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Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.

Atherosclerotic cardiovascular disease (ASCVD) remains an important contributor of morbidity and mortality in patients with chronic kidney disease (CKD). CKD is recognized as an important risk enhancer that identifies patients as candidates for more intensive low-density lipoprotein (LDL) cholesterol lowering. However, there is controversy regarding the efficacy of lipid-lowering therapy, especially in patients on dialysis. Among patients with CKD, not yet on dialysis, there is clinical trial evidence for the use of statins with or without ezetimibe to reduce ASCVD events. Newer cholesterol lowering agents have been introduced for the management of hyperlipidemia to reduce ASCVD, but these therapies have not been tested in the CKD population except in secondary analyses of patients with primarily CKD stage 3. This review summarizes the role of hyperlipidemia in ASCVD and treatment strategies for hyperlipidemia in the CKD population.

Background Patients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing. Objectives In this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches–Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy. Methods In the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed. Results Compared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54–1.54) and 1.03 (95% CI: 0.78–1.37) for those listed and not listed, respectively (pinteraction= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55–1.46) in listed and 1.17 (95% CI: 0.89–1.53) in those not listed (pinteraction = 0.35). Conclusions In ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360 )

Background Heart failure is a significant cause of morbidity and mortality, yet patient risk stratification may be difficult. Prevention or treatment of atrial fibrillation (AF) may be an important strategy in these patients that could positively affect their outcome. It has been demonstrated that in patients with systolic dysfunction, prolonged QRS duration (QRSd), an easily measured electrocardiographic parameter, is associated with AF. Hypothesis Prolonged QRSd is associated with an increase in prevalence of AF in patients with heart failure with preserved ejection fraction(HFPEF). Methods Between February 2006 and February 2009, 718 patients were discharged with a diagnosis of HF from the Dartmouth-Hitchcock Medical Center. Of these, 206 had EF ≥50% by echocardiography performed within 72 hours of admission. After exclusions, 82 patients remained, of which 25 had AF and 57 had sinus rhythm. Characteristics of the AF and sinus-rhythm patients were compared in this pilot study. Results After adjustment for age, prior diagnosis of HF, and left atrial area, there was a nonsignificant trend (odds ratio: 2.2, 95% CI of 0.3-17.2) for a QRSd >120 ms to be associated with AF. Conclusions Similar to results in patients with systolic dysfunction, patients with preserved EF may have an association between a prolonged QRSd and AF.

An elevated pulmonary pressure (PASP >35 mm Hg) is a highly prevalent finding in patients with chronic kidney disease (CKD) – approaching over 30% of patients with CKD in some studies. This is often first detected on an echocardiogram, which is a very common test performed in patients with kidney failure, as the volume overload consistent with CKD can often be confused for congestive heart failure at times. In addition, some national guidelines have recommended a screening echocardiogram at the start of dialysis to rule out possible cardiac contribution to poor kidney function. Often, the high pulmonary pressure is a reflection of chronic volume overload and diastolic dysfunction (WHO group 2 pulmonary HTN), but patients with chronic kidney disease may have other unique factors that make them more susceptible to pulmonary hypertension, including elevated levels of endothelin, decreased levels of nitric oxide, metabolic abnormalities of calcium handling, anemia, and high-flow states associated with an AV fistula. Whether as a marker of underlying disease or as a contributing factor, significant pulmonary hypertension has been associated with worse outcomes in patients with CKD as well as kidney transplant recipients. An invasive hemodynamic study can be used to further classify pulmonary hypertension into sub-groups and help generate targets for optimal treatment. Further work is needed to determine whether some of the advances in the treatment of pulmonary hypertension can help improve clinical outcomes in this challenging group of patients.

Cardiorenal syndrome encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in 1 organ may induce acute or chronic dysfunction in the other organ. It represents the confluence of heart-kidney interactions across several interfaces. These include the hemodynamic cross-talk between the failing heart and the response of the kidneys and vice versa, as well as alterations in neurohormonal markers and inflammatory molecular signatures characteristic of its clinical phenotypes. The mission of this scientific statement is to describe the epidemiology and pathogenesis of cardiorenal syndrome in the context of the continuously evolving nature of its clinicopathological description over the past decade. It also describes diagnostic and therapeutic strategies applicable to cardiorenal syndrome, summarizes cardiac-kidney interactions in special populations such as patients with diabetes mellitus and kidney transplant recipients, and emphasizes the role of palliative care in patients with cardiorenal syndrome. Finally, it outlines the need for a cardiorenal education track that will guide future cardiorenal trials and integrate the clinical and research needs of this important field in the future.

