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Biomedical subjects

Padmini Varadarajan

Publications and source records attributed to Padmini Varadarajan.

13 recordsLinked to original sources
PubMed2006

Survival in elderly patients with severe aortic stenosis is dramatically improved by aortic valve replacement: Results from a cohort of 277 patients aged > or =80 years.

BACKGROUND: Calcific aortic stenosis (AS) is a disease of the elderly. However, there is reluctance to offer aortic valve replacement (AVR) for elderly patients with severe AS. We investigated if AVR confers a survival benefit in elderly patients with severe AS. METHODS: We screened our echocardiographic database from 1993 to 2003 for patients with severe AS (AV area < or = 0.8 cm2) and age > or =80 years. Two hundred and seventy seven patients were identified. Complete chart reviews were performed for clinical data. Mortality data were obtained from National Death Index. Survival curves of patients who underwent AVR during the follow-up period were compared with those managed nonsurgically. RESULTS: Patient characteristics were as follows: age 85+/-4 years, 53% male, AV area 0.68+/-0.16 cm2, EF 52+/-20%, CAD 47%, diabetes 17%. Over a mean follow-up of 2.5 years, 55 (20%) had AVR and there were 175 deaths. One-year, 2-year and 5-year survival rates among patients with AVR were 87, 78 and 68% respectively, compared with 52, 40 and 22%, respectively, in those who had no AVR (p < 0.0001). Hazard ratio for death with AVR adjusted for 19 covariates including age, EF, gender, comorbidities and pharmacotherapy was 0.38 (95% CI 0.26-0.66, p < 0.0001). CONCLUSION: Prognosis of medically managed severe calcific AS in the elderly patients is dismal. AVR appears to improve survival of these patients and should be strongly considered in the absence of other major comorbidities.

Aged, 80 and over↗
PubMed2006

Prognostic significance of hemoglobin level in patients with congestive heart failure and normal ejection fraction.

BACKGROUND: Previous studies have shown low hemoglobin (Hb) to have an adverse effect on survival in patients with congestive heart failure (CHF) and reduced left ventricular (LV) ejection fraction (EF); but its effect on survival in patients with CHF and normal EF is not known. HYPOTHESIS: This study sought to determine whether low Hb has an effect on survival in patients with both CHF and normal EF. METHODS: Detailed chart reviews were performed by medical residents on 2,246 patients (48% with normal EF) with a discharge diagnosis of CHF in a large tertiary care hospital from 1990 to 1999. The CHF diagnosis was validated using the Framingham criteria. Mortality data were obtained from the National Death Index. Survival analysis was performed using Kaplan-Meier and Cox regression models. RESULTS: By Kaplan-Meier analysis, low Hb (< 12 gm/dl) compared with normal hemoglobin was associated with a lower 5-year survival in patients with CHF and both normal (38 vs. 50%, p = 0.0008) and reduced (35 vs. 48%, p = 0.0009) EF. Using the Cox regression model, low Hb was an independent predictor of mortality after adjusting for age, gender, renal dysfunction, diabetes mellitus, hypertension, and EF in both groups of patients. CONCLUSION: Low Hb has an independent adverse effect on survival in patients with CHF and both normal and reduced EF in both groups of patients.

Aged↗
PubMed2006

Malignant natural history of asymptomatic severe aortic stenosis: benefit of aortic valve replacement.

