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The aim of this study was to compare 5-year cardiovascular, renal, and bioprosthetic valve durability outcomes in patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).Patients with severe AS and CKD undergoing TAVR or SAVR are a challenging, understudied clinical subset.Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate 60 mL/min/mThe study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs 68.0%; P = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs 58.7%; P = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs 10.3%; P 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (P 0.05) but not for SAPIEN 3 TAVR.In intermediate-risk patients with AS and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses.

ObjectiveImmediate facial nerve reconstruction is the standard of care following radical parotidectomy; however, quality of life comparisons with those undergoing limited superficial parotidectomy without facial nerve sacrifice is lacking.MethodPatients who underwent parotidectomy were contacted to determine quality of life using the University of Washington Quality of Life and Parotidectomy Specific Quality of Life questionnaires. A total of 29 patients (15 in the radical parotidectomy and 14 in the limited superficial parotidectomy groups) completed and returned questionnaires.ResultsUsing the University of Washington Quality of Life Questionnaire, similar quality of life was noted in both groups, with the radical parotidectomy group having significantly worse speech and taste scores. Using the Parotidectomy Specific Quality of Life Questionnaire, the radical parotidectomy group reported significantly worse speech, eye symptoms and eating issues.ConclusionThose undergoing radical parotidectomy with reconstruction had comparable overall quality of life with the limited superficial parotidectomy group. The Parotidectomy Specific Quality of Life Questionnaire better identified subtle quality of life complaints. Eye and oral symptoms remain problematic, necessitating better rehabilitation and more focused reconstructive efforts.

Introduction: The development of adeno-associated virus (AAV) vectors as safe vehicles for in vivo delivery of therapeutic genes has been a major milestone in the advancement of gene therapy, enabl...

Left atrial appendage occlusion has become a safe and effective alternative for stroke-risk reduction among patients with non-valvular atrial fibrillation (AF). Although complete closure is ideal, residual peri-device leaks (PDL) are not uncommon and have been associated with an increased residual risk of stroke. PDL closure has been proposed as an alternate strategy to allow for the safe discontinuation of oral anticoagulation. We describe the safety and feasibility of successful PDL closure using a non-fenestrated Cardioform (Gore Medical, Flagstaff, Arizona) septal occluder after initial Watchman (Boston Scientific, Marlborough, Massachusetts) implantation.

OBJECTIVES Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P. METHODS Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics. RESULTS In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11–1.55) vs 1.02 (0.89–1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96–2.14) vs 1.27 (0.80–2.02)]. CONCLUSIONS In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.

OBJECTIVE This study aimed to examine the cumulative experience of peri-device leak (PDL) closure following left atrial appendage (LAA) closure. BACKGROUND The management of PDL following LAA closure remains controversial. While PDL closure has been proposed, procedural features and clinical outcomes have not been well established. METHODS A systematic review of all published cases of PDL closure with available anatomical, procedural, and clinical outcomes was performed. RESULTS We identified 18 indexed publications and 110 cases between April 2013 and March 2020. 71 patients (mean age 72 ± 8 yrs), met study criteria and were included. PDL closure was most common in males, bilobar LAA morphology, and after Watchman procedures. The mean PDL size was 7.6 ± 5.8 mm (range 2-26 mm). Leaks were classified according to size: small (

Background The effect of transcatheter aortic valve replacement (TAVR) on kidney function stage in patients with aortic stenosis remains poorly understood. We hypothesized that in some patients, TAVR results in improved kidney function by alleviating cardiorenal syndrome. Objectives The purpose of this study was to assess change in chronic kidney disease (CKD) stage following TAVR, identify variables associated with pre- and post-TAVR estimated glomerular filtration rate (eGFR), and assess association of post-TAVR eGFR with mortality. Methods Patients (n = 5,190) receiving TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) 1, 2, and PARTNER 2 S3 trials between April 2007 and October 2014 were included. Pre-TAVR and procedural variables associated with post-TAVR eGFR, change in CKD stage at ≤7 days post-TAVR, and association of post-TAVR eGFR on intermediate-term mortality were assessed. Results At baseline, CKD stage ≥2 was present in 91% of patients. CKD stage either improved or was unchanged following TAVR in the majority of patients (77% stage 1, 90% stage 2, 89% stage 3A, 94% stage 3B, and 99% stage 4). Progression to CKD stage 5 occurred in 1 (0.035%) of 2,892 patients within 7 days post-TAVR. Of 3,546 patients in whom data were available, 70 (2.0%) underwent post-TAVR dialysis. Higher pre-TAVR eGFR and transfemoral approach were strongly associated with higher post-TAVR eGFR. Lower baseline and longitudinal post-TAVR eGFR were associated with lower intermediate-term survival. Conclusions In patients with severe aortic stenosis undergoing TAVR, even with baseline impaired eGFR, CKD stage is more likely to stay the same or improve than worsen. Aortic stenosis may contribute to cardiorenal syndrome that improves with TAVR.

