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Objectives The purpose of this study was to determine whether the mitral valve (MV) total leaflet area (TLA)-to-mitral annular area (MAA) (TLA/MAA) ratio measured using 3-dimensional (3D) transesophageal echocardiography (TEE) was associated with residual mitral regurgitation (MR) after MitraClip implantation in patients with secondary MR. Background The factors influencing the results of MitraClip implantation for secondary MR are controversial. This study hypothesized that insufficient remodeling of the mitral leaflets relative to the annular dilation may be associated with significant MR after MitraClip implantation. Methods This study included patients with secondary MR treated with MitraClips. Using 3D TEE dataset, the TLA in diastole and MAA in systole were measured with dedicated software. Results In a total cohort of 119 patients (mean age 74 ± 9 years; 61% male), significant residual MR (≥2+) was present in 43 patients (36%). In patients with significant residual MR, MAA was greater than in patients without residual MR (10.7 ± 2.4 cm2 vs. 9.0 ± 2.1 cm2; p Conclusions In patients with secondary MR, insufficient mitral leaflet remodeling relative to the annulus dilation, as reflected by a lower TLA/MAA ratio, is associated with significant residual MR after MitraClip implantation.

The present study aimed to examine differences in left- and right atrial characteristics between atrial fibrillation (AF) patients with and without chronic obstructive pulmonary disease (COPD). For this, 420 patients (mean age 68 +/- 10 years, 73% female) with first diagnosis of AF and baseline echocardiography were included. Of these, 143 COPD patients were compared with 277 patients without COPD matched by age, gender and body surface area. Additionally 38 healthy controls without cardiovascular risk factors, matched for age, were included. For all 3 groups, left atrial (LA) volumes and diameter, LA reservoir strain (LASr), left ventricular ejection fraction (LVEF), right atrial (RA) area and diameter, RA reservoir strain (RASr) and tricuspid annular plane systolic excursion were evaluated on transthoracic echocardiography. Baseline characteristics were similar in patients with and without COPD except for smoking and a history of heart failure (42% vs 11%, p < 0.001 and 48% vs 37%, p = 0.036 for COPD and non-COPD patients, respectively). Also, COPD patients less often used beta-blockers (63% vs 75%, p = 0.017). There were no significant differences in LVEF, LA volume and RA area between COPD and non-COPD patients. Compared to the controls, AF patients had impaired LVEF, LASr and RASr. Only RASr was significantly worse in COPD patients as compared to non-COPD patients (15.3% [9.0 to 25.1] vs 19.6% [11.8 to 28.5], p = 0.013). Additionally, a trend towards worse RASr was observed with increasing COPD severity. In conclusion, AF patients with concomitant COPD have more impaired RA function compared to patients without COPD but with similar atrial size and LA function. (C) 2020 The Author(s). Published by Elsevier Inc.

In the recent worldwide coronavirus 2019 pandemic, a notable rise in pneumomediastinum and pneumothorax complications has been witnessed in numerous mechanically ventilated patients infected with severe acute respiratory syndrome coronavirus 2. Most cases have reported these complications as barotrauma from mechanical ventilation with COVID-19 disease. We aim to report three polymerase chain reaction-confirmed COVID-19 patients who developed pneumomediastinum and pneumothorax unrelated to mechanical ventilation. We originally analyzed 800 patients with COVID-19 disease at Orlando Regional Medical Center from March 1, 2020, to July 31, 2020, of which 12 patients developed pneumomediastinum and pneumothorax in their hospital course. Interestingly, three patients developed pneumomediastinum on chest imaging prior to intubation. We present these three patients, one female and two males, ages of 42, 64, and 65, respectively, who were diagnosed with COVID-19 disease through nasopharyngeal sampling tests with acute respiratory distress syndrome. Spontaneous pneumomediastinum and pneumothorax are potential complications of COVID-19 disease in the lungs unrelated to mechanical ventilation. This is similar to previous outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) diseases. Further investigation is needed to define the causality of pneumomediastinum in nonintubated COVID-19 patients to define the incidence of disease.

