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Apical left ventricular (LV) aneurysms in hypertrophic cardiomyopathy (HCM) are associated with adverse outcomes. The reported frequency of mid-LV obstruction has varied from 36% to 90%. The authors sought to ascertain the frequency of mid-LV obstruction in HCM apical aneurysms. The authors analyzed echocardiographic and cardiac magnetic resonance examinations of patients with aneurysms from 3 dedicated programs and compared them with 63 normal controls and 47 controls with apical-mid HCM who did not have aneurysms (22 with increased LV systolic velocities). There were 108 patients with a mean age of 57.4 ± 13.5 years; 40 (37%) were women. A total of 103 aneurysm patients (95%) had mid-LV obstruction with mid-LV complete systolic emptying. Of the patients with obstruction, 84% had a midsystolic Doppler signal void, a marker of complete flow cessation, but only 19% had Doppler systolic gradients ≥30 mm Hg. Five patients (5%) had relative hypokinesia in mid-LV without obstruction. Aneurysm size is not bimodal but appears distributed by power law, with large aneurysms decidedly less common. Comparing mid-LV obstruction aneurysm patients with all control groups, the short-axis (SAX) systolic areas were smaller (P < 0.007), the percent SAX area change was greater (P < 0.005), the papillary muscle (PM) areas were larger (P < 0.003), and the diastolic PM areas/SAX diastolic areas were greater (P < 0.005). Patients with aneurysms had 22% greater SAX PM areas compared with those with elevated LV velocities but no aneurysms (median: 3.00 cm2 [IQR: 2.38-3.70 cm2] vs 2.45 [IQR: 1.81-2.95 cm2]; P = 0.004). Complete emptying occurs circumferentially around central PMs that contribute to obstruction. Late gadolinium enhancement was always brightest and the most transmural apical of, or at the level of, complete emptying. The great majority (95%) of patients in the continuum of apical aneurysms have associated mid-LV obstruction. Further research to investigate obstruction as a contributing cause to apical aneurysms is warranted. [Display omitted] [ABSTRACT FROM AUTHOR]

The aim of this study was to clarify the dynamics of the mitral annulus throughout the cardiac cycle and its relevance to transcatheter mitral valve replacement (TMVR) sizing and case selection. Limited data are available regarding the relevance of mitral annular (MA) and neo–left ventricular outflow tract (LVOT) dynamics in the overall population presenting with significant mitral valve disease. Patients attending a combined surgical-transcatheter heart valve clinic for severe symptomatic mitral valve disease were assessed using multiphase computed tomography. The relative influence of MA and neo-LVOT dynamics to TMVR case selection was studied. A total of 476 patients with significant mitral valve disease were evaluated. In 99 consecutive patients with severe mitral regurgitation, a 10-phase assessment showed that the mitral annulus was on average largest in late systole. On comparing maximal MA dimension with late systolic dimension, TMVR size assignment changed in 24.2% of patients. If the average MA perimeter was used to determine sizing, 48.5% were excluded because of MA dimension being too large; in a multiphase assessment of the neo-LVOT, an additional 16.2% were excluded on the basis of neo-LVOT dimension. In an expanded series of 312 consecutive patients, selection protocol influenced anatomical exclusion: a manufacturer-proposed early systolic approach excluded 69.2% of patients, whereas a late systolic approach excluded 82.7% of patients, the vast majority because of large mitral annuli. Contemporary TMVR can treat only a minority of patients with severe mitral regurgitation, principally because of limitations of large MA dimension. [Display omitted] [ABSTRACT FROM AUTHOR]

This review comprises 2 main subjects: the percutaneous and surgical closure of the left atrial appendage (LAA) and atrial septal defect (ASD). The aim of the authors was to provide a detailed description of: 1) anatomy of LAA, normal interatrial septum, and the various types of ASD as revealed by noninvasive imaging techniques; 2) preprocedure planning of secundum ASD and LAA percutaneous closure; 3) key steps of the procedural guidance emphasizing the role of 2-dimensional/3-dimensional transesophageal echocardiography; and 4) surgical closure of LAA and ASD. • Imaging is of fundamental relevance for LAA and ASD percutaneous and surgical closure. • Key elements for LAA closure include anatomic characterization, ruling out thrombus, measurements of orifice, and depth. • Key elements for ASD closure include assessment of type, size, rims, and hemodynamic consequences. [ABSTRACT FROM AUTHOR]

