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BACKGROUND: LV hypertrophy is an independent risk factor for cardiovascular outcomes. There are limited data about modifiable factors associated with progression of LV hypertrophy in the older adults. Our objective is to describe the changes in left ventricular (LV) mass and geometry over time in a predominantly older multi-ethnic cohort and to identify possible predictors of changes over time. METHODS: We analyzed data from participants in the Northern Manhattan Study (NOMAS) who underwent serial echocardiographic studies, comparing the baseline and the most recent echocardiograms. We recorded changes in LV mass and geometry and correlated them with baseline characteristics using linear regression models. RESULTS: There were 826 participants (mean age 64.2 ± 8.0 years) included in the analysis (time between measurements: 8.5 ± 2.7 years). Overall, LV mass index increased from 45.0 ± 12.7 to 50.3 ± 14.6 g/m(2.7) (p < 0.001). There were 548 participants (66.3%) with LV mass increase; 258 subjects (31.2%) showed worsening LV geometry. Multivariable analysis showed that change in LV mass index was independently associated with baseline LV mass index (β estimate: −17.000, [standard error: 1.508], p < 0.001), hypertension (2.094 [0.816], p=0.011), body mass index (0.503 [0.088], p < 0.001) and waist-to-hip ratio (1.031 [0.385], p=0.008).Both waist-to-hip ratio or waist-to-height ratio remained significantly associated with LV mass increase even after adjusting for body mass index (p= 0.008 and p=0.036, respectively) CONCLUSIONS: Regardless of race/ethnicity, LV mass progressed over time in the older adults. We also observed worsening geometry was frequent. Assessment of central obesity in the older population is important because indicators of central obesity add prognostic value over body mass index for the risk of LV mass increase.

Background Aortic valve calcification (AVC) without stenosis is common in the elderly, is associated with cardiovascular morbidity and mortality, and may progress to aortic valve stenosis. Arterial stiffness and pulse-wave reflection are important components of proximal aortic hemodynamics, but their relationship with AVC is not established. Methods To investigate the relationship of arterial wave reflection and stiffness with AVC, pulse wave analysis and AVC evaluation by echocardiography were performed in 867 participants from the Cardiovascular Abnormalities and Brain Lesions study. Participants were divided into four categories on the basis of the severity and extent of AVC: (1) none or mild focal AVC, (2) mild diffuse AVC, (3) moderate to severe focal AVC, and (4) moderate to severe diffuse AVC. Central blood pressures and pulse pressure, total arterial compliance, augmentation index, and time to wave reflection were assessed using applanation tonometry. Results Indicators of arterial stiffness and wave reflection were significantly associated with AVC severity, except for central systolic and diastolic pressures and time to reflection. After adjustment for pertinent covariates (age, sex, race/ethnicity, and estimated glomerular filtration rate), only augmentation pressure ( P = .02) and augmentation index ( P = .002) were associated with the severity of AVC. Multivariate logistic regression analysis revealed that augmentation pressure (odds ratio per mm Hg, 1.14; 95% confidence interval, 1.02–1.27; P = .02) and augmentation index (odds ratio per percentage point, 1.07; 95% confidence interval, 1.01–1.13; P = .02) were associated with an increased risk for moderate to severe diffuse AVC, even when central blood pressure value was included in the same model. Conclusions Arterial wave reflection is associated with AVC severity, independent of blood pressure values. Increased contribution of wave reflection to central blood pressure could be involved in the process leading to AVC.

The American Society of Echocardiography recommends calculating left atrial (LA) biplane volume because of its greater accuracy and prognostic value over LA diameter. However, biplane methods are not always feasible. The aim of this study was to assess the correlation between the echocardiographic LA biplane and single-plane volumes and their agreement in the classification of LA size when American Society of Echocardiography cutoffs are applied.Two-dimensional echocardiography was performed on the participants of the population-based Cardiovascular Abnormalities and Brain Lesions study. LA volume was calculated by the biplane area-length and single-plane modified Simpson's methods and validated against three-dimensional echocardiography.The study sample consisted of 527 participants (mean age 69.6 +/- 9.7 years; 61.9% women). Both single-plane and biplane LA volumes correlated well with three-dimensional echocardiography (r = 0.93, P.001). The correlation between the single-plane and biplane methods was excellent (r = 0.95, P.001; intraclass correlation coefficient, 0.92; 95% confidence interval, 0.80-0.96). Categorical agreement between the single-plane and biplane methods was modest (kappa = 0.51; 95% confidence interval, 0.45-0.57; disagreement rate, 26.0%), mainly because of overestimation by the single-plane method. The correction of the single-plane volume by a regression equation improved the agreement (kappa = 0.70; 95% confidence interval, 0.64-0.76), but misclassifications remained in 14.0% of cases.Single-plane and biplane LA volume measurements have strong correlations, but their agreement for categorical classification is suboptimal. Specific cutoff points should be developed for the single-plane method.