BACKGROUND: Patients with asymptomatic severe aortic stenosis (AS) are reported to have a benign prognosis and hence the American College of Cardiology/American Heart Association guidelines do not recommend aortic valve replacement (AVR) for patients with isolated asymptomatic severe AS. However, symptoms are subjective and would depend upon patient's life style. We examined the natural and unnatural history of initially asymptomatic patients with severe AS. METHODS: A search of our echocardiographic database between 1993 and 2003 yielded 740 patients with severe AS defined as aortic valve area 0.8 cm2 or less. Thorough chart reviews were conducted to collect clinical and pharmacologic data. Of these, 338 patients were asymptomatic at the initial encounter forming the study cohort. RESULTS: Patient characteristics were the following: age 71 +/- 15 years, males 51%, aortic valve area 0.72 +/- 0.17 cm2, left ventricular ejection fraction 0.59 +/- 0.17. Ninety-nine (29%) patients had AVR during a mean follow-up of 3.5 years. Survival at 1, 2, and 5 years in the nonoperated patients were 67%, 56%, and 38%, respectively, compared with 94%, 93%, and 90% in those who underwent AVR (p < 0.0001). The Cox regression model was used to adjust for the effect of 18 clinical, echocardiographic, and pharmacologic variables on survival. The adjusted hazard ratio for death with AVR was 0.17 (95% confidence interval [CI] 0.10 to 0.29). In the nonoperated group, renal insufficiency (risk ratio [RR] 3.1, 95% CI 1.5 to 6.6), beta blocker use (RR 0.52, 95% CI 0.31 to 0.88), statin use (RR 0.52, 95% CI 0.27 to 0.99), age (per year RR 1.03, 95% CI 1.02 to 1.05), and left ventricular ejection fraction (per % RR 0.99, 95% CI 0.98 to 1.00) were found to be the independent predictors of mortality. The benefit of AVR was further supported by sensitivity and propensity score analyses. CONCLUSIONS: Our observational data indicate that the natural history of asymptomatic AS is not benign and that survival is dramatically improved by AVR. Survival of the asymptomatic unoperated or nonoperable patients may potentially be improved by the use of beta blockers and statins.

Adrenergic beta-Antagonists↗
PubMed2006

Clinical profile and natural history of 453 nonsurgically managed patients with severe aortic stenosis.

BACKGROUND: Severe aortic stenosis (AS) is a surgically correctable condition. However, aortic valve replacement (AVR) is not offered to many patients with severe AS for various reasons. We investigated the profile and survival patterns of patients with severe AS who did not have AVR. METHODS: Our echocardiographic database was screened for patients with severe AS, defined as a Doppler estimated aortic valve area of 0.8 cm2 or less between 1993 and 2003. Seven hundred and forty patients with severe AS were identified, of whom 453 patients had no AVR through the follow-up period, forming the study cohort. These patients were comprehensively characterized by obtaining clinical, pharmacologic, and surgical data through a comprehensive chart review and extracting survival data from the National Death Index. RESULTS: Patient characteristics were as follows: age 75 +/- 13 years, 48% male, left ventricular (LV) ejection fraction 52 +/- 21%, coronary artery disease in 34%, hypertension in 35%, serum creatinine level greater than 2 mg/dL in 11%, and diabetes mellitus in 14%. The survival at 1 year, 5 years, and 10 years was 62%, 32%, and 18%, respectively. The univariate predictors of reduced survival were advanced age, low LV ejection fraction, heart failure, elevated serum creatinine level, severe mitral regurgitation, and pulmonary hypertension; and the independent predictors were advanced age, low LV ejection fraction, heart failure, elevated serum creatinine level, and systemic hypertension. Concomitant pharmacotherapy had no impact on survival. CONCLUSIONS: Conservatively treated patients with severe AS have a grave prognosis, and it is worse in the presence of advanced age, LV dysfunction, heart failure, and renal failure.

Aged↗
PubMed2006

High prevalence of clinically silent severe mitral regurgitation in patients with heart failure: role for echocardiography.

