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Women in cardiology (WIC) sections have emerged as important leadership, career development, and advocacy forums for female cardiologists. Over the past 3 decades, they have grown from small groups to large sections within volunteer science organizations. In addition to providing a sense of community and promulgating the principles of diversity, equity, inclusion, and belonging, the WIC sections have contributed to improving workplace culture and dynamics by generating evidence-based and actionable data, fostering leadership by and scientific enrichment of women, developing task forces and health policy documents targeted toward reduction of burnout and bias in medicine, and providing a platform to voice the unique challenges and opportunities of female cardiologists. The future holds great promise, as the WIC sections continue to play a pivotal role by being intentional, transparent, iterative, and sustainable, and working with important stakeholders, including men, to share data, best practices, and strategies to create and maintain a culture of equity and achieve its core principles. Résumé: Les sections WIC (“Women In Cardiology”) des femmes en cardiologie sont devenues d'importants forums de leadership, de développement de carrière et de défense des intérêts des femmes cardiologues. Au cours des trois dernières décennies, leur potentiel est passé de petits groupes à de grandes sections au sein d'organisations scientifiques bénévoles. En plus de donner un sentiment d'appartenance à une communauté et de promouvoir les principes de diversité, d'équité, d'inclusion et d'appartenance, les sections WIC ont contribué à améliorer la culture et la dynamique du milieu de travail en proposant des données factuelles et exploitables, en encourageant le leadership et l'enrichissement scientifique des femmes, en créant des groupes de travail et des documents de politique de santé visant à réduire l'épuisement professionnel et les préjugés en médecine, et en offrant une plateforme pour exprimer les défis et les opportunités uniques des femmes cardiologues. L'avenir semble très prometteur puisque les sections WIC continuent de jouer un rôle central en étant conscientes, transparentes, itératives et durables et en travaillant avec des parties prenantes importantes, y compris masculines, pour partager des données, des meilleures pratiques et des stratégies afin de créer et d'en maintenir la culture et de concrétiser ses principes fondamentaux.

BACKGROUND AND PURPOSE: Cardiovascular disease (CVD) encompasses a range of disorders that affect health and functioning in older adults. While cognitive declines have been linked to both cardiovascular and cerebral blood perfusion, protective neurovascular mechanisms raise the question whether cerebrovascular perfusion differs as a function of cardiovascular health status. The present study examined whether cerebrovascular perfusion significantly differs between healthy older adults with and without diagnosed CVD. The study also examined whether previously documented sex differences in cerebral perfusion would be replicated. METHODS: Twenty CVD patients without significant heart failure and 39 healthy controls were recruited to undergo a comprehensive assessment including an interview, echocardiogram, and magnetic resonance imaging (MRI). Arterial spin labeling (ASL) was used to quantify cerebral blood perfusion. RESULTS: Both groups exhibited mean left ventricular ejection fractions that fell within normal limits. In line with previous research, women exhibited significantly higher cerebral perfusion than men. There were no significant group differences in whole brain cerebrovascular perfusion, regional perfusion, or white matter perfusion by patient status after accounting for sex and age. CONCLUSIONS: These findings suggest that the effects of mild CVD on cerebrovascular perfusion are minimal. Future studies are needed to investigate the mechanisms involved in maintaining cerebrovascular perfusion in the context of altered peripheral perfusion determine and to determine whether this finding extends to more acute or severe CVD.

Importance: There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19. Objective: To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection. Design, Setting, and Participants: Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449). Exposures: Active COVID-19 infection present during the same encounter. Main Outcomes and Measures: The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year. Results: The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001). Conclusions and Relevance: Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association.

Discrimination and emotional and sexual harassment create a hostile work environment (HWE). The global prevalence of HWE in cardiology is unknown, as is its impact.This study sought to evaluate emotional harassment, discrimination, and sexual harassment experienced by cardiologists and its impact on professional satisfaction and patient interactions worldwide.The American College of Cardiology surveyed cardiologists from Africa, Asia, the Caribbean, Eastern Europe, the European Union, the Middle East, Oceana, and North, Central, and South America. Demographics, practice information, and HWE were tabulated and compared, and their impact was assessed. The p values were calculated using the chi-square, Fisher exact, and Mann-Whitney U tests. Univariate and multivariate logistic regression analysis determined the association of characteristics with HWE and its subtypes.Of 5,931 cardiologists (77% men; 23% women), 44% reported HWE. Higher rates were found among women (68% vs. 37%; odds ratio [OR]: 3.58 vs. men), Blacks (53% vs. 43%; OR: 1.46 vs. Whites), and North Americans (54% vs. 38%; OR: 1.90 vs. South Americans). Components of HWE included emotional harassment (29%; n = 1,743), discrimination (30%; n = 1,750), and sexual harassment (4%; n = 221), and they were more prevalent among women: emotional harassment (43% vs. 26%), discrimination (56% vs. 22%), and sexual harassment (12% vs. 1%). Gender was the most frequent cause of discrimination (44%), followed by age (37%), race (24%), religion (15%), and sexual orientation (5%). HWE adversely affected professional activities with colleagues (75%) and patients (53%). Multivariate analysis showed that women (OR: 3.39; 95% confidence interval: 2.97 to 3.86; p 0.001) and cardiologists early in their career (OR: 1.27; 95% confidence interval: 1.14 to 1.43; p 0.001) had the highest odds of experiencing HWE.There is a high global prevalence of HWE in cardiology, including discrimination, emotional harassment, and sexual harassment. HWE has an adverse effect on professional and patient interactions, thus confirming concerns about well-being and optimizing patient care. Institutions and practices should prioritize combating HWE.

Echocardiography provides both qualitative and quantitative evaluation of the aortic root, thoracic and proximal abdominal aorta. Transthoracic echocardiography (TTE) provides good views of the aortic root and proximal abdominal aorta, adequate views of the proximal ascending aorta and aortic arch, while only limited views of the descending thoracic aorta, in some patients. Transesophageal echocardiography (TEE), with its superior image quality due to high frequency transducers and close approximation of the esophagus to the thoracic aorta, provides nearly complete assessment of the ascending and descending thoracic aorta, especially in the emergency evaluation of Acute Aortic Syndromes (AAS). Presence of the trachea/left bronchus impedes complete visualization of the distal ascending aorta and proximal aortic arch.