The 2019 American College of Cardiology Scientific Sessions displayed innovation in many areas for the evaluation and management of cardiovascular disease from preventive evaluation and care to advanced interventions. Imaging played a central role in these developments with a highlight of the conference being the imaging research presented. This review will summarize key imaging studies which were presented at this scientific meeting which will lead to innovation in the evaluation and management of cardiovascular disease. Experts in nuclear imaging (DW/MA), echocardiography (MS), cardiac magnetic resonance (SL), and cardiac computed tomography (RB) selected abstracts which they found to be of particular interest to the multimodality imaging audience and were integrated into this review (LP). [ABSTRACT FROM AUTHOR]

This study sought to minimize the risk of permanent pacemaker implantation (PPMI) with contemporary repositionable self-expanding transcatheter aortic valve replacement (TAVR). Self-expanding TAVR traditionally carries a high risk of PPMI. Limited data exist on the use of the repositionable devices to minimize this risk. At NYU Langone Health, 248 consecutive patients with severe aortic stenosis underwent TAVR under conscious sedation with repositionable self-expanding TAVR with a standard approach to device implantation. A detailed analysis of multiple factors contributing to PPMI was performed; this was used to generate an anatomically guided MInimizing Depth According to the membranous Septum (MIDAS) approach to device implantation, aiming for pre-release depth in relation to the noncoronary cusp of less than the length of the membranous septum (MS). Right bundle branch block, MS length, largest device size (Evolut 34 XL; Medtronic, Minneapolis, Minnesota), and implant depth > MS length predicted PPMI. On multivariate analysis, only implant depth > MS length (odds ratio: 8.04; 95% confidence interval: 2.58 to 25.04; p < 0.001) and Evolut 34 XL (odds ratio: 4.96; 95% confidence interval: 1.68 to 14.63; p = 0.004) were independent predictors of PPMI. The MIDAS approach was applied prospectively to a consecutive series of 100 patients, with operators aiming to position the device at a depth of < MS length whenever possible; this reduced the new PPMI rate from 9.7% (24 of 248) in the standard cohort to 3.0% (p = 0.035), and the rate of new left bundle branch block from 25.8% to 9% (p < 0.001). Using a patient-specific MIDAS approach to device implantation, repositionable self-expanding TAVR achieved very low and predictable rates of PPMI which are significantly lower than previously reported with self-expanding TAVR. [ABSTRACT FROM AUTHOR]

Mitral regurgitation (MR) is one of the most commonly encountered valvular lesions in clinical practice. MR can be either primary (degenerative) or secondary (functional) depending on the etiology of MR and the pathology of the mitral valve (MV). Echocardiography is the primary diagnostic tool for MR and is key in determining this etiology as well as MR severity. While clinicians usually turn to 2 Dimensional echocardiography as first-line imaging, 3 Dimensional echocardiography (3DE) has continually shown to be superior in terms of describing MV anatomy and pathology. This review article elaborates on 3DE techniques, modalities, and advances in software. Furthermore, the article demonstrates how 3DE has reformed MR evaluation and has played a vital role in determining patient management. [ABSTRACT FROM AUTHOR]

Background We have developed a novel and practical cardiovascular magnetic resonance (CMR) technique to evaluate left ventricular (LV) mitral annular motion by tracking the atrioventricular junction (AVJ). To test AVJ motion analysis as a metric for LV function, we compared AVJ motion variables between patients with hypertrophic cardiomyopathy (HCM), a group with recognized systolic and diastolic dysfunction, and healthy volunteers. Methods We retrospectively evaluated 24 HCM patients with normal ejection fractions (EF) and 14 healthy volunteers. Using the 4-chamber view cine images, we tracked the longitudinal motion of the lateral and septal AVJ at 25 time points during the cardiac cycle. Based on AVJ displacement versus time, we calculated maximum AVJ displacement (MD) and velocity in early diastole (MVED), velocity in diastasis (VDS) and the composite index VDS/MVED. Results Patients with HCM showed significantly slower median lateral and septal AVJ recoil velocities during early diastole, but faster velocities in diastasis. We observed a 16-fold difference in VDS/MVED at the lateral AVJ [median 0.141, interquartile range (IQR) 0.073, 0.166 versus 0.009 IQR -0.006, 0.037, P < 0.001]. Patients with HCM also demonstrated significantly less mitral annular excursion at both the septal and lateral AVJ. Performed offline, AVJ motion analysis took approximately 10 minutes per subject. Conclusions Atrioventricular junction motion analysis provides a practical and novel CMR method to assess mitral annular motion. In this proof of concept study we found highly statistically significant differences in mitral annular excursion and recoil between HCM patients and healthy volunteers. [ABSTRACT FROM AUTHOR]

