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Heart transplantation is the definitive management for select patients with end-stage heart failure. Owing to an ongoing organ donor shortage, organs are sometimes allocated from distant locales. These organs may be perceived as less desirable because of donor risk factors and ischemic times. We compared survival after heart transplantation by donors originating from British Columbia (BC), other Canadian provinces, and the United States. This retrospective cohort analysis included all patients transplanted in BC between December 1, 1988, and October 21, 2014, and excluded those with missing data or retransplantation. Among 382 patients, 297 (77.7%) recipients and 238 (62.3%) donors were male. The median recipient age was 54.6 years (interquartile range, 46.0-61.0 years) and the median donor age was 33 years (interquartile range, 22-46 years). Overall 10-year survival was 62.1% (95% confidence interval, 56.3-67.4). There was no difference in 10-year survival when comparing donors from BC, other Canadian provinces, and the United States despite significantly lower median ischemic times in donors from BC. Donor location was not predictive of mortality after controlling for recipient age, donor age, and cold ischemic time. Donor origin did not impact 10-year survival after heart transplantation despite increased ischemic time, suggesting that distant donors result in similar outcomes in BC.

There is little data on right ventricular (RV) remodeling patterns in complex congenital heart disease (CHD) patients with right ventricle to pulmonary artery (PA) conduits, and novel RV imaging modalities have not been explored in this population. Knowledge of the RV remodeling process is an important first step to future understanding and tracking of the RV response to pressure and volume overload in this diverse population. Three-dimensional knowledge-based reconstruction (3DKBR) derived from two-dimensional transthoracic echocardiography (TTE-3DKBR) is a novel approach to RV assessment. The aims of this study were twofold: (1) to assess the feasibility and accuracy of 3DKBR in patients with CHD with RV to PA conduits and (2) to characterize the three-dimensional shape of the RV across the spectrum of CHD with RV to PA conduits.Seventeen patients with tetralogy of Fallot, pulmonary atresia with ventricular septal defect, or truncus arteriosus (mean age, 29 ± 8 years; 24% women) and a conduit referred for cardiac magnetic resonance imaging (CMR) were prospectively recruited and underwent TTE-3DKBR. TTE-3DKBR echocardiographic image acquisition was performed using a standard ultrasound scanner linked to a Ventripoint Medical Systems unit. The surface RV volumetric reconstruction was performed by transmitting two-dimensional data points to an online database and comparing these with a lesion-specific catalog to derive the RV reconstruction. Parameters analyzed were end-diastolic volume (EDV), end-systolic volume, and ejection fraction. Intertechnique agreement was assessed using Pearson's correlation analysis, coefficients of variation, and Bland-Altman analysis. Three-dimensional shape comparisons of RV surface reconstructions were performed via automated validation testing of CMRs from 43 patients (mean age, 30 ± 8 years; 32% women) with RV to PA conduits (tetralogy of Fallot, n = 15; pulmonary atresia, n = 19; and truncus arteriosus, n = 9) distinct from patients in the 3DKBR comparison.There was good correlation and agreement between the two modalities: EDV, R = 0.77, P = .0004; end-systolic volume, R = 0.93, P .0001; ejection fraction, R = 0.75, P .0005. On Bland-Altman analyses, CMR EDV was slightly larger TTE-3DKBR, while EF was slightly higher by 3DKBR. Qualitative and quantitative assessment both demonstrated RV shape diversity based on surface reconstructions.This study demonstrates that TTE-3DKBR is an alternative technology that can be used to assess the RV in patients with complex CHD with a conduit. A novel method was used to compare RV shapes in this important population, and our results draw specific attention to the fact that the RV both within and outside diagnostic groups has very different unpredictable shapes and should not be treated equally. Our findings should set into motion future work focused on indices of RV shape and their impact on overall RV function and clinical outcomes, hence defining optimal timing of conduit revision, which at the current time is very unclear.