Although cardiac evaluation before kidney transplantation commonly focuses on coronary artery disease, a comprehensive pretransplant cardiac evaluation must consider other prognostically important cardiac conditions including functional and structural heart disease. Pulmonary hypertension (PH) is increasingly recognized among patients with kidney failure and may be driven by left heart failure, high cardiac output from arteriovenous fistula, hypoxic lung diseases, and metabolic derangements associated with renal disease. In this article, we examine several key concepts and controversies relevant to optimizing the assessment and management of PH in kidney transplant candidates and recipients. First, categorizing PH according to underlying pathophysiologies, hemodynamic characteristics, and treatment responses as currently defined by the World Health Organization can be challenging in this population, but should be pursued to direct appropriate management. Second, echocardiographic PH (based on variable definitions) has been reported in 13% to 50% of selected pretransplant cohorts, but use of more precise diagnostic methods is needed to better define epidemiology and underlying etiologies. Third, although measures of PH have been associated with adverse patient and graft outcomes after kidney transplantation, pilot data suggest that PH may improve with successful transplantation. Fourth, recent advances in PH treatment in the general population focus on World Health Organization group 1 pulmonary arterial hypertension, and the efficacy of management strategies for any PH type in patients with renal failure is largely unproven. Broader prospective data, including attention to the impact of transplantation, are needed to advance understanding of the frequency, causes, and optimal management of PH in kidney transplant candidates and recipients.

Eric S. Williams, MD, MACC, Chair Jonathan L. Halperin, MD, FACC, Co-Chair James A. Arrighi, MD, FACC Eric H. Awtry, MD, FACC Eric R. Bates, MD, FACC John E. Brush, Jr, MD, FACC Salvatore Costa, MD, FACC Lori Daniels, MD, MAS, FACC Susan Fernandes, LPD, PA-C Rosario Freeman, MD, MS, FACC

Focused cardiac ultrasound (FCU) is a useful bedside tool that is often utilized by internal medicine residents. Multiple studies have shown that FCU adds valuable information beyond the history and physical. No formal recommendations exist regarding which physiologic parameters should be included in FCU, how those parameters should be assessed, or how to adequately train residents in its use. This review highlights the available literature on FCU training for medicine residents and provides in-depth analysis of the existing programs. There is significant variability among FCU training of internal medicine residents. A standard FCU training protocol should be considered to incorporate this powerful modality throughout the American Post-Graduate Medical Education System. This review offers recommendations for standard training.

Background The revised 2014 American College of Cardiology (ACC)/American Heart Association valvular heart disease guidelines provide evidenced-based recommendations for the management of mitral regurgitation (MR). However, knowledge gaps related to our evolving understanding of critical MR concepts may impede their implementation. Methods The ACC conducted a multifaceted needs assessment to characterize gaps, practice patterns, and perceptions related to the diagnosis and treatment of MR. A key project element was a set of surveys distributed to primary care and cardiovascular physicians (cardiologists and cardiothoracic surgeons). Survey and other gap analysis findings were presented to a panel of 10 expert advisors from specialties of general cardiology, cardiac imaging, interventional cardiology, and cardiac surgeons with expertise in valvular heart disease, especially MR, and cardiovascular education. The panel was charged with assessing the relative importance and potential means of remedying identified gaps to improve care for patients with MR. Results The survey results identified several knowledge and practice gaps that may limit implementation of evidence-based recommendations for MR care. Specifically, half of primary care physicians reported uncertainty regarding timing of intervention for patients with severe primary or functional MR. Physicians in all groups reported that quantitative indices of MR severity were frequently not reported in clinical echocardiographic interpretations, and that these measurements were not consistently reviewed when provided in reports. In the treatment of MR, nearly 30% of primary care physician and general cardiologists did not know the volume of mitral valve repair surgeries by their reference cardiac surgeons and did not have a standard source to obtain this information. After review of the survey results, the expert panel summarized practice gaps into 4 thematic areas and offered proposals to address deficiencies and promote better alignment with the 2014 ACC/American Heart Association valvular disease guidelines. Conclusion Important knowledge and skill gaps exist that may impede optimal care of the patient with MR. Focused educational and practice interventions should be developed to reduce these gaps.

