (HR 1.044, 95%CI 1.017-1.073) appeared to have a significant negative effect on overall survival in the univariate model. Conclusion Pericardiectomy performed for radiation associated constrictive pericarditis has poor long-term outcomes. The early mortality, though high (˜10%), has been showing a decreasing trend in the test of time.

Research paper thumbnail of Outcomes and periprocedural management of cardiac implantable electronic devices in patients with carcinoid heart disease

Heart Rhythm, 2021

BACKGROUND Carcinoid heart disease (CHD) is a rare complication of hormonally active neuroendocri... more BACKGROUND Carcinoid heart disease (CHD) is a rare complication of hormonally active neuroendocrine tumors that often requires surgical intervention. There are limited data on cardiac implantable electronic device (CIED) implantation in patients with CHD. OBJECTIVES We evaluated the experience of CIED implantation in patients with CHD. METHODS Patients with a diagnosis of CHD and a CIED procedure from January 1, 1995 through June 1, 2020 were identified using a Mayo Clinic proprietary data retrieval tool. Retrospective review was performed to extract relevant data. These included indications for implant, procedural details, complications, and mortality. RESULTS A total of 27 patients (55.6% males, mean age at device implant at 65.6+/- 8.8 years) with a cumulative follow up of 75 patient years (median 1.1, IQR: 0.4-4.6 years) were included for analysis. The majority of implanted devices were dual-chamber permanent pacemakers (63%). Among all CHD patients who underwent any cardiac surgery, the incidence of CIED implantation was 12%. The most common indication for implantation was high-grade heart block (66.7%). Device implant complication rates were modest (14.8%). No patient suffered carcinoid crisis during implantation and there was no peri-implant mortality. The median time from implant to death was 2.5 years, with a one-year mortality of 15%. CONCLUSIONS CHD is a morbid condition and surgical valve intervention carries associated risks, in particular a high requirement for post-operative pacing needs. Our data suggest that CIED implantation can be performed relatively safely. Clinicians must be aware of the relevant carcinoid physiology and take appropriate precautions to mitigate risks.

Research paper thumbnail of Haemodynamic determinants of improved aerobic capacity after tricuspid valve surgery in Ebstein anomaly

Heart, 2020

BackgroundAlthough tricuspid valve surgery improves functional capacity in patients with Ebstein ... more BackgroundAlthough tricuspid valve surgery improves functional capacity in patients with Ebstein anomaly, it is not always associated with improvement in aerobic capacity. The purpose of this study was to identify the determinants of improved aerobic capacity after tricuspid valve surgery in adults with Ebstein anomaly with severe tricuspid regurgitation.MethodsRetrospective study of patients with severe tricuspid regurgitation due to Ebstein anomaly that had tricuspid valve surgery at Mayo Clinic Rochester (2000–2019) and had preoperative and postoperative cardiopulmonary exercise tests and echocardiograms. The patients were divided into aerobic capacity(+) and aerobic capacity(-) groups depending on whether they had postoperative improvement in %-predicted peak oxygen consumption (VO2).ResultsOf 76 patients with severe tricuspid regurgitation due to Ebstein anomaly, 28 (37%) and 48 (63%) were in aerobic capacity(+) and aerobic capacity(-) groups, respectively. The average improvem...

Research paper thumbnail of Diagnosis of Constrictive Pericarditis Using Ejection Times in the Pulmonary Artery and Ascending Aorta

Journal of the American College of Cardiology, 2021

Research paper thumbnail of Comparing Risk Factors and Early Postoperative Outcomes in Adults with Ebstein Anomaly Following Cone Reconstruction Versus Tricuspid Valve Replacement

Journal of the American College of Cardiology, 2021

Research paper thumbnail of Preoperative Imaging Parameters and Early Postoperative Outcomes in Adult Patients with Tetralogy of Fallot