We present a case of a 46-year-old man with advanced acquired immunodeficiency syndrome and congenitally bicuspid aortic valve endocarditis caused by methicillin- and gentamicin-resistant Staphylococcus aureus. Endocarditis led to root abscess formation, a complete heart block, and fistulous tract formation between the ascending aorta and the right ventricle. Although perivalvular abscess is not an unusual complication of native valve endocarditis, a fatal fistulous communication between the ascending aorta and the right ventricle is exceedingly rare. [Copyright &y& Elsevier]

An abstract of the article "Diagnostic performance of CMR and transthoracic echocardiography in clinical evaluation of cardiac masses with histopathological correlation," by Rima D. Patel and colleagues is presented.

An abstract of the article "Cardiac MRI correlates of diastolic left ventricular function assessment by echocardiography," by Shahryar G. Saba and colleagues is presented.

Abstract: Anteriorly displaced right coronary artery (RCA) and anomalous origin RCAs occur in ≈1% and 0.1% of adult patients, respectively, and are the leading cause of incomplete coronary angiography and prolonged procedure times. We present a case in which anteriorly displaced RCA occlusion resulted in an acute inferior–posterior–right ventricular myocardial infarction complicated by complete atrioventricular block and hypotension. Failure to image the RCA resulted in considerable delay in reperfusion time with fibrinolysis. The authors discuss the most frequent anatomic locations of ectopic RCAs and suggest an algorithm to be employed when an ectopic RCA cannot be imaged with conventional diagnostic catheters. Contrary to popular belief, the search for an ectopic RCA has <90° boundaries limited to the anterior third of the right sinus and anterior half of the left sinus. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To assess the effects of shortened door-to-intervention (DTI) time on appropriate clinical decisions regarding the four most critical and costly decisions during primary percutaneous coronary intervention (PCI): cath-lab activation (CLA), use of glycoprotein IIb/IIIa inhibitors (GPI), use of PCI, and deployment of drug-eluting stent (DES). Background: STEMI PCI patients are frequently subject to decision making based on abbreviated medical encounter and limited medical information. Methods: Clinical data were prospectively collected in a STEMI registry over 19 months. Retrospective chart reviews were conducted to determine the level of appropriateness of the above-mentioned decisions. Results: Between June 2006 and December 2007, 200 EKGs with suspected STEMI were transmitted; 88 (44%) resulted in CLA. Compared to prior year, DTI times decreased from 145.7 to 69.9 min (P=.00001). DTI was longer during nights and weekends (87.5 vs. 51.8 min, P=.001) and the initial 6 months of the registry (86.8 vs. 66.8 min, P=.07). Nineteen (21.6%) of the patients undergoing angiography did not require revascularization, 56 (63.6%) received GPIs, and 65 patients (73.8%) underwent at least one vessel PCI, and at least one DES was used in 39 patients (60% of PCI cohort). When assessed for appropriateness, CLA was appropriate in 81.8% of the time and rendered borderline or inappropriate in 5.7% and 12.5%, respectively. GPI use was appropriate in 66% of the patients but seemed borderline or inappropriate in 28.5% and 5.4%, respectively. PCI was appropriate in 90% of the lesions treated, and borderline or inappropriate in 7.1% and 2.9%, respectively. DES use was viewed appropriate in 38.4%, and borderline or inappropriate in 51% and 10.2% of the DES deployments, respectively. Conclusions: (1) In view of expedited care, certain information required for decision-making process is either not available or ignored during primary PCI. (2) Appropriate use of resources in primary PCI needs to be better defined. (3) Measures of extracting patients'' previous medical records and imaging studies along with in-lab immediate blood work and echocardiography and establishing new “time-out” protocols for STEMI patients may improve resource utilization and patient care and outcome. [Copyright &y& Elsevier]