Unroofed coronary sinus (CS) defects are rare anomalies that result from embryologic developmental abnormalities, leading to partial or complete absence of the common wall between the CS and the left atrium. They account for less than 1% of atrial septal defects, having a strong association with a

Highlights • The coumadin ridge is a very unusual location for a cardiac PFE. • Although benign, large, mobile cardiac PFEs can pose a significant embolic risk. • Multimodality CV imaging can differentiate cardiac PFE from other cardiac tumors., Graphical abstract

Graphical abstract, Highlights • A pulmonary artery intimal sarcoma can grow significantly within the mediastinum. • This case is an interesting example of an anterior wall myocardial infarction. • Multimodality cardiac imaging is important in assessing a large extracardiac mass.

Self-assessment is a critical skill for health care professionals. Because these professionals must be lifelong, self-directed learners and self-regulating practitioners, the ability to self-assess is essential for them. The aims of this study were to measure how dental students self-assessed and peer-assessed their performance in preclinical operative procedures and to evaluate any relationship between their assessment ability and preclinical skills or academic performance. The study was conducted from 2015 to 2016. Third-year students at Harvard School of Dental Medicine self-assessed their work on four preclinical practical exams: Class II amalgam preparation, Class II amalgam restoration, Class III composite preparation, and Class III composite restoration. Three faculty members graded the same preparations and restorations. The difference between the students' self-assessment and the mean faculty assessment was calculated as the student-faculty (S-F) gap. An absolute S-F gap was also calculated with absolute values of differences. A total of 71 students completed these practical exams: 36 in the Class of 2016 and 35 in the Class of 2017. All 71 self-assessments for each of the four practical exams were collected for a response rate of 100%. The results showed that the mean S-F gap ranged from 2% to 8%, and the absolute S-F gap ranged from 7% to 12%. Preclinical performance was correlated with self-assessment accuracy. Low-performing students significantly overestimated their self-assessments compared to the rest of the class. High-performing students had more accurate self-assessments and tended to underestimate themselves. Overall, these results showed that the students had room for improving the accuracy of their self-assessments.

Graphical abstract, Highlights • Malignant mesothelioma of the pericardium presents with progressive constrictive pathophysiology. • Multimodality imaging provides advanced tissue characterization of unknown pericardial collections. • Pericardial tumors can mimic constrictive pericarditis.

Nonsteroidal anti-inflammatory drugs and colchicine remain the standard of care as the initial treatment of acute pericarditis. Corticosteroids and traditional immunosuppressive medications are often added if patients develop recurrent symptoms and remain medically refractory. There has been growing interest in the use of interleukin-1 receptor antagonists (IL-1RAs) in managing pericarditis, especially, in medically refractory cases. Anakinra-Treatment for Recurrent Idiopathic Pericarditis is a recent pilot trial showing a benefit of using the IL-1RA, anakinra, in recurrent pericarditis. Publications remain limited and more outcomes trials are needed. This review focuses on the mechanism of action, clinical utility, current, and future studies that investigate the role of IL-1RAs in the management of recurrent pericarditis.

ObjectiveCongenital pericardial defect (CPD) is a rare entity with an estimated frequency of 0.01%–0.04%. The recognition of this anomaly is important since it can be associated with serious complications. The aim of this study and review was to describe clinical and imaging features that help in establishing the diagnosis of this condition.MethodsWe retrospectively reviewed all adult patients at the Cleveland Clinic Health System with the diagnosis of CPD between the years 2000 and 2015. Baseline clinical characteristics, clinical manifestations, ECG, transthoracic echocardiography (TTE), cardiac CT and cardiac magnetic resonance (CMR) images were reviewed.ResultsEight patients were included in the study. Sixty-three percent of patients were males with mean age at diagnosis of 48 years, 63% had a partial pericardial defect on the left side and right ventricular (RV) dilation on TTE. Three patients had CMR. Levocardia was present in all CMRs. One patient had greater than 60° clockwise rotation and none of the CMRs showed ballooning of the left ventricular apex. One patient required surgical pericardioplasty. The remaining seven patients had a median follow-up of 17.3 months (5–144.9 months) and all remained asymptomatic.ConclusionCPDs are more likely to be partial on the left side and patients often have RV dilation on the TTE and levocardia on CMR. Most patients remain stable and do not require surgical intervention. TTE and CMR play an important role in making the diagnosis of this anomaly.