Journal of the American College of Cardiology, 2020

Background: Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart diseas... more Background: Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease with the majority of patients requiring additional surgical interventions in adulthood. We examined preoperative imaging in adult TOF patients to identify factors impacting early postoperative morbidity and mortality. Methods: We performed a single institution, retrospective review of patients ≥18 years with TOF who underwent cardiac surgery between 1/8/2008-6/21/2018. Data were analyzed using 2-tail Fisher's exact test and logistic regression. Results: There were 219 patients included (median age 40, range 18-83 yrs, 60% male) with TOF who underwent cardiac surgery. Surgical interventions included repair or replacement of the pulmonary valve (n=200), tricuspid valve (n=70), mitral valve (n=13), and aortic valve (n=8). Early postoperative complications included arrhythmias (n=46, 21%), mechanical circulatory support (n=7, 3%), dialysis (n=7, 3%), reoperation (n=5, 2%), cardiac arrest (n=3, 1%) and 30-day mortality (n=3, 1%). Low right ventricular ejection fraction (EF) on MRI, right ventricular systolic pressure >1/3 systemic, left ventricular (LV) enlargement and low LV EF conferred the greatest relative risk for complications (Table). Conclusion: Surgical interventions for adult TOF patients can be performed with low early morbidity and mortality. Preoperative imaging parameters can predict patients at higher risk for complications in the early postoperative period.

Research paper thumbnail of Cardiac Intensive Care Unit Outcomes After Cone Repair in Adults with Ebstein Anomaly

Journal of the American College of Cardiology, 2020

Background: Adults with Ebstein anomaly (EA) have excellent mid and late outcomes following cone ... more Background: Adults with Ebstein anomaly (EA) have excellent mid and late outcomes following cone repair (CR); however, early morbidity and mortality are not well described. We examined the impact of perioperative comorbid conditions on early postoperative outcomes in adults with EA following CR. Methods: This is a single institution, retrospective review of 153 patients ≥18 years that had CR for EA from 6/2007-12/2018. Data were analyzed using t-test or chi-squared test as appropriate. Univariate and multivariate analyses were applied for significant variables. Results: We included 153 adults (mean age 36.2±13.7 years; 40% males) that had CR for EA. Of these, 55 (36%) had previous cardiac surgery. Preoperative echocardiography demonstrated ≥ moderate tricuspid valve (TV) regurgitation in 151 (99%); 70 (46%) had ≥ moderately decreased right ventricular (RV) function. Baseline comorbidities include arrhythmia in 78 (51%), body mass index >30 kg/m 2 in 37 (24%), and smoking history in 38 (25%). Concomitant procedures at time of CR included atrial septal defect/patent foramen ovale closure (n=88), bidirectional cavopulmonary anastomosis (n=5), RV plication (n=70), and Maze procedure (n=57). Mean cardiopulmonary bypass and aortic cross clamp times were 88±22 and 73±19 minutes respectively. Median duration of mechanical ventilation was 1 (1, 1) days, cardiac intensive care unit length of stay (LOS) 2 (1, 2) days and hospital LOS 4 (4, 5) days. Mean peak serum lactate was 6.2±3.4 mmol/L; 80% of patients were on vasoactive support >24 hours. Postoperative morbidities include new arrhythmia (62, 41%), reoperation for valve re-repair/replacement (6, 4%), delayed sternal closure (2, 1%), readmission <30 days (4, 3%) and mortality <30 days (1, 0.7%). Degree of TV regurgitation, RV dilation and left ventricular ejection fraction improved postoperatively (p<0.01 for all). On multivariate analyses, hospital LOS increased with older age (p<0.01), higher peak lactate (p=0.02) and occurrence of new arrhythmia (p=0.02). Conclusion: Adults with EA following CR have excellent early postoperative outcomes. Older age, higher peak lactate level and onset of new arrhythmia could predict longer hospital LOS.

Research paper thumbnail of Low Flow, Low Gradient Severe Mitral Stenosis: Hemodynamics, Clinical Characteristics and Outcomes