From almost the time of the initial randomized controlled trials demonstrating a benefit to cardiac resynchronization therapy (CRT) in the early 2000s,1,2 clinicians, investigators, and industry have all been drawn to the concept that quantitative parameters derived from echocardiographic images might be a powerful tool to enhance patient selection. The need for a tool was magnified by the early observation that approximately one third of patients remain nonresponders despite implantation of a CRT device—an observation that remains mostly unchanged today. See Article by Delgado-Montero et al The task seemed simple at first: because CRT is designed to resynchronize the mechanical motion of the left ventricular (LV) walls, all one needs is a tool that can measure the degree of dyssynchrony—the patients with the most dyssynchrony should have the most to gain. The high temporal resolution available through M-mode seemed well suited to the task of measuring differences in timing, and some of the earliest reports demonstrated that in patients with a left bundle branch block, a simple parasternal long-axis view with a septal to posterior delay of ≥ 130 ms on M-mode was associated with an improved likelihood of response to CRT.3 Around this same time, there were significant advances in echocardiographic technology with tissue Doppler that applied Doppler principles to the low velocity of the LV walls (tissue). These quantitative tools display the change in speed or distance over time, allow for simultaneous sampling of multiple sites, have high frame rates with excellent temporal resolution (although an order of magnitude less than M-mode), and some vendors even created specialized software that would color-code the timing of cardiac events allowing for a snapshot of synchrony or dyssynchrony (tissue synchronization index; GE). These factors converged to contribute to an exponential rise in published research because investigators raced …

The challenges inherent in conducting accurate, clinically effective, and cost-effective cardiac evaluations among transplantation candidates relate to the large size of the target population, the prevalence of disease, the limited number of donated organs, and the often extended waiting periods between initial evaluation and transplantation surgery. According to Organ Procurement and Transplant Network (OPTN) records, nearly 85 000 candidates were on the waiting list for kidney transplantation in 2010, and ≈17 700 kidney transplantations (including 828 kidney-pancreas transplantations) were performed.1 Also in 2010, 16 000 people were awaiting liver transplantation and 6000 received liver allografts.1 Marked shifts in the age composition of transplant waitlists toward older adults are also raising the average medical complexity and comorbidity burden among listed candidates. In 2011, 62% of kidney transplantation candidates were ≥50 years of age compared with 28.7% of kidney transplantation candidates in 1991.1 A similar shift in age distribution has occurred among liver transplantation candidates; now, 77% are ≥50 years of age.1 Cardiovascular disease is a leading cause of morbidity and mortality among patients with end-stage failure of noncardiac organs before and after transplantation. Estimates of the cumulative incidence of myocardial infarction (MI) based on Medicare billing claims have ranged from 8.7% to 16.7% by 3 years after kidney transplant listing and from 4.7% to 11.1% after kidney transplantation.2,3 Observational data suggest particularly high frequencies of cardiovascular events in the first months after kidney transplantation.2,4,5 Cardiovascular diseases in aggregate make up the most common cause of death in patients with functioning allografts at all times after kidney transplantation, accounting for 30% of mortality overall, with highest rates in the peritransplantation period.6 Guidelines and position papers by national organizations can serve as useful tools for informing cardiac evaluation practices before …

The challenges inherent in conducting accurate, clinically effective, and cost-effective cardiac evaluations among transplantation candidates relate to the large size of the target population, the prevalence of disease, the limited number of donated organs, and the often extended waiting periods

Chronic kidney disease is now widely accepted as an independent risk factor for coronary disease and the dialysis population may represent the highest risk subgroup. Among all dialysis patients, a cardiac cause of mortality has been estimated at 40%. In addition, prior studies have demonstrated that when cardiac catheterization is obtained in a consecutive series of asymptomatic diabetic patients on dialysis the rates of coronary disease can approach 50%. However, the ability to define the problem continues to be greater than the ability to treat or prevent it. Coronary revascularization strategies have limitations in the general population which are amplified in the dialysis population. The ability to accurately diagnose an acute coronary syndrome is more difficult, clinical outcomes have a smaller margin of benefit, and technical challenges result in higher complication rates. Recent data demonstrate an inverse relationship between glomerular filtration rate and the risk of presenting with an acute myocardial infarction rather than unstable angina suggesting that patients with CKD may have a unique pathophysiologic profile that is more prone to plaque rupture. However, these "vulnerable" plaques typically are associated with stenoses