Purpose of review This article reviews the role of multimodality imaging in the in evaluation of patients with mitral regurgitation referred for transcatheter interventions. Recent findings Transcatheter therapies for mitral regurgitation in patients with high surgical risk or contraindications for surgery are evolving rapidly. Three-dimensional imaging techniques (transesophageal echocardiography, computed tomography, and cardiovascular magnetic resonance) are key to determine the anatomical suitability for each transcatheter therapy, to accurately quantify mitral regurgitation, and to plan and guide the procedure. Fusion imaging is being implemented in catheterization laboratories to precisely guide the procedure and to maximize safety and optimal results. Transcatheter edge-to-edge mitral valve repair with the MitraClip device (Abbott Vascular, Santa Clara, CA) provides the largest evidence on the safety and efficacy of this minimally invasive therapy and the importance of accurate patient selection to improve outcomes has been recently shown in two randomized trials. Summary Multimodality imaging is key in the work-up of patient with mitral regurgitation undergoing transcatheter therapies. Preprocedural imaging with three-dimensional echocardiography, computed tomography, and cardiac magnetic resonance is important to evaluate the eligibility of patients for transcatheter interventions, whilst three-dimensional transesophageal echocardiography provides soft-tissue information that can be overlaid onto fluoroscopy allowing more accurate guidance of transcatheter interventions.

Aims Cardiac resynchronization therapy (CRT) restores mechanical efficiency to the failing left ventricular (LV) by resynchronization of contraction. Global, LV myocardial work efficiency (GLVMWE) can be quantified non-invasively with echocardiography. The prognostic implication of GLVMWE remains unexplored, and we therefore related GLVMWE before CRT to long-term prognosis. Methods and results Data were analysed from an ongoing registry of patients with Class I indications for CRT. GLVMWE was defined as the ratio of constructive work in all LV segments, divided by the sum of constructive and wasted work in all LV segments, as a percentage. It was derived from speckle tracking strain echocardiography and non-invasive blood pressure measurements, taken pre-CRT. Patients were dichotomized according to baseline, median GLVMWE [75%; interquartile range (IQR) 66–81%]. A total of 153 patients (66 ± 10 years, 72% male, 48% ischaemic heart disease) were analysed. After a median follow-up of 57 months (IQR 28–76 months), 31% of patients died. CRT recipients with less efficient baseline energetics (GLVMWE Conclusion GLVMWE can be derived non-invasively from speckle tracking strain echocardiography and non-invasive blood pressure recordings. A lower GLVMWE before CRT is independently associated with improved long-term outcome.

The aim of this study is to evaluate the agreement between three-dimensional (3D) transesophageal echocardiography (TEE) and multidetector computed tomography (MDCT) for assessing mitral annular (MA) dimensions. A total of 105 patients (79 ± 9 years old, 52% male) who underwent clinically indicated 3D TEE and MDCT feasible for MA geometrical assessment were included. Using dedicated semi-automated postprocessing software, MA geometry, including mitral annular area (MAA), perimeter, septal-lateral (SL) diameter, and inter-trigonal (TT) diameter, was evaluated using 3D TEE and MDCT. Compared to 3D TEE, MAA, perimeter, and SL distance measured on MDCT data were larger (9.9 ± 3.0 vs. 9.3 ± 3.1 cm2 for MAA, 115 ± 18 vs. 108 ± 18 mm for perimeter, and 35 ± 5 vs. 32 ± 5 cm for SL distance, all p &lt, 0.001). By contrast, the TT distance was comparable between MDCT and 3D TEE (26 ± 4 vs. 26 ± 4 cm, p = 0.258). The correlations of all the MA dimensions were good to excellent between the two modalities (R = 0.911 for MAA, 0.890 for perimeter, 0.739 for TT distance, and 0.857 for SL distance, respectively, all p &lt, 0.001). This study showed good agreement between 3D TEE- and MDCT-derived MA measurements although MDCT systematically provided larger MAA, perimeter, and SL distance compared with 3D TEE.