Congenital absence of the pericardium (CAP) is one of the rarest cardiac congenital anomalies. It can occur as a complete absence of the entire pericardium, absence of the right or left portion of the pericardium or a partial, foramen-like defect of the right or left pericardium. While the majority of cases are clinically silent, multiple reports associate CAP with symptomatic presentation. The most feared complication of CAP is sudden death due to cardiac strangulation across a partial defect of the left pericardium. Given its rare occurrence, most clinicians and imaging specialists will have little experience with this condition and may fail to recognize it on thoracic or cardiac studies. Thus, the purpose of this review is to highlight the common clinical and multimodality imaging features associated with this anomaly and suggest a management algorithm.

Coronary artery calcification (CAC) is a known risk factor for adverse outcomes in the general population and in patients with coronary artery disease. We performed a survey of United States radiologists to evaluate the trends in reporting the presence or absence of CAC on NCCT examinations. An 11 multiple-choice questionnaire was distributed to members of the American College of Radiology, and 530 members participated in the study. Eighty-seven percent of the analyzed group report the presence of CAC on standard CT scans of the chest, and approximately half them (52 %) use a qualitative modifier. Only 32 % of cardiac imagers were aware of the published data correlating qualitative and quantitative calcium scores on non-gated chest CT examinations compared to 17 % of non-cardiac imagers. We believe that subjective or objective grading of coronary calcified plaque burden on standard chest CT exams is warranted as it may not only help risk-stratify patients, but also may eliminate the need for dedicated CACS in many patients and may be useful in treatment guidance.

A person's right to access his or her protected health information is a core feature of the U.S. Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. If the information is stored electronically, covered entities must be able to provide patients with some type of machine-readable, electronic copy of their data. The aim of this study was to understand how academic dental institutions execute the Privacy Rule's right of access in the context of electronic health records (EHRs). A validated electronic survey was distributed to the clinical deans of 62 U.S. dental schools during a two-month period in 2014. The response rate to the survey was 53.2% (N=33). However, three surveys were partially completed, and of the 30 completed surveys, the 24 respondents who reported using axiUm as the EHR at their dental school clinic were the ones on which the results were based (38.7% of total schools at the time). Of the responses analyzed, 86% agreed that clinical modules should be considered part of a patient's dental record, and all agreed that student teaching-related modules should not. Great variability existed among these clinical deans as to whether administrative and financial modules should be considered part of a patient record. When patients request their records, close to 50% of responding schools provide the information exclusively on paper. This study found variation among dental schools in their implementation of the Privacy Rule right of access, and although all the respondents had adopted EHRs, a large number return records in paper format.

Ventricular septal defect (VSD) is a rare complication of acute myocardial infarction (MI) often resulting in refractory cardiogenic shock with a poor prognosis. Reported mortality rates are as high as 80% in the abscence of intervention. A 56-year-old woman presented with active chest pain for 48

A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardial syndromes, calling for a better understanding of its pathophysiology, diagnoses, and management. Uremic pericarditis, the most common manifestation of uremic pericardial disease, is a contemporary problem that calls for intensive hemodialysis, anti-inflammatories, and often, drainage of large inflammatory pericardial effusions. Likewise, asymptomatic pericardial effusions can become large and impact the hemodynamics of patients on chronic hemodialysis. Constrictive pericarditis is also well documented in this population, ultimately resulting in pericardiectomy for definitive treatment. The management of pericardial diseases in ESRD patients involves internists, cardiologists, and nephrologists. Current guidelines lack clarity with respect to the management of pericardial processes in the ESRD population. Our review aims to describe the etiology, classification, clinical manifestations, diagnostic imaging tools, and treatment options of pericardial diseases in this population.