Journal of the American College of Cardiology, 2018

Background: In aortic stenosis, it is well accepted that severe valvular stenosis can coexist wit... more Background: In aortic stenosis, it is well accepted that severe valvular stenosis can coexist with low stroke volume and low transvalvular gradient in the setting of factors such as left ventricular dysfunction or increased arterial elastance. This concept has not been established in patients with severe mitral valve stenosis. We sought to describe the hemodynamics, clinical characteristics and outcome after valvuloplasty of patients with low flow (LF), low gradient (LG) severe MS. Methods: We examined 101 consecutive patients with severe rheumatic MS (mitral valve area ≤ 1.5 cm 2) who underwent balloon valvuloplasty. LF was defined as stroke volume index ≤ 35 mL/m 2 and LG as mean mitral valve gradient < 10 mmHg by echocardiography. To characterize systolic, diastolic, and arterial function, global and segmental strain, left ventricular end systolic elastance (Ees), diastolic capacitance (volume at end diastolic pressure 30 mmHg, V 30), and effective arterial elastance (Ea) were measured. Results: LF/LG severe MS was present in 11 %, LF/high gradient (HG) in 13%, normal flow (NF)/LG in 44%, and NF/HG in 32%. Compared to other groups, patients in the LF/LG group were older (p<0.0001) with a higher prevalence of permanent atrial fibrillation (64%) (p=0.0002). LF/LG was associated with a decreased preload (LV diastolic dimension), higher afterload (Ea), lower ejection fraction (EF), and lower global longitudinal strain (p<0.05 for all). All LF/LG patients had severe subvalvular thickening associated with their decreased LV compliance and basal systolic strain suggesting subvalvular tethering of myocardium. All 4 groups had significant improvement in valve area following valvuloplasty but the LF/LG group demonstrated the least hemodynamic improvement. Conclusion: LF/LG severe MS is a distinct entity characterized by a high prevalence of atrial fibrillation, ventricular-vascular uncoupling, and diastolic left ventricular stiffening. These distinct features may contribute to the lesser benefit from valvuloplasty.

Research paper thumbnail of Impact of Left Ventricular Ejection Fraction Between 50 and 60% Versus ≥60% on Mortality After Aortic Valve Replacement for Severe Aortic Stenosis

Journal of the American College of Cardiology, 2018

Background: Left ventricular ejection fraction (LVEF) is a major prognostic indicator for the out... more Background: Left ventricular ejection fraction (LVEF) is a major prognostic indicator for the outcome of patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS). Currently, LVEF of 50% is defined as low normal for AS. However, a clear cut off value of LVEF related to the best outcome after AVR remains undetermined. Methods: Clinical outcome based on LVEF was assessed in 621 consecutive patients with severe AS [aortic valve area (AVA) ≤1 cm 2 ]. Results: Mean AVA was 0.83±0.13 cm 2 and LVEF was 59±14%. LVEF≥60% was present in 419 (67%), 80 (13%) had 50≤ LVEF<60%, and 122 (20%) had an LVEF<50%. During the median follow-up of 2.7 years, the mortality was worse for patients with an LVEF <50% and also worse for patients with 50% ≤ LVEF <60% compared to patients with an LVEF ≥60% (P<.001, Fig 1.). Even after AVR, patients with a 50%≤ LVEF<60% had a worse outcome compared to patients with an LVEF≥60% (P<.001, Fig 1.). In the Cox model, LVEF <60% was associated with worse survival outcomes (hazard ratio [HR]: 1.94; 95%CI: 1.45-2.58; P <.001) after adjusting for age, sex, AVA, symptoms, ischemic heart disease, diabetes mellitus and atrial fibrillation. The risk remained higher in patients with 50% ≤ LVEF <60% compared with patients with LVEF ≥60% (HR: 1.61; 95%CI: 1.09-2.32). Conclusion: In patients with severe AS, LVEF <60% is abnormal and predicts a poor outcome even after AVR compared to the patients with LVEF >60%. AVR may be considered when LVEF is < 60% (not 50%) even in asymptomatic patients with severe AS.

Research paper thumbnail of Hemodynamic Impact of Isolated Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Mitral Stenosis: A Doppler Echocardiographic Study

Journal of the American College of Cardiology, 2019

Background: Mitral stenosis (MS) frequently coexists in patients with severe aortic stenosis (sAS... more Background: Mitral stenosis (MS) frequently coexists in patients with severe aortic stenosis (sAS). However, the impact of aortic valve replacement (AVR) on MS is unknown. Methods: We retrospectively investigated patients who underwent AVR or transcatheter AVR (TAVR) for sAS from 2008 to 2015. Transmitral gradient by Doppler echocardiography ≥ 4 mmHg was identified as MS; patients were stratified according to mitral valve area (MVA, by continuity equation) as > or ≤ 2.0 cm 2. We compared MVA before and after AVR in patients with MS. We investigated the clinical outcomes of patients with vs. without MS using 1:2 matching for age, sex, LVEF, percent with TAVR and year of AVR. Results: Of 204 patients with sAS and MS (age 76 ± 9 years), 198 could be matched with 390 with sAS without MS. In those with MS, MVA increased after AVR in 126 (62%). Among all MS patients, the mean MVA increased after AVR (2.0 ± 0.5 to 2.3 ± 0.7 cm 2 , p < 0.01). Increase in stroke volume (SV) was a predictor for increase of MVA (odds ratio 7.1, 95% CI 3.3-15, p<0.01). Of 109 (55%) patients with MVA≤2 cm 2 , MVA increased to > 2.0 cm 2 after AVR in 53 and remained ≤ 2.0 cm 2 in 56. Patients with MS had poorer prognosis compared with those without MS (Figure). MVA ≤ 2.0 cm 2 after AVR was an independent predictor of overall mortality (hazard ratio 1.6, 95% CI 1.1-2.4, p=0.024). Conclusion: MVA by CE improved with increase of SV after AVR in two-thirds patients with sAS and MS. Patients with MS, especially MVA ≤ 2.0 cm 2 after AVR had higher mortality compared with those without MS.