The development of transcatheter mitral valve replacement therapies requires accurate post-processing analysis tools to provide D-shaped mitral annulus dimensions from 3-dimensional (3D) data. The agreement between two semi-automated, software packages to process 3D transesophageal echocardiography (TEE) data for the measurement of the mitral valve annulus dimensions was evaluated. 3DTEE data of patients with moderate&ndash, severe mitral regurgitation (MR) were postprocessed with semi-automated, vendor-independent (VI) software and vendor-specific (VS) software. Both post-processing software provided key measurements for the selection of transcatheter valve prosthesis size: annulus area, annulus circumference and the septal-to-lateral distance of the annulus. The intertrigonal distance was provided only by the VS software. The inter- and intra-observer agreements were assessed with Bland&ndash, Altman analysis. Of 105 patients (63.8 &plusmn, 11 years, 66% male) with MR, 28 had secondary MR, 45 fibroelastic deficiency, and 32 Barlow&rsquo, s disease. Using VS software, the dimensions for the overall population were 16.1 &plusmn, 4.6 cm2 for annulus area, for circumference 14.4 &plusmn, 1.9 cm, intertrigonal distance 3.4 &plusmn, 0.5 cm and septal-to-lateral distance 3.8 &plusmn, 0.6 cm. Similar dimensions were obtained using VI software: 15.7 &plusmn, 4.6 cm2 for annulus area, 14.5 &plusmn, 2.0 cm for circumference, and 4.1 &plusmn, 0.6 cm for septal-to-lateral distance. The inter- and intra-observer agreement for both software programs was excellent. In conclusion, current post-processing software programs for 3DTEE data of the mitral valve annulus provide good reproducibility of key measurements to select the transcatheter prosthesis size.

Remdesivir is a direct-acting nucleoside RNA polymerase inhibitor with activity against the novel severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) virus used in the treatment of coronavirus disease 2019 (COVID-19) pneumonia. Here, we present two cases of suspected remdesivir-associated acute liver failure (ALF) in which the liver failure improved after continuous infusion acetylcysteine and withdrawal of remdesivir. Both patients had significant increases in transaminases between day 3 and day 10 of remdesivir therapy accompanied by coagulopathy and encephalopathy. After initiation of continuous infusion acetylcysteine, the transaminases of both patients rapidly improved. Ultimately, one patient fully recovered while the other died of suspected septic shock. Due to its novel nature and only recent widespread use, there are very little data on the risk of ALF from remdesivir. Additionally, the data for the use of acetylcysteine to manage non-acetaminophen-induced ALF are limited. It is important to consider the risk of remdesivir-associated ALF when weighing the risk versus benefits of use, and acetylcysteine may have a role in its management.

Catastrophic thrombotic syndrome, otherwise known as thrombotic storm (TS) is an extreme prothrombotic clinical syndrome that presents as rapid onset of multiple thromboembolic events affecting a large variety of vasculature. In recent studies, there has been a correlation of high plasma levels of factor VIII with thrombotic events. We present the case of a young man who exhibited multi-organ failure due to thrombotic storm. A 38-year-old male presented to the emergency department for progressive dyspnea and was diagnosed to have pulmonary embolism. The patient developed respiratory distress requiring intubation and was diagnosed with both an ST-elevation myocardial infarction and right cerebral infarction during the hospital course. The patient expired and autopsy revealed the cause of death to be myocardial, cerebral and renal infarction from widespread vascular thrombosis. Autopsy revealed cause of death to be elevated factor VIII associated thrombotic coagulopathy. Factor VIII level upon autopsy was 375% (55-200%). Although TS is rare, it can be lifethreatening if not recognized early. Survival depends on the prompt initiation and duration of anticoagulation.

Cardiac resynchronization therapy (CRT) is a well-established heart failure (HF) treatment and exerts its effects through restoration of synchronous ventricular contraction. Myocardial work (MW) is a novel semiautomatic echocardiographic method which characterizes the efficacy of the left

Valvular atrial fibrillation (AF) is defined as AF in the presence of mitral stenosis or mechanical valve prosthesis. However, there are patients with AF who have significant native valvular heart disease (VHD) others than mitral stenosis that are classified as nonvalvular AF. The characteristics and prognostic implications of these entities have not been extensively studied. Of 1,885 AF patients referred for electrical cardioversion (64 +/- 13years, 71% male), 171 (9.1%) had valvular AF (any grade of mitral stenosis or mechanical/biological valve prostheses) and 1,714 patients were identified as nonvalvular AF, of whom 329 (17.5%) had significant left-sided VHD. Patients with nonvalvular AF but with significant left-sided VHD were older, more frequently women and had more co-morbidities compared with the other groups. Furthermore, nonvalvular AF patients with significant left-sided VHD showed the worst left ventricular systolic function and largest left atrial volumes. During a median follow-up of 64 months (interquartile range: 33 to 96 months), 488 patients presented with the combined endpoint of all-cause mortality, heart failure hospitalization, and ischemic stroke. Patients with nonvalvular AF and with significant left-sided VHD had more events of heart failure whereas patients with valvular AF had higher all-cause mortality events. There were no differences in ischemic stroke events. Type of AF was not associated with outcomes after correcting for echocardiographic variables. In conclusion, the frequency of AF patients with significant VHD is relatively high. The consequences of VHD and AF on cardiac structure and function are more important determinants of adverse outcome than the type of AF. (C) 2020 Elsevier Inc. All rights reserved.