National prosthesis use in active aortic valve infective endocarditis (IE) is unreported. Prosthesis usage and outcomes in patients undergoing an aortic valve operation with active IE was evaluated.The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to identify patients with active IE who underwent an aortic valve operation from January 1, 2005, to June 30, 2011. All patients with active IE were included. Demographics, procedures, outcomes, and trends were analyzed.Of 11,560 patients who were identified as having active IE, 8,421 (73%) had no prior operations (primary) and 3,139 (27%) had a history of any prior cardiac operation (reoperative). Operations for primary vs reoperative patients included isolated replacement in 88.5% vs 58.7% and root replacement in 7.2% vs 29.9%. Major morbidity was 60.8% vs 68%, and the unadjusted mortality rate was 9.8% vs 21.1%. Over time, for primary operations, biologic valve use increased (57% to 67%), and mechanical and homograft valve use decreased (30% to 24% and 9% to 6%; p0.001). For reoperations, biologic valve use increased (38% to 52%), and mechanical and homograft use decreased (20% to 17% and 38% to 28%; p0.001). Homografts were used more often in reoperations (32% vs 7%).Morbidity and mortality rates death are high for operations for active IE. Biologic valves were increasingly used vs mechanical and homograft valves. Homograft valves were used more often in reoperative patients after any prior cardiac operation. The mortality rate varied among prosthesis groups but may be related to the severity of infection and type of procedure performed.

Background Giant cell myocarditis (GCM) is a cardiac inflammatory disease that is characterized by the widespread infiltration of multinucleated giant cells interspersed in the myocardium, cardiomyocyte necrosis and eventually fibrosis. This disorder is rare, rapidly progressive and frequently fatal. Typically, it manifests with fulminant heart failure, atrioventricular blocks and/or ventricular tachyarrhythmias. Current therapies rely on the use of immunosuppression, ventricular assist devices and ultimately cardiac transplantation. Introduction We describe the successful cessation of ventricular tachyarrhythmias in the setting of GCM with the use of a stellate ganglion blockade. Case A 47-year-old female with a history of Hashimoto's thyroiditis presented to an outside hospital with flu-like symptoms and dyspnea. Had a NT-proBNP of 6,080 pg/mL and TroponinT of 1.3 ng/mL. EKG demonstrated ST depressions in the anterolateral leads. Echocardiography showed severe LV dysfunction with global hypokinesis and an LVEF 25%. Telemetry revealed multiple runs of polymorphic sustained ventricular tachycardia (VT). Coronary angiography demonstrated normal coronary arteries. The patient was started on IV amiodarone, IV lidocaine, a continuous magnesium drip and transferred to our facility. A cardiac MRI showed extensive late gadolinium enhancement of the subendocardium at the inferobasal septum, mid wall and the epicardium along the mid septum. She continued to have incessant multifocal VT, despite being on three AAD's. Thus, we intubated her and placed her under general anesthesia, but she continued to have VT. The decision was made to perform a left stellate ganglion blockade, which was immediately successful at suppressing the electrical storm. A right heart catheterization revealed a cardiac index of 1.4 L/min/m2 and a mean PCWP of 27 mmHg. The patient underwent IABP insertion followed by an endomyocardial biopsy of the RV. Biopsy was consistent with GCM and the patient was started on cyclosporine and high dose steroids while she was evaluated for cardiac transplantation. Two days later she received a heart and has been doing well post-operatively. Conclusion To our knowledge this is the first case reported where incessant VT in GCM is treated with a stellate ganglion nerve blockade. This technique should be considered in GCM patients presenting with electrical storm refractory to AAD's.

Background Heart failure (HF) is the leading cause of hospitalizations and readmissions in the United States. Approximately one-third of patients admitted for HF are readmitted within 3 months; however, there are few markers that can identify those at highest risk for readmission. The purpose of this study was to identify clinical and laboratory markers associated with hospital readmission in decompensated HF. Hypothesis Clinical and laboratory markers are associated with readmission rates in decompensated HF. Methods Clinical and laboratory data from 412 patients admitted with HF were analyzed using a multivariable logistic regression analysis to find predictors of HF readmission by 30 days. Results HF readmission rates at 30 days were lowest in those with at least 2 of the following discharge criteria: net fluid reduction >1.3 L (odds ratio [OR]: 0.27, P = 0.019), serum sodium level >135 (OR: 0.46, P = 0.034), and N-terminal brain natriuretic peptide level reduction >23% (OR: 0.11, P = 0.048). In multivariate analysis, those patients meeting ≥2 criteria had a very low risk of 30-day readmission (OR: 0.10, 95% confidence interval: 0.01-0.68, P = 0.019) compared to patients who failed to meet 2 criteria. Conclusions A negative fluid balance, normal serum sodium, and net reduction in N-terminal brain natriuretic peptide level during hospitalization may be important indices to target to help reduce the likelihood of HF readmission within 30 days.

