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BACKGROUND: Obesity causes significant cardiac remodelling even in health, and yet the contribution of this maladaptation in the setting of an additional cardiomyopathic process is poorly understood. Cardiovascular magnetic resonance is the gold-standard tool for assessing cardiac geometry, especially in an obese population, and hence perfectly suited to investigate this important question. METHODS: Using data from our extensive imaging registry (n=1,554), we documented the relationship between increasing BMI and left ventricular (LV) remodelling in patients with dilated (DCM; n=529) and hypertrophic cardiomyopathy (HCM; n=297), compared to the normal heart (n=728). RESULTS: Regardless of cardiac status, increasing BMI resulted in similar increases in LV stroke volume (P>0.18). However, there was a difference in the degree of LV cavity dilatation associated with this change in stroke volume; when compared to normal hearts [increase in end-diastolic volume of 0.7 mL per unit of rising BMI (mL/kg/m(2))], there was a threefold greater LV cavity dilatation in DCM (+2.2 mL/kg/m(2)) and twofold greater in HCM (+1.9 mL/kg/m(2), all P

Background Phase contrast velocity mapping sequences utilising ultrashort echo time (UTE) radial k-space sequences have been used to reduce intravoxel dephasing at high velocities. We evaluated the accuracy of the UTE flow sequence for mitral regurgitation (MR) quantification, including patients with atrial fibrillation. Methods Forty patients underwent cardiac MRI for indirect MR quantification by assessment of aortic flow using a UTE phase contrast sequence (TE 0.65 ms) combined with left ventricular stroke volume. Retrospective ECG-gating was used in sinus rhythm (30 patients), prospective ECG-triggering in atrial fibrillation (10). MR was also quantified by a standard phase contrast sequence (TE 2.85 ms, standard flow method) and by comparing stroke volumes (volumetric method). Results UTE flow-derived MR measurement showed modest agreement in sinus rhythm (95% limits of agreement: ±38.2 ml; ±29.8%) and atrial fibrillation (±33.7 ml; ±30.3%) compared to standard flow assessment. There was little systematic bias in sinus rhythm (mean offset −4.4 ml /−3.5% compared to standard flow assessment), but a slight bias towards greater regurgitation in atrial fibrillation (+15.2 ml /+14.0%). There were wider limits of agreement between the UTE flow method and volumetric method than between the regular flow method and the volumetric method in sinus rhythm (±48.4 ml; ±36.4%; mean offset: −12.2 ml /−9.0%) and similar limits of agreement in atrial fibrillation (±29.6 ml; 25.8%; +12.0 ml /+10.3%). Conclusions UTE flow imaging is inferior to conventional flow techniques for MR assessment in patients with sinus rhythm as well as atrial fibrillation. However, the number of atrial fibrillation patients in this initial study is small.

For >40 years, the British Royal Air Force has maintained an aeromedical evacuation facility, the Deployable Air Isolator Team (DAIT), to transport patients with possible or confirmed highly infectious diseases to the United Kingdom. Since 2012, the DAIT, a joint Department of Health and Ministry of Defence asset, has successfully transferred 1 case-patient with Crimean-Congo hemorrhagic fever, 5 case-patients with Ebola virus disease, and 5 case-patients with high-risk Ebola virus exposure. Currently, no UK-published guidelines exist on how to transfer such patients. Here we describe the DAIT procedures from collection at point of illness or exposure to delivery into a dedicated specialist center. We provide illustrations of the challenges faced and, where appropriate, the enhancements made to the process over time.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew following non-coronary surgery or percutaneous cardiology interventions (both pilots and non-pilot aviation professionals). Aircrew may have pathology identified earlier than non-aircrew due to occupational cardiovascular screening and while aircrew should be treated using international guidelines, if several interventional approaches exist, surgeons/interventional cardiologists should consider which alternative is most appropriate for the aircrew role being undertaken; liaison with the aircrew medical examiner is strongly recommended prior to intervention to fully understand this. This is especially important in aircrew of high-performance aircraft or in aircrew who undertake aerobatics. Many postoperative aircrew can return to restricted flying duties, although aircrew should normally not return to flying for a minimum period of 6 months to allow for appropriate postoperative recuperation and assessment of cardiac function and electrophysiology.