Research paper thumbnail of Yes, You Can Use the Tricuspid Regurgitation Signal for the Right Ventricular to Right Atrial Gradient, No Matter How Severe the Tricuspid Regurgitation: A Simultaneous Echocardiography: Catheterization Study

Journal of the American College of Cardiology, 2019

Background: The performance of the modified Bernoulli equation to estimate the RV-RA pressure gra... more Background: The performance of the modified Bernoulli equation to estimate the RV-RA pressure gradient by continuous wave Doppler in severe tricuspid regurgitation (TR) is not known. Methods: Simultaneous continuous wave (CW) Doppler of the TR jet was prospectively obtained at time of cardiac catheterization in seven patients with a diagnosis of severe TR by transthoracic echocardiography. Simultaneous right ventricle (RV) and right atrial (RA) pressures were measured for the calculation of RV-RA gradients. CW Doppler data was digitized and the gradient was calculated according to the modified Bernoulli equation. Correlation between Doppler-derived and invasively measured RV-RA gradients was performed by simple linear regression (Pearson's correlation) and the Bland-Altman method. Results: Seven patients (mean age 62 years, 43% female) had 27 cardiac cycles analyzed (range 3-5 per patient) (see Figure). The mechanism of severe TR was thickened restricted leaflets in one patient, mixed device lead and annular dilation in 4, and isolated annular dilatation in 2. Mean RA pressure by cardiac catheterization was 16±6.7 mmHg and RV systolic pressure was 41±17.6. The peak RV-RA gradient was on average 17.8±8.1 mmHg by catheterization and 20.8±8.4 by Doppler. The correlation coefficient was r=0.93 with a mean difference of 3.7±3.1 mmHg (p<0.0001). Conclusion: In patients with severe TR, the modified Bernoulli equation can be used to accurately determine the peak RV-RA pressure gradient.

Research paper thumbnail of Outcomes of Pregnancy in Women with Left Ventricular Noncompaction

Journal of the American College of Cardiology, 2019

Background: Left ventricular noncompaction (LVNC) is an inherited cardiomyopathy characterized by... more Background: Left ventricular noncompaction (LVNC) is an inherited cardiomyopathy characterized by prominent left ventricular trabeculations and deep intertrabecular recesses. LVNC is associated with an increased risk of arrhythmia, embolic events, and heart failure. There is limited information regarding pregnancy outcomes in women with LVNC. Methods: Echocardiography and radiology databases were queried from 2000-2017 to identify female patients with LVNC between the ages of 18 and 40. LVNC was defined on transthoracic echo (TTE) based on an end systolic noncompacted:compacted ratio >2, and end diastolic epicardium to trough:epicardium to peak of trabeculation (X:Y) ratio <0.5. Results: Sixty-one patients with LVNC were identified. Obstetric data was not available for 16 patients. Of the remaining 45, 29 patients had 72 documented pregnancies (range, 1 to 5), of which 55 culminated in a live born neonate. Mean maternal age at first pregnancy was 27 years ± 4.6. Three women (10%) delivered by cesarean section, all performed for obstetric indications. Only two women were diagnosed with LVNC prior to pregnancy, and nine women (31%) were diagnosed with LVNC peripartum, after presenting with heart failure symptoms. Those diagnosed in the peripartum period had a mean ejection fraction (EF) of 33% ± 15.1. Significant peripartum cardiovascular events included new-onset atrial fibrillation with rapid ventricular rates in a patient 35 weeks pregnant with no prior diagnosis of cardiomyopathy. Cesarean section was performed at 37 weeks, and she was diagnosed with LVNC and a reduced EF (41%) postpartum. Another patient, with no prior diagnosis, suffered a resuscitated ventricular fibrillation arrest at five weeks postpartum. TTE at that time illustrated LVNC with an EF of 40%. Conclusion: Pregnancy with LVNC was well-tolerated for the majority of women in this series. However, LVNC may first present as heart failure in the peripartum period and should be considered in the differential diagnosis of peripartum cardiomyopathy. LVNC can cause cardiovascular events with hemodynamic instability in the peripartum period, including atrial fibrillation and ventricular fibrillation arrest.

