Chaim Yosefy

Introduction the outbreak of the Israel-Gaza conflict, initiated by a major attack on the civilian population in Israel provided a tragic opportunity to study the community wide association between severe emotional stressors related to acts of war and the incidence and clinical characteristics of Takotsubo cardiomyopathy (TCM) in this scenario. Methods Eight consecutive cases of TCM diagnosed during the first 50 days of the Israel-Gaza conflict were retrospectively collected from two southern medical centers who provided care to most of the war victims throughout the period of monitoring. The medical records were thoroughly reviewed and analyzed. Results During the monitoring period, the incidence of TCM increased substantially compared to the control period. Eight patients were included in the analysis. All patients were female and 100% of patients presented within the first 3 weeks of conflict whereas after this initial phase, despite the continuing war, the incidence of TCM reverted to pre-conflict levels. Two patients (25%) were under 50 years of age. All patients had hazardous clinical characteristics including severe left ventricular (LV) dysfunction (≤35%) and prolonged QTc interval (>500 ms). Five patients (62.5%) experienced complications. Nevertheless, no in-hospital mortality was reported. Conclusions Repeated exposure to severe emotional stress, on both personal and national level, due to mass crisis such as war is associated with an increased incidence of TCM potentially with high-risk phenotype in comparison to TCM following other, less potent, psychological insults.

Background: There is conflicting data regarding the association between low levels of plasma vitamin D and ischemic heart disease. We aimed to investigate the relationship between plasma vitamin D levels and heart valve calcification in hospitalized patients with ischemic heart disease versus non-ischemic heart disease controls. Methods: A prospective case-control study comprising two age and gender-matched groups. The study group included consecutive patients hospitalized due to acute coronary syndrome; the control group included consecutive non-ischemic heart disease patients hospitalized for noncardiac causes. Blood samples for 25-hydroxyvitamin D level were drawn. An echocardiogram was performed during the first 3 days of hospitalization and reviewed for presence and degree of valvular calcification. Results: Forty patients with acute coronary syndrome and 40 controls (age 58 ± 11 years, 64% male in both groups) were included. Mean plasma 25-hydroxyvitamin D vitamin level in the entire cohort was 24.5 ± 8 ng/ml. Valve calcification rates were similar in acute coronary syndrome versus non-acute coronary syndrome group (28 vs. 21 had valvular calcification; 18 vs. 12 had aortic valve calcification; 21 vs. 14 had mitral valve calcification, respectively; P = NS for all). We found no significant relationship between vitamin D level and valvular calcification, aortic valve calcification, or mitral valve calcification rate or degree in the entire cohort and in each group alone ( P = NS for all). There was a negative correlation between 25-hydroxyvitamin D levels and age in the acute coronary syndrome group ( r = −0.399, P = 0.012). Conclusions: We did not find a significant relationship between plasma vitamin D levels and the rate or degree of calcification of either aortic/mitral/both valves in hospitalized patients with or without ischemic heart disease.

Not all echo laboratories have the capability of measuring direct online 3D images, but do have the capability of turning 3D images into 2D ones “online” for bedside measurements. Thus, we hypothesized that a simple and rapid rotation of the sagittal view (green box, x-plane) that shows all needed left atrial appendage (LAA) number of lobes, orifice area, maximal and minimal diameters and depth parameters on the 3D transesophageal echocardiography (3DTEE) image and LAA measurements after turning the images into 2D (Rotational 3DTEE/“Yosefy Rotation”) is as accurate as the direct measurement on real-time-3D image (RT3DTEE). We prospectively studied 41 consecutive patients who underwent a routine TEE exam, using QLAB 10 Application on EPIQ7 and IE33 3D-Echo machine (BORTHEL Phillips) between 01/2013 and 12/2015. All patients underwent 64-slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between RT3DTEE and Rotational 3DTEE versus CT. Rotational 3DTEE measurements of LAA were not statistically different from RT3DTEE and from CT regarding: number of lobes (1.6 ± 0.7, 1.6 ± 0.6, and 1.4 ± 0.6, respectively, p = NS for all); internal area of orifice (3.1 ± 0.6, 3.0 ± 0.7, and 3.3 ± 1.5 cm2, respectively, p = NS for all); maximal LAA diameter (24.8 ± 4.5, 24.6 ± 5.0, and 24.9 ± 5.8 mm, respectively, p = NS for all); minimal LAA diameter (16.4 ± 3.4, 16.7 ± 3.3, and 17.0 ± 4.4 mm, respectively, p = NS for all), and LAA depth (20.0 ± 2.1, 19.8 ± 2.2, and 21.7 ± 6.9 mm, respectively, p = NS for all). Rotational 3DTEE method for assessing LAA is a simple, rapid and feasible method that has accuracy similar to that of RT3DTEE and CT. Thus, rotational 3DTEE (“Yosefy rotation”) may facilitate LAA closure procedure by choosing the appropriate device size.