Aims The COVID-19 pandemic required a significant redeployment of worldwide healthcare resources. Fear of infection, national lockdowns and altered healthcare priorities have the potential to impact utilisation of healthcare resources for non-communicable diseases. To survey health professionals’ views of the impact of the COVID-19 pandemic on the rate and timing of admission of patients with ST-elevation myocardial infarction (STEMI), the European Society of Cardiology (ESC) administered an internet-based questionnaire to cardiologists and cardiovascular nurses across 6 continents. Methods and results 3101 responses were received from 141 countries across 6 continents. 88.3% responded that their country was in “total lockdown” and 7.1% in partial lockdown. 78.8% responded that the number of patients presenting with STEMI was reduced since the coronavirus outbreak and 65.2% indicated that the reduction in STEMI presentations was >40%. Approximately 60% of all respondents reported that STEMI patients presented later than usual and 58.5% that >40% of STEMI patients admitted to hospital presented beyond the optimal window for primary percutaneous intervention (PCI) or thrombolysis. Independent predictors of the reported higher rate of delayed STEMI presentation were a country in total lockdown, >100 COVID-19 cases admitted locally, and the complete restructuring of the local cardiology service. Conclusion The survey indicates that the impact of COVID-19 on STEMI presentations is likely to be substantial, with both lower presentations and a higher rate of delayed presentations occurring. This has potentially important ramifications for future healthcare and policy planning in the event of further waves of this pandemic.

Objective: Clinical predictors of ischemic stroke in the setting of atrial fibrillation (AF) have been identified, but there is limited data on predictors in the context of abnormal flow originating from the left atrial appendage. We hypothesize that reduced LAA flow velocity is associated with cerebrovascular ischemic events in patients with AF. Methods: We investigated consecutive patients with AF evaluated for ablation. Peak flow velocities at the orifice of the left atrial appendage (LAA) were obtained by transeosphageal echocardiography (TEE) studies, and elevated velocities were defined as greater than 40 cm/sec, in line with prior studies. The primary outcome was defined as the presence of any of the following: history of stroke/transient ischemic event, or non-lacunar brain infarct on brain imaging performed before the TEE. Univariate and multivariable analyses were performed to determine the association between LAA peak flow and the primary outcome, adjusting for CHADS2Vasc score. Results: We identified 322 patients with TEE performed. The mean age was 62.1 years and 24.5% men. Patients with LAA-flow velocity < 40 cm/sec were more likely to have the primary outcome (10.7% vs 4.3%, p=0.023). This association persisted after adjusting for CHADS2VASc (OR, 2.62; 95% CI, 1.09-6.33, p = 0.032). Conclusion: Low velocity in the LAA is associated with cerebrovascular ischemic events in patients with AF. More studies are needed to deterine whether LAA flow velocity can help risk stratify “low risk” patients with AF.

Background and Purpose: While studies have stratified cardioembolic (CE) stroke risk by qualitative left atrial appendage (LAA) morphology and biomarkers of atrial dysfunction, the quantitative properties that underlie these observations are not well established. Accordingly, we hypothesized that LAA volume and contrast density (attenuation) on computerized tomography (CT) may capture the structural and hemodynamic processes that underlie CE stroke risk. Methods: Data were collected from a single center prospective ischemic stroke database over 18 months and included all patients with ischemic stroke who previously underwent routine, non-gated, contrast enhanced thin-slice (≤2.5 mm) chest CT. Stroke subtype was determined based on the inpatient diagnostic evaluation. LAA volume and attenuation were determined from CT studies performed for various clinically appropriate indications. Univariate and multivariable analyses were performed to determine factors associated with ischemic stroke subtype, including known risk factors and biomarkers, as well as LAA density and morphologic measures. Results: We identified 311 patients with a qualifying chest CT (119 CE subtype, 109 ESUS, and 83 non-CE). In unadjusted models, there was an association between CE (vs. non-CE) stroke subtype and LAA volume (OR per mL increase 1.15, 95% CI 1.07-1.24, pth quartile vs. 1 st quartile; OR 2.95, 95% CI 1.28-6.80, p=0.011), but not with ESUS (vs. non-CE) subtype. In adjusted models, only the association between LAA density and CE stroke subtype persisted (adjusted OR 3.71, 95% CI 1.37-10.08, p=0.010). Conclusion: The LAA volume and density values on chest CT are associated with CE stroke subtype but not ESUS subtype. Patients with ESUS and increased LAA volume or attenuation may be a subgroup where the mechanism is cardioembolic and anticoagulation can be tested for secondary stroke prevention.

Hypertension and its cardiovascular sequelae remain one of the major causes of death and disability worldwide, and the prevalence of hypertension in the US and Europe is high. Hypertension is a leading modifiable risk factor for cardiovascular events. Pharmacological approaches and lifestyle modification to treat hypertension early have been consistently shown to improve cardiovascular outcomes in primary and secondary prevention. Recent guidelines recommend initiating treatment at lower blood pressure levels, with normal blood pressure being defined as

Graphical abstract, Highlights • P-MAIVF is usually a complication of endocarditis or aortic valve surgery. • It is promptly recognized on transesophageal echocardiography. • It may cause symptoms and complications that warrant surgical intervention. • Surgical intervention remains the recommended management for P-MAIVF.

Background Pulmonary hypertension in the setting of renal transplantation has been associated with early allograft dysfunction and increased mortality, but this relationship has not been extensively studied. Methods We performed a retrospective cohort study of adult patients who underwent their first renal transplantation in the years 2003–2009 and had pre-transplantation echocardiograms. Pulmonary hypertension was defined as right ventricular systolic pressure ≥40 mm Hg in the absence of left-sided valvular disease and/or left ventricular ejection fraction ≤50%. Eighty-two of 205 patients (40%) met the inclusion criteria. The relationship between pulmonary hypertension and death-censored allograft failure (hemodialysis dependence or retransplantation) and serum creatinine was assessed with the use of Cox hazard regression and generalized mixed models. Results The presence of pulmonary hypertension was associated with a 3-fold increase in the risk of death-censored allograft failure (95% confidence interval, 1.20–7.32; P = .02). Failure rates were 19% at 24 months and 51% at 96 months for those with pulmonary hypertension versus 7% at 24 months and 20% at 86 months for those without pulmonary hypertension ( P = .01). Among those without graft failure, there was an increase in creatinine levels after transplantation ( P = .01). Effect estimates were unchanged by adjustment for multiple covariates and when pulmonary hypertension was defined as right ventricular systolic pressure ≥36 mm Hg. Conclusions Pulmonary hypertension before renal transplantation carries a 3-fold increased risk of death-censored allograft failure. The relationship between the pulmonary circulation and renal allograft failure warrants further study.

Acute rheumatic fever and rheumatic valvular disease remain prevalent in many parts of the world, and are probably the most common cause of heart disease in pregnancy. Mitral stenosis is the most frequently encountered rheumatic valvular lesion. A variety of pregnancy-associated cardiovascular changes often exacerbate the signs and symptoms of valvular lesions. Pregnancy should not be allowed to proceed, if possible, in patients with uncorrected severe valvular lesions or mechanical heart valves requiring anticoagulation, as maternal and fetal morbidity and mortality are high. For those with milder disease, pregnancy is best undertaken after the valvular lesion has been rectified or stabilised. Recent advances in the management of valvular disease include the use of beta-blockers for patients with mitral stenosis, vasodilators in those with aortic and mitral regurgitation, and percutaneous balloon valvuloplasty for mitral and aortic stenosis. Application of these therapies in the pregnant patient is as yet unclear, and management decision needs to be individualized, weighing the risk and benefit to ensure maternal survival and to promote fetal well-being.