Background Large aortic arch plaques are associated with ischemic stroke. Carotid intima-media thickness (CIMT) is a marker of subclinical atherosclerosis and a strong predictor of cardiovascular disease and stroke. The association between CIMT and aortic arch plaques has been studied in patients with strokes, but not in the general population. The aim of this study was to investigate this association in an elderly asymptomatic cohort and to assess the possibility of using CIMT to predict the presence or absence of large aortic arch plaques. Methods Stroke-free control subjects from the Aortic Plaque and Risk of Ischemic Stroke (APRIS) study underwent transesophageal echocardiography and high-resolution B-mode ultrasound of the carotid arteries. CIMT was measured at the common carotid artery, bifurcation, and internal carotid artery. The association between CIMT and aortic arch plaques was analyzed using multivariate regression models. The positive and negative predictive values of CIMT for large (≥4 mm) aortic arch plaques were calculated. Results Among 138 subjects, large aortic arch plaques were present in 35 (25.4%). Only CIMT at the bifurcation was associated with large aortic arch plaques after adjustment for atherosclerotic risk factors ( P = .007). The positive and negative predictive values of CIMT for aortic arch plaque ≥ 4 mm at the bifurcation above the 75th percentile (≥0.95 mm) were 42% and 80%, respectively. The negative predictive value increased to 87% when the median CIMT value (0.82 mm) was used. Conclusions CIMT at the bifurcation is independently associated with aortic arch plaque ≥ 4 mm. Its strong negative predictive value for large plaques indicates that CIMT may be used as an initial screening test to exclude severe arch atherosclerosis in the general population.

This is the first feasibility study using real-time 3-dimensional (3D) (RT3D) transthoracic contrast echocardiography with full-volume acquisition to evaluate left ventricular wall motion in patients undergoing dobutamine stress echocardiography. RT3D contrast and noncontrast 3D images were obtained at rest and peak dose dobutamine infusion and reviewed for image quality. A total of 14 patients underwent complete rest and stress RT3D contrast and noncontrast imaging. Ultrasound contrast significantly increased the proportion of segments adequately visualized during rest and peak dobutamine infusion (91%-98%, P = .001, and 87%-99%, P = .001, respectively). With contrast there was almost complete concordance between observers (96.9% at rest and 98.2% at peak stress with almost no interobserver variability), whereas noncontrast studies had much lower agreement (84.4% at rest and 79.9% at peak stress with kappa values < 0.4). Three-dimensional contrast studies compared favorably with standard 2-dimensional imaging. Time for acquisition of all data sets with and without contrast was less than 90 seconds. RT3D dobutamine contrast stress echocardiography is feasible, greatly improves image quality compared with noncontrast images, and quickly acquires full data sets for subsequent analysis.

Transvenous endomyocardial biopsy is a well established procedure to diagnose rejection after heart transplantation as well as to assess for other cardiomyopathic processes. However, it is rarely used to obtain samples of unidentified cardiac masses. We report a case of a primary cardiac sarcoma in which the histologic diagnosis was provided by transesophageal echocardiography–guided transvenous biopsy. This procedure is accurate and can avoid the potential risk of a diagnostic thoracotomy. (J Am Soc Echocardiogr 1997;10:752-5.)

Left ventricular assist devices are increasingly used as a bridge to transplantation in patients with end-stage cardiac disease. Potential complications of these devices include thromboembolism and infection. Because conventional cardiac diagnostic techniques cannot be used to obtain an image of the interior of a left ventricular assist device, we assessed the ability of intravascular ultrasonography to obtain an image of the interior of the Heartmate 1000 IP left ventricular assist device. Feasibility of intravascular ultrasound imaging was initially demonstrated in vitro on a left ventricular assist device immersed in water. Five soft rubber masses were then placed in the device intake port adherent to the wall, and their images were obtained by intravascular ultrasonography. Excellent correlation between actual size and size as measured by intravascular ultrasonography was noted (long-axis, r = 0.98, short-axis, r = 0.89). After the device was implanted in two calves, intravascular ultrasound imaging was performed in vivo in the animals. The catheter was easily advanced through the device, and excellent images were obtained. In conclusion, intravascular ultrasonography can easily be used to obtain an image of the left ventricular assist device interior and can accurately assess the presence and size of abnormal masses inside the device. Intravascular ultrasonography may be clinically useful in evaluating cases of thrombus or vegetation related to left ventricular assist devices.

Platypnea-orthodeoxia is a rare syndrome that is often associated with interatrial shunting through a patent foramen ovale or atrial septal defect. we describe the case of a 65-year-old woman with progressive dyspnea and hypoxia when standing and walking, which was relieved by assuming the recumbent position. The diagnosis was confirmed by tilt-table transesophageal echocardiography demonstrating a large right- to-left shunt through a patent foramen ovale while the patient was in a semiupright position and no significant shunt while in a recumbent position. This case demonstrates that platypnea-orthodeoxia caused by a patent foramen ovale can be clearly demonstrated by the technique of contrast transesophageal echocardiography performed on a tilt table.

A 66-year-old man without symptoms, referred for the treatment of moderate hypertension, was found to have a right atrial mass by two-dimensional echocardiography. On transesophageal echocardiography two masses were detected on the tricuspid valve, the first one on the posterior leaflet and the second smaller one on the anterior leaflet. These findings were confirmed at surgery. Histologic analysis revealed that the masses represented papillary fibroelastomas.