Publications by authors named "Jeffrey B Geske"

123 Publications

Myocardial Histopathology in Patients With Obstructive Hypertrophic Cardiomyopathy.

J Am Coll Cardiol 2021 May;77(17):2159-2170

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.

Background: Hypertrophic cardiomyopathy (HCM) is characterized by multiple pathological features including myocyte hypertrophy, myocyte disarray, and interstitial fibrosis.

Objectives: This study sought to correlate myocardial histopathology with clinical characteristics of patients with obstructive HCM and post-operative outcomes following septal myectomy.

Methods: The authors reviewed the pathological findings of the myocardial specimens from 1,836 patients with obstructive HCM who underwent septal myectomy from 2000 to 2016. Myocyte hypertrophy, myocyte disarray, interstitial fibrosis, and endocardial thickening were graded and analyzed.

Results: The median age at operation was 54.2 years (43.5 to 64.3 years), and 1,067 (58.1%) were men. A weak negative correlation between myocyte disarray and age at surgery was identified (ρ = -0.22; p < 0.001). Myocyte hypertrophy (p < 0.001), myocyte disarray (p < 0.001), and interstitial fibrosis (p < 0.001) were positively associated with implantable cardioverter-defibrillator implantation. Interstitial fibrosis (p < 0.001) and endocardial thickening (p < 0.001) were associated with atrial fibrillation pre-operatively. In the Cox survival model, older age (p < 0.001), lower degree of myocyte hypertrophy (severe vs. mild hazard ratio: 0.41; 95% confidence interval: 0.19 to 0.86; p = 0.040), and lower degree of endocardial thickening (moderate vs. mild hazard ratio: 0.75; 95% confidence interval: 0.58 to 0.97; p = 0.019) were independently associated with worse post-myectomy survival. Among 256 patients who had genotype analysis, patients with pathogenic or likely pathogenic variants (n = 62) had a greater degree of myocyte disarray (42% vs. 15% vs. 20%; p = 0.022). Notably, 13 patients with pathogenic or likely pathogenic genetic variants of HCM had no myocyte disarray.

Conclusions: Histopathology was associated with clinical manifestations including the age of disease onset and arrhythmias. Myocyte hypertrophy and endocardial thickening were negatively associated with post-myectomy mortality.
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http://dx.doi.org/10.1016/j.jacc.2021.03.008DOI Listing
May 2021

Echocardiographic Characteristics of Severe Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy.

J Am Soc Echocardiogr 2021 Apr 2. Epub 2021 Apr 2.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address:

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http://dx.doi.org/10.1016/j.echo.2021.03.011DOI Listing
April 2021

Impact of Body Mass Index on Outcome of Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy.

Ann Thorac Surg 2021 Mar 24. Epub 2021 Mar 24.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.

Background: Obesity is highly prevalent in patients with obstructive hypertrophic cardiomyopathy (HCM). In this study, we investigated the impact of body mass index (BMI) in patients undergoing septal myectomy (SM) for obstructive HCM.

Methods: We reviewed 2,746 patients who underwent transaortic SM for obstructive HCM from February 1993 through September 2018. Patients were stratified into 3 groups based on BMI (normal weight < 25 kg/m, overweight 25 to < 30 kg/m, and obese ≥ 30 kg/m).

Results: Preoperatively, median left ventricular outflow tract (LVOT) gradient was 58 mmHg, and there was no difference in gradients across BMI strata (P=0.35). Obese patients had lower percentage with moderate or greater mitral valve regurgitation (45.8%) compared to normal (52.9%) and overweight (55.4%) patients (P<0.001). However, patients with higher BMI were more likely to have New York Heart Association class III/IV limitation at presentation (P<0.001). After myectomy, both anteroseptal thickness (P=0.115) and LVOT gradient (P=0.210) did not differ between groups. There were 14 (0.5%) deaths < 30 days postoperatively and the risk was similar across BMI strata (P=0.448). Model-estimated changes in average BMI at 10 years post procedure showed stratum-specific increases ranging from 0.60 to 1.56 kg/m. During a median (IQR) follow-up of 7.2 (3.2-13.3) years, higher BMI was associated with reduced survival after adjusting for baseline covariates (P=0.001).

Conclusions: Septal myectomy is safe and effective in HCM patients with obesity, but risk of late mortality increased with increasing BMI. Attention to risk factor management through weight loss may improve late results after SM.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.038DOI Listing
March 2021

Jeffrey B. Geske, MD.

Authors:
Jeffrey B Geske

Eur Heart J 2021 Mar 25. Epub 2021 Mar 25.

Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.1093/eurheartj/ehab142DOI Listing
March 2021

'Heart within a heart': echocardiographic assessment of hypertrophic cardiomyopathy.

Eur Heart J 2021 Mar 10. Epub 2021 Mar 10.

Mayo Clinic Alix School of Medicine, 200 1st SW, Rochester, MN, USA.

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http://dx.doi.org/10.1093/eurheartj/ehab150DOI Listing
March 2021

Squat-to-stand provocation of dynamic left ventricular outflow tract obstruction in hypertrophic cardiomyopathy: a case report.

Eur Heart J Case Rep 2021 Jan 28;5(1):ytaa450. Epub 2020 Dec 28.

Department of Cardiovascular Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.

Background: Left ventricular outflow tract (LVOT) obstruction is an important determinant of the management of hypertrophic cardiomyopathy (HCM). With a nationwide shortage of amyl nitrite in 2019, we implemented a 'repetitive squat-to-stand' manoeuvre to provoke LVOT obstruction during echocardiography.