OBJECTIVE To evaluate the performance of B-type natriuretic peptide as a diagnostic tool for heart failure in pregnant or postpartum women with singleton gestations. METHODS We conducted a retrospective study of diagnostic accuracy. We identified pregnant and postpartum women with B-type natriuretic peptide and echocardiography performed at an obstetric teaching hospital from 2007 to 2018. Women with known cardiac disease or multiple gestation were excluded. A panel of two cardiovascular disease experts, blinded to B-type natriuretic peptide values, determined the diagnosis of heart failure by consensus. Their judgement was based on detailed clinical features and parameters at the time of presentation with suspected heart failure. Where consensus could not be reached, differences were adjudicated by a third expert. A receiver operating characteristic curve estimated the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of B-type natriuretic peptide at various thresholds. RESULTS In total, 22 pregnant and 38 postpartum women were included in the cohort. Average age was 32±6.8 years. The most common clinical features at the time of presentation with suspected heart failure included preeclampsia (33/60, 55%), dyspnea (50/60, 83%), chest discomfort (34/60, 58%), and bilateral lower extremity edema (32/60, 53%). In total, 39 (65%) women had heart failure. The median B-type natriuretic peptide level was 326 pg/mL (interquartile range 200.5-390.5) in women with heart failure, as compared with 75.5 pg/mL (interquartile range 19-245) in women without heart failure (P

Background and Purpose— Left atrial enlargement has been shown to be associated with ischemic stroke, but the association with embolic stroke mechanisms remains unknown. We aim to study the associations between left atrial volume index (LAVI) and embolic stroke subtypes and atrial fibrillation (AF) detection on cardiac event monitoring in patients with embolic stroke of unknown source. Methods— Data were collected from a prospective cohort of consecutive patients with ischemic stroke admitted to a comprehensive stroke center over 18 months. Stroke subtype was classified into cardioembolic stroke, noncardioembolic stroke of determined mechanism (NCE), or embolic stroke of undetermined source (ESUS). Univariate and prespecified multivariable analyses were performed to assess associations between LAVI and stroke subtype and AF detection in patients with ESUS. Results— Of 1224 consecutive patients identified during the study period, 1020 (82.6%) underwent transthoracic echocardiography and had LAVI measurements. LAVI was greater in patients with cardioembolic stroke than NCE (41.4 mL/m 2 ±18.0 versus 28.6 mL/m 2 ±12.2; P 2 ±12.6 versus 28.6 mL/m 2 ±12.2; P =0.61). In multivariable logistic regression models, LAVI was greater in cardioembolic stroke versus NCE (adjusted odds ratio per mL/m 2 , 1.07; 95% CI, 1.05–1.09; P 2 , 1.00; 95% CI, 0.99–1.02; P =0.720). Among 99 patients with ESUS who underwent cardiac monitoring, 18.2% had AF detected; LAVI was independently associated with AF detection in ESUS (adjusted odds ratio per mL/m 2 , 1.09; 95% CI, 1.02–1.15; P =0.007). Conclusions— LAVI is associated with cardioembolic stroke as well as AF detection in patients with ESUS, 2 subsets of ischemic stroke that benefit from anticoagulation therapy. Patients with increased LAVI may be a subgroup where anticoagulation may be tested for stroke prevention.

Background and purpose The current left atrial appendage (LAA) classification system (cLAA-CS) categorizes it into 4 morphologies: chicken wing (CW), windsock, cactus, and cauliflower, though there is limited data on either reliability or associations between different morphologies and stroke risk. We aimed to develop a simplified LAA classification system and to determine its relationship to embolic stroke subtypes. Methods Consecutive patients with ischemic stroke from a prospective stroke registry who previously underwent a clinically-indicated chest CT were included. Stroke subtype was determined and LAA morphology was classified using the traditional system (in which CW = low risk) and a new system (LAA-H/L, in which low risk morphology (LAA-L) was defined as an acute angle bend or fold from the proximal/middle portion of the LAA and high risk morphology (LAA-H) was defined as all others). As a proof of concept study, we determined reliability for the two classification systems, and we assessed the associations between both classification systems with stroke subtypes in our cohort and previous studies. Results We identified 329 ischemic stroke patients with a qualifying chest CT (126 cardioembolic subtype, 116 embolic stroke of undetermined source (ESUS), and 87 non-cardioembolic subtypes). Intra- and inter-rater agreements improved using the LAA-H/L (0.95 and 0.85, respectively) vs. cLAA-CS (0.50 and 0.40). The LAA-H/L led to classifying 69 LAA morphologies that met criteria for CW as LAA-H. In fully adjusted models, LAA-H was associated with cardioembolic stroke (OR 5.4, 95%CI 2.1–13.7) and ESUS (OR 2.8 95% CI 1.2–6.4). Non-CW morphology was also associated with embolic stroke subtypes, but the effect size was much less pronounced. Studies using the cLAA-CS yielded mixed results for inter- and intra-rater agreements but most showed an association between a non-CW morphology and stroke with no difference among the three non-CW subtypes. Conclusion The LAA-H/L classification system is simple, has excellent intra and inter-rater agreements, and may help risk identify patients with cardioembolic stroke subtypes. Larger studies are needed to validate these findings.

Background: The left atrial appendage (LAA) is the main source of thrombus in atrial fibrillation (AF); biomarkers of LAA dysfunction are associated with ischemic stroke (IS) risk in patients with AF. We hypothesized that high risk LAA features [High risk morphology (LAA-H), LAA volume (LAAV), and LAA orifice surface area (LAAOSA)] would be more prevalent among patients with cardioembolic (CE) stroke and embolic stroke of undetermined source (ESUS) than among those with non-cardioembolic stroke (NCS). Methods: Consecutive patients with IS from a prospective comprehensive stroke center registry who previously underwent a clinically-indicated qualifying chest CT were included. Patients underwent inpatient diagnostic evaluation for ischemic stroke, and stroke subtype was determined based on ESUS criteria. LAA morphology [Low risk morphology was defined as two lobes with an acute angle between them or chicken wing morphology and LAA-H defined as all others], LAAOSA (measured in a plane parallel to the left atrium), and LAAV (measured using a volumetric analysis software) were determined using contrast enhanced thin-slice chest CT (≤2.5 mm thickness) by investigators blinded to stroke subtype. Results: Of 1234 patients with ischemic stroke, 329 (26.7%) patients had a qualifying chest CT performed (126 CE, 116 ESUS, and 87 NCS). The baseline characteristics of patients with and without chest CT were similar. When compared to NCS, LAA-H was more prevalent in ESUS (86.4% vs. 70.1%, p=0.018) and CE stroke (82.5% vs. 70.1%, p=0.042). The LAAOSA and volume did not significantly differ between the 3 groups (Table). Conclusion: LAA characteristics associated with cardioembolic stroke are also more prevalent in patients with ESUS. Larger studies are needed to confirm that LAA features are a risk factor for stroke among patients without AF, and whether anticoagulation is effective in patients with high-risk LAA features.