BACKGROUND Hypoxemia can adversely affect outcome after traumatic brain injury (TBI). However, the effect of high PaO2 on TBI outcomes is controversial. The primary aim of this study was to identify the optimal PaO2 range early after severe TBI. METHODS In this single-center retrospective study conducted at a level-1 trauma center, patients with severe TBI (head Abbreviated Injury Scale score >3, admission Glasgow Coma Scale score ≤8) were included. The crude and adjusted (including chest injuries and acute respiratory distress syndrome) effects of 50 mm Hg incremental PaO2 thresholds during the first 72 hours on discharge survival were examined. RESULTS Data from 193 patients (44±18 y; 77% male; admission Glasgow Coma Scale score 4±2) were reviewed. Overall survival was 57%. PaO2 thresholds in increments of 50 mm Hg between 250 and 486 mm Hg (68%) were associated with discharge survival in patients with severe TBI compared with PaO2 60 mm Hg

Congenital absence of the pericardium (CAP) is a rare condition. Failure to recognize the clinical features of this condition can lead to incorrect and delayed diagnosis. Limited data are available regarding the optimal approach to diagnose and manage patients with suspected CAP. Due to the rare nature of CAP, this condition can present diagnostic and management dilemmas for clinicians. Using 3 cases of CAP as a framework, a clinically focused review on the diagnosis and management of CAP is presented. Clinicians will be provided with a systematic approach to evaluating patients with suspected CAP, incorporating key history, examination, and multimodality cardiovascular imaging investigations.

Preoperative renal dysfunction is a predictor of acute kidney injury and mortality following transcatheter aortic valve replacement (TAVR). Consequently, there is reluctance to perform TAVR in some pts. Little data exists on the variations in renal function and CKD Stage post-TAVR. 5,190 pts

Prior epidemiologic studies have shown that increasing body mass index (BMI) is associated with higher total cholesterol and low-density lipoprotein cholesterol (LDL). However, these studies were limited by underrepresentation of obese subjects. The aim of this study was to determine whether there is an association between BMI and lipid profiles in a population of patients with a broad spectrum of BMI values. A case-control study was performed involving patients seen at the Cleveland Clinic Florida. Cases (BMI >30 kg/m(2)) were obtained from the obesity surgery database between August 31, 2000, and April 4, 2002. Controls (BMI ≤ 30 kg/m(2)) were obtained from a database of primary care physicians between May 1, 2004, and November 18, 2004. Pearson correlation coefficients were used to assess the relationship between BMI and lipid fractions. Multiple linear regression was performed to assess the independent effect of BMI on lipid levels while adjusting for potential confounders and propensity scores. Six hundred thirty-seven patients were analyzed (females, n = 362, 57%). There was no association between higher BMI and LDL (r = 0.19 p = 0.07), a negative association with high-density lipoprotein cholesterol (HDL; r = 0.45, p < 0.001), and a positive association with the log transformation of triglycerides (r = 0.32, p = 0.005).Higher BMI was inversely associated with HDL and directly associated with TG. BMI showed no significant association with LDL. Although the association between BMI and both HDL and TG may be explained by insulin resistance, the lack of a significant association between BMI and LDL remains an unexpected finding that requires further investigation.

Clinical outcomes associated with pericardial effusions related to uremic pericarditis (UP) have not been clearly differentiated from asymptomatic effusions in patients with ESRD. Our objectives are: 1) to assess whether pericardial effusions associated with UP are more likely to result in

OBJECTIVE. The purpose of our study was to evaluate the feasibility of detecting mitral valve prolapse with ECG-gated 64-MDCT angiography in comparison with the reference standard, transthoracic echocardiography. MATERIALS AND METHODS. The charts of patients consecutively referred for clinically indicated 64-MDCT angiography were reviewed. The study cohort consisted of patients who had undergone transthoracic echocardiography. Two experienced radiologists performed blinded consensus review of the MDCT angiograms of 20 patients, and the findings were com pared with those of transthoracic echocardiography, which was the reference standard. RESULTS. With the findings on each anterior and posterior leaflet as separate data points, sensitivity was calculated to be 69.2–84.6% and specificity, 100%. The positive and negative predictive values were estimated to be 100% and 87.0–93.1%. CONCLUSION. ECG-gated cardiac 64-MDCT angiography can be used reliably to detect mitral valve prolapse.