Background: Tissue synchronization imaging (TSI), a parametric imaging technique based on tissue velocity imaging, often demonstrates patterns other than lateral delay in patients evaluated for cardiac resynchronization therapy (CRT). The prevalence of these patterns and their response to CRT has not been well described. We hypothesized that regional patterns of dyssynchrony might correlate with the extent of reverse remodeling. Methods: A consecutive series of 32 patients underwent echocardiographic study prior to CRT implant and 3 months postimplant. TSI was used to color-code the time-to-peak positive systolic velocity at six basal and six mid-LV segments. Each patient was assigned to one of four groups based on the predominant location of greatest delay (≥2 segments): (1) posterolateral delay, (2) septal delay, (3) no dyssynchrony, or (4) other. Results: Patients were classified as follows: posterolateral delay in 44% of patients (n = 14), septal delay in 28% (n = 9), no dyssynchrony in 16% (n = 5), and other pattern in 13% (n = 4). At 3-month follow-up, the group with the lateral delay pattern was associated with the greatest decrease in left ventricular end-systolic volume (LVESV) and the largest improvement in left ventricular ejection fraction (LVEF) (−45 mL and +9.3%, respectively, P < 0.05). The LVESV in the other three groups changed as follows: −24 mL (septal), −28 mL (no dyssynchrony), and −15 mL (other). Similar trends were observed for LVEF and left ventricular end-diastolic volume. Conclusions: Despite the presence of wide QRS and a left bundle branch block, the most delayed segment is not always the posterolateral wall. Posterolateral delay is associated with the best response to CRT, while other patterns respond at a lower magnitude. (Echocardiography 2012;29:554-559)

Background. Early graft dysfunction is a significant complication after renal transplantation and is a marker of adverse outcomes. Although multiple predictors of graft dysfunction have been previously described, the reported prevalence of pulmonary hypertension (pulmonary HTN) in the dialysis population (40–50%), along with biologic and physiologic principles, led us to hypothesize that pulmonary HTN might be an additional risk factor for early graft dysfunction. Methods. We performed a retrospective study that screened all adult renal transplants performed at our institution over a 3-year period and limited the evaluation to those subjects who had an estimated pulmonary artery systolic pressure on a preoperative echocardiogram report (n = 55). The primary outcome of this study was to investigate the impact of pulmonary HTN on early graft dysfunction using a combined endpoint of delayed graft function or slow graft function. Results. Among patients receiving a living donor kidney, early graft dysfunction was not observed regardless of pulmonary HTN status. However, among patients receiving a deceased donor kidney, pulmonary HTN was found to be associated with a significant increased risk of early graft dysfunction (56 vs 11.7%, P = 0.01). Univariate and multivariable logistic regression supported this observation as an independent risk factor beyond potential confounding recipient, donor and graft-based risk factors for early graft dysfunction (P < 0.05). Conclusion. Pulmonary HTN detected on non-invasive imaging prior to renal transplantation appears to be an independent predictor of early graft dysfunction among those patients who receive a deceased donor kidney.

Background: Cardiac perforation with tamponade is an infrequent occurrence during an electrophysiologic procedure. The customary approach to management includes volume resuscitation followed by pericardiocentesis. Such a procedure, however, is not without its own risk, especially when performed emergently. We hypothesized that some patients experiencing this type of complication can be managed successfully in a conservative fashion, without the need for an additional invasive procedure. Methods: We retrospectively analyzed the clinical outcomes and echocardiographic features of 33 consecutive patients who experienced this complication during cardiac electrophysiology (EP) procedures performed at our institution from 1988 to 2007. Nineteen patients (58%) were managed conservatively with intravenous fluids and vasopressors (Group A). Fourteen patients (42%) were managed invasively with pericardiocentesis (Group B). Results: The mean systolic blood pressure at diagnosis did not differ between the two groups (64 vs 71 mmHg, P = 0.134). The mean lengths of hospitalization (4.7 vs 4.9 days, P = 0.75) and survival to hospital discharge (100% in both groups) were also similar. A large pericardial effusion (≥2 cm) was seen predominantly among Group B patients. There was a statistically significant temporal trend toward managing this type of complication invasively (P = 0.038). Conclusion: Among patients who experience cardiac perforation as an acute complication of EP procedure, there appears to be a role for conservative management in a subset of patients who do not have echocardiographic evidence of a large effusion and who respond well to initial stabilizing measures consisting of fluids and vasopressors. (PACE 2010; 33:667–674)