Mitral regurgitation (MR) is common in patients with congestive heart failure (CHF) and has adverse effects on prognosis. In view of the altered hemodynamics in CHF, we examined the accuracy of auscultation for its detection in CHF with reduced systolic function. We examined 370 patients on stable heart failure therapy enrolled in our CHF clinic, if they had a physical examination by one of the two senior cardiologists and an echocardiogram within 2 weeks after the physical examination. The MR murmur was graded 0 to 6 on physical examination. MR was graded 0 to 4 on echocardiography using standard echocardiographic criteria. The left ventricular (LV) ejection fraction was 21 +/- 12% and age was 65 +/- 15 years. By echocardiography MR was present in 345 patients (94%), being 1+ in 162 (44%), 2+ in 80 (22%), 3+ in 54 (15%), and 4+ in 51 (14%). The frequency of an audible MR murmur by physical examination was 4% in 1+ MR, 11% in 2+ MR, 13% in 3+ MR, and 37% in 4+ MR. The audibility of MR murmur was not related to age, sex, body size, LV size, ejection fraction, or left atrial size. In conclusion, grade 3 or 4+ MR is present in one third of patients with CHF and reduced ejection fraction, and is inaudible in three quarters of them by physical examination. Echocardiography is needed for its detection. Audibility of MR murmur cannot be predicted by body size, LV size, or LV function in these patients.

Aged↗
PubMed2006

Noncatheter-associated vegetative phlebitis of the superior vena cava presenting with multiple lung abscesses.

We present a patient with a large vegetation in the superior vena cava (SVC) presenting with multiple staphylococcal lung abscesses. We believe that this is the first reported case of vegetative phlebitis of the SVC without a history of central venous catheter line. Our case emphasizes the need for careful imaging SVC using transesophageal echocardiography in bacteremic patients even in the absence of a central catheter.

Diagnosis, Differential↗
PubMed2006

Prosthetic valve thrombosis presenting as an acute embolic myocardial infarction in a pregnant patient: issues on anticoagulation regimens and thrombolytic therapy.

Mechanical valves are inherently thrombogenic and require meticulous anticoagulation. Pregnancy produces a hypercoagulable state and achieving adequate anticoagulation is difficult. We present a pregnant patient who had a nonobstructive thrombus of mechanical mitral valve causing embolic acute myocardial infarction. Issues surrounding management of anticoagulation and use of thrombolytic therapy during pregnancy are discussed. Education regarding the critical nature of adequate anticoagulation in these patients is important.

Adult↗
PubMed2005

Massive posterior mitral annular calcification causing dynamic left ventricular outflow tract obstruction: mechanism and management implications.

We report a case of massive posterior mitral annular calcification causing severe systolic anterior motion of the anterior mitral leaflet and dynamic left ventricular outflow tract obstruction. Mechanism of genesis of systolic anterior motion by this unusual mechanism is illustrated. Importance of recognizing this mechanism and its implications for surgical therapy are discussed. Our patient also had liquefaction necrosis of mitral annular calcification causing its extension into left ventricular myocardium mimicking a tumor.

Calcinosis↗
PubMed2004

Relative duration of transmitted mitral A wave as a measure of left ventricular end-diastolic pressure and stiffness.

BACKGROUND AND OBJECTIVES: The mitral A wave is transmitted to the left ventricular (LV) outflow tract where it is registered as Ar wave. We have related its transit time to the LV late diastolic stiffness. We also observed incidentally that the duration of the transmitted Ar wave exhibited marked variability and hence investigated its hemodynamic correlates. METHODS AND RESULTS: Mitral A wave and the Ar wave in the LV outflow tract were recorded using pulsed wave Doppler technique simultaneous with high fidelity LV pressure recordings in 20 patients undergoing cardiac catheterization. A high-speed contrast left ventriculogram was obtained as well. The duration of both these wave forms were measured and A wave duration minus the Ar wave duration was measured. The A minus Ar wave duration (range 0-95 ms) correlated with LV end-diastolic pressure (r = 0.54, P = 0.014, range 4-32 mmHg), LV late diastolic stiffness (r = 0.62, P = 0.004, range 0.1-1.6 mmHg/ml) and the amount of LV pressure rise with atrial contraction (r = 0.67, P = 0.001, range 2-13 mmHg). CONCLUSION: A minus Ar wave duration is an easily obtainable Doppler parameter that is related to LV late diastolic filling pressures and stiffness and gives insights into aspects of LV diastolic function.