PURPOSE: Ischemic mitral regurgitation (iMR) augments risk for right ventricular dysfunction (RV(DYS)). Right and left ventricular (LV) function are linked via common coronary perfusion, but data is lacking regarding impact of LV ischemia and infarct transmurality – as well as altered preload and afterload – on RV performance. METHODS: In this prospective multimodality imaging study, stress CMR and 3-dimensional echo (3D-echo) were performed concomitantly in patients with iMR. CMR provided a reference for RV(DYS) (RVEF

While studies have stratified cardioembolic (CE) stroke risk by qualitative left atrial appendage (LAA) morphology and biomarkers of atrial dysfunction, the quantitative properties that underlie these observations are not well established. Accordingly, we hypothesized that LAA volume and contrast density (attenuation) on computerized tomography (CT) may capture the structural and hemodynamic processes that underlie CE stroke risk.Data were collected from a single center prospective ischemic stroke database over 18 months and included all patients with ischemic stroke who previously underwent routine, nongated, contrast enhanced thin-slice (≤2.5 mm) chest CT. Stroke subtype was determined based on the inpatient diagnostic evaluation. LAA volume and attenuation were determined from CT studies performed for various clinically appropriate indications. Univariate and multivariable analyses were performed to determine factors associated with ischemic stroke subtype, including known risk factors and biomarkers, as well as LAA density and morphologic measures.We identified 311 patients with a qualifying chest CT (119 CE subtype, 109 Embolic Stroke of Undetermined Source (ESUS), and 83 non-CE). In unadjusted models, there was an association between CE (versus non-CE) stroke subtype and LAA volume (OR per mL increase 1.15, 95% CI 1.07-1.24, P.001) and LAA density (4th quartile versus 1st quartile; OR 2.95, 95% CI 1.28-6.80, P = .011), but not with ESUS (versus non-CE) subtype. In adjusted models, only the association between LAA density and CE stroke subtype persisted (adjusted OR 3.71, 95% CI 1.37-10.08, P = .010).The LAA volume and density values on chest CT are associated with CE stroke subtype but not ESUS subtype. Patients with ESUS and increased LAA volume or attenuation may be a subgroup where the mechanism is CE and anticoagulation can be tested for secondary stroke prevention.

Functional tricuspid regurgitation (FTR) is a maker increased mortality and is frequently associated with left-sided heart disease, RV failure and annulus dilation. However, FTR surgical interventions may not change patient outcomes. A single center, retrospective chart review of 32 patients who

Bicuspid aortic valve (BAV) is a common congenital defect. This is a unique case of a patient with concomitant severe aortic regurgitation across a BAV and severe mitral regurgitation, presenting in shock. 55-year-old male with known BAV but no follow-up for 6 years, presented with two days of

Rapid diagnosis of Brugada syndrome is critical to therapy, which is aimed at reversing provoking factors to suppress/terminate malignant arrhythmias.…, Rapid diagnosis of Brugada syndrome is critical to therapy, which is aimed at reversing provoking factors to suppress/terminate malignant arrhythmias. This case highlights the diagnosis and peri-operative management of patients with Brugada syndrome at high risk for sudden cardiac death. (Level of Difficulty: Beginner.), Graphical abstract

Background The role of warfarin in anterior ST-segment elevation myocardial infarction (STEMI) complicated by left ventricular (LV) dysfunction in patients treated with primary percutaneous coronary intervention (PCI) and dual antiplatelet therapy is unclear. Warfarin may prevent cardioembolic events but significantly increases bleeding in the setting of dual antiplatelet therapy. Hypothesis The incidence of LV thrombus in anterior STEMI patients treated with PCI is low, and clinical predictors might be valuable in determining patients at risk. Methods We performed a retrospective, single-center study of 687 consecutive patients with anterior STEMI treated with PCI from 2006 to 2013. Baseline variables were evaluated in 310 patients at high risk for LV thrombus based on echocardiographic criteria. Patients with definite, probable, and no LV thrombus were compared by ANOVA, χ(2), or t test where appropriate. Logistic regression analysis was performed. Results The incidence of LV thrombus was 15% (n = 47 probable/definite thrombus). Cardiac arrest was the only independent characteristic associated with increased risk of LV thrombus (odds ratio [OR]: 4.06, 95% confidence interval [CI]: 1.3-12.7). Trends were observed for a lower risk in cardiogenic shock (OR: 0.33, 95% CI: 0.10-1.05) and aspirin use at baseline (OR: 0.43, 95% CI: 0.17-1.1). Treatment variables associated with LV thrombus included unfractionated heparin use post-PCI (OR: 2.43, 95% CI: 1.16-5.1) and use of balloon angioplasty without stent. Conclusions In contemporary practice with primary PCI, definite LV thrombus following anterior STEMI with LV dysfunction is challenging to predict. Further investigation is needed to determine if there is a subset of patients that should be treated with prophylactic warfarin.

Human immunodeficiency virus (HIV) infection is a risk factor for pulmonary hypertension (PH). Chronic hepatitis C virus (HCV) infection may have unique or synergistic effects on the pulmonary vasculature, but the prevalence and risk factors for PH in HIV-HCV coinfected persons are not known.To define the prevalence of echocardiographic PH in a cohort of patients with HIV-HCV coinfection, to compare this estimate with the reported prevalence of PH among those with HIV infection alone, and to identify potential risk factors for PH in coinfected individuals.We performed a retrospective study of HIV-HCV coinfected patients followed at our institution from 2003 to 2012 with evidence of HCV infection (positive HCV antibody, measurable HCV ribonucleic acid viral load, and/or genotype) within 6 months of transthoracic echocardiogram. PH was defined by an estimated pulmonary artery systolic pressure (PASP) of greater than or equal to 40 mm Hg or more than moderate right ventricular dysfunction. We excluded those diagnosed with cirrhosis, left ventricular ejection fraction less than 50%, or more than moderate aortic or mitral valve disease.Sixty-eight patients were included, and 43 had adequate estimates of PASP. The median (interquartile range) age was 52 (48-57) years, and 45 (67%) were men. Eight (19%) had PH, and three (7%) had more than moderate right ventricular dysfunction. After age and sex adjustment, interferon (IFN)-based HCV treatment was associated with higher PASP (β, 6.00 mm Hg; 95% confidence interval, 0.09-11.90; P = 0.047) and with the risk of PH (odds ratio, 5.65; 95% confidence interval, 1.07-29.93; P = 0.042). These associations persisted after adjustment for comorbidities but were attenuated by adjustment for duration of HCV diagnosis.The prevalence of echocardiographic PH may be higher in HIV-HCV coinfected individuals than in those with HIV monoinfection. IFN-based HCV treatment and time since HCV diagnosis were associated with the development of PH as assessed by echocardiography. Further studies are needed to examine HIV-HCV coinfection, HCV treatment, and duration of infection as possible causes of pulmonary vascular disease.