Aims: Currently, two‐dimensional transesophageal echocardiography (2DTEE) at a cut‐plane angulation of 135° is the recommended method to size maximal left atrial appendage (LAA) orifice diameter before introducing a percutaneous LAA closure device. We compared real time three‐dimensional TEE (RT3DTEE) and 2DTEE for measuring LAA dimensions versus computed tomography (CT) as gold standard.Methods and Results: We prospectively studied 30 consecutive patients who underwent a routine TEE examination, using QLAB 10.0 Application on EPIQ7 iE33 3D echo machine between December 2012 and December 2013. All patients underwent 64‐slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between 135 2DTEE and RT3DTEE. Results were compared with CT measurements. Using RT3DTEE, larger LAA diameters were measured versus 2DTEE (23.5 ± 3.9 vs. 24.5 ± 4.7 mm). In seven patients (23.3%), the measurements in 135° 2DTEE were smaller than the cut‐plane angulation with maximal orifice diameter. RT3DTEE measurements of LAA were not different from CT regarding number of lobes, area of orifice, and maximal diameter. LAA volume could not be measured directly using RT3DTEE. No difference was found between LAA depth using RT3DTEE (19.5 ± 2.3 mm) vs. CT (19.6 ± 2.3, P = NS) and 2DTEE (19.4 ± 2.2 mm) vs. CT (P = NS). However, RT3DTEE (24.5 ± 4.7 mm) vs. CT (24.6 ± 5, P = NS) was more accurate in measuring maximal LAA diameter compared to 2DTEE (23.5 ± 3.9 mm) vs. CT (P < 0.01).Conclusion: RT3DTEE method is more accurate than 2DTEE for assessment of maximal LAA orifice diameter. Bedsides, RT3DTEE LAA measurements are not statistically different from CT. Thus, RT3DTEE may facilitate LAA closure procedure by choosing the appropriate device size.

Background: Alteration of diastolic function is considered a sensitive means for detecting changes in the normal cardiac adaptation to pregnancy. Our aim was to evaluate volumetric and functional atrial parameters, using real time three‐dimensional echocardiography (RT3DE) in women in early and late third trimester of pregnancy. Methods: We studied pregnant women in early third trimester (III‐E = gestational age 26–33 weeks), in late third trimester (III‐L = gestational age 34–40 weeks), and control nonpregnant women (C). Two‐dimensional (2D‐Echo) and RT3DE were used to study 3D left atrial (LA) systolic and diastolic stroke volumes and index (LASVI, LAEDVI), emptying fraction, left ventricular and LA cavities. Results: Although the LA end systolic volume index increased significantly (from 19.42 ± 0.1 to 24.7 ± 3.5 mm², P < 0.01), the EF did not change significantly. This was mainly achieved by increasing atrial contraction (A‐wave), maintaining cardiac output by increasing heart rate. A decrease in diastolic E‐wave, increased atrial kick (A‐wave) with reduced E/A ratio, was noted as the pregnancy progressed. Pulmonary pressure increased from 16.9 ± 6.6 to 20.5 ± 2.9 mmHg (P < 0.01), Using 2D‐Echo revealed no change in LA diameter from control to III‐E and III‐L, respectively (from 17.1 ± 2.3 to 16.7 ± 2.6, 17.5 ± 2.2 mm) and area (from 11.7 ± 3.1 to 16.5 ± 2.3, 17.6 ± 1.6 cm²). However, using RT3DE, a significant increase in the LASVI, LAEDVI, and LA stroke volume index (from 12.02 ± 2.5 to 14.7 ± 3.2, and 15.1 ± 2.7 mL/m²) was detected. Conclusions: Enlargement of the LA volume with unchanged blood pressure values, as found using RT3DE, may be part of the adaptation to increased blood volume during pregnancy.