Aged↗
PubMed2003

Prognosis of congestive heart failure in patients with normal versus reduced ejection fractions: results from a cohort of 2,258 hospitalized patients.

BACKGROUND: Patients with congestive heart failure have an annual mortality of 10% to 20% depending on disease severity. Though one third of these patients have normal left ventricular (LV) ejection fraction (EF), their natural history is poorly defined. Small population-based studies have suggested a more benign prognosis for patients with preserved LVEF. However, prognosis in hospitalized patients, who form a higher risk group, is not known. METHODS: We investigated the survival patterns of 2,258 patients with a primary hospital discharge diagnosis of congestive heart failure between 1990 and 1999. Survival was analyzed and patients with normal and reduced LVEF were compared. RESULTS: Their age was 71 +/- 11 years, and 97% were men. There were 1,535 deaths over a mean follow up of 786 days. Of these, 963 (43%) patients had a normal LVEF (>/=55%). Patients with normal LVEF were of the same age as those with reduced LVEF, but had a lower prevalence of atrial fibrillation (20 versus 26%, P =.03), left bundle branch block (2 versus 12%, P <.0001), significant mitral regurgitation (5 versus 31%, P <.0001) and electrocardiographic evidence of myocardial infarction (38 versus 60%, P <.0001). Despite lesser comorbidities, they had a higher mortality hazard, with a 5-year survival of 22% compared with 28% for those with systolic heart failure (P =.007). Proportional hazards model showed presence of normal EF as a categoric variable to be an independent predictor of mortality in those with heart failure after correcting for age and rhythm. CONCLUSIONS: Prognosis of hospitalized patients with congestive heart failure and normal LVEF is worse than those with reduced EF despite lesser comorbidities. Studies addressing optimal management of these patients are warranted.

Aged↗
PubMed2003

Effect of atrial fibrillation on the dynamics of mitral annular area.

BACKGROUND AND AIMS OF THE STUDY: The mitral annulus shows dynamic changes in shape and size during the cardiac cycle. A smaller size in end-diastole is attributed to the sphincteric action of atrial systole, and this may be important for functional integrity of the mitral valve. However, the effect of atrial fibrillation (AF) on dynamic changes in mitral annular size in humans is not known. METHODS: Mitral annular diameters in apical four- and two-chamber views were measured using echocardiography in 25 patients in atrial fibrillation, and in 37 subjects in normal sinus rhythm at mid-diastole, end-diastole and end-systole. Mitral annular area was computed assuming elliptical geometry. RESULTS: Patients in sinus rhythm showed a significant increase in mitral annular area of 25.9 +/- 12.8% with ventricular systole compared to its area in end-diastole (p < 0.0001), and a 10.5 +/- 8.4% reduction with atrial systole compared to mid-diastole (p < 0.001). Patients in AF had larger mitral annuli which showed non-significant changes in size between these three phases of the cardiac cycle. Percent reduction in mitral annular area in the latter half of diastole correlated significantly with left atrial (LA) diameter (r = -0.54, p < 0.0001), LA volume (r = -0.50, p < 0.0001), left ventricular (LV) fractional shortening (r = 0.37, p = 0.0036), mitral annular area in mid-diastole (r = -0.41, p = 0.0011) and mitral annular area in end-diastole (r = -0.64, p < 0.0001). That is, atrial sphincteric action on the mitral annulus was less in the presence of larger left atrium or the mitral annulus. Stepwise multiple regression analysis showed rhythm and mitral annular size to be independent predictors of dynamic changes in mitral annular area. CONCLUSION: It is concluded that AF blunts or eliminates the phasic changes in mitral annular size during the cardiac cycle with loss of its presystolic sphincteric action; this may have implications in the genesis and surgical correction of mitral regurgitation.

Aged↗