Case Summary: A 64-year-old female was referred with symptomatic HCM refractory to pharmacologic therapy. Transthoracic echocardiography showed minor LVOT obstruction with conventional imaging at rest and during Valsalva manoeuvre, but severe obstruction was confirmed with the repetitive squat-to-stand manoeuvre. Alcohol septal ablation via the first septal perforator was performed with subsequent resolution of symptoms.

Discussion: Due to the dynamic nature of LVOT obstruction, a series of provocative manoeuvres including Valsalva manoeuvre, inhalation of amyl nitrite, and exercise are often necessary to maximally augment ventricular obstruction. The recent unavailability of amyl nitrite during a nationwide shortage prompted the implementation of a protocol of repetitive squat-to-stand manoeuvre in our echocardiography laboratory. Rising from the squatting position decreases preload and afterload, both of which augment dynamic LVOT obstruction. Repetition of squatting and standing appears to enhance the sensitivity of the manoeuvre, particularly when exertional symptoms are reproduced. In this case, repetitive squat-to-stand manoeuvre led to the identification of severe LVOT obstruction which may not have been diagnosed otherwise, alteration of treatment to septal reduction therapy, and subsequent resolution of symptoms.
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http://dx.doi.org/10.1093/ehjcr/ytaa450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898584PMC
January 2021

Is anterior mitral valve leaflet length important in outcome of septal myectomy for obstructive hypertrophic cardiomyopathy?

J Thorac Cardiovasc Surg 2021 Jan 21. Epub 2021 Jan 21.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.

Objectives: Elongation of mitral valve leaflets is a phenotypic feature of hypertrophic cardiomyopathy, and some surgeons advocate plication of the anterior leaflet at the time of septal myectomy. The present study investigates mitral valve leaflet length and outcomes of patients undergoing septal myectomy for obstructive hypertrophic cardiomyopathy.

Methods: We reviewed the records and echocardiograms of 564 patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy between February 2015 and April 2018. Extended septal myectomy without plication of the anterior leaflet was the standard procedure. From intraoperative prebypass transesophageal echocardiograms, we measured anterior and posterior mitral valve leaflets and their coaptation length. For comparison, we performed these mitral valve leaflet measurements in 90 patients who underwent isolated coronary artery bypass grafting and 92 patients undergoing aortic valve replacement in the same period. Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, we assessed left ventricular outflow tract gradient relief and 1-year survival in relation to leaflet length.

Results: Median patient age (interquartile range) was 60.3 (50.2-67.7) years, and 54.1% were male. Concomitant mitral valve repair was performed in 36 patients (6.4%), and mitral valve replacement was performed in 8 patients (1.4%), primarily for intrinsic mitral valve disease. Patients in the hypertrophic cardiomyopathy cohort had significantly longer mitral valve leaflet measurements compared with patients undergoing coronary artery bypass grafting or aortic valve replacement (P < .001 for all 3 measurements). Preoperative resting left ventricular outflow tract gradients were not related to leaflet length (<30 mm, median 49 [21, 81.5] mm Hg vs ≥30 mm, 50.5 [21, 77] mm Hg; P = .76). Further, gradient reduction after myectomy was not related to leaflet length; patients with less than 30 mm anterior leaflet length had a median gradient reduction of 33 (69, 6) mm Hg compared with 36.5 (62, 6) mm Hg for patients with leaflet length 30 mm or more (P = .36). Anterior mitral valve leaflet length was not associated with increased 1-year mortality (P = .758).

Conclusions: Our study confirms previous findings that patients with hypertrophic cardiomyopathy have slight (5 mm) elongation of mitral valve leaflets. In contrast to other reports, increased anterior mitral valve leaflet length was not associated with higher left ventricular outflow tract gradients. Importantly, we found no significant relationship between anterior mitral valve leaflet length and postoperative left ventricular outflow tract resting gradients or gradient relief. Thus, in the absence of intrinsic mitral valve disease, transaortic septal myectomy with focus on extending the excision beyond the point of septal contact is sufficient for almost all patients.
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http://dx.doi.org/10.1016/j.jtcvs.2020.12.143DOI Listing
January 2021

Latent outflow tract obstruction in hypertrophic cardiomyopathy: Clinical characteristics and outcomes of septal myectomy.

J Thorac Cardiovasc Surg 2020 Dec 10. Epub 2020 Dec 10.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.

Objective: This investigation analyzed clinical characteristics of patients with hypertrophic cardiomyopathy (HCM) and latent left ventricular outflow tract (LVOT) and outcomes following septal myectomy.

Methods: We reviewed patients with HCM and LVOT obstruction undergoing septal myectomy from 2001 to 2016 at our center. Follow-up data on functional status were obtained through mailed survey questionnaires.

Results: There were 629 (31.8%) patients with latent obstruction (resting LVOT gradient <30 mm Hg, provoked gradient >30 mm Hg) among 1981 patients undergoing septal myectomy. Patients with latent obstruction were more likely to be male (65.7% vs 51.8%, P < .001), but there were no important differences in other clinical characteristics. The New York Heart Association functional classes and measured/predicted maximal oxygen consumption (62 [51, 72] vs 60 [48, 72], P = .158) in cardiopulmonary exercise tests were comparable between the 2 groups. Patients with latent obstruction had both lower septal thickness and lower posterior wall thickness. Median intraoperative provoked pressure gradient decreased from 96 (68, 126) mm Hg to 0 (0, 6) mm Hg after myectomy (P < .001). There was no difference in early (<30 days) deaths (3/629 vs 5/1352, P = .726) and long-term survival between patients with latent obstruction and resting obstruction. In follow-up, both general health status and New York Heart Association functional class were significantly improved following septal myectomy.

Conclusions: Patients with HCM and latent LVOT obstruction generally have milder left ventricular hypertrophy but similarly impaired functional capacity compared to those with resting obstruction. Septal myectomy improves functional capacity and symptoms.
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http://dx.doi.org/10.1016/j.jtcvs.2020.12.016DOI Listing
December 2020

Assessment of left ventricular filling pressure with Doppler velocities across the patent foramen ovale.