As the lowest natural site on earth (-415 meters), the Dead Sea is unique for its high pressure and oxygen tension in addition to the unparalleled combination of natural resources. Furthermore, its balneotherapeutic resorts have been reported to be beneficial for patients with various chronic diseases. To evaluate the safety, quality of life (QoL), exercise capacity, heart failure, and arrhythmia parameters in patients with systolic congestive heart failure (SCHF) and implantable cardioverter defibrillator (ICD) following descent and stay at the Dead Sea. The study group comprised patients with SCHF, New York Heart Association functional class II-III after ICD implantation. The following parameters were tested at sea level one week prior to the descent, during a 4 day stay at the Dead Sea, and one week after return: blood pressure, 02 saturation, ejection fraction (echocardiography), weight, B-type natriuretic peptide (BNP), arrhythmias, heart rate, heart rate variability (HRV), and QoL assessed by the Minnesota Living with Heart Failure questionnaire. We evaluated 19 patients, age 65.3 +/- 9.6 years, of whom 16 (84%) were males and 18 (95%) had ICD-cardiac resynchronization therapy. The trip to and from and the stay at the Dead Sea were uneventful and well tolerated. The QoL score improved by 11 points, and the 6 minute walk increased by 63 meters (P < 0.001). BNP levels increased slightly with no statistical significance. The HRV decreased (P = 0.018). There were no significant changes in blood pressure, weight, 02 saturation or ejection fraction. Descent to, ascent from, and stay at a Dead Sea resort are safe and might be beneficial in some aspects for patients with SCHF and an ICD.

Abstract: The importance of diabetes mellitus (diabetes) as a cause of mortality and morbidity is well known. The number of patients increases alongside aging of the population and increase in the prevalence of obesity and sedentary life style.Diabetes affects approximately 8% of the USA population.Type I (insulin-dependent) diabetes occurs in 20% of cases, and type II (insulin-independent or maturity onset) diabetes occurs in 80% of the diabetic populationiabetes mellitus type II is preceded by longstanding asymptomatic hyperglycemia, which accounts for the development of long-term diabetic complications. The main macrovascular complications for which diabetes has been a well established risk factor throughout the cardiovascular system, are: coronary artery disease (CAD), peripheral vascular disease (PVD), increased intima-media thickness (IMT) and stroke. Considering the cardiovascular surgeon, diabetes is associated with an increased rate of early and late complications following coronary artery bypass grafting. Diabetic patients have also been known to have an increased incidence of complications after elective major vascular surgery such as carotid endarterectomy (CEA) and leg amputations due to PVD. Cardiovascular surgeons frequently treat diabetic patients either because diabetes is incidental to another disease requiring surgery, or due to diabetes-related complication such as occlusive vascular disease, neuropathy or infection. Approximately 50% of diabetics undergo one,or more operations during their lifetime. This paper reviews the relationship between diabetic patients and their cardiovascular surgeons. In order to understand this relationship, one must first examine the underlying mechanisms by which hyperglycemia causes hazardous pre and post operative consequences. Then, one must examine the existing evidence of how diabetes correlates with these cardiovascular consequences, followed by the need for multidisciplinary team work which helps the surgeon to cope with diabetic patients.

Mitral valve prolapse (MVP) is a defect in the mitral valve where a redundancy of valve tissue is associated with a variety of clinical expressions, ranging from an isolated mild bulging of the mitral valve to a severe prolapse of the mitral valve with extensive mitral regurgitation. As the natural history and complications of MVP are not always benign, it seems essential to strive for the proper management of these patients. The identification of functionally related genes could provide helpful clues and increase the present understanding of the pathogenesis of MVP, with the ultimate goal of developing targeted therapies. The genetics of MVP can be divided into two parts: (i) Genetics in floppy mitral valve/MVP; and (ii) genetics in heritable connective tissue disorders (Marfan syndrome, polycystic kidney, etc.) associated with floppy mitral valve. Herein, the known genetic aspects of MVP are described, according to the above-mentioned scheme.

This study aims to calculate the health effects and costs of a proposed national hypertension prevention and control program.