Background: Prior studies have described the potential benefit of using echocardiographic rather than ECG techniques to help select the subgroup of heart failure patients that are most likely to benefit from cardiac resynchronization therapy (CRT). Currently, the most commonly used echocardiographic techniques to assess dyssynchrony include discrepancies in radial motion derived from M-mode and in longitudinal motion derived from tissue Doppler; however, there are little data available on the range of these measurements in the general cardiology population. Methods and Results: A consecutive series of patients referred for a stress echocardiogram were screened for normal LV systolic function and normal QRS width. Fifty-one patients met inclusion criteria and underwent dyssynchrony measurements in addition to their baseline echo. Previously proposed cutoff values were applied. We observed 17% of study subjects were above the reported normal values for radial dyssynchrony and 41% were above the reported normal values for longitudinal dyssynchrony. However, when both criteria were required to be abnormal only 4% were classified as dyssynchronous. Conclusions: Echocardiographic indices in general cardiology patients appear most accurate when radial and longitudinal parameters are used in combination. While the ideal cutoff values remain to be determined, this combination may optimize patient selection for CRT response.

Cardiac arrest presenting as pulseless electrical activity (PEA) currently has a very low survival rate. Many of the conditions underlying PEA (cardiac tamponade, hypovolemia, and pulmonary embolus) are associated with specific cardiac ultrasound findings. The aim of this study was to evaluate a rapid cardiac ultrasound assessment performed by trained nonexpert sonographers integrated into the ACLS response system at a major medical center. Methods: An emergency sonography system was created and deployed to each inpatient cardiac arrest occurring at Dartmouth Hitchcock Medical Center between November 1, 2003 and April 30, 2004. Thirteen internal medicine house officers received training to perform a limited subcostal cardiac ultrasound examination designed to diagnose cardiac tamponade, pulmonary embolus, severe hypovolemia, and lack of cardiac motion. Time from arrest alert to sonographic result, and correlation with over-reading by blinded echocardiography physicians were assessed. Results: A complete emergency ultrasound examination was performed in five PEA arrests. The average time from arrest alert to interpretation was 7.75min. (95% CI 2.8–18.3min). Three of these examinations (60%, 95% CI 14.7–94.7%) were adequate for interpretation. Agreement between the nonexpert sonographer and echocardiography physician occurred in four of five (kappa=0.706) cases. Conclusion: Rapid cardiac sonography can be successfully integrated in the ACLS response. Nonexpert sonographers may be able to provide useful interpretive information when sufficiently trained.

Background: Technological advances have made it feasible to obtain real-time 3D volume datasets using transthoracic echo; however, despite its widespread availability, only a few echocardiography labs utilize it in daily clinical practice. We hypothesized that an automated system would facilitate

Cardiovascular disease is a leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD) including transplant candidates and recipients. Although transplantation improves cardiovascular risk in the long term compared with dialysis, cardiovascular diseases in aggregate comprise the most common cause of death in patients with functioning allografts at all times after kidney transplant. Achieving clinically and cost-effective management of cardiovascular disease in kidney transplant candidates is a challenging endeavor due to the large size of the target population, prevalent disease burden, and the often extended waiting periods between initial candidate evaluation and transplantation surgery. Further, there is a paucity of randomized clinical trials addressing the efficacy of cardiac screening, surveillance, coronary revascularization, and medical management among patients with ESRD, and extrapolation from trials performed in other populations or observational studies is often necessary to formulate practice recommendations. Recently, the American Heart Association and American College of Cardiology Foundation convened a working group including cardiologists, nephrologists, and intensivists to compose a Scientific Statement on “Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates.” The current chapter provides a practical summary of some of the key recommendations in this Scientific Statement relevant to kidney transplant candidates, focused as a practical guide for the clinician. Our synthesis includes a final algorithm emphasizing the importance of history and physical examination to assess for active cardiac conditions, use of resting echocardiography in dialysis patients to evaluate ventricular function and screen for valvular disease and pulmonary hypertension, and use of noninvasive stress testing in asymptomatic transplant candidates with three or more coronary disease risk factors to target screening on the subgroup with the highest pretest probability of prognostically significant coronary artery disease. Moving forward, we believe that pursuit of more evidence, ideally from randomized clinical trials, is an urgent priority to strengthen the evidence base for pretransplant cardiac evaluation and the management of cardiovascular disease before, during, and after transplant.