J Echocardiogr 2021 Jan 12. Epub 2021 Jan 12.

Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA.

Background: The utility of Doppler velocities across the patent foramen ovale (PFO) to estimate left ventricular (LV) filling pressure is not well known.

Methods: The best cut-off value of peak interatrial septal velocity across a transeptal puncture site measured by transesophageal echocardiography for estimating high mean left atrial (LA) pressure (≥ 15 mmHg) was determined in 17 patients. This cut-off value was subsequently applied to 67 patients with a PFO undergoing transthoracic echocardiography (TTE) for assessing the value of PFO velocity in determining LV filling pressure.

Results: The peak systolic interatrial septal velocities significantly correlated with directly measured mean LA pressures during transcatheter mitral valve procedure (r = 0.77, P < 0.001). The best cut-off value was 1.7 m/s for predicting high LA pressure (AUC 0.91; sensitivity 90%, specificity 86%). When this cut-off was applied to patients undergoing TTE, peak PFO velocity ≥ 1.7 m/s correlated with reduced e', higher E/e', and higher tricuspid regurgitation velocity (P < 0.01). LV filling pressure according to the 2016 diastolic guideline was compared with peak PFO velocity in 51 patients. Among patients with high filling pressure according to the guidelines (n = 20), peak PFO velocity ≥ 1.7 m/s was present in 60% of patients. In patients with normal filling pressure per the guidelines (n = 31), PFO velocity < 1.7 m/s was present 84%. Sensitivity and specificity were 75% and 92%, respectively, in patients with sinus rhythm, but were only 50% and 57%, respectively, among patients with atrial fibrillation.

Conclusions: Doppler-derived peak PFO velocities could be valuable in the assessment of increased LV filling pressure using 1.7 m/s as the cut-off value.
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http://dx.doi.org/10.1007/s12574-020-00509-2DOI Listing
January 2021

Conversion of left atrial volume to diameter for automated estimation of sudden cardiac death risk in hypertrophic cardiomyopathy.

Echocardiography 2021 Feb 16;38(2):183-188. Epub 2020 Dec 16.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.

Background: A subset of patients with hypertrophic cardiomyopathy (HCM) is at high risk of sudden cardiac death (SCD). Practice guidelines endorse use of a risk calculator, which requires entry of left atrial (LA) diameter. However, American Society of Echocardiography (ASE) guidelines recommend the use of LA volume index (LAVI) for routine quantification of LA size. The aims of this study were to (a) develop a model to estimate LA diameter from LAVI and (b) evaluate whether substitution of measured LA diameter by estimated LA diameter derived from LAVI reclassifies HCM-SCD risk.

Methods: The study cohort was comprised of 500 randomly selected HCM patients who underwent transthoracic echocardiography (TTE). LA diameter and LAVI were measured offline using digital clips from TTE. Linear regression models were developed to estimate LA diameter from LAVI. A European Society of Cardiology endorsed equation estimated SCD risk, which was measured using LA diameter and estimated LA diameter derived from LAVI.

Results: The mean LAVI was 48.5 ± 18.8 mL/m . The derived LA diameter was 45.1 mm (SD: 5.5 mm), similar to the measured LA diameter (45.1 mm, SD: 7.1 mm). Median SCD risk at 5 years estimated by measured LA diameter was 2.22% (interquartile range (IQR): 1.39, 3.56), while median risk calculated by estimated LA diameter was 2.18% (IQR: 1.44, 3.52). 476/500 (95%) patients maintained the same risk classification regardless of whether the measured or estimated LA diameter was used.

Conclusions: Substitution of measured LA diameter by estimated LA diameter in the HCM-SCD calculator did not reclassify risk.
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http://dx.doi.org/10.1111/echo.14943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986336PMC
February 2021

Early septal reduction therapy for patients with obstructive hypertrophic cardiomyopathy.

J Thorac Cardiovasc Surg 2020 Oct 28. Epub 2020 Oct 28.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.

Objective: This study was conducted to determine the influence of early septal reduction therapy (SRT) after referral on survival in patients with obstructive hypertrophic cardiomyopathy.

Methods: We reviewed the patients with obstructive hypertrophic cardiomyopathy (resting pressure gradient ≥30 mm Hg or provoked pressure gradient ≥50 mm Hg) who were evaluated at our clinic from 2000 to 2012. Early SRT was defined as undergoing septal myectomy or alcohol septal ablation during the 6 months after index evaluation. Survival after the 6-month landmark period was analyzed in a multivariable Cox model.

Results: A total of 1351 patients were included in the landmark analysis. Patients who were more symptomatic and had received more medical treatment at index evaluation were more likely to undergo early SRT. Over a median follow-up period of 10.2 years, the survival was comparable (P = .207) but patients undergoing early SRT had, on average, improved survival compared with the medical treatment group (hazard ratio, 0.66; 95% confidence interval, 0.48-0.90) after adjustment by age and comorbidities. Further analysis revealed significant treatment heterogeneity, with increased benefit of early SRT seen in women (hazard ratio, 0.51; 95% confidence interval, 0.35-0.75), those who are in New York Heart Association functional class III or IV (hazard ratio, 0.52; 95% confidence interval, 0.36-0.76), and patients without diabetes (hazard ratio, 0.59; 95% confidence interval, 0.42-0.82).

Conclusions: In experienced hypertrophic cardiomyopathy centers, early SRT is similar to continued medical treatment for patients with obstructive hypertrophic cardiomyopathy. It appears to improve survival of female patients and those who are in New York Heart Association functional class III or IV.
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http://dx.doi.org/10.1016/j.jtcvs.2020.10.062DOI Listing
October 2020

Prevalence and Clinical Correlates of Aortic Dilation in Hypertrophic Cardiomyopathy.