To establish Canadian guidelines for training in adult perioperative transesophageal echocardiography (TEE). Guidelines were established by the Canadian Perioperative Echocardiography Group with the support of the cardiovascular section of the Canadian Anesthesiologists’ Society (CAS) in conjunction with the Canadian Society of Echocardiography. Guidelines for training in echocardiography by the American Society of Echocardiography, the American College of Cardiology and the Society of Cardiovascular Anesthesiologists were reviewed, modified and expanded to produce the 2003 Quebec expert consensus for training in perioperative echocardiography. The Quebec expert consensus and the 2005 Guidelines for the provision of echocardiography in Canada formed the basis of the Canadian training guidelines in adult perioperative TEE. Basic, advanced and director levels of expertise were identified. The total number of echocardiographic examinations to achieve each level of expertise remains unchanged from the 2002 American Society of Echocardiography-Society of Cardiovascular Anesthesiologists guidelines. The increased proportion of examinations personally performed at basic and advanced levels, and the level of autonomy at the basic level suggested by the Quebec expert consensus are retained. These examinations can be performed in a perioperative setting and are not limited to intraoperative TEE. Training “on the job”, the role of the perioperative transesophageal echocardiography examination, requirements for maintenance of competence, and duration of training are also discussed for each level of training. The components of a TEE report and comprehensive TEE examination are also outlined. The Canadian guidelines for training in adult perioperative TEE reflect the unique Canadian practice profile in perioperative TEE and address the training requirements to obtain expertise in this field.

Purpose To establish Canadian guidelines for training in adult perioperative transesophageal echocardiography (TEE). Methods Guidelines were established by the Canadian Perioperative Echocardiography Group with the support of the cardiovascular section of the Canadian Anesthesiologists' Society in conjunction with the Canadian Society of Echocardiography. Guidelines for training in echocardiography by the American Society of Echocardiography, the American College of Cardiology and the Society of Cardiovascular Anesthesiologists were reviewed, modified and expanded to produce the 2003 Quebec expert consensus for training in perioperative echocardiography. The Quebec expert consensus and the 2005 guidelines for the provision of echocardiography in Canada formed the basis of the Canadian training guidelines in adult perioperative TEE. Results Basic, advanced and director levels of expertise were identified. The total number of echocardiographic examinations to achieve each level of expertise remains unchanged from the 2002 American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists guidelines. The increased proportion of examinations personally performed at basic and advanced levels, as well as the level of autonomy at the basic level suggested by the Quebec expert consensus are retained. These examinations may be performed in a perioperative setting and are not limited to intraoperative TEE. Training ‘on-the-job', the role of the perioperative TEE examination, the requirements for maintenance of competence and the duration of training are also discussed for each level of training. The components of a TEE report and comprehensive TEE examination are also outlined. Conclusion The Canadian guidelines for training in adult perioperative TEE reflect the unique Canadian practice profile in perioperative TEE and address the training requirements to obtain expertise in this field.

Background: Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valve replacement. Most are asymptomatic and benign, but some may cause symptoms due to a large regurgitant volume or hemolysis. Medical therapy is palliative, while reoperation carries significant morbidity and mortality. Percutaneous transcatheter closure techniques, now routinely applied in the management of pathological cardiac and vascular communications, may be adaptable to PVL closure, potentially offer symptomatic relief. Methods: We reviewed our experience with attempted percutaneous closure of PVLs, using data from medical and procedural records. Results: Between 2001 and 2004, 14 procedures were performed in 10 patients, all under general anesthesia, with transesophageal and radiographic guidance. Mitral (9) and aortic (1) valve replacements were involved, both mechanical and bioprosthetic. A variety of devices were used, including atrial septal occluders, patent ductus arteriosus occluders, and coils (all of label use). Six had a single procedure, which was technically successful in four: in two, the PVL could not be crossed. Four underwent a second procedure, which was technically successful in three; in one the previously deployed device was dislodged necessitating urgent, but ultimately uneventful, surgical removal and leak repair. One patient had transient severe hemolysis, which resolved after 1 week. At 1-year follow-up (9/10 pts) three had died, five had sustained symptomatic improvement while 1 patient with a residual leak still required regular blood transfusions. Conclusions: Percutaneous closure of PVLs is time-consuming but feasible in selected patients, with a reasonable degree of technical and clinical success. A second procedure may be necessary and a variety of complications can occur. © 2006 Wiley-Liss, Inc.