Pulmonary hypertension (PH) is prevalent in patients with aortic stenosis (AS); however, previous studies have demonstrated inconsistent results regarding the association of PH with adverse outcomes after aortic valve replacement (AVR). The goal of this study was to evaluate the effects of preoperative PH on outcomes after AVR. We performed a regional prospective cohort study using the Northern New England Cardiovascular Disease Study Group database to identify 1,116 consecutive patients from 2005 to 2010 who underwent AVR ± coronary artery bypass grafting for severe AS with a preoperative assessment of pulmonary pressures by right-sided cardiac catheterization. PH was defined as a mean pulmonary artery pressure of ≥25 mm Hg, with severity based on the pulmonary artery systolic pressure-mild, 35 to 44 mm Hg; moderate, 45 to 59 mm Hg; and severe, ≥60 mm Hg. We found that PH was present in 536 patients (48%). Postoperative acute kidney injury, low-output heart failure, and in-hospital mortality increased with worsening severity of PH. In multivariate logistic regression, severe PH was independently associated with postoperative acute kidney injury (adjusted odds ratio 4.1, 95% confidence interval [CI] 1.7 to 10, p = 0.002) and in-hospital mortality (adjusted odds ratio 6.9, 95% CI 2.5 to 19.1, p0.001). There was a significant association between PH and decreased 5-year survival (adjusted log-rank p value = 0.006), with severe PH being associated with the poorest survival (adjusted hazard ratio 2.4, 95% CI 1.3 to 4.2, p = 0.003). In conclusion, severe PH in patients with severe AS is associated with increased rates of in-hospital adverse events and decreased 5-year survival after AVR.

344 The study by Bhatia et al., ‘‘Comparison of the 2008 and 2011 Appropriate Use Criteria for Stress Echocardiography’’ in the current issue of JASE has identified a gap in the literature that at first seems insignificant but upon further examination has very important clinical and cost implications, particularly for academic centers with solidorgan transplantation programs. Patients being considered for solidorgan transplantation may seem a small niche population until one realizes that kidney transplantation alone in the United States has more than quadrupled since 1991. The most recent data from the US Department of Health and Human Services Organ Procurement and Transplantation Network report 23,360 kidney transplantations from January to October 2012 and 117,053 patients on the waiting list. All of these patients (plus those who are evaluated but not listed) will undergo some type of preoperative evaluation, and many will undergo cardiac testing for ‘‘screening’’ purposes. However, survey and registry data have demonstrated that significant variation exists from institution to institution with regard to the ‘‘standard’’ workup of asymptomatic transplantation candidates, ranging from routine coronary angiography to imaging stress testing to no testing at all. Because waiting times before eventual transplantation can be years, repeat cardiac testing compounds the problem, as some professional societies have suggested routine surveillance of waitlisted patients. Suddenly, the numbers start to add up. The observations made in the study by Bhatia et al. at the Massachusetts General Hospital are probably not that far off from the situation at other large hospitals with dedicated solid-organ transplantation programs. The question is, who needs to change? Are clinical practice patterns out of step with appropriateness criteria? Or are appropriateness criteria a step behind with regard to good clinical practice? In the retrospective chart review by Bhatia et al., the 2008 and 2011 appropriate use criteria were applied to a consecutive series of 252 clinically requested stress echocardiograms at a single large academic hospital (Massachusetts General Hospital; requesting providers consisted of 83 different health care providers, of whom 50% were cardiologists), and the appropriateness classifications were examined. An initial review of the results suggests that the 2008 guideline left too many studies unclassified, and the newer

