This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Related Collections Related Articles

INSIDE THIS ISSUE

Inside This Issue

	State-of-the-Art Papers

Top State-of-the-Art Papers Clinical Research

Carole A. Warnes

The importance of the right ventricle (RV) in congenital heart disease (CHD) is reviewed by Warnes. The RV has a remarkable ability to adapt to pressure and volume load, but its size and function are often overlooked. Patients with various forms of CHD may develop symptoms only after RV dysfunction has occurred, at which point they are at risk for lethal ventricular arrhythmias, and surgical outcomes are less favorable. Appropriate imaging of the size and function of the RV is reviewed and the conclusion is that adults with CHD should be followed at centers that have expertise in these issues to optimize outcomes.

State-of-the-Art Paper.   Adult Sequelae of Kawasaki Disease

1911

John B. Gordon, Andrew M. Kahn, Jane C. Burns

1921

Walton M. Gersony

Kawasaki disease (KD) is an acute, self-limited vasculitis that typically occurs in young children and was first described in 1967. It is currently believed to result from an unknown infectious trigger in patients with a genetic susceptibility. KD is the most common cause of acquired heart disease in the pediatric age group in developed countries. Gordon and colleagues review the natural history of KD, which can result in not only aneurysmal coronary artery dilations but also valvulitis and myocarditis. The damage to the heart may have the potential to result in several complications approximately 20 years later that adult cardiologists should be aware of, and are reviewed in this paper. In an accompanying commentary, Gersony points out that definitive late clinical coronary manifestations have not been reported in any series of KD patients who had small aneurysms or no significant coronary involvement noted during the acute illness. Since, in the modern era such individuals make up over 97% of the emerging post-KD population, he cautions against generating unnecessary lifetime anxiety.

	Clinical Research

Top State-of-the-Art Papers Clinical Research

 
Interventional Cardiology.   Incidence and Predictors of DES Fracture

1924

Gaku Nakazawa, Aloke V. Finn, Marc Vorpahl, Elena Ladich, Robert Kutys, Isidora Balazs, Frank D. Kolodgie, Renu Virmani

Clinically the incidence of stent fracture with drug-eluting stents (DES) is reported to be 1% to 2%; however, the true incidence may be underestimated because of the limited sensitivity of angiography to detect these fractures. Nakazawa and colleagues studied hearts obtained at autopsy from patients who had previously received a DES. Stent fracture was graded on a scale and was found in 29% of the stents. Stent fracture was more likely in older stents, longer stents, Cypher (Cordis Corp., Miami Lakes, Florida) compared with Taxus (Boston Scientific, Natick, Massachusetts) stents, and in overlapping stents. While simple fractures did not appear to be clinically detrimental, two-thirds of the stents with transection of the struts causing a gap in stent segment were associated with thrombosis or restenosis. This study suggests that the true incidence of stent fracture is much higher than 1% to 2% and may be clinically relevant.

Editorial Comment

Andrew J. Carter, p. 1932

Antithrombotic Therapy.   No Difference in Clopidogrel Efficacy/Safety Between Women and Men
1935

Jeffrey S. Berger, Deepak L. Bhatt, Christopher P. Cannon, Zhengming Chen, Lixin Jiang, James B. Jones, Shamir R. Mehta, Marc S. Sabatine, Steven R. Steinhubl, Eric J. Topol, Peter B. Berger

Berger and colleagues investigated whether there were differences in the clinical benefits of clopidogrel for men and women by performing a meta-analysis of all large trials that randomized subjects to clopidogrel or placebo. These trials included 80,000 subjects, 30% of whom were female. The overall reduction in cardiovascular events was similar for men and women. However, in women the risk reduction was only significant for myocardial infarction (odds ratio [OR]: 0.81) and was not statistically significant for stroke (OR: 0.91) or total death (OR: 0.99), although there were significant reductions in men. Clopidogrel increased the risk of major bleeding in both women (OR: 1.43) and men (OR: 1.22) similarly. Clopidogrel reduces the risk of cardiovascular events in both women and men but the nature of the benefits is somewhat altered.