Hypertension may increase risk for dementia possibly because of its association with decreased cortical thickness. Disturbed cerebral autoregulation is one plausible mechanism by which hypertension impacts the cerebral structure, but the associations among hypertension, brain perfusion, and cortical thickness are poorly understood. The current sample consisted of 58 older adults with varying levels of vascular disease. Diagnostic history of hypertension and antihypertensive medication status was ascertained through self-report, and when available, confirmed by medical record review. All participants underwent arterial spin labeling and T1-weighted magnetic resonance imaging to quantify total and regional cortical perfusion and thickness. Analysis of covariance adjusting for medical variables showed that participants with hypertension exhibited reduced temporal and occipital brain perfusion and total and regional cortical thickness relative to those without hypertension. The effects of hypertension on total brain perfusion remained unchanged even after adjustment for age, although no such pattern emerged for cortical thickness. Decreased total brain perfusion predicted reduced thickness of the total brain and of the frontal, temporal, and parietal lobe cortices. Antihypertensive treatment was not associated with total cerebral perfusion or cortical thickness. This study provides initial evidence for the adverse effects of a diagnostic history of hypertension on brain hypoperfusion and reduced cortical thickness. Longitudinal studies are needed to investigate the role of hypertension and its interaction with other contributing factors (eg, age) in the manifestation of cerebral hypoperfusion and reduced cortical thickness.

Objective This study examined the geometric changes of the mitral valve (MV) after repair using conventional and three-dimensional echocardiography. Design Prospective evaluation of consecutive patients undergoing mitral valve repair. Type of hospital Tertiary care university hospital. Participants Fifty consecutive patients scheduled for elective repair of the mitral valve for regurgitant disease. Interventions Intraoperative transesophageal echocardiography. Measurements Assessments of valve area (MVA) were performed using two-dimensional planimetry (2D-Plan), pressure half-time (PHT), and three-dimensional planimetry (3D-Plan). In addition, the direction of ventricular inflow was assessed from the three-dimensional imaging. Main Results Good correlations (r = 0.83) and agreement (−0.08 +/− 0.43 cm 2 ) were seen between the MVA measured with 3D-Plan and PHT, and were better than either compared to 2D-Plan. MVAs were smaller after repair of functional disease repaired with an annuloplasty ring. After repair, ventricular inflow was directed toward the lateral ventricular wall. Subgroup analysis showed that the change in inflow angle was not different after repair of functional disease (168 to 171 degrees) as compared to those presenting with degenerative disease (168 to 148 degrees; p Conclusions Three-dimensional imaging provides caregivers with a unique ability to assess changes in valve function after mitral valve repair.

Brugada syndrome is an inherited channelopathy that conveys an increased risk of sudden cardiac death (SCD). Baseline ECG may be normal, confounding the diagnosis. Provoking factors may be required to unmask the Brugada ECG pattern. A 50 year old woman with HTN and HLD presented with fever and

Left atrial (LA) diameter is easily attainable from echocardiograph and sensitive to underlying cardiovascular disease severity, although its association with neurocognitive outcomes is not well understood. Fifty older adults (64.50 ± 9.41 years), recruited from outpatient cardiology clinics and local papers who underwent magnetic resonance imaging, were administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and completed psychosocial self-report measures. LA diameter was quantified using echocardiogram. Hierarchical regression analyses revealed that greater LA size was independently associated with reduced performance on the following RBANS composites: language, delayed memory, and total index (p0.05 for all). Hierarchical regression analysis demonstrated no significant association between LA diameter and whole brain volume (p0.05). The current study suggests that greater LA size is associated with cognitive dysfunction in older adults and prospective studies are needed to validate these findings and elucidate underlying mechanisms.

HE NORMAL NATIVE MITRAL VALVE exists in a dynamic balance involving all components of the apparatus to provide optimal coaptation during ventricular systole and minimal resistance to forward flow during ventricular diastole. The repaired myxomatous mitral valve has a similar balance, but with different annular and leaflet dimensions. Most commonly, repairs include resection and reduction of the posterior leaflet (PL) and a reduction annuloplasty, with or without repair of the anterior leaflet (AL). Green et al 1 described the postrepair PL as restricted, acting to buttress the coapting AL. Functionally, this repaired valve appears like a “unicuspid valve,” which relies heavily on a normally functioning AL. 1,2 Although not a new concept, there has been renewed interest in preserving and repairing a prolapsing PL (“respect rather than resect” [RRR]). 3-7 Proponents of RRR seek to treat the prolapse and return the PL toward a normal dimension, yielding a bileaflet valve, with a larger diastolic area and a larger coapting surface. 3-7 Whether RRR involves preservation of the entire PL 3,5-7 or a combination of resection and preservation 4 is decided case by case. The authors present 3 patients in whom repair and preservation of the PL were performed. These 3 cases represent the authors’ initial experience with the placement of new chordae to repair the PL. Two patients developed systolic anterior motion (SAM) with left ventricular outflow tract obstruction (LVOTO) and mitral regurgitation (MR), one immediately after cardiopulmonary bypass (CPB) and the other in the postoperative period. In the third patient, hemodynamic assessment showed mitral stenosis. For all 3 patients, the authors speculate that the complications were the result of excess postrepair leaflet tissue below the annular plane. CASE REPORTS Case 1 An 80-year-old woman presented with myxomatous mitral valve disease, severe MR, and a history of congestive heart failure and was scheduled for valve repair. Transesophageal echocardiography (TEE) immediately before CPB visualized a torn posterior (P) chordae, flail of the P3, and prolapse of P2 leaflet scallops (Fig 1). The AL appeared to have myxomatous changes but did not prolapse. Risk assessment for postrepair SAM was based on previously published data8 and included ratios of the systolic heights of the AL and PL (AL/PL; 0.9) and the distance from the mitral coaptation point to the proximal ventricular septum (CSEPT; 2.0 cm). Based on these data (AL/PL 1.4; CSEPT 2.5 cm), this patient was at risk for postrepair SAM and LVOTO.8

Aims: The present study examines cognitive function among transcription factor 7-like 2 (TCF7L2) genotype groups in a sample of older adults with cardiovascular disease. Methods: We recruited 111 older adults with diagnosed cardiovascular disease from outpatient cardiology clinics. Neuropsychological tests assessed the following domains of cognitive functioning: global function, attention/executive/psychomotor speed, learning and memory, visuospatial/construction, motor, and language. Genotyping of TCF7L2 single nucleotide polymorphism rs7903146 was conducted to determine membership in the TT, CT, or CC genotype groups. Results: Controlling for diabetes status, participants with the TT genotype of TCF7L2 (n= 12) performed worse on tests of attention/executive function/processing speed than those with the CC (n= 46) and CT (n= 53) genotypes, despite no between-group differences in demographic or medical variables. Conclusions: Older cardiovascular disease patients with the TCF7L2 TT genotype performed worse on tests of attention/executive/ psychomotor speed than CC and CT genotype carriers. Further work using neuroimaging and glucose tolerance indices is needed to clarify underlying mechanisms.

