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Despite advances in cardiovascular imaging, the diagnosis of constrictive pericarditis remains challenging. A multimodality approach to the diagnosis of CP is essential to (a) fully assess the extent of pericardial thickening and calcification, (b) detect the functional and hemodynamic consequences of the constricting pericardium, and (c) implement the optimal management strategy in these often complex cases. This case-based review highlights the role and diagnostic ambiguities of multimodality imaging.

While the classical apical ballooning takotsubo cardiomyopathy (TC) was first reported in the 1990s, the rarer mid-ventricular and basal variants were not formally recognized until recently and they remain poorly understood. In this case report, we describe a 67-year-old woman who, during her hospitalization for a subarachnoid hemorrhage and subsequent readmission, experienced multiple complications, each of which resulted in a different variant of TC. To our knowledge, this is the first report of a single patient developing all three variants of TC.

Quadricuspid pulmonary valve is a rare entity that can be associated with pulmonary artery aneurysm. It is usually asymptomatic and diagnosed incidentally. Association with other congenital or acquired heart diseases has been reported. Echocardiography and gated CT angiography can provide useful functional and anatomic information that can help in the diagnosis and management.

Pericarditis is a rare but debilitating complication of cytarabine therapy. While echocardiography can aid with the diagnosis, cardiac MRI has superior accuracy in establishing the diagnosis. In this case, we describe a 65-year-old patient receiving cytarabine as part of induction chemotherapy for acute myeloid leukemia who developed acute pericarditis. Her cardiac MRI revealed pericardial edema on T2-weighted STIR imaging and pericardial late gadolinium enhancement which confirmed the diagnosis.

BACKGROUND Transcatheter aortic valve replacement (TAVR) can be an effective option for high-risk Aortic Regurgitation (AR) patients. Although international experiences of TAVR for AR are published, U.S. data are limited. This study sought to report the short-term outcomes of TAVR in AR in the U.S. POPULATION METHODS Study cohorts were derived from the Nationwide Inpatient Sample (NIS) and Nationwide Readmissions Database (NRD) 2016-17. TAVR and AR were identified using ICD-10-CM-codes. The key outcomes were all-cause mortality, disabling stroke, valvular complications, complete heart block (CHB)/permanent pacemaker placement (PPM), open-heart surgery, acute kidney injury (AKI) requiring dialysis, and vascular complications. Multivariate logistic regression was used to adjust for confounders. RESULTS 915 patients from the NIS (male-71%, age ≥65-84.2%) and 822 patients from the NRD (male-69.3%, age ≥65-80.5%) underwent TAVR for AR. The median length of stay (LOS) was 4 days for both cohorts. In-hospital mortality was 2.7%, and 30-day mortality was 3.3%. Disabling strokes were noted in 0.6% peri-procedurally and 1.8% at 30-days. Valve-related complications were 18-19% with paravalvular leak (4-7%) being the most common. Approximately 11% of patients developed CHB and/or needed PPM in both cohorts. In NRD, 2.2% of patients required dialysis for AKI, 1.5% developed vascular complications, and 0.6% required open-heart surgery within 30-days post-procedure. Anemia was predictive of increased overall complications and valvular complications, whereas peripheral vascular disease was a predictor of increased valvular complications and CHB/PPM. CONCLUSION TAVR is a promising option in AR. Further studies are necessary for the expansion of TAVR as the standard treatment in AR.

Aortic prosthetic valve endocarditis is often a challenging disease process that carries high morbidity and mortality. Echocardiography is widely used to identify infected valves and associated complications. One major complication of an infection involving the aortic annulus is dehiscence of the prosthetic valve from the aortic root and is usually associated with paravalvular regurgitation. Here, we present a rare case of complete prosthetic valve dehiscence without paravalvular regurgitation on transthoracic and transesophageal echocardiography.

Myocardial contusion and aortic injury are well-known cardiac complications of blunt chest trauma, but valvular injury is rare. Traumatic valve injuries most commonly involve the aortic valve, with isolated mitral valve injury being quite rare. We report a case of acute severe mitral regurgitation due to ruptured chordae tendineae requiring surgical repair following a motor vehicle accident.