Editorial Comment

David P. Faxon, p. 1946

Cardiac Imaging and Stent Failure.   Stent Gap: Detectable by CTA, Linked to In-Stent Restenosis

1949

Harvey S. Hecht, Sotir Polena, Vladimir Jelnin, Marcelo Jimenez, Tandeep Bhatti, Manish Parikh, Georgia Panagopoulos, Gary Roubin

This study by Hecht and colleagues used computed tomographic angiography (CTA) to study the incidence and pathogenesis of stent fracture with drug-eluting stents. CTA studies were performed on almost 300 subjects with over 600 stents. Stent gap was diagnosed when both of the following criteria were fulfilled: 1) partial or complete (circumferential) gap or a "crush" pattern on visual inspection; and 2) confirmation of Hounsfield units <300 at the site of separation, consistent with the absence of metallic material. In patients who had both catheter coronary angiography (CCA) and CTA, stent gap was noted in 16.9% by CTA but only 1.0% by CCA. In-stent restenosis was noted in 46% of the stent gaps, and stent gap detected by CTA accounted for 28% of the cases of in-stent restenosis. CTA appears to be a powerful tool for understanding the relationship between stent fracture and in-stent restenosis.

Valvular Heart Disease.   LVESD >40 mm Predicts Poor Outcomes in Patients With Flail Mitral Leaflets

1961

Christophe Tribouilloy, Francesco Grigioni, Jean François Avierinos, Andrea Barbieri, Dan Rusinaru, Catherine Szymanski, Marinella Ferlito, Laurence Tafanelli, Francesca Bursi, Faouzi Trojette, Angelo Branzi, Gilbert Habib, Maria G. Modena, Maurice Enriquez-Sarano, on behalf of the MIDA Investigators

Tribouilloy and colleagues analyzed the association between left ventricular end-systolic diameter (LVESD) and survival after diagnosis in patients with organic mitral regurgitation (MR) due to flail leaflets in a registry that has enrolled almost 800 subjects. LVESD 40 mm independently predicted overall (hazard ratio [HR]: 1.95) and cardiac mortality (HR: 3.09) under conservative management. During the entire follow-up (including post-surgical), LVESD 40 mm independently predicted cardiac mortality due to persistence of excess mortality after surgery (HR: 1.81). In MR due to flail leaflets, LVESD 40 mm is independently associated with increased mortality under medical management but also after surgical correction, suggesting that patients should be operated before LVESD reaches 40 mm.

Editorial Comment

Luc A. Pierard, Julien Magne, p. 1969

Pulmonary Hypertension.   Prolonged Benefit for Ambrisentan in Patients With PAH

1971

Ronald J. Oudiz, Nazzareno Galiè, Horst Olschewski, Fernando Torres, Adaani Frost, Hossein A. Ghofrani, David B. Badesch, Michael D. McGoon, Vallerie V. McLaughlin, Ellen B. Roecker, Brooke C. Harrison, Darrin Despain, Christopher Dufton, Lewis J. Rubin, for the ARIES Study Group

This study evaluated the long-term safety and efficacy of ambrisentan in almost 400 patients with pulmonary arterial hypertension (PAH). For this study, all subjects received ambrisentan but at varying doses. After 2 years, the mean change from baseline in 6-min walk distance was improved for the 5- and 10-mg groups. The rates of survival and freedom from clinical worsening were better than predicted for this cohort of patients. The annualized risk of aminotransferase abnormalities >3x the upper limit of normal was 2% per year, similar to the rate of abnormalities seen with placebo treatment in this type of patient. Two years of ambrisentan treatment was associated with sustained improvements in exercise capacity and a low risk of clinical worsening and death in patients with PAH.

Cardiovascular Risk.   Left Atrial Enlargement Linked to Both Hypertension and Obesity

1982

Jan Stritzke, Marcello Ricardo Paulista Markus, Stefanie Duderstadt, Wolfgang Lieb, Andreas Luchner, Angela Döring, Ulrich Keil, Hans-Werner Hense, Heribert Schunkert, for the MONICA/KORA Investigators

Although left atrial enlargement (LAE) is an independent risk factor for atrial fibrillation, stroke, and death, little information is available about the determinants of left atrial (LA) size. Stritzke and colleagues performed a prospective study of over 1,000 subjects with LA volume determined by standardized echocardiography at baseline and again after 10 years. LA volume was indexed to body height (iLA) and LAE was defined as iLA >35.7 and >33.7 ml/m in men and women, respectively. At baseline, the prevalence of LAE was 9.8%. Both obesity and hypertension were independent predictors of LAE. Adjusted mean values for iLA were significantly lower in normal weight hypertensive patients than in obese normotensive patients with the highest iLA in the obese hypertensive subgroup. Obesity appears to be the most important risk factor for LAE.

Related Articles

Adult Congenital Heart Disease: Importance of the Right Ventricle

Carole A. Warnes
J. Am. Coll. Cardiol. 2009 54: 1903-1910. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Related Collections Related Articles