Chronic kidney disease is now widely accepted as an independent risk factor for coronary disease and the dialysis population may represent the highest risk subgroup. Among all dialysis patients, a cardiac cause of mortality has been estimated at 40%. In addition, prior studies have demonstrated that when cardiac catheterization is obtained in a consecutive series of asymptomatic diabetic patients on dialysis the rates of coronary disease can approach 50%. However, the ability to define the problem continues to be greater than the ability to treat or prevent it. Coronary revascularization strategies have limitations in the general population which are amplified in the dialysis population. The ability to accurately diagnose an acute coronary syndrome is more difficult, clinical outcomes have a smaller margin of benefit, and technical challenges result in higher complication rates. Recent data demonstrate an inverse relationship between glomerular filtration rate and the risk of presenting with an acute myocardial infarction rather than unstable angina suggesting that patients with CKD may have a unique pathophysiologic profile that is more prone to plaque rupture. However, these "vulnerable" plaques typically are associated with stenoses50% prior to rupture and are thus poor targets for revascularization and perhaps best treated with medical therapy. Although the benefits of revascularization may continue to outweigh the risks in the context of acute coronary syndromes, preventive strategies would have to overcome the lower margin of benefit and higher complication rates.

Tissue synchronization imaging (TSI), a parametric imaging technique based on tissue velocity imaging, often demonstrates patterns other than lateral delay in patients evaluated for cardiac resynchronization therapy (CRT). The prevalence of these patterns and their response to CRT has not been well described. We hypothesized that regional patterns of dyssynchrony might correlate with the extent of reverse remodeling.A consecutive series of 32 patients underwent echocardiographic study prior to CRT implant and 3 months postimplant. TSI was used to color-code the time-to-peak positive systolic velocity at six basal and six mid-LV segments. Each patient was assigned to one of four groups based on the predominant location of greatest delay (≥ 2 segments): (1) posterolateral delay, (2) septal delay, (3) no dyssynchrony, or (4) other.Patients were classified as follows: posterolateral delay in 44% of patients (n = 14), septal delay in 28% (n = 9), no dyssynchrony in 16% (n = 5), and other pattern in 13% (n = 4). At 3-month follow-up, the group with the lateral delay pattern was associated with the greatest decrease in left ventricular end-systolic volume (LVESV) and the largest improvement in left ventricular ejection fraction (LVEF) (-45 mL and +9.3%, respectively, P0.05). The LVESV in the other three groups changed as follows: -24 mL (septal), -28 mL (no dyssynchrony), and -15 mL (other). Similar trends were observed for LVEF and left ventricular end-diastolic volume.Despite the presence of wide QRS and a left bundle branch block, the most delayed segment is not always the posterolateral wall. Posterolateral delay is associated with the best response to CRT, while other patterns respond at a lower magnitude.

Two-dimensional strain echocardiography (2DS) has been used to assess ventricular function in several disease states. In previous studies of 2DS, strain analysis was usually performed offline by experienced echocardiographers. The applicability of 2DS in busy clinical labs would be enhanced if 2DS could be reproducibly measured by sonographers at the time of the echo exam. In this study we compared the reproducibility of strain measurements between sonographers at the time of the echo exam with those performed offline by an experienced echocardiographer.Apical left ventricular (LV) B-mode images were acquired in 98 consecutive patients being evaluated for aortic stenosis. 2DS analysis was performed at the time of the exam by a sonographer. The same images were analyzed offline by an experienced echocardiographer. Global longitudinal strain (GLS) results were analyzed for interobserver reproducibility. Additionally, the regional longitudinal strain (RLS) of 20 randomly selected patients was analyzed for intraobserver reproducibility.Acceptable data quality was available in 97.8% of the segments measured at the time of the exam and in 96.9% at the workstation. Interobserver reproducibility of the global peak strain was high (r = 0.855, P0.001). Additionally, applying cutoffs for separating normal from abnormal GLS revealed good agreement between sonographer and experienced echocardiographer [kappa analysis (κ= 0.739, P0.001)]. Overall RLS intraobserver reproducibility was high (raw mean adjusted r = 0.915).The GLS in aortic stenosis patients can be reliably measured at the bedside by a sonographer without additional benefit of offline analysis.