OBJECTIVE: To prospectively investigate whether baseline findings on specific cardiovascular indices are predictive of subsequent rate of decline in Attention-Executive-Psychomotor function in a cohort of ambulatory older adults with cardiovascular diseases (CVDs). METHODS: One hundred seventy-two older adults with CVD were administered a neuropsychological battery of executive functions tests at study entry, and at 12 and 36 months thereafter. At study entry, they also underwent vascular assessments including cardiac output, ejection fraction, blood pressure (BP), brachial artery reactivity, and carotid intima media thickness. Random coefficient regressions were used to investigate the effect of these cardiac indices on rate of decline in Attention-Executive-Psychomotor function. RESULTS: Cardiac output, systolic BP variability, and diastolic BP variability predicted decline in Attention-Executive-Psychomotor function. Specifically, lower cardiac output, reduced variability in systolic BP, and increased variability in diastolic BP were associated with a faster rate of decline in Attention-Executive-Psychomotor function. Mean resting systolic and diastolic blood pressure did not predict decline in Attention-Executive-Psychomotor function. CONCLUSIONS: Decline in frontal-subcortical cognitive functions among patients with CVDs appears to be mediated by systemic hypoperfusion and variability in blood pressure. The precise nature of these relationships, especially with regard to blood pressure variability, is complex and demands continued investigation.

Background: Cardiovascular disease has long been associated with poor neurocognitive outcome, with multiple pathophysiological mechanisms that are linked to cognitive impairment in older adults. Although less frequently examined, insulin dysregulation is known to affect vascular function and the associated brain dysfunction in cardiovascular disease. Accordingly, genetic factors tied to insulin regulation may make certain people with cardiovascular disease more susceptible to cognitive dysfunction. Specifically, the calmodulin-binding transcription activator 1 (CAMTA1) genotype, which has been examined as a risk factor for Type 2 diabetes and has been linked to reduced episodic memory performance in healthy young adults, is a potential candidate gene. Methods: Blood samples were obtained from 113 older adults with cardiovascular disease who also underwent neuropsychological testing. Carriers of either one or two copies of the T allele of CAMTA1 were categorized into one group (n= 63), whereas non-carriers were categorized into a second group (n= 50). Results: Analyses showed that carriers of the T allele performed more poorly on tests of attention, executive function, and psychomotor speed, but not on tests of memory. Carriers of the T allele also performed more poorly on a measure of global cognitive function. Conclusions: Results indicate that CAMTA1 genotype is associated with cognitive function in older adults with cardiovascular disease, because carriers of the T allele performed more poorly on tests of attention, executive function, and psychomotor speed. Contrary to expectations, there were no differences in memory performance among carriers and non-carriers of the T allele. Given these mixed findings, further studies are necessary to elucidate the association between CAMTA1 and cognition, particularly gene expression and neuroimaging studies.

A 37-year-old woman (body surface area 1.75 m2) was monitored using standard American Society of Anesthesiologists noninvasive monitors, intra-arterial and pulmonary artery catheters, and transesoph- ageal echocardiography (TEE). Baseline hemodynamic data are shown in Table 1. At the time of surgery, she was in a normal sinus rhythm. Before CPB, the examination showed diffuse bileaflet myxomatous dis- ease including prolapse of all scallops. There was severe mitral regur- gitation. The left ventricular ejection fraction was estimated to be 55%. Right ventricular function also was reduced. The remainder of the examination was not remarkable. The surgical procedure consisted of plication of P1 and P3, resection of P2, and placement of commissural sutures between A1 and P1 and between A3 and P3. Neochordae were placed to reduce the prolapsing middle anterior leaflet scallop. A 28-mm flexible Carpentier-Edwards (Irvine, CA) annuloplasty ring was placed. To facilitate separation from CPB, an epinephrine infusion was begun. Echocardiographic measurements and calculations of mitral valve

Purpose In patients with heart failure, reduced cardiac ejection fraction has been associated with impaired cognition. Improving cardiac function may have beneficial effects on cognition; however, no controlled intervention studies have examined this possibility. Cardiac resynchronization therapy (CRT) is one intervention that has been shown to increase cardiac function. The goals of the current study were to (1) evaluate neuropsychological performance before and 3 months after crt and (2) examine follow-up neuropsychological performance of patients classified on the basis of extent of improved left ventricular ejection fraction (LVEF). Methods Twenty-seven patients with moderate to severe heart failure completed a neuropsychological assessment, 6-minute walk test, and transthoracic echocardiography before and 3 months after CRT. Patients were classified on the basis of improvement in LVEF. Results of a multivariate analysis of variance revealed a significant effect of improvement in LVEF on change in cognition (Wilks Λ, P = .031). Results Patients with improved LVEF demonstrated significant increases on measures of executive functioning (F = 8.57, P = .007) and visuospatial function (F = 7.52, P = .011) and less decline on global cognition (F = 5.73, P = .024) than those without LVEF improvement. Conclusions Findings provide preliminary evidence that improved LVEF in response to CRT is associated with enhanced cognitive outcomes within 3 months of CRT. Patients with improved LVEF showed better outcomes on measures of executive functioning, global cognition, and visuospatial functioning. Future, controlled, large-scale trials will be necessary to determine whether there is an underlying causal relationship linking increase in LVEF and cognition.

Bicuspid aortic valve (BAV)-associated aortopathy is a complex phenomenon, and the current lack of univocal interpretation of its causes and treatment can be ascribed to the multiform nature of its clinical presentation. Although there is strong bias in the literature favoring more aggressive treatment of ascending aortic dilatation in patients with BAV, evidence supporting this opinion is lacking. This review discusses some of the relevant issues relating to causation to facilitate a better analysis of the current recommendations used to guide surgical management, and concludes that treatment should be tailored by individual valvular pathology, clinical phenotype, and relevant comorbidities, using well-documented evidence-based clinical size criteria.

Mitral regurgitation (MR) is a nidus for RV dysfunction (RVdys) - a known poor prognostic marker. Echocardiography (echo) is widely used to screen for RVdys but relative utility of established and emerging echo approaches is unknown. Population comprised ischemic MR (iMR) pts undergoing a

Cardiovascular disease in women during pregnancy poses particular challenges. It continues to be a leading cause of maternal mortality and contributes to significant morbidity. Echocardiography is essential in characterizing the extent and effects of heart disease prior to, during, and after pregnancy. By understanding the physiologic adaptation in pregnancy with increases in heart rate, blood volume, and cardiac output, and decrease in vascular resistance, one can anticipate and recognize the effects of these changes on various cardiac lesions. Cardiomyopathy, severe, obstructive valvular disease, aortic dilation due to Marfan's disease, and cyanotic congenital heart disease are poorly tolerated in pregnancy. These disorders can be readily distinguished from normal structural changes of pregnancy and their severity assessed by echocardiography. Cardiovascular disease in women of reproductive age requires careful, multidisciplinary management by obstetric and medical teams ideally beginning preconception and continuing through the postpartum period.