Degenerative aortic valve stenosis (AS) has an incidence of 2–7% in the Western European and North American populations over 65 years of age. The aim of this study was to perform a meta-analysis of the published literature evaluating the accuracy of CT planimetry to measure the aortic valve area. The PUBMED and OVID databases were searched up to May 2008. Major criteria for article inclusion was the use of (a) multi-detector computed tomography as a diagnostic test for the assessment of AVA in patients with AS, and (b) TTE as the reference standard. Nine studies were included in the analysis with 175 women and 262 men. The mean AVA as measured by CT was 1.0 ± 0.1. The mean AVA measured by TTE was 0.9 ± 0.1. The correlation between CT and TTE AVA measurements was r = 1.45. The mean difference was 0.03 ± 0.05. The results of our meta-analysis suggest that multi-detector CT is an accurate method for obtaining AVA measurements in patients with AS.

BACKGROUND: National Cholesterol Education Program (NCEP) guidelines have been used to define treatment goals in patients with hypercholesterolemia. However, epidemiology‐based guidelines are unable to identify all subjects with coronary artery disease for aggressive lipid intervention. OBJECTIVE: We sought to evaluate the additive value of multislice computed tomography (MSCT) angiography to the NCEP guideline classification for lipid treatment. METHODS: Multislice computed tomography was performed in 114 consecutive patients (mean age 57 ± 14 y; 59% male) without known coronary artery disease. Subjects were classified into 3 categories (low‐, intermediate‐, and high‐risk) according to their Framingham risk scores (FRS). RESULTS: Traditional cardiac risk factors were common: hypertension 59%, diabetes 13%, and smoking 22%. On the basis of the FRS, 11% (n= 12/114) of the patients met high‐risk criteria requiring aggressive cholesterol reduction. Of those in the low‐ and intermediate‐risk groups, MSCT found coronary plaque in 76% (n= 77/102), with moderate or severe plaque in 38% (n=39/102), thus reclassifying them in the high‐risk category. Use of statin drugs increased from 32% at baseline to 53% (p= 0.002) based on MSCT results; statin dose was increased in 31% of the patients who were already on a statin. The mean low‐density lipoprotein cholesterol (LDL‐c) decreased from 114 mg/dL to 91 mg/dL after MSCT (p < 0.001). CONCLUSION: Multislice computed tomography reclassifies a high percentage of patients considered to be low‐ to intermediate‐risk into the high‐risk category based on their coronary artery lesions. Thus, the rise in MSCT use at present may have a large impact on clinician practice patterns in lipid‐lowering therapy. Copyright © 2008 Wiley Periodicals, Inc.

The ACUTE trial randomly assigned patients who had atrial fibrillation (AF) of >2 days' duration to a transesophageal echocardiographically guided or a conventional strategy before cardioversion. In the 571 patients who underwent transesophageal echocardiography (TEE) in the ACUTE trial, we assessed the relative predictive value of baseline data derived by history, transthoracic echocardiography, and TEE for prediction of thrombus and adjudicated embolism (thromboembolism) as a composite end point. TEE was performed at 70 centers in 571 patients, 549 in the transesophageal echocardiographically guided group and 22 crossovers in the conventional group. Six patients (1.1%) who had embolism and 79 (13.8%) who had thrombi were identified in this group. Thrombus was completely resolved in 76.5% of patients who had repeat transesophageal echocardiographic procedures after 31.7 +/- 7.5 days of anticoagulation. For patients who had embolic events, none had a transesophageal echocardiographically identified thrombus; 5 of 6 (83.3%) had >/=1 transesophageal echocardiographic risk factors (including spontaneous echocardiographic contrast, aortic atheroma, patent foramen ovale, atrial septal aneurysm, mitral valve strands), and 4 of 6 (66.66%) had subtherapeutic anticoagulation or no anticoagulation. Clinical, transthoracic echocardiographic, and transesophageal echocardiographic risk factors contributed significantly to the prediction of composite thrombus/embolism. However, transesophageal echocardiographic thromboembolic risk factors were the strongest predictors of thromboembolism and provided statistically significant incremental value (chi-square 38.0, p