Cardiovascular diseasesiare the most common cause of loss of flying licence globally, and cardiac arrhythmia is the main disqualifier in a substantial proportion of aircrew. Aircrewiioften operate within a demanding physiological environment, that potentially includes exposure to sustained acceleration (usually resulting in a positive gravitational force, from head to feet (+Gz)) in high performance aircraft. Aeromedical assessment is complicated further when trying to discriminate between benign and potentially significant rhythm abnormalities in aircrew, many of whom are young and fit, have a resultant high vagal tone, and among whom underlying cardiac disease has a low prevalence. In cases where a significant underlying aetiology is plausible, extensive investigation is often required and where appropriate should include review by an electrophysiologist. The decision regarding restriction of flying activity will be dependent on several factors including the underlying arrhythmia, associated pathology, risk of incapacitation and/or distraction, the type of aircraft operated, and the specific flight or mission criticality of the role performed by the individual aircrew.

© 2014, BMJ Publishing Group. All rights reserved. Introduction: Valvular heart disease (VHD) is an increasingly important cardiac condition, driven by an ageing population and lack of progress in the development of medical therapies. There is a dearth of accurate information to guide decision-makers in the development of strategies to combat VHD, and no population-based study has been performed specifically to investigate its contemporary epidemiology. This document describes the design and methodology of the OxVALVE population cohort study (OxVALVE-PCS), which was conceived to address this need. Methods and analysis: Participants aged 65 years and older attending a participating general practice in Oxfordshire, UK, are invited to attend a screening examination. Exclusion criteria include previously diagnosed VHD, inability to provide consent, terminal illness or excessive frailty. Demographics, a focused cardiovascular history and vital signs are recorded at the initial screening examination, accompanied by an echocardiogram. Any finding of significant VHD triggers a separate, more formal echocardiographic assessment (including acquisition of a threedimensional dataset) and collection of blood samples for future genetic and biomarker analysis. Participants provide consent for longitudinal follow-up and enrolment in future cohort substudies. We also assess the acceptability of community-based echocardiographic examination and compare self-assessed quality of life between those with and without VHD. Conclusions: OxVALVE-PCS will provide contemporary epidemiological data concerning the community prevalence of undiagnosed VHD, facilitate accurate deployment of scarce resources to meet the anticipated increase in demand for VHD-associated healthcare and create a series of subcohorts with carefully defined genotypes and echocardiographic phenotypes for long overdue clinical studies. Ethics and dissemination: This study was approved by the local research ethics committee (Southampton, UK; REC Ref: 09/H0502/58). Results: Results will be submitted for publication in peer-reviewed scientific journals.

Key Points Transthoracic echocardiography should be considered in all patients with potential valve disease Cardiac magnetic resonance provides accurate assessment of valvular function, particularly quantification of regurgitation, and accurate left ventricular mass and volumes Management

Background The morphology of the aortic valve is of increasing importance in the evaluation of patients with calcific aortic stenosis (AS). The finding of a bicuspid valve can influence the suitability for transcutaneous aortic valve implantation, the attention paid to the proximal aorta, and consideration of family screening. More recent work has also suggested that the type of bicuspid valve can provide important information for planning surgery. Methods 65 patients with moderate-severe calcific AS underwent routine clinical trans-thoracic echocardiography (Echo) by an experienced echocardiographer, followed by CMR at 1.5T. Echo was performed using the parasternal short axis view through the aortic valve. CMR was performed in a short axis view through the valve, using SSFP sequences (linear and radial k-space acquisition) and analysis undertaken independently by 2 experienced CMR practitioners. For both imaging modalities, aortic valve morphology was examined over multiple heartbeats, in systole and diastole, and classified according to the Sievers criteria. Results Echo identified 13/65 patients with bicuspid valves. Valve morphology was clearly visualised by CMR in all subjects, and agreed with all 13 identified as bicuspid by Echo. However, CMR also identified an additional 11 subjects with bicuspid aortic valves not identified by Echo (a total of 24/65; p