Inflammatory, noninfectious aortitis is an unusual cause of aortic regurgitation and ascending aortic aneurysm formation, occurring in

Past studies link elevated blood pressure (BP) and BP variability to adverse neurocognitive changes in community samples. However, little is known about the relationship between BP indices and cognitive function in older CVD patients.A total of 99 older adults with CVD completed a comprehensive neuropsychological test battery. Resting BP measurements were collected every 10 min for 2 hr during a separate cardiac assessment. Five BP indices were generated: average and standard deviation of systolic blood pressure (SBP), average and standard deviation of diastolic blood pressure (DBP), and a function of systolic variability and average diastolic pressure. We examined the relationship between these BP indices and cognitive function.Partial correlation adjusting for age and education revealed that the function of systolic variability and average diastolic pressure (SBP standard deviation divided by the average DBP) was most closely related to test performance, showing significant associations to both Learning/Memory (r = 0.25) and Language functioning (r = 0.22). SBP indices were also related to Language functioning (SBP avg., r = 0.22; SBP SD, r = 0.25), though DBP indices were unrelated to performance in any cognitive domain.The current findings indicate that BP is modestly related to cognitive function in older CVD patients. Contrary to expectations, greater BP variability was associated with better, not poorer, cognitive test performance. Such findings suggest that the relationship between BP and cognitive function is more complicated than typically believed and requires further examination.

Cardiovascular disease (CVD) is associated with cognitive deficits even in the absence of stroke. We examined the relationship between cardiac performance, as measured by cardiac output (CO) and ejection fraction (EF), and brain activity during a verbal working memory (VWM) task in elderly CVD patients who tend to be at increased risk for vascular cognitive impairments. Seventeen patients were recruited from a cohort participating in an ongoing prospective study examining the effects of CVD on cognitive function in the elderly. Participants were diagnosed with CVD (age 68 ± 8) and completed a 2-back VWM task in a 1.5T fMRI paradigm. CO and EF were calculated from echocardiogram measures. Task-related activation was averaged in a priori regions of interest. The relationship between CO, EF, and 2-back-related activity was modeled using partial correlations (two-tailed p < .05) controlling for age and 2-back accuracy. All participants were globally cognitively intact as indicated by Mini-Mental Status Exam and Dementia Rating Scale scores. Mean accuracy on the 2-back was 78 ± 9% while reaction time averaged 1,027 ± 192 ms. Mean CO and EF values showed a large range (CO: 3.55 to 6.31; EF: 0.36 to 0.76) but average values were within the normal range. After controlling for age and 2-back accuracy, lower EF was related to decrease in left insula activity (r = 0.61, p = 0.03). There were trends for EF to be related to accuracy (r = 0.47, p = 0.09) and reaction time (r = −0.48, p = 0.09). CO was also related to insula activity (r = 0.60, p = 0.04) and activity in the supplementary motor area activity (r = 0.66, p = 0.01). Cardiac performance was related to decreased efficiency in task related brain areas and tended to be related to performance on a VWM task in elderly patients with CVD. Results have implications for a line of investigation indicating that cardiac and systemic vascular indices could be used as proxy measures to examine mechanisms of cerebrovascular dysfunction in the elderly.

Young women may have asymptomatic mitral valve disease which becomes unmasked during the haemodynamic stress of pregnancy. Rheumatic mitral stenosis is the most common cardiac disease found in women during pregnancy. The typical increased volume and heart rate of pregnancy are not well tolerated in patients with more than mild stenosis. Maternal complications of atrial fibrillation and congestive heart failure can occur, and are increased in patients with poor functional class and severe pulmonary artery hypertension. Patients can be diagnosed by echocardiography and symptoms treated with beta-1 antagonists and cautious diuresis. Patients with heart failure unresponsive to treatment can undergo percutaneous balloon mitral valvuloplasty. Labour and delivery goals include reducing tachycardia by adequate pain control and minimized volume shifts. Mitral valve regurgitation, even when severe, is usually very well tolerated in pregnancy as the increase in volume is offset by a decrease in vascular resistance. On the other hand, patients with left ventricular dysfunction, moderate pulmonary hypertension or NYHA functional class III-IV are at increased risk for heart failure and arrhythmias. They may need cautious diuresis and limitations on physical activity during pregnancy, as well as invasive haemodynamic monitoring for labour and delivery. Vaginal delivery is preferred and caesarean section reserved for obstetric indications.

This study examines the relationship between systemic vascular function, neurocognitive performance, and structural brain abnormalities on magnetic resonance imaging (MRI) among geriatric outpatients with treated, stable cardiovascular disease and no history of neurological illness (n = 88, ages 56-85 years). Vascular function was assessed by cardiac ejection fraction and output, sequential systolic and diastolic blood pressures, flow mediated brachial artery reactivity (BAR), and carotid intima media thickness (IMT). White matter hyperintensities (WMH) on MRI were quantified and examined relative to cognitive and vascular function. Principal component analysis revealed two primary vascular components: one associated with cardiac function, the other with atherosclerotic burden/endothelial dysfunction. Both factors were significantly associated with cognitive function and WMH volume. Reduced systolic variability and increased IMT were most strongly related to reduced attention, executive function, and information-processing speed. These findings suggest the possibility that systemic vascular indices may provide proxy measures of cerebrovascular dysfunction and reinforce the importance of achieving greater understanding of interaction between systemic vascular disease and brain dysfunction among elderly people with cardiovascular disease.

Increased carotid artery intima-media thickness (IMT) is a non-invasive marker of systemic arterial disease. Increased IMT has been associated with atherosclerosis, abnormal arterial mechanics, myocardial infarction, and stroke. Given evidence of a relationship between cardiovascular health and attention-executive-psychomotor functioning, the purpose of this study was to examine IMT in relation to neuropsychological test performance in patients with a variety of cardiovascular diagnoses.One hundred and nine participants, ages 55 to 85, underwent neuropsychological assessment and B-mode ultrasound of the left common carotid artery. IMT was calculated using an automated algorithm based on a validated edge-detection technique. The relationship between IMT and measures of language, memory, visual-spatial abilities and attention-executive-psychomotor functioning was modeled using hierarchical linear regression analyses adjusted for age, education, sex, cardiovascular risk, current systolic blood pressure, and history of coronary artery disease (CAD).Increased IMT was associated with significantly lower performance in the attention-executive-psychomotor domain (IMT beta=-0.26, p.01), independent of age, education, sex, cardiovascular risk, current systolic blood pressure, and CAD (F(10,100)=3.61, p.001). IMT was not significantly related to language, memory, or visual-spatial abilities.Our findings suggest that, in patients with cardiovascular disease, IMT may be associated with the integrity of frontal subcortical networks responsible for attention-executive-psychomotor performance. Future studies are needed to clarify the mechanisms by which IMT affects cognition and examine potential interactions between increased IMT and other measures of cardiovascular health such as blood pressure variability, cardiac systolic performance, and systemic perfusion.