Research paper thumbnail of The Prognosis of Patients with Moderate Aortic Stenosis

Journal of the American College of Cardiology, 2019

Background: The natural history of moderate aortic stenosis (mod AS) requires clarification to pr... more Background: The natural history of moderate aortic stenosis (mod AS) requires clarification to provide optimal management strategy. Methods: Patients with aortic valve area > 1 and ≤1.5cm 2 in 2012 were identified and stratified by stroke volume index (SVI) and left ventricular ejection fraction (LVEF). All-cause death was compared to age-and sex-matched Minnesota population. Results: Table shows patient characteristics. Mod AS mortality was higher than expected (P<.001, Fig A). When stratified by LVEF (Fig B, C) or SVI (Fig D, E), mortality was significantly higher in patients with low LVEF and/or SVI (P<.001 for all) Conclusion: Mod AS patients showed poor survival. A clinical trial examining role of aortic valve replacement in all patients with mod AS would be beneficial especially in those with low LVEF or SVI.

Research paper thumbnail of Flow dynamics in the false lumen in distal aorta following surgery for type A aortic dissection

European Heart Journal, 2018

Research paper thumbnail of Echo-Doppler assessment of ventricular filling pressures in adult Fontan patients

International Journal of Cardiology, 2018

Background: Diastolic dysfunction is felt to be part of the natural history of patients with prio... more Background: Diastolic dysfunction is felt to be part of the natural history of patients with prior Fontan operation. Despite that, data on noninvasive assessment of diastolic function and ventricular filling pressures in Fontan patients are limited. Methods: We included 48 adult Fontan patients who underwent right heart catheterization with pulmonary artery wedge pressure measurement (PAWP) and transthoracic echo-Doppler assessment within 7 days. Offline measurement of systemic atrioventricular valve pulsed-wave (PW) and medial/lateral tissue Doppler velocities were performed and correlated to PAWP. Results: Median age was 31.4 years (IQR 25-37.4); 52% of patients were females. Median ventricular ejection fraction was 55% (IQR 50.3-57.5) and median PAWP was 10 mmHg (IQR 8-11.3). PW Doppler E velocity (r=0.65, p=<.0001), deceleration time (r=-0.40, p=0.006), and isovolumic relaxation time (IVRT) (r=-0.40, p=0.005) correlated with PAWP, whereas E/A ratio did not (p=0.10). Median medial and lateral E/e' ratios also correlated to PAWP (r=0.59; p=0.009 and r=0.75, p<.0001, respectively). An E velocity >75 cm/s had a sensitivity of 89% and specificity 85% for predicting a PAWP>12 mmHg (97% negative predictive value) whereas a deceleration time <135 ms has a sensitivity of 89% and a specificity of 84% (97% negative predictive value). Positive predictive values were 55% and 50%, respectively. Conclusion: Our data suggest that PW Doppler atrioventricular E velocity and deceleration time could be used to identify adult Fontan patients with normal and elevated filling pressures. However, positive predictive values for PAWP>12 mmHg were poor. Further studies, particularly prospective, simultaneous echo-catheterization correlation, are critically needed.

Research paper thumbnail of E/E’ < 15 Performs Poorly in Patients with Elevated Left Filling Pressures and Atrial Fibrillation/Flutter: A Simultaneous Doppler-Catheterization Study

Journal of the American College of Cardiology, 2017

Background: As reinforced by the 2016 American Society of Echocardiography (ASE) diastology guide... more Background: As reinforced by the 2016 American Society of Echocardiography (ASE) diastology guidelines, early mitral inflow velocity (E) to medial mitral early diastolic tissue Doppler velocity (e') ratio is a key component in the noninvasive assessment of left-sided filling pressures. However, the