Background: Despite the American Society of Echocardiography recommendation to use left atrial volume indexed for body surface area (LAVI) for quantification of left atrial size, a variety of methods are used in clinical practice. Our objectives were to evaluate the accuracy of M-mode and two-dimensional (2D) echocardiographic LA size estimates to LAVI and to determine their ability to predict left ventricular diastolic dysfunction. Methods: In 150 consecutive patients, LA diameter (LAD), LA diameter indexed for body surface area (LADI), LA area in the apical two- and four-chamber views (LAA 2c and LAA 4c), biplane area–length LA volume (LAV), and LAVI were obtained. The accuracy of these methods to quantify LA enlargement by LAVI, correlation with clinical parameters, and ability to act as a surrogate for diastolic dysfunction were determined using Pearson correlation coefficients along with univariate and multiple logistic analysis. Results: The true degree of LA size (with LAVI as standard) was identified by LAD in 45%, LADI in 42%, LAA 4c in 43%, and LAA 2c in 41%. All methods showed positive correlation with age, E/E′, mitral regurgitation, and right atrial size and negative correlation with ejection fraction. LAVI was the strongest method to predict any (c = 0.655, P = 0.012) or moderate–severe (P = 0.856 and P < 0.001) diastolic dysfunction. All methods have greater capacity to identify moderate or severe diastolic dysfunction than any degree of diastolic dysfunction alone. Conclusions: One-dimensional and 2D methods inaccurately quantify LA size and are inferior to LAVI to predict diastolic dysfunction. (Echocardiography 2012;29:379-384)

Objective Pulmonary arterioles respond to hypoxia with constriction that raises vascular resistance and pulmonary artery blood pressure. The response is sustained indefinitely by the chronic hypoxia of high-altitude residence among highlanders of European and Andean descent, but not Tibetans. The objective of this study was to identify the consequences of lifelong hypoxia exposure for the pulmonary vasculature among Amhara high-altitude natives from Ethiopia. Methods A three-way static group comparison tested for the effect of Amhara ancestry and high residence altitude on pulmonary hemodynamics measured using echocardiography in samples of 76 healthy adult Amhara lifelong residents at 3700 m, 54 Amhara lifelong residents at 1200 m, and 46 U.S. low-altitude residents at 282 m. Results Amhara at 3700 m had average Doppler-estimated pulmonary artery systolic pressure (tricuspid regurgitant gradient) of 27.9 ± 8.4 (SD) mm Hg as compared with 21.9 ± 4.0 among Amhara at low altitude and 16.5 ± 3.6 in the U.S. low-altitude reference sample. However, there was no residence altitude effect on pulmonary blood flow or vascular resistance. Amhara ancestry was associated with greater pulmonary artery systolic pressure and pulmonary blood flow, yet lower pulmonary vascular resistance. Conclusions The Amhara at 3700 m had elevated pulmonary artery pressure, but without the elevated pulmonary vascular resistance characteristic of the classic model of the response to long-term hypoxia by the pulmonary vasculature. The elevated pressure among Amhara may be a consequence of high pulmonary blood flow regardless of altitude and represent a newly identified pattern of response. Am. J. Hum. Biol., 2011. © 2010 Wiley-Liss, Inc.

The pericardium is composed of visceral and parietal components. In view of the pericardium's simple structure, pathologic processes involving it are understandably few. However, despite a limited number of clinical syndromes, the pericardium is affected by virtually every category of disease, including infectious, neoplastic, immune-inflammatory, metabolic, iatrogenic, and traumatic. Thus, the recognition of pericardial heart disease remains challenging. Treatment of pericardial disease is also problematic in that there is a paucity of randomized, placebo-controlled trials from which appropriate therapy may be selected and important clinical decisions assisted. This article reviews pericarditis and its sequelae, pericardial effusions, cardiac tamponade and constrictive pericarditis.

Introduction Isoproterenol (ISO)-induced myocardial injury is widely used as an experimental animal model; however, the optimal route of delivery, i.e., subcutaneous (SC) versus intraperitoneal (IP) has not been clarified. We systematically compared changes in cardiac function (echocardiography, Doppler and strain imaging) and exercise capacity induced by ISO via SC versus IP delivery. Methods Twelve rats were used in this study and classified into three groups: Control (n = 2), SC-ISO (n = 5), and IP-ISO (n = 5), each receiving serial injections of ISO (100 mcg/kg) for 5 days (days 1-5). All rats underwent echocardiographic analysis of left ventricular function and functional capacity (FC) assessment on a treadmill protocol at baseline and post treatment. Hearts were excised and weighed at the end of the study. Results Left ventricular (LV) systolic and diastolic dysfunctions were adequately induced by both SC and IP delivery: > or =13% reduction in fractional shortening, > or =12% increase in wall motion score index, and > or =35% increase in myocardial performance index; > or =49% increase in E/A ratio; > or =9% decline in anterior wall tissue velocity; > or =12% decline in circumferential and radial tissue strain and strain rates; > or =20% decline in FC; and > or =40% increase in echocardiographic LV mass and gross heart weight in both groups. Conclusion Short-duration ISO administration with serial injections via SC and IP routes induces significant myocardial dysfunction and impairs FC with few differences between both modalities.