Transcutaneous aortic valve implantation (TAVI) is rapidly gaining acceptance as a viable alternative to open-heart surgery aortic valve replacement (SAVR) in high-risk surgical candidates with aortic stenosis. To date, there have been reports on the procedural success, early mortality, and short-term and intermediate-term clinical outcomes, but there are limited data on long-term outcomes of TAVI. The study by Bauer et al in this issue of JASE adds to the accumulating evidence base with the echocardiographic experience of the longest follow-up after TAVI for aortic stenosis with the Sapien series of balloon expandable aortic prostheses (Edwards Lifesciences, Irvine, CA).

BACKGROUND: Computed tomography (CT) annular measurements are predictive of paravalvular regurgitation after transcatheter aortic valve replacement (TAVR) which is a predictor of mortality and morbidity. OBJECTIVES: To demonstrate the rationale and potential implications of new CT sizing recommendations for TAVR. METHODS: The CT sizing recommendations aim to ensure routine transcatheter heart valve (THV) oversizing of the aortic annular area [(THV external area/systolic annular area 1) × 100; range 1 20; target 10 15]. Consecutive patients (n = 120) underwent CT before TAVR with balloon expandable valves sized by transesophageal echocardiography (TEE). Retrospectively the CT recommended THV size was compared with the actual size implanted. RESULTS: Compared with TEE application of the newly developed CT based sizing recommendations would have led to implantation of a larger valve in 33.3 (40/120) no change in valve size in 55.8 (67/120) and a smaller valve in 10.8 (13/120). In patients when CT recommended a larger valve the incidence of at least moderate paravalvular regurgitation was 25 (10/40) compared with 4.5 (3/67; P < 0.01) when both TEE and CT recommendations were in agreement. Using diastolic versus systolic CT measurements results in 20 of patients receiving smaller THVs. TEE sizing resulted in 33.3 (40/120) of valves being undersized (THV area < CT systolic annular area) with a mean annular oversizing of 9.4 ± 17.4 (range: 21.5 to 65.9) without annular rupture. In contrast the CT sizing recommendations results in mean annular oversizing of 13.9 ± 8.0 (range 1.3 29.8). CONCLUSION: These CT sizing recommendations enable standardized moderate overexpansion of the aortic annulus. Clinical outcomes from these recommendations are being prospectively assessed in a multicenter trial.

BACKGROUND: Echocardiography volumes have increased at a rate that exceeds the increase in disease prevalence. This has led to concerns by health care insurers about the appropriateness of echocardiography studies. Appropriate Use Criteria (AUC) for echocardiography have been developed, however, there is no published Canadian data on adherence to these criteria. We investigated the AUC adherence rate in a contemporary Canadian cohort and explored factors associated with AUC nonadherence. METHODS: We prospectively evaluated consecutive referrals for transthoracic echocardiography (TTE) at the UOHI echocardiography laboratory over a 4-week period to determine adherence to ACCF/AHA/ASE 2011 AUC for echocardiography. Patient demographics, inpatient/outpatient status, previous echocardiography study, referring physician specialty, and primary indication for the study were identified. RESULTS: During the 4-week period, there were 1303 referrals for TTE (median age 65 years, 56.1% male). Inpatient examinations accounted for 24.4% of all referrals (n1⁄4313). Cardiologists accounted for the largest physician referral group (49.0% of referrals). Primary care physicians and non-internal-medicine specialists accounted for 19.3% and 14.7%, respectively. The TTE referral requisition alone was inadequate to determine AUC adherence in 26.2% (n1⁄4341) of referrals. After review of the referral requisition, electronic records and contact with the referring physicians where necessary, 85.9% (n1⁄41119), 6.1% (n1⁄479) and 3.6% (n1⁄447) of TTE referrals were classified as adherent (appropriate), non-adherent (inappropriate) and uncertain by AUC, respectively. Only 3.1% (n1⁄440) of TTE referrals were unclassifiable. The AUC category of “Evaluation of Valvular Function” accounted for the largest number of non-adherent referrals (n1⁄448). Outpatient referrals were more likely than inpatient referrals to be nonadherent to AUC (7.7% vs. 0.9%, p