J Am Soc Echocardiogr 2021 Mar 17;34(3):279-285. Epub 2020 Nov 17.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.

Background: Aortic dilation has been associated with various cardiac conditions, although its prevalence and clinical correlates in hypertrophic cardiomyopathy (HCM) remain unclear.

Objectives: The purposes of this study were to define the prevalence of ascending aortic dilation in a large referral population of patients with HCM and to determine clinical and echocardiographic correlates of aortic dilation.

Methods: A total of 1,698 patients with HCM underwent echocardiographic measurement of the tubular ascending aorta (proximal and midlevel) during index evaluation at a tertiary HCM referral center. End-diastolic ascending aorta dimension was indexed to body surface area, with dilation defined for the tubular ascending aorta as 2 SD above the mean (>19 mm/m) and independently as greater than published age-, sex-, and body surface area- adjusted norms (for the sinus of Valsalva and midlevel). Aortic size and presence of aortic enlargement were correlated with clinical and echocardiographic parameters.

Results: Tubular ascending aortic dilation >19 mm/m was present in 303 patients with HCM (18%), and dilation above adjusted norms was present in 210 patients with HCM (13%). The median indexed tubular ascending thoracic aortic dimension was 16.5 (interquartile range, 14.8-18.2) mm/m. Indexed dimension increased linearly with age (R = 0.53, P < .0001). Women and patients with a history of systemic hypertension were more likely to have tubular aortic enlargement >19 mm/m (29.8% vs 9.9% and 24.1% vs 10.5%, respectively, P < .0001 for both). Patients with obstructive physiology were more likely to have tubular aortic enlargement >19 mm/m than those without resting or provocable obstruction (19.6% vs 14.4%, P = .007). Using adjusted norms, aortic enlargement was more frequent at the midlevel compared with the sinus of Valsalva (71% vs 29%), more common in patients with hypertension (15.4% vs 10.6%, P = .009), and more common in patients with paroxysmal atrial fibrillation (16.3% vs 11.5%, P = .036), but no other relationships remained statistically significant.

Conclusions: In this large cohort of patients with HCM, aortic dilation was common. The key correlate of tubular aortic enlargement >19 mm/m, and aortic enlargement greater than adjusted norms included a history of systemic hypertension. Given an increased prevalence of aortic dilation in HCM, further study is needed on the clinical impact of aortic dilation.
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http://dx.doi.org/10.1016/j.echo.2020.11.003DOI Listing
March 2021

Is there referral bias in outcomes of septal myectomy for hypertrophic cardiomyopathy?

J Thorac Cardiovasc Surg 2020 Oct 9. Epub 2020 Oct 9.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address:

Purpose: To determine the potential impact of referral bias on short- and long-term outcomes following septal myectomy for hypertrophic cardiomyopathy.

Methods: We reviewed 2303 adult patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy from January 1993 to April 2016. Patients were divided into 3 groups according to their permanent address: local (state) residents (n = 324), regional (surrounding 5 states) patients (n = 515), and national (outside 5 states) patients (n = 1464).

Results: Patient groups were similar for age, sex, preoperative New York Heart Association class, and left ventricular ejection fraction. Local patients had increased prevalence of diabetes mellitus (13%, 11%, 8%; P = .006), coronary artery disease (25%, 21%, 19%; P = .031), severe chronic lung disease (2.3%, 1.9%, 0.4%; P < .001), and atrial fibrillation (24%, 18%, 19%; P = .045) when compared with regional and national patients. Echocardiographic features did not differ between the 3 groups, including prevalence of moderate or greater mitral regurgitation (59%, 61%, 56%; P = .161). Local and regional patients were more likely to undergo concomitant procedures than national patients (P < .001). Mitral valve surgery was performed in 9.6% of the patients, more commonly in local and regional patients (12%, 12%, 8%; P = .018). There were 11 operative deaths (0.5%), and early mortality was similar among the groups. Geographic origin did not impact overall late survival.

Conclusions: Compared with distant referrals, local patients who undergo septal myectomy at our institution have more comorbid conditions, and require more concomitant surgical procedures. Despite these differences, referral patterns did not impact early or late outcomes following transaortic septal myectomy.
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http://dx.doi.org/10.1016/j.jtcvs.2020.08.118DOI Listing
October 2020

Late Health Status of Patients Undergoing Myectomy for Obstructive Hypertrophic Cardiomyopathy.

Ann Thorac Surg 2020 Oct 27. Epub 2020 Oct 27.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.

Background: Surgical myectomy eliminates symptoms in the majority of patients with obstructive hypertrophic cardiomyopathy (HCM), but dyspnea and/or angina can recur in some. This study investigates clinical features associated with a lack of clinical improvement postoperatively.

Methods: Between March 2007 and December 2012, 963 patients underwent transaortic septal myectomy at our Clinic. 601 patients received standardized follow-up questionnaires, which were answered by 409 (68.1%). We compared clinical characteristics of patients with and without improvement, and identified predictors of worsening health using a multivariable proportional odds ordinal logistic model.

Results: Of 409 patients, 329 (80.4%) indicated better health status at follow-up, and 80 (19.6%) responded that their health had stayed the same or worsened. The median (IQR) age of patients with perceived better health was 56.8 (47.4, 65.7) years, and those without improvement was 63.0 (50.0, 70.2) years. New York Heart Association class III/ IV dyspnea was present in 90.3% of patients who reported improvement, and 79.7% who did not. In multivariable analysis, presence of coronary artery disease (OR [95% CI]=2.76 [1.17-6.50]; P=0.020), lower preoperative left ventricular ejection fraction (per IQR increase, OR [95% CI]= 0.76 [0.57 - 0.99]; P=0.047), and worse preoperative health status (e.g., poor:fair OR [95% CI]=1.63 [1.05-2.54]; P=0.004) were associated with worse health status at follow-up.