Right atrial (RA) masses are rare entities often detected incidentally during imaging studies. Leading etiologies of right atrial masses are tumor, thrombi, and vegetations. We present two cases of right atrial masses, a cardiac lipoma and an artifact. Clinical and echocardiographic characteristics of benign cardiac tumors are reviewed. We then highlight the importance of considering artifact in the differential diagnosis of atrial masses. Finally, we discuss echocardiographic characteristics of right atrial masses that may provide clues for diagnosis. Right atrial masses, often detected incidentally during imaging studies, are uncommon and can be due to many etiologies including tumors, thrombus, vegetations, normal variants, and artifacts. We describe 2 patients with RA masses detected on routine transthoracic echocardiogram.

Although the evidence that right ventricular (RV) function has significant impact on cardiac hemodynamics and outcome is indisputable, its evaluation has been hampered by problems with image quality, geometric variability, and the absence of a standard of reference. A resurgence of research activity has sought to discern the pathophysiology of RV dysfunction and to explore new methods for measuring performance. Noninvasive techniques such as tissue Doppler echocardiography, three-dimensional echocardiography, and magnetic resonance imaging provide new quantitative information and may improve prediction of outcomes. These advances in technology, and the recognition that RV systolic function is essential in many conditions, provide the impetus for future studies. This review highlights the past and present efforts to incorporate RV systolic function into the mainstream of cardiology practice.

Cardiac resynchronization therapy improves hemodynamics in selected patients with heart failure. Mechanic asynchrony parameters that may guide patient selection or therapy optimization are still being investigated. A biventricular (BiV) pacemaker was implanted in 34 patients with dilated ischemic, idiopathic, or valvular cardiomyopathy, and a QRS duration ofor =130 milliseconds. Two-dimensional standard and Doppler tissue echocardiography was performed during right ventricular (RV), left ventricular (LV), BiV, and no pacing in a random and blinded manner. LV and BiV pacing increased stroke volume (P.02 for both) and ejection fraction (P.001 for both). Regional contractility assessed by displacement, strain rate, and peak systolic strain was improved in some segments (P.05) during LV and BiV pacing. A homogenization of segmental contractions was observed during LV and BiV pacing as evaluated by net systolic displacement and segmental myocardial performance index. LV and BiV pacing provides benefits that can be quantified by echocardiography.

We sought to determine the potential use of recently introduced cardiac 3-dimensional computed tomography as an alternative to transesophageal echocardiography for examination of the left atrial appendage. Our data suggest that computed tomography is a potential alternative for assessing the anatomy of the left atrial appendage and for detecting thrombi.

The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial was the first randomized prospective study to compare the conventional strategy of 3 weeks of anticoagulation before direct current cardioversion (DCC) for atrial fibrillation (AF) to a transesophageal echocardiography (TEE) guided approach with an expedited course of anticoagulation. This was a multicenter, international study with 70 sites enrolling 1222 patients between 1994-1999. The primary endpoint of composite embolic events and secondary endpoints including bleeding, functional status, prevalence of sinus rhythm, and death were assessed at 8 weeks following randomization. The ACUTE trial demonstrated that the TEE guided approach was safe and effective. There was no difference in the primary outcome of embolic events for the 2 strategies (0.8% TEE group vs. 0.5% conventional group, p =.50). There was a difference between the groups with respect to the number of bleeding events, with minor and major bleeding seen in 2.9% of patients in the TEE guided group and 5.5% in the conventional group (relative risk 0.53, 95% confidence interval 0.30-0.93, p = 0.03). The remaining secondary endpoints did not differ. Clinicians now have a viable alternative approach to cardioversion for patients with AF. Several factors influence the choice of strategies including (1) severity of symptoms and hemodynamic effect; (2) level and chronicity of anticoagulation; (3) risks of bleeding; (4) duration of AF and likelihood of reversion; and (5) risk and likelihood of left atrial thrombi. Future studies, such as ACUTE II are ongoing, with the aim of using low molecular weight heparin to further streamline the TEE guided approach to DCC and shorten hospital stay and costs.