1. Alterations in myocardial energy metabolism accompany pressure overload-induced hypertrophy. We previously described a novel model of catecholamine-induced hypertrophy in which A/J mice exhibit more robust cardiac hypertrophy than B6 mice. Accordingly, we assessed the influence of mouse strain on the activities of key myocardial metabolic enzymes and whether there are strain-related metabolic adaptations to short-term, high-dose isoproterenol (ISO) administration. 2. Thirty-nine male mice (19 A/J mice, 20 B6 mice), aged 12-15 weeks, were randomly assigned to receive either ISO (100 mg/kg, s.c.) or vehicle (sterile water) daily for 5 days. On Day 6, all hearts were excised, weighed, freeze clamped and assayed for pyruvate dehydrogenase (PDH), medium chain acyl-CoA dehydrogenase, carnitine palmitoyl transferase I and citrate synthase activities. Plasma fatty acids (FA) were also measured. 3. The ISO-treated A/J mice demonstrated greater percentage increases in gravimetric heart weight/bodyweight ratio than ISO-treated B6 mice (24 vs 3%, respectively; P < 0.001). All enzyme activities were significantly greater in vehicle-treated B6 mice than in A/J mice, illustrating a greater capacity for aerobic metabolism in B6 mice. Administration of ISO reduced PDHa (active form) activity in B6 mice by 47% (P < 0.001), with no significant change seen in A/J mice. Free FA levels were not significantly different between groups; thus, the differences in PDHa were not due to changes in FA. 4. The basal activity of myocardial metabolic enzymes is greater in B6 mice than in A/J mice and ISO alters myocardial PDH activity in a mouse strain-dependent manner. Compared with A/J mice, B6 mice demonstrate less ISO-induced cardiac hypertrophy, but greater activity of key enzymes regulating FA and carbohydrate oxidation, which may protect against the development of hypertrophy. The metabolic adaptations associated with ISO-induced hypertrophy differ from those reported with pressure overload hypertrophy.

Studies in advanced heart failure show down-regulation of fatty acid oxidation genes, possibly due to decreased expression of the nuclear transcription factors peroxisome proliferator activated receptor alpha (PPARalpha) and retinoid X receptor alpha (RXRalpha). We assessed mRNA and protein expression of PPARalpha and RXRalpha, and for several PPAR/RXR regulated metabolic proteins at 8 and 20 weeks following myocardial infarction induced by coronary artery ligation. Infarction resulted in heart failure, as indicated by reduced LV fractional shortening and increased end diastolic area compared to sham. There was a progressive increase in LV end systolic area, myocardial ceramide content and atrial natriuretic peptide mRNA, and a deterioration in LV fractional area of shortening from 8 to 20 weeks. Protein and mRNA expression of PPARalpha and RXRalpha were not different among groups. The mRNA for PPAR/RXR regulated genes (e.g. medium chain acyl-CoA dehydrogenase (MCAD)) was down-regulated at 8 and 20 weeks post-infarction; however, neither the protein expression nor activity of MCAD was reduced compared to sham. In conclusion, reduced mRNA expression of PPAR/RXR regulated genes is not dependent on reduced PPAR/RXR protein expression.

Background: Approximately 20% of cerebral infarctions are cardioembolic in nature. Transesophageal echocardiography (TEE) is widely regarded as the initial study of choice for evaluating cardiac source of embolism. Although the majority of cerebrovascular accidents occur in elderly patients, the value of TEE in this population is poorly defined. Methods: We compared 491 patients older than 65 years with suspected embolic stroke or transient ischemic attack (TIA) who had undergone TEE evaluation between April 2000 and February 2004 to an age-, sex-, and time-matched control group that consisted of 252 patients. Studies were reviewed for abnormalities associated with thromboembolic disease. Results: The overall incidence of stroke risk factors was significantly higher in the study than in the control group. However, the four patients with left atrial thrombi had a history of atrial fibrillation. Although ascending and aortic arch sessile atheromata were observed more frequently in the study than control group, there were no significant differences in the incidence of either complex or mobile aortic atheromata. The incidence of atrial septal aneurysm was higher in the stroke/TIA group, but not in association with patent foramen ovale. Finally, there were also no differences in the incidence of spontaneous echocontrast, and/or patent foramen ovale between study and control groups. Conclusions: We conclude: (1) There is a higher incidence of abnormalities implicated as sources of thromboembolic disease on TEE in elderly patients with cerebral infarctions, but (2) this incidence is driven by the presence of sessile aortic atheroma and atrial septal aneurysm. Until the benefits of specific therapies for these conditions are known, routine TEE in elderly patients with suspected embolic neurological events appears to be unwarranted.