Fat embolism syndrome (FES) typically occurs following orthopedic trauma and may present with altered mental status and even coma. Nonconvulsive status epilepticus is an electroclinical state associated with an altered level of consciousness but lacking convulsive motor activity and has been reported in fat embolism. The diagnosis is clinical and is treated with supportive care, antiepileptic therapy, and sedation. A 56-year-old male presented with altered mental status following internal fixation for an acute right femur fracture due to a motor vehicle accident 24 hours earlier. Continued neuromonitoring revealed nonconvulsive status epilepticus. Magnetic resonance imaging of the brain showed multiple bilateral acute cerebral infarcts with a specific pattern favoring the diagnosis of fat embolism syndrome. He was found to have a significant right to left intracardiac shunt on a transesophageal echocardiogram. He improved substantially over time with supportive therapy, was successfully extubated on day 6, and discharged to inpatient rehabilitation on postoperative day 15. Fat embolisms can result in a wide range of neurologic manifestations. Nonrefractory nonconvulsive status epilepticus that responds to antiepileptic drugs, sedation, and supportive therapy can have a favorable outcome. A high index of suspicion and early recognition reduces the chances of unnecessary interventions and may improve survival.

Headache is a common source of pain in children after traumatic brain injury (TBI); however, relatively little is known about nonheadache pain in this pediatric population. The present review seeks to map the extant literature to determine the prevalence, characteristics, and impact of nonheadache pain in children post-TBI of all severities. We found that of 109 studies published on pain in children after a TBI, 95 (87%) were focused exclusively on headache pain and only 14 (13%) reported on nonheadache pain or overall pain, with half (n = 7) in the form of case studies. Overall, the level of evidence was low, with only three level 1 high-quality prospective studies. In one study, over half (57.1%) of adolescents who experienced persistent pain post-TBI reported pain in multiple body sites (e.g., back, lower limb, and neck).(1) For each additional noncephalic pain site, the risk for developing chronic migraine is also increased. Nevertheless, pain in body regions other than the head is often not assessed systematically in pediatric TBI research. Findings of the current review suggest that pain assessment in children post-TBI needs improvement, given that pain is linked to worse recovery, poorer quality of life, and can be long-lasting. More rigorous examination of nonheadache pain and its role in impeding recovery in children post-TBI is imperative and has the potential to improve the care and management of children with TBI. We conclude with recommendations for pain assessment, discuss gaps in the literature, and highlight directions for future research.

Preterm birth is associated with proinflammatory conditions and alterations in adult cardiac shape and function. Neonatal exposure to high oxygen, a rat model of prematurity-related conditions, leads to cardiac remodeling, fibrosis, and dysfunction. TLR (Toll-like receptor) 4 signaling is a critical link between oxidative stress, inflammation, and the pathogenesis of cardiovascular diseases. The current study sought to investigate the role of TLR4 signaling in neonatal oxygen-induced cardiomyopathy. Male Sprague-Dawley pups were kept in 80% oxygen or room air from day 3 to 10 of life and treated with TLR4 antagonist lipopolysaccharide from the photosynthetic bacterium Rhodobacter sphaeroides (LPS-RS) or saline. Echocardiography was performed at 4, 7, and 12 weeks. At 12 weeks, intraarterial blood pressure was measured before euthanization for histological and biochemical analyses. At day 10, cardiac TLR4, Il (interleukin) 18, and Il1β expression were increased in oxygen-exposed compared with room air controls. At 4 weeks, compared with room air-saline, saline-, but not LPS-RS treated-, oxygen-exposed animals, exhibited increased left ventricle mass index, reduced ejection fraction, and cardiac output index. Findings were similar at 7 and 12 weeks. LPS-RS did not influence echocardiography in 12 weeks room air animals. Systolic blood pressure was higher in saline- but not LPS-RS treated-oxygen-exposed animals compared with room air-saline and -LPS-RS controls. LPS-RS prevented cardiac fibrosis and cardiomyocytes hypertrophy, the increased TLR4, Myd88, and Il18 gene expression, TRIF expression, and CD68+ macrophages infiltration associated with neonatal oxygen exposure, without impact in room air rats. This study indicates that neonatal exposure to high oxygen programs TLR4 activation, which contributes to cardiac remodeling and dysfunction.

