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New England Journal of Medicine

Alzheimer’s Disease in Physicians — Assessing Professional Competence and Tempering Stigma
New England Journal of Medicine, Volume 378, Issue 12, Page 1073-1075, March 2018.
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Myth and Measurement — The Case of Medical Bankruptcies
New England Journal of Medicine, Volume 378, Issue 12, Page 1076-1078, March 2018.
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Broken Hearts and Opened Eyes
New England Journal of Medicine, Volume 378, Issue 12, Page 1078-1080, March 2018.
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SIGECAPS, SSRIs, and Silence — Life as a Depressed Med Student
New England Journal of Medicine, Volume 378, Issue 12, Page 1081-1083, March 2018.
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Heartbeat: phenotypic heterogeneity of bicuspid aortic valve disease
Bicuspid aortic valve (BAV) disease is common, affecting 1%–2% of the entire population, with nearly all BAV patients eventually requiring aortic valve replacement, often with concurrent aortic surgery for dilation of the sinuses or ascending aorta. Although echocardiography allows easy diagnosis of the presence of BAV disease early in life, we are unable to predict disease progression or aortic dilation in an individual patient and we have no effective therapies to preserve normal valve function. In this issue of Heart, Evangelista and colleagues1 sought to identify phenotypic predictors of valve dysfunction and aortic root dilation in a series of 802 consecutive adults diagnosed with BAV at eight tertiary care hospitals. As in previous studies, BAV leaflet morphology characterised by fusion of the right and left (RL) coronary cusps was most common (73%), followed by fusion of the right and non-coronary cusps (24%). Aortic regurgitation was associated with...
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Bicuspid aortic valve type: it takes two
Not all patients with bicuspid aortic valves behave similarly. Some patients have early valve dysfunction and require intervention in infancy or childhood. More commonly, bicuspid valves degenerate gradually throughout adulthood and valve failure does not occur until the fifth decade or later. Some patients have primarily aortic stenosis while others have aortic regurgitation. Others have mixed valve dysfunction. The aorta dilates in some, but not all patients with bicuspid aortic valves. Furthermore, dilation can occur at the sinuses, in the mid-ascending aorta, or in both regions. Numerous authors have attempted to explain this heterogeneity in valve dysfunction and aortic morphology. However, to date, the reason for the variability in presentation remains incompletely explained. The most common way to categorise bicuspid aortic valves is according to the morphology of leaflet fusion, since most valves are trileaflet with a fused commissure. Fusion of the right and left coronary cusps (RL fusion) is most...
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JACC Instructions for Authors
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Transcatheter Aortic Valve Replacement in Patients With Low-Flow, Low-Gradient Aortic Stenosis: The TOPAS-TAVI Registry
AbstractBackground Few data exist on patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR). Also, very scarce data exist on the usefulness of dobutamine stress echocardiography (DSE) before TAVR in these patients. Objectives The authors sought to evaluate clinical outcomes and changes in left ventricular ejection fraction (LVEF) following TAVR in patients with classical LFLG-AS. Methods This multicenter registry included 287 patients with LFLG-AS undergoing TAVR. DSE was performed before TAVR in 234 patients and the presence of contractile reserve was defined as an increase of ≥20% in stroke volume. Transthoracic echocardiography was repeated at hospital discharge and at 1-year follow-up. Clinical follow-up was obtained at 1 and 12 months, and yearly thereafter. Results The median Society of Thoracic Surgeons score of the study population was 7.7% (interquartile range 5.3% to 12.0%), and the mean LVEF and transvalvular gradient were 30.1 ± 9.7% and 25.4 ± 6.6 mm Hg, respectively. The presence of contractile reserve was observed in 45% of patients at DSE. Mortality rates were 3.8%, 20.1%, and 32.3% at 30 days, 1 year, and 2 years, respectively. On multivariable analysis, chronic obstructive pulmonary disease (p = 0.022) and lower hemoglobin values (p < 0.001) were associated with all-cause mortality. Lower hemoglobin values (p = 0.004) and moderate-to-severe aortic regurgitation post-TAVR (p = 0.018) were predictors of the composite of mortality and rehospitalization due to heart failure. LVEF increased by 8.3% (95% confidence interval: 6% to 11%) at 1-year follow-up, and the lack of prior coronary artery bypass graft (p = 0.004), a lower LVEF at baseline (p < 0.001), and a lower stroke volume index at baseline (p = 0.019) were associated with greater increase in LVEF. The absence of contractile reserve at baseline DSE was not associated with any negative effect on clinical outcomes or LVEF changes at follow-up. Conclusions TAVR was associated with good periprocedural outcomes in patients with LFLG-AS. However, approximately one-third of LFLG-AS TAVR recipients died at 2-year follow-up, with pulmonary disease, anemia, and residual paravalvular leaks associated with poorer outcomes. LVEF improved following TAVR, but DSE failed to predict clinical outcomes or LVEF changes over time. (Multicenter Prospective Study of Low-Flow Low-Gradient Aortic Stenosis [TOPAS Study]; NCT01835028)
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Low-Flow, Low-Gradient Aortic Stenosis: TAVR In, Dobutamine Stress Echocardiography Out?
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Reduced Left Ventricular Ejection Fraction in Patients With Aortic Stenosis
AbstractBackground Left ventricular ejection fraction (LVEF) is reduced in a subset of patients with severe aortic stenosis (AS). Objectives The authors sought to determine the temporal course of reduced LVEF, its predictors, and its impact on prognosis in severe AS. Methods Serial echocardiograms of 928 consecutive patients with first-time diagnosis of severe AS (aortic valve area [AVA] ≤1 cm2) who had at least 1 echocardiogram before the diagnosis were evaluated. A total of 3,684 echocardiograms (median 3 studies per patient) within the preceding 10 years were analyzed. Results At the initial diagnosis, 196 (21%) patients had an LVEF <50% (35.1 ± 9.7%) and 732 (79%) had an LVEF ≥50% (64.2 ± 6.1%). LVEF deterioration had begun before AS became severe for those with an LVEF <50% and accelerated after AVA reached 1.2 cm2, whereas mean LVEF remained >60% in patients with LVEF ≥50% at initial diagnosis. The strongest predictor for LVEF deterioration was LVEF <60% at 3 years before AS became severe (odds ratio: 0.86; 95% confidence interval: 0.83 to 0.89; p < 0.001). During the median follow-up of 3.3 years, mortality was significantly worse, not only for patients with an LVEF <50%, but for patients with an LVEF of 50% ≤ LVEF <60% compared with patients with an LVEF ≥60% even after aortic valve replacement (p < 0.001). Conclusions In patients with severe AS and reduced LVEF, a decline in LVEF began before AS became severe and accelerated after AVA reached 1.2 cm2. LVEF <60% in the presence of moderate AS predicts further deterioration of LVEF and appears to represent abnormal LVEF in AS.
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Heart Rhythm