Conclusions: Septal myectomy leads to excellent symptomatic relief in the majority of patients, and more than 80% report subjective improvement in health status. Important predictors of worsening health included coronary artery disease and poor preoperative health status.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.011DOI Listing
October 2020

Does ablation of atrial fibrillation at the time of septal myectomy improve survival of patients with obstructive hypertrophic cardiomyopathy?

J Thorac Cardiovasc Surg 2021 Mar 25;161(3):997-1006.e3. Epub 2020 Aug 25.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.

Objective: To evaluate the outcomes after septal myectomy in patients with obstructive hypertrophic cardiomyopathy according to atrial fibrillation and surgical ablation of atrial fibrillation.

Methods: We reviewed patients with obstructive hypertrophic cardiomyopathy who underwent septal myectomy at the Mayo Clinic from 2001 to 2016. History of atrial fibrillation was obtained from patient histories and electrocardiograms. All-cause mortality was the primary end point.

Results: A total of 2023 patients underwent septal myectomy, of whom 394 (19.5%) had at least 1 episode of atrial fibrillation preoperatively. Among patients with atrial fibrillation, 76 (19.3%) had only 1 known episode, 278 (70.6%) had recurrent paroxysmal atrial fibrillation, and 40 (10.2%) had persistent atrial fibrillation. Surgical ablation was performed in 190 patients at the time of septal myectomy, including 148 with pulmonary vein isolation and 42 with the classic maze procedure. Among all patients, operative mortality was 0.4%, and there were no early deaths in patients undergoing surgical ablation. Over a median follow-up of 5.6 years, patients with preoperative atrial fibrillation had increased mortality (hazard ratio, 1.36; 95% confidence interval, 0.97-1.91; P = .070) after multivariable adjustment for comorbidities. When considering the impact of atrial fibrillation with or without surgical treatment, the adjusted hazard ratio for mortality in patients undergoing ablation compared with no ablation was 0.93 (95% confidence interval, 0.52-1.69; P = .824).

Conclusions: Atrial fibrillation is present preoperatively in one-fifth of patients with obstructive hypertrophic cardiomyopathy undergoing myectomy and showed a trend toward higher all-cause mortality. Survival of patients undergoing septal myectomy with preoperative atrial fibrillation was similar between those who did and did not receive concomitant surgical ablation.
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http://dx.doi.org/10.1016/j.jtcvs.2020.08.066DOI Listing
March 2021

Transapical Septal Myectomy for Hypertrophic Cardiomyopathy With Midventricular Obstruction.

Ann Thorac Surg 2021 03 6;111(3):836-844. Epub 2020 Aug 6.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Background: Midventricular obstruction (MVO) is an uncommon variant of hypertrophic cardiomyopathy (HCM). In patients receiving septal myectomy for HCM, failure to recognize the concurrent MVO in the context of basal septum thickening can lead to inadequate excision and residual gradient. In this report, we detail the operative outcomes of MVO with and without coexistent basal septal hypertrophy.

Methods: From February 1997 through September 2018, 196 patients underwent midventricular myectomy. Medical records and follow-up databases were reviewed to obtain patient characteristics and perioperative features.

Results: At baseline, 156 patients (80%) were in New York Heart Association Functional Classification III/IV. Obstruction was isolated to the midventricle in 80 patients, and 63 (79%) were treated by isolated transapical myectomy. The remaining 116 patients had intraventricular obstruction at both subaortic and midcavity levels; in 108 (93%), a combined transaortic and transapical approach was adopted to achieve complete relief of the obstruction. After septal myectomy, the resting peak instantaneous gradient decreased from a median 48 mm Hg (interquartile range [IQR], 23-77 mm Hg) preoperatively to 8 mm Hg (IQR, 0-19 mm Hg) before hospital dismissal. Median follow-up was 2.9 years (IQR, 0.7-5.0 years), and the estimated 1-, 5-, and 10-year survivals were 99%, 98%, and 90%, respectively. There were no late complications attributable to the transapical incision.

Conclusions: Transapical exposure is a safe and effective approach for relief of midventricular obstruction, and hemodynamic results are similar to those achieved by standard myectomy for subaortic obstruction. The technique can be combined with transaortic myectomy for patients with left ventricular outflow obstruction at both levels.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.182DOI Listing
March 2021

Septal Myectomy in patients with previous coronary revascularization - hypertrophic cardiomyopathy masquerading as ischemic heart disease.

Int J Cardiol 2020 Nov 20;319:97-100. Epub 2020 Jun 20.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: Patients with obstructive hypertrophic cardiomyopathy (HCM) may have symptoms mimicking ischemic heart disease, including chest pain and shortness of breath. Some patients undergo coronary revascularization which may not lead to symptomatic improvement. This study assesses clinical presentations and outcomes of patients with previous coronary revascularization undergoing septal myectomy.

Method: From 08/1996 to 07/2017, 166 adult patients with obstructive HCM underwent septal myectomy at our Clinic with a history of percutaneous coronary intervention (PCI, N = 153) or coronary artery bypass grafting (CABG, N = 13). We assessed their functional status before and after coronary intervention and outcomes following myectomy.