Functional mitral regurgitation (FMR) and atrial fibrillation (AF) are frequent heart failure (HF) complications. Cardiac resynchronization therapy (CRT) can improve FMR; however, little is known about the influence of AF on FMR improvement.The purpose of this study was to investigate the mechanisms and impact of baseline AF on FMR improvement after CRT.CRT recipients with HF, AF, or sinus rhythm (SR) at baseline with moderate or severe FMR, were included from an ongoing registry. Left atrial (LA), mitral annular (MA), and left ventricular (LV) dimensions were evaluated echocardiographically. FMR improvement was defined as ≥1 grade decrease from baseline to 6-month follow-up. Clinical and echocardiographic measurements were performed at baseline and 6-month follow-up.A total of 419 patients (age 66 ± 8 years; 73% male) were analyzed. At 6-month follow-up, FMR improved in 145 patients (45.6%) with SR vs 31 of AF patients (30.7%) (P = .011). Despite similar LV reverse remodeling at 6 months after CRT (LV end-systolic volume decreased by 32.1 ± 43.2 mL in the SR group and by 27.7 ± 6.3 mL in those with AF; P = .353), patients with SR exhibited smaller LA volumes (63.0 ± 26.5 mL vs 103.1 ± 41.0 mL; P.001) and MA diameters (42.3 ± 5.6 mm vs 46.1 ± 5.8 mm; P.001) compared to AF patients.FMR improvement is more common in CRT recipients in SR vs AF, despite a similar degree of LV remodeling. LA volume and MA diameter are greater in the AF group, causing the negative impact of AF on FMR improvement in CRT, as well as indicating a potential therapeutic target (ie, AF rhythm control).

Very preterm birth is associated with increased cardiovascular diseases and changes in myocardial structure. The current study aimed to investigate the impact of endothelial colony‐forming cell (ECFC) treatment on heart morphological changes in the experimental model of neonatal high oxygen (O2)‐induced cardiomyopathy, mimicking prematurity‐related conditions. Sprague–Dawley rat pups exposed to 95% O2 or room air (RA) from day 4 (P4) to day 14 (P14) were randomized to receive (jugular vein) exogenous human cord blood ECFC or vehicle at P14 (n = 5 RA‐vehicle, n = 8 RA‐ECFC, n = 8 O2‐vehicle and n = 7 O2‐ECFC) and the hearts collected at P28. Body and heart weights and heart to body weight ratio did not differ between groups. ECFC treatment prevented the increase in cardiomyocyte surface area in both the left (LV) and right (RV) ventricles of the O2 group (O2‐ECFC vs. O2‐vehicle LV: 121 ± 13 vs. 179 ± 21 μm2, RV: 118 ± 12 vs. 169 ± 21 μm2). In O2 rats, ECFC treatment was also associated with a significant reduction in interstitial fibrosis in both ventricles (O2‐ECFC vs. O2‐vehicle LV: 1.07 ± 0.47 vs. 1.68 ± 0.41% of surface area, RV: 1.01 ± 0.74 vs. 1.77 ± 0.67%) and in perivascular fibrosis in the LV (2.29 ± 0.47 vs. 3.85 ± 1.23%) but in not the RV (1.95 ± 0.95 vs. 2.74 ± 1.14), and with increased expression of angiogenesis marker CD31. ECFC treatment had no effect on cardiomyocyte surface area or on tissue fibrosis of RA rats. Human cord blood ECFC treatment prevented cardiomyocyte hypertrophy and myocardial and perivascular fibrosis observed after neonatal high O2 exposure. ECFC could constitute a new regenerative therapy against cardiac sequelae caused by deleterious conditions of prematurity.