Implantation of left ventricular assist devices through small incisions, avoiding cardiopulmonary bypass, may decrease the activation of the inflammatory and coagulation cascades and decrease bleeding and vasoplegia. One patient with severe, inotrope-dependant cardiomyopathy received the HeartWare left ventricular assist device (HeartWare Inc, Framingham, MA) through an upper ministernotomy and left minithoracotomy. The outflow graft was connected to the ascending aorta, and the inflow of the left ventricular assist device was attached through to the apex of the heart. The apical puncture was performed under rapid ventricular pacing, followed by insertion of the inflow of the pump. The patient was extubated rapidly and discharged home 14 days later.

BACKGROUND: Patients with systemic sarcoidosis manifest symptomatic cardiac involvement in approximately 5% of cases. With the availability of advanced cardiac imaging, including cardiacMRI and FDG-PET, evidence of asymptomatic cardiac sarcoidosis (CS) has been detected in up to 50% of patients. Cardiac involvement in patients with sarcoidosis portends a poor prognosis. PURPOSE: To evaluate contemporary practice patterns for the diagnosis of CS compared to current 2014 HRS expert consensus recommendations. METHODS: Retrospective cohort study of patients from the St. Paul’s Hospital CS Clinic. Baseline characteristics, diagnostic imaging and pathology were reviewed for patients between January 2013 andMarch 2015. Patients were analyzed according to 2014 HRS guidelines. Group 1 (22 patients) consisted of patients with biopsy proven extra-cardiac sarcoidosis referred for cardiac screening. Group 2 (13 patients) included those under the age of 60, with unexplainedMobitz II or third degree heart block. Group 3 (12 patients) consisted of patients with unexplained VT and Group 4 (13 patients) included all others, particularly unexplained LV dysfunction. RESULTS: Of the 115 patients referred to theCS clinic, 25 remain incompletely evaluated, 12 refused further evaluation, and18were discharged after initial triage. Complete data was available for 60 patients. The median age was 57 years (IQR 18) and 58.3% were males. Overall, there were 27 (45.0%) patients with an ICD and 17 (28.3%)with a pacemaker. Themean LVEFwas 46.1% (95% CI 34.0-58.2). Endomyocardial biopsy was performed in 24 (40.0%) of patients, cardiacMRI in 39 (65.0%) andFDG-PET in 54 (90.0%). According to 2014 HRS recommendations, patients were considered to have probable cardiac involvement in 15 (68.2%), 10 (76.9%), and 11 (91.7%) cases inGroups 1, 2 and 3, respectively. Similarly, advanced imaging was performed, but not recommendedby current guidelines, in 6 (27.3%), 1 (7.7%) and4 (33.3%) patients for Groups 1, 2 and 3, respectively. FDG-PET was negative for CS in 7/9 (77.8%) Group 4 patients with LV dysfunction and an abnormal biopsy or cardiac MRI. We found FDG-PET to be positive in a pattern consistent with active CS in 3/8 (37.5%) of cases where ordering FDG-PET was not recommended by current guidelines. CONCLUSION: In our study, contemporary screening and diagnosis of CS would often be considered not recommended by current HRS expert consensus recommendations. More liberal use of FDG-PET in patients evaluated for CS may help stratify this high risk population. 548 CINE MRI-BASED 4D-STRAIN ANALYSIS OF THE LEFT VENTRICLE FOR THE EVALUATION OF MYOCARDIAL FIBROSIS IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY

Percutaneous transcatheter closure techniques are now routinely applied in the management of atrial and ventricular septal defects, patent ductus arteriosus, and other pathological cardiac and vascular communications. Recently, these same techniques have been applied to paravalvular defects. Reports are few; success variable and techniques vary widely. We review the current considerations and techniques of percutaneous transcatheter closure of paravalvular leaks.