Cardiac perforation with tamponade is an infrequent occurrence during an electrophysiologic procedure. The customary approach to management includes volume resuscitation followed by pericardiocentesis. Such a procedure, however, is not without its own risk, especially when performed emergently. We hypothesized that some patients experiencing this type of complication can be managed successfully in a conservative fashion, without the need for an additional invasive procedure.We retrospectively analyzed the clinical outcomes and echocardiographic features of 33 consecutive patients who experienced this complication during cardiac electrophysiology (EP) procedures performed at our institution from 1988 to 2007. Nineteen patients (58%) were managed conservatively with intravenous fluids and vasopressors (Group A). Fourteen patients (42%) were managed invasively with pericardiocentesis (Group B).The mean systolic blood pressure at diagnosis did not differ between the two groups (64 vs 71 mmHg, P = 0.134). The mean lengths of hospitalization (4.7 vs 4.9 days, P = 0.75) and survival to hospital discharge (100% in both groups) were also similar. A large pericardial effusion (or=2 cm) was seen predominantly among Group B patients. There was a statistically significant temporal trend toward managing this type of complication invasively (P = 0.038).Among patients who experience cardiac perforation as an acute complication of EP procedure, there appears to be a role for conservative management in a subset of patients who do not have echocardiographic evidence of a large effusion and who respond well to initial stabilizing measures consisting of fluids and vasopressors.

The early mitral filling velocity (E)/early diastolic mitral annular velocity (E′) ratio is increasingly being used as a simplified approach to estimate left ventricular (LV) filling pressure. The validity of applying this Doppler parameter to patients with severe mitral regurgitation is unknown. We retrospectively identified 20 patients in sinus rhythm who had LV end-diastolic pressure (LVEDP) invasively measured within 72 hours of a full echocardiogram including diastolic parameters. We observed a poor correlation between E/E′ ratio and LVEDP in these patients ( r = −0.07, P = not significant). Previously described E/E′ cut-off values did not accurately identify patients with low, intermediate, and high LVEDP. Of the diastolic parameters measured, the most significant correlation with LVEDP was found with mitral deceleration time ( r = −0.66, P = .002) and systolic/diastolic peak velocity ratio ( r = −0.52, P = .02). We conclude that E/E′ ratio is not reliable in predicting LV filling pressure in the setting of severe mitral regurgitation, and that in these cases mitral deceleration time or systolic/diastolic peak velocity ratio may be better indicators of LVEDP.

Background The incidence, risks, and outcomes associated with pulmonary hypertension (P-HTN) in the kidney transplant (KTx) population are not well described. Methods We linked U.S. transplant registry data with Medicare claims (2006-2016) to investigate P-HTN diagnoses among Medicare-insured KTx recipients (N=35,512) using billing claims. Cox regression was applied to identify independent correlates and outcomes of P-HTN (adjusted hazard ratio, aHR, 95%LCLaHR95%UCL), and to examine P-HTN diagnoses as time-dependent mortality predictors. Results Overall, 8.2% of recipients had a diagnostic code for P-HTN within 2 years preceding transplant. By 3 years posttransplant, P-HTN was diagnosed in 10.310.6%11.0 of the study cohort. After adjustment, posttransplant P-HTN was more likely in KTx recipients who were older (aHR for age >60 vs. 18-30 years: 1.912.403.01) or female (aHR, 1.151.241.34), who had pretransplant P-HTN (aHR, 4.384.795.24), coronary artery disease (aHR, 1.051.151.27), valvular heart disease (aHR, 1.221.321.43), peripheral vascular disease (aHR, 1.051.181.33), chronic pulmonary disease (aHR, 1.201.311.43), obstructive sleep apnea (aHR, 1.151.281.43), longer dialysis duration, pretransplant hemodialysis (aHR, 1.171.371.59), or who underwent transplant in the more recent era (2012-2016 vs. 2006-2011: aHR, 1.291.391.51). Posttransplant P-HTN was associated with >2.5-fold increased risk of mortality (aHR, 2.572.843.14) and all-cause graft failure (aHR, 2.422.642.88) within 3 years posttransplant. Outcome associations of newly-diagnosed posttransplant P-HTN were similar. Conclusions Posttransplant P-HTN is diagnosed in 1 in 10 KTx recipients and is associated with an increased risk of death and graft failure. Future research is needed to refine diagnostic, classification, and management strategies to improve outcomes in KTx recipients who develop P-HTN.