Results: The median (IQR) age was 65 (59-71) years, and 106 (64%) were male. Among 150 patients whose extent of disease was known, single vessel disease was identified in 109 (73%) who had PCI and 1 (9%) who had CABG. Following revascularization, many (59%) reported no improvement in shortness of breath from preoperative status. Myectomy was performed at a median of 3.2 (1.0-6.3) years following coronary revascularization, and 40 (25%) required myectomy within 1 year. Patients whose shortness of breath persisted after PCI/CABG (N = 90) underwent myectomy earlier than those whose symptoms initially improved (N = 63) after coronary revascularization (1.4 [0.6-4.0] years vs. 5.1 [2.8-9.5] years, p < .001).

Conclusion: Almost 25% of patient's required septal myectomy within 1 year of coronary intervention for continued symptoms originally thought to be due to ischemic heart disease. These findings highlight the overlap of obstruction and ischemic symptoms and the importance of complete evaluation for dynamic obstruction in HCM.
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http://dx.doi.org/10.1016/j.ijcard.2020.06.015DOI Listing
November 2020

Cardiovascular Imaging Through the Prism of Modern Metrics.

JACC Cardiovasc Imaging 2020 05 16;13(5):1256-1269. Epub 2020 Mar 16.

Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: https://twitter.com/RonBlankstein.

Since its inception in 2008, JACC: Cardiovascular Imaging (iJACC) has served as an important publication for all contemporary aspects of cardiovascular imaging. Understanding the dissemination trends in cardiovascular imaging has traditionally been evaluated through citations that assess interest in the research community. Recently, social media, alternative metrics (Altmetrics), and other modern metrics have enabled a more broader understanding of the interests of clinical readership. Through the prism of Altmetrics, this review discusses the most impactful studies across the spectrum of cardiovascular imaging within and outside of iJACC during a 3-year period (2017 to 2019). The top 100 Altmetrics iJACC articles in this timeframe, included articles with the highest impact with the combination of high Altmetrics (median: 66; interquartile range [IQR]: 56 to 108), high citations (median: 26; IQR: 17 to 34), and high downloads (median: 9,626; IQR: 5,770 to 11,435). This review aims to provide a framework to understand how to incorporate these metrics for a modern approach to dissemination of knowledge in the field of cardiovascular imaging.
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http://dx.doi.org/10.1016/j.jcmg.2020.03.003DOI Listing
May 2020

Septal Myectomy and Concomitant Coronary Artery Bypass Grafting for Patients With Hypertrophic Cardiomyopathy and Coronary Artery Disease.

Mayo Clin Proc 2020 03;95(3):521-525

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.

Severe coronary artery disease is associated with disproportionately increased risks of death in patients with hypertrophic cardiomyopathy. There is a paucity of data on the long-term effect of coronary revascularization at the time of myectomy. Between January 1, 1961, and October 31, 2017, 2913 adult patients underwent transaortic septal myectomy at Mayo Clinic. Concomitant coronary artery bypass grafting (CABG) was performed in 246 (8.4%). We compared baseline characteristics of patients who underwent septal myectomy with and without CABG and assessed the effect of surgical revascularization on the risk of all-cause mortality. Patients who underwent concomitant CABG were older (median [interquartile range], 66.3 [59.8-72.1] years vs 54.4 [43.5-64.8] years; P<.0001) and more likely to be male (63.0% vs 54.2%; P=.008) than those who did not undergo coronary revascularization at operation. There was no significant difference in preoperative left ventricular outflow tract gradients (55 [25-81] mm Hg vs 58 [25-88] mm Hg; P=.116). Overall operative mortality (≤30 days after surgery) was 1.0% and higher in patients who underwent concomitant CABG (2.2% vs 0.8%; P=.048). In multivariable analysis (n=2641), factors independently associated with mortality included concomitant CABG (hazard ratio [95% CI], 1.89 [1.39-2.58]; P<.0001), older age at operation (per interquartile range increase, 2.79 [1.95-3.98]; P<.0001), atrial fibrillation (1.46 [1.11-1.92]; P=.006), diabetes (1.45 [1.04-2.04]; P=.031), higher body mass index (change from 0.95 to 0.5 quantile, 1.95 [1.46-2.59]; P<.0001), and surgery performed earlier in the study period (2.02 [1.31-3.11]; P=.001). In conclusion, obstructive coronary artery disease severe enough to prompt concomitant CABG at the time of septal myectomy is an important risk factor for late mortality.
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http://dx.doi.org/10.1016/j.mayocp.2019.12.001DOI Listing
March 2020

Cardiac Magnetic Resonance Imaging Features in Hypertrophic Cardiomyopathy Diagnosed at <21 Years of Age.

Am J Cardiol 2020 04 28;125(8):1249-1255. Epub 2020 Jan 28.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address:

Hypertrophic cardiomyopathy (HC) is the most common inherited cardiomyopathy, with varied timing of phenotypic and clinical presentation. Literature describing cardiac magnetic resonance (CMR) imaging and late gadolinium enhancement (LGE) in young patients with HC is limited. This study included patients diagnosed with HC at young age (<21 years) between January 1990 and January 2015 who underwent transthoracic echocardiography and CMR with assessment of LGE at a single tertiary referral center. LGE was quantified via a method of 6 standard deviations and patients were grouped based upon presence or absence of LGE (≤1% and >1% LGE, respectively). Sudden cardiac death (SCD) risk was assessed in patients >16 years of age using the European SCD risk score. A composite outcome of New York Heart Association class III-IV symptoms, aborted SCD, heart transplantation, and all-cause mortality was assessed via Kaplan-Meier curves with log-rank analysis. Overall, 126 patients were included (78 male; 62%). Median age of diagnosis was 15 (12 to 18) years. LGE was present in 81 (64%) patients, although only 4 (3%) patients had LGE >15%. Median age at CMR imaging was 19 (15 to 23) years. Patients with LGE had greater wall thickness (25 ± 8 mm vs 22 ± 7 mm, p = 0.01). Median European SCD risk score was 4.7 (2.9 to 6.5). Median follow-up was 6.5 (2.5 to 13) years with 26 patients (21%) meeting the composite outcome. There were no significant differences in composite outcome since age of diagnosis when stratified by presence/absence of LGE (p = 1.0). The presence of LGE in young HC patients was not an independent risk factor for cardiovascular morbidity and mortality. Wall thickness was greater in patients with LGE. There remains a need for further evaluation of this unique HC cohort.
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http://dx.doi.org/10.1016/j.amjcard.2020.01.027DOI Listing
April 2020

Detection of Hypertrophic Cardiomyopathy Using a Convolutional Neural Network-Enabled Electrocardiogram.