Percutaneous transseptal mitral valvuloplasty was attempted in a patient with severe rheumatic mitral stenosis. Introduction of the balloon into the left atrium resulted in thrombotic occlusion of the mitral valve. Circulatory arrest ensued. The thrombus was disrupted during cardiopulmonary resuscitation. Thrombolysis was administered and the patient recovered uneventfully.

Cardiac side effects of mesalamine are uncommon. A young man with ulcerative colitis who developed recurrent chest pain and electrocardiographic changes while on mesalamine is presented. Various causes of mesalamine-induced chest pain are discussed.

Infectious complications of coronary angioplasty and stenting are uncommon. A 70-year-old man is presented who underwent percutaneous transluminal coronary angioplasty (PTCA) and stenting of an occluded left anterior descending artery. This was complicated by Staphylococcus aureus pericarditis with tamponade. He was successfully treated with a closed drainage and antibiotics. This is the first reported case in the literature that documents purulent pericarditis and tamponade following percutaneous revascularization.

Exercise-induced left bundle branch block is a relatively rare finding during exercise tolerance testing. A 36-year-old female with intermittent exercise-induced left bundle branch block, a MIBI study suggesting anterior ischemia and normal coronary arteries is reported. A review of the English and French language literature published from January 1985 to January 1996 is presented. Exercise-induced left bundle branch block has been reported in association with and without structural heart disease. Pooled mortality in the group with structural heart disease was 2.7% per year, and mortality was 0.17% per year when no structural heart disease was identified. Exercise-induced left bundle branch block has been reported to resolve with therapy. Noninvasive testing appears to have limited ability to detect or exclude coronary artery disease in this group. If a definitive cardiac diagnosis is required, strong consideration should be given to coronary angiography.

Pulmonary hypertension (PHT) is a complication of Gaucher disease. Screening with echocardiography is recommended for Gaucher patients. Two patients naive to enzyme replacement therapy are presented in whom resting echocardiography revealed no evidence of PHT. One of the patients also had normal pulmonary artery pressures at cardiac catheterization. The diagnosis of PHT was made with open lung biopsy in one patient and dobutamine echocardiography in the other. In both cases, diagnosis of PHT altered patient management. Resting echocardiographic assessment may fail to identify PHT in patients with Gaucher disease.

Pulmonary hypertension is the most frequent cause of death in patients with mixed connective tissue disease. The pulmonary hypertension is progressive and difficult to treat effectively. These patients experience considerable morbidity secondary to diminished cardiac function. We describe a case in which sequential administration of cyclophosphamide and cyclosporine A favorably altered the clinical and hemodynamic course of this serious complication.

We report a 39-year-old female patient with a hepatic hemangioblastoma, polycythemia and elevated plasma erythropoietin (Epo) levels. Following orthotopic liver transplantation (OLTx), her plasma Epo levels and hematocrit normalized but began to rise several months later. This rise correlated with the appearance of multiple lung metastases. The tumor was implicated as the source of excess Epo production using Northern analysis of a resected metastatic lung nodule. Based on our results, the measurement of plasma Epo levels in patients with Epo secreting tumors could be of general utility in assessing tumor burden.

1. 1. Total cholesterol and high density lipids (HDL) were measured in the blood of Atlantic salmon (Salmo salar), brook trout (Salvelinus fontinalis) and rainbow trout (Salmo gairdneri) from a variety of dietary and environmental regimes. 2. 2. At spawning the total cholesterol of cage reared S. salar was high compared to sea ranched S. salar. 3. 3. Starvation of S. salar in freshwater for 6–11 months depressed total blood cholesterol levels, but not to unusually low levels. 4. 4. A cholesterol supplement of 0.02 g/100 g body weight to a chow diet of 0.38g/100g body weight had no significant effect on the total blood cholesterol level in Salvelinus fontinalis. 5. 5. The high proportion of HDL in the blood of S. salar is discussed in terms of its possible importance during the atherosclerotic lesion formation that normally accompanies spawning in these salmon.