Although transesophageal echocardiography (TEE) is a well-established tool in delineating the cardiac and aortic sources of emboli in stroke patients, its reproducibility in detecting aortic atherosclerosis (AA) that may lead to stroke is not well documented. The aim of this study is to demonstrate the inter- and intra-observer agreement in diagnosing AA based on the TEE study. During the study period, 2 echocardiographers read 32 TEE studies performed on a group of stroke patients. The AA was estimated by measuring the largest atheroma thickness in millimeters (mm). The intra-observers and intraclass correlation coefficients (ICC) were 0.97 and 0.85, respectively, for the 2 TEE observers. The inter-rater ICC coefficient between TEE readers was 0.91. In conclusion, TEE detected AA and defined high proportions of the morphological characteristics of atheroma with good reproducibility among inter and intra-observers.

An 84-year-old woman with a history of severe systolic heart failure, a mechanical mitral valve, and atrial fibrillation presented to the hospital with syncope and is found to have a free-floating intracardiac mass on transthoracic echocardiogram that was absent 5 months earlier. Real time three-dimensional (3D) transesophageal echocardiography (TEE) images reveal a billiard-ball-looking mass thought to be a large left atrial thrombus causing syncope by transiently obstructing the mitral valve orifice. Real time 3D TEE offers several potential advantages for the evaluation of intracardiac masses.

OBJECTIVE M-mode echocardiography has been used extensively for estimating left ventricular (LV) mass in mice, but accuracy is limited by its unidimensional nature. This study tested whether two-dimensional (2-D) echocardiographic measurement of LV mass using area-length and truncated ellipsoid methods overcomes this limitation. METHODS Twenty-five anesthetized FVB/N mice (Mus musculus) underwent high resolution (15 MHZ) two-dimensionally directed M-mode and 2-D echocardiography. End-diastolic epicardial and endocardial areas from short-axis views and the LV orthogonal long-axis views were measured, while LV mass was calculated by 2-D area-length and truncated ellipsoid methods. LV mass was calculated from M-mode using the uncorrected cube equation. Hearts were removed and weighed after completing the echocardiographic studies. The correlation and agreement between echocardiographic-determined LV mass and gravimetric LV weight were examined. RESULTS LV mass using the area-length method correlated better with autopsy LV weight (r = 0.87, slope = 0.87, standard error of the estimate [SEE] = 12.4 mg, P < 0.001) than M-mode echocardiography (r = 0.85, slope = 0.71, SEE = 11.1 mg, P < 0.001), and the degree of agreement (bias +/- 2 SD) was better (10.2 +/- 25.1 mg vs 13.1 +/- 25.8 mg, P = NS). Although 2-D truncated ellipsoid LV mass showed a good correlation with necropsy LV weight (r = 0.87, slope = 0.78, SEE = 11.0 mg, P < 0.001), the agreement between the truncated ellipsoid estimates and LV weight was less than that between M-mode and gravimetric LV mass. CONCLUSIONS The 2-D area-length method is an accurate method of LV mass determination in symmetrical ventricles and can be used as an alternative for in vivo measurement of LV mass in mice.

A 76-year-old male was admitted with increasing fatigue and shortness of breath. Transesophageal echocardiogram revealed moderate-to-severe mitral regurgitation and an oscillating mass on the pulmonic valve that was confirmed by magnetic resonance imaging. The patient underwent repair of the mitral valve and excision of the pulmonic valve mass, which was confirmed as a papillary fibroelastoma by histology.

Pulsus paradoxus is an exaggerated fall in systolic blood pressure with inspiration (usually greater than 10 mm). Understanding the accuracy of pulsus paradoxus for a diagnosis of cardiac tamponade requires a consideration of the mechanisms underlying its genesis, and a knowledge of its presence in other conditions and its variable absence in cardiac tamponade with associated disease states. Echocardiography (M-mode, 2-D, and Doppler) has aided considerably our understanding of pulsus paradoxus. Inspiratory increases in right heart filling and output are widely accepted as necessary for pulsus paradoxus to occur; inspiration causes increases in right ventricular dimensions and pulmonic and tricuspid velocities, and decreases in left ventricular (LV) dimensions and aortic and mitral velocities and LV diastolic compliance. Doppler studies of pulmonary venous inflow confirm that an inspiratory fall in left atrial filling is necessary for pulsus paradoxus. Pulsus paradoxus is complex and multifactorial in origin; it may be absent in cardiac tamponade when certain conditions (e.g., LV dysfunction) coexist and may accompany disease states other than cardiac tamponade (e.g., obstructive airway disease). Thus, the significance of pulsus paradoxus (and its Doppler echo correlates) must be considered in the clinical context.

We report a case of pacemaker syndrome where the diagnosis of retrograde ventriculoatrial conduction was made by Doppler analysis of left atrial appendage flow. Doppler analysis of left atrial appendage flow provides another noninvasive parameter to diagnose retrograde ventriculoatrial conduction.