J Am Coll Cardiol 2020 02;75(7):722-733

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Hypertrophic cardiomyopathy (HCM) is an uncommon but important cause of sudden cardiac death.

Objectives: This study sought to develop an artificial intelligence approach for the detection of HCM based on 12-lead electrocardiography (ECG).

Methods: A convolutional neural network (CNN) was trained and validated using digital 12-lead ECG from 2,448 patients with a verified HCM diagnosis and 51,153 non-HCM age- and sex-matched control subjects. The ability of the CNN to detect HCM was then tested on a different dataset of 612 HCM and 12,788 control subjects.

Results: In the combined datasets, mean age was 54.8 ± 15.9 years for the HCM group and 57.5 ± 15.5 years for the control group. After training and validation, the area under the curve (AUC) of the CNN in the validation dataset was 0.95 (95% confidence interval [CI]: 0.94 to 0.97) at the optimal probability threshold of 11% for having HCM. When applying this probability threshold to the testing dataset, the CNN's AUC was 0.96 (95% CI: 0.95 to 0.96) with sensitivity 87% and specificity 90%. In subgroup analyses, the AUC was 0.95 (95% CI: 0.94 to 0.97) among patients with left ventricular hypertrophy by ECG criteria and 0.95 (95% CI: 0.90 to 1.00) among patients with a normal ECG. The model performed particularly well in younger patients (sensitivity 95%, specificity 92%). In patients with HCM with and without sarcomeric mutations, the model-derived median probabilities for having HCM were 97% and 96%, respectively.

Conclusions: ECG-based detection of HCM by an artificial intelligence algorithm can be achieved with high diagnostic performance, particularly in younger patients. This model requires further refinement and external validation, but it may hold promise for HCM screening.
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http://dx.doi.org/10.1016/j.jacc.2019.12.030DOI Listing
February 2020

Temporal Occurrence of Arrhythmic Complications After Alcohol Septal Ablation.

Circ Cardiovasc Interv 2020 02 24;13(2):e008540. Epub 2020 Jan 24.

Department of Cardiovascular Diseases (R.A.N., G.W.B., Y.-M.C., J.B.G., M.F.E.), Mayo Clinic, Rochester, MN.

Background: The temporal occurrence of arrhythmic complications after alcohol septal ablation (ASA) is unclear. As a result, the appropriate time to monitor patients after ASA is controversial. The purpose of this study is to determine the temporal occurrence of complete heart block (CHB) and ventricular tachyarrhythmia (VT) after ASA to better understand when patients can be safely discharged.

Methods: Consecutive patients treated with ASA for hypertrophic cardiomyopathy from 2003 to 2019 at a tertiary referral center were reviewed retrospectively. The incidence and timing of CHB or sustained VT within 30 days post-ASA were assessed.

Results: A total of 243 patients were included in this study. Mean maximal septal thickness was 19.0±3.9 mm, and total volume of ethanol injected was 1.7±0.6 mL. CHB occurred in 59 (24.3%) patients, including transient CHB in 33 (13.6%) and permanent in 26 (10.7%). The initial episode of CHB occurred within 24 hours post-ASA in 51 (21.0%) patients, between 24 and 48 hours in 3 (1.2%), between 48 and 72 hours in 3 (1.2%), and after 72 hours in 2 (0.8%). New permanent pacemaker was placed in 46 (18.3%). Presence of baseline bundle branch block and age ≥70 were significantly associated with CHB but not CHB presenting after 24 hours. VT occurred in 3 (1.2%) patients, including 1 (0.4%) within 24 hours, 1 (0.4%) between 24 and 48 hours, and 1 (0.4%) after 72 hours. VT required cardioversion in 2 patients and new implantable cardioverter-defibrillator placement in 2.

Conclusions: The incidence of CHB or VT presenting after 72 hours post-ASA was low. These findings suggest that timely discharge of patients without evidence of early conduction disturbances after ASA can be considered as a potentially safe management strategy, especially in patients without preexisting conduction abnormalities.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008540DOI Listing
February 2020

Comparison of expected and observed outcomes for septal myectomy in hypertrophic obstructive cardiomyopathy.

Am Heart J 2020 03 18;221:159-164. Epub 2019 Dec 18.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN.

Background: Septal myectomy remains the criterion standard for treatment of symptomatic, medically refractory hypertrophic cardiomyopathy (HCM). There is no specific surgical risk calculator for septal myectomy.

Methods: This study compares the outcomes of septal myectomy at a tertiary referral center with predicted outcomes of mitral valve (MV) repair and aortic valve replacement (AVR) using the Society of Thoracic Surgeons Adult Cardiac Surgery Risk Calculator (STS Calculator). A total of 298 consecutive patients with HCM underwent isolated septal myectomy from 2011 to 2014. Observed outcomes of septal myectomy were compared with the STS Calculator predicted risk of isolated MV repair and AVR predicted within this population using 1-sample tests of proportions.