ASHER, C.R., ET AL.: Transesophageal Echocardiography in Patients with Atrial Fibrillation. Over the past decade transesophageal echocardiography (TEE) has become an integral tool in the management of patients with AF. Thrombi can be readily detected and the function of the left atrium and left atrial appendage (LAA) can be easily assessed by this modality. With this knowledge, informed decisions regarding anticoagulation, cardioversion, and the likelihood of restoring and maintaining sinus rhythm can be made. An alternative TEE-guided strategy for achieving sinus rhythm in patients with AF is now available with efficacy and safety similar to the conventional approach. Refinements of this strategy may include the use of low molecular weight heparin to avoid hospitalization in patients planned for cardioversion. Further uses of TEE in patients with AF are in their early stages including evaluation of patients following pulmonary vein radiofrequency ablation and those undergoing percutaneous or surgical closure of the LAA.

The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial compared cardioversion following transesophageal echocardiography (TEE) against conventional management of atrial fibrillation (ie, cardioversion following 3 weeks of anticoagulation) in patients scheduled to undergo electrical cardioversion.

OBJECTIVE: We sought to assess whether aortic valve replacement (AVR) among patients with severe aortic stenosis (AS), severe left ventricular (LV) dysfunction and a low transvalvular gradient (TVG) is associated with improved survival. BACKGROUND: The optimal management of patients with severe AS with severe LV dysfunction and a low TVG remains controversial. METHODS: Between 1990 and 1998, we evaluated 68 patients who underwent AVR at our institution (AVR group) and 89 patients who did not undergo AVR (control group), with an aortic valve area < or = 0.75 cm(2), LV ejection fraction < or = 35% and mean gradient < or = 30 mm Hg. Using propensity analysis, survival was compared between a cohort of 39 patients in the AVR group and 56 patients in the control group. RESULTS: Despite well-matched baseline characteristics among propensity-matched patients, the one- and four-year survival rates were markedly improved in patients in the AVR group (82% and 78%), as compared with patients in the control group (41% and 15%; p < 0.0001). By multivariable analysis, the main predictor of improved survival was AVR (adjusted risk ratio 0.19, 95% confidence interval 0.09 to 0.39; p < 0.0001). The only other predictors of mortality were age and the serum creatinine level. CONCLUSIONS: Among select patients with severe AS, severe LV dysfunction and a low TVG, AVR was associated with significantly improved survival.

Patients with prosthetic heart valves require regular examinations and echocardiograms, antithrombotic therapy, and appropriate antibiotic prophylaxis against endocarditis. Physicians must also be on the alert for several uncommon but potentially devastating complications: valve structural failure, thrombosis, embolism, endocarditis, paravalvular leak, and hemolytic anemia.

Background Treatment options for wild-type BRAF melanoma patients remain limited. Selumetinib, a MEK 1/2 inhibitor, suppresses pERK levels independent of BRAF and NRAS mutation status, and combination with docetaxel has demonstrated synergy in xenograft models. The aim of this study was to assess the efficacy and safety of selumetinib plus docetaxel as first-line treatment in patients with wild-type BRAF advanced melanoma. Patients and methods In this double-blind multicentre phase II trial patients with wild-type BRAF melanoma were randomized (1:1) to docetaxel with selumetinib or placebo. Docetaxel 75 mg/m2 was administered intravenously every 3 weeks up to six cycles. Selumetinib 75 mg or placebo was given orally twice daily until disease progression or unacceptable toxicity. The primary end point was progression-free survival (PFS). Tumour NRAS mutation status was analysed retrospectively and correlated with treatment outcomes. Results Eighty-three patients were randomized to docetaxel plus selumetinib (n = 41) or docetaxel plus placebo (n = 42). The PFS hazard ratio (HR) (selumetinib:placebo) was 0.75 [90% confidence interval (CI) 0.50–1.14; P = 0.130], with a median PFS of 4.23 months (90% CI 3.63–6.90) for docetaxel plus selumetinib and 3.93 months (90% CI 2.07–4.16) for docetaxel alone. There was no significant difference in overall survival. The objective response rate was 32% with selumetinib versus 14% with placebo (P = 0.059). In a retrospective subset analysis, NRAS mutation status did not affect significantly upon clinical outcomes in either arm. The combination of docetaxel and selumetinib could be administered effectively to patients with metastatic melanoma, although the combination was less well tolerated than docetaxel alone. Conclusions The combination of docetaxel with selumetinib showed no significant improvement in PFS compared with docetaxel alone, although more patients showed a response to combination therapy. We found no evidence to support using tumour NRAS mutation as a basis for selecting patients for combined MEK inhibitor and chemotherapy. Clinical trial DOC-MEK (EudraCT no: 2009-018153-23).