Results: Thirty-day mortality for myectomy in this cohort was zero. STS Calculator predicted risk of mortality for MV repair was 0.7% (P = .14) and for AVR = 1.1% (P = .06). Follow-up for vital status was 6.0 ± 0.7 years, at which 294 (98.7%) patients were alive. Hospital stay length was 4.9 ± 1.9 days. One (0.3%) patient experienced a postoperative deep sternal wound infection, and 1 (0.3%) patient experienced a prolonged ventilated state. Postoperative atrial fibrillation occurred in 64 (21.5%) patients. During 30 days of follow-up, no patients experienced stroke, renal failure, or needed dialysis.

Conclusions: Septal myectomy, performed in a tertiary referral center, had a 30-day mortality rate of 0% and low morbidity rate. There was no difference between observed myectomy mortality and STS Calculator predicted risk for AVR and MV repair. It is possible that a larger sample could reveal lower mortality than STS prediction.
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http://dx.doi.org/10.1016/j.ahj.2019.11.020DOI Listing
March 2020

An unusual coronary embolus in a patient with prosthetic endocarditis.

Eur Heart J 2020 06;41(23):2179

Department of Cardiothoracic Surgery, Mayo Clinic, 200 First Street SW,Rochester, MN 55905, USA.

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http://dx.doi.org/10.1093/eurheartj/ehz883DOI Listing
June 2020

Reinvigorating Continuing Medical Education: Meeting the Challenges of the Digital Age.

Mayo Clin Proc 2019 12;94(12):2501-2509

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.

Clinicians in today's health care environment face an overwhelming quantity of knowledge that requires continued education and lifelong learning. However, traditional continuing medical education (CME) courses cannot meet these educational needs, particularly given the proliferation of knowledge and increasing demands on clinicians' time and resources. CME courses that previously offered only in-person, face-to-face education must evolve in a learner-centric manner founded on principles of adult learning theory to remain relevant in the current era. In this article, we describe the transition of the Mayo Clinic Cardiovascular Review for Cardiology Boards and Recertification (CVBR) from a traditional course with only live content to a course integrating live, online, and enduring materials. This evolution has required leveraging technology to maximize learner engagement, offering faculty development to ensure content alignment with learner needs, and strong leadership dedicated to providing learners an unparalleled educational experience. Despite stagnation in growth of the traditional live course, these changes have increased the overall reach of the Mayo Clinic CVBR. Learners engaging with digital content have demonstrated larger increases in knowledge with less educational time commitment. Courses seeking to implement similar changes must develop formal learning objectives focused on learner needs, build an online presence that includes an assessment of learner knowledge, enlist a cohort of dedicated faculty who teach based on principles of adult learning theory, and perpetually refresh educational content based on learner feedback and performance. Following these principles will allow traditional CME courses to thrive despite learners' resource constraints and alternative means to access information.
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http://dx.doi.org/10.1016/j.mayocp.2019.07.004DOI Listing
December 2019

Mitral Valve Disease in Hypertrophic Cardiomyopathy:Evaluation and Management.

Curr Cardiol Rep 2019 10 31;21(11):136. Epub 2019 Oct 31.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.

Purpose Of Review: To discuss the critical role of the mitral valve (MV) in the pathophysiology of obstruction in hypertrophic cardiomyopathy (HCM), evaluation of the MV in HCM, the impact of MV characteristics on treatment in HCM, and management of the MV at the time of septal myectomy.

Recent Findings: Multimodality imaging helps describe mitral abnormalities in HCM, though significant controversy persists on what to do with these abnormalities. In certain cases, intervention on the MV may be necessary, although outcomes may be worse in those who undergo mitral interventions. Thorough assessment of MV anatomy and function is paramount in evaluating a patient with HCM. Emphasis should be placed on thorough evaluation and description of mitral abnormalities in HCM. Given significant practice variation, future studies could compare MV practice differences across institutions and how these impact long-term outcomes.
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http://dx.doi.org/10.1007/s11886-019-1231-8DOI Listing
October 2019

Sex, Survival, and Cardiomyopathy: Differences Between Men and Women With Hypertrophic Cardiomyopathy.

J Am Heart Assoc 2019 11 30;8(21):e014448. Epub 2019 Oct 30.

Department of Cardiovascular Diseases Mayo Clinic Rochester MN.

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http://dx.doi.org/10.1161/JAHA.119.014448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6898853PMC
November 2019

A case report of prosthetic valve endocarditis: an extremely rare presentation with characteristic findings.

Eur Heart J Case Rep 2019 Sep 17;3(3):ytz127. Epub 2019 Sep 17.

Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.

Background : is an extremely rare cause of prosthetic valve endocarditis (PVE) and can present with non-specific symptoms leading to a delay in diagnosis with unfavourable outcomes.

Case Summary : A 65-year-old male patient with a history of a bioprosthetic aortic valve replacement and non-obstructive coronary artery disease was admitted for altered mentation, failure to thrive, and a 20-pound unintentional weight loss over the past 4 months. Upon examination, he was lethargic but afebrile and haemodynamically stable. A late peaking ejection murmur was heard on exam. Skin exam was significant for embolic phenomenon involving the extremities. Inflammatory markers and serum calcium were elevated. A bedside echocardiogram showed severe obstruction across the aortic valve prosthesis. Two years prior, he had an echocardiogram with a normal functioning prosthesis. Routine blood cultures were negative and serologic screening was unrevealing. Urine antigen screen was positive on hospital day 3 and on hospital day 10, fungal blood cultures were positive for . Unfortunately, the patient died shortly afterwards as a result of multiorgan failure from embolic manifestations of the infection.

Discussion : Based on our patient's findings and those of previously reported cases in the literature, PVE should be strongly considered in patients from endemic areas with non-specific symptoms and negative routine blood cultures.
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http://dx.doi.org/10.1093/ehjcr/ytz127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6764570PMC
September 2019