OBJECTIVES: To preliminarily examine the association between cardiac output, a measure of systemic blood flow, and structural brain magnetic resonance imaging indices of white matter hyperintensities (WMHs). DESIGN: Cross-sectional. SETTING: University medical setting. PARTICIPANTS: Thirty-six older adults withoutdementia with prevalent cardiovascular disease (aged 56‐85). MEASUREMENTS: Cardiac output, WMHs. RESULTS: Partial correlations, adjusting for age and history of hypertension, yielded an inverse relationship between WMHs adjacent to subcortical nuclei and cardiac output (correlation coefficient 5 � 0.48, P 5.03); as cardiac output decreased, WMHs increased significantly. No significant associations were found between cardiac output and total WMHs or periventricular WMHs. CONCLUSION: These preliminary data suggest that systemic blood flow, measured according to cardiac output, is inversely associated with WMHs adjacent to the subcortical nuclei. Cerebrovascular degeneration and the chronicity of hypoperfusion may exacerbate the susceptibility of white matter integrity to alterations in blood flow in older adults. J Am Geriatr Soc 55:1044–1048, 2007.

Background and Purpose. Intimal–medial thickening (IMT) of the carotid wall is an accepted peripheral marker of atherosclerosis. It is associated with increased risk for myocardial infarction and stroke, and lower attention-executive-psychomotor functioning. The purpose of this study was to examine the relationship between IMT and brain activity during a verbal working memory (VWM) task in patients with cardiovascular disease (CVD). Methods. Thirteen CVD patients underwent functional magnetic resonance imaging (fMRI) during a 2-Back VWM task, and B-mode ultrasound of the carotid arteries. IMT was calculated using an automated algorithm based on a validated edge-detection technique. The relationship between IMT and 2-Back-related brain activity was modeled using partial correlations controlling for age and small vessel disease as measured by white matter signal hyperintensities on MRI (WMH). Results. Higher IMT was associated with lower 2-Back-related signal intensity and in the right middle frontal gyrus, independent of age and WMH. Conclusions. IMT may be one mechanism contributing to brain dysfunction in CVD. The blood oxygenation level-dependent (BOLD) contrast appears to be highly sensitive to peripheral vascular health as measured by IMT. Future studies should examine the sensitivity and specificity of the BOLD response for predicting cognitive decline in CVD.

Background and Purpose— The presence of white matter hyperintensities on brain MRI is common among elderly individuals. Previous research suggests that cardiovascular risk factors are associated with increased white matter hyperintensities. Examining the role of direct physiological measures of vascular function will help to clarify the vascular mechanisms related to white matter hyperintensities. The aim of the present study was to examine the association between endothelial-dependent and endothelial-independent vasodilatation and white matter hyperintensity volume. Methods— Twenty-five older adults with a range of cardiovascular diseases underwent brain MRI and completed assessments of blood vessel integrity using endothelial-dependent and independent flow-mediated dilation of the brachial artery. A semi-automated pixel-based method was used to quantify total brain volume and white matter hyperintensity volume, with white matter hyperintensity volume corrected for total brain volume. The association between measures of flow-mediated dilation and log-transformed white matter hyperintensities was examined. Results— Correlation analysis revealed that endothelial-dependent vasodilatation was significantly and inversely associated with white matter hyperintensity volume. In contrast, endothelial-independent vasodilatation was not associated with white matter hyperintensities. Neither endothelial-dependent nor endothelial-independent vasodilatation was associated with total brain volume. Conclusions— These data provide preliminary evidence that the integrity of the vascular endothelium is associated with white matter hyperintensities in older adults with cardiovascular disease. Impaired vascular function may be one mechanism that contributes to the development of white matter hyperintensities in the brain. Additional longitudinal research combining measures of vessel function, neuroimaging and cognition will be helpful in clarifying this potential mechanism.

C b w f c 4 OBUTAMINE STRESS echocardiography (DSE) has a dual purpose during the assessment of patients with severe eft ventricular systolic dysfunction (LVSD) and low-gradient ortic valve stenosis. First, the detection of viable myocardium nd, second, the differentiation between pseudoand fixed ortic valve stenosis, the latter being a condition in which the entricle does not eject forcefully enough to open the aortic eaflets fully (Table 1).1-11 For patients with severe fixed aortic tenosis (AS) and reversible LVSD, aortic valve replacement AVR) improves outcome.3-6 Conversely, for patients with ireversible LVSD, the perioperative mortality is high and the ong-term benefits of AVR are small.1,7-11 Differentiating beween pseudoand fixed AS helps to determine whether or not VR is indicated. Although intraoperative DSE has been reported for assessent of coronary artery disease (CAD), the intraoperative ssessment of aortic valve function using DSE has not been escribed.12-15 The authors describe 2 patients presenting emerently for coronary artery bypass graft (CABG) surgery who lso had suspected aortic valve pathology in which the intraperative use of DSE aided in surgical decision making.

Cardiovascular disease (CVD) is a risk factor for cognitive impairment and dementia. Recent studies implicate homocysteine (HCY) and C-reactive protein (CRP) in this increased risk, as both are associated with cognitive dysfunction in demented and non-demented patients. However, it remains unclear whether they confer added risk in older adults with CVD. A total of 126 older CVD patients underwent blood and neuropsychological evaluation as part of a prospective examination of the neurocognitive consequences of CVD. A subset of these participants (n = 37) also underwent neuroimaging to quantify the degree of white matter disease. After adjusting for demographic and medical factors, no significant relationship emerged between HCY and cognitive performance. In contrast, CRP showed significant independent relationships to test performance, including global cognitive performance, attention/psychomotor function, executive function, memory, and visuospatial abilities. Neither HCY nor CRP was related to extent of white matter disease or whole brain volume on magnetic resonance imaging. Further study is needed to identify mechanisms by which inflammatory processes impact on cognitive function and to determine whether reducing circulating levels of inflammatory markers results in improved cognition.

Objectives These studies were conducted to evaluate the feasibility of percutaneous left atrial appendage (LAA) occlusion using the PLAATO system (ev3 Inc., Plymouth, Minnesota). Background Patients with atrial fibrillation (AF) have a five-fold increased risk for stroke. Other studies have shown that more than 90% of atrial thrombi in patients with non-rheumatic AF originate in the LAA. Transvenous closure of the LAA is a new approach in preventing embolism in these patients. Methods Within two prospective, multi-center trials, LAA occlusion was attempted in 111 patients (age 71 ± 9 years). All patients had a contraindication for anticoagulation therapy and at least one additional risk factor for stroke. The primary end point was incidence of major adverse events (MAEs), a composite of stroke, cardiac or neurological death, myocardial infarction, and requirement for procedure-related cardiovascular surgery within the first month. Results Implantation was successful in 108 of 111 patients (97.3%, 95% confidence interval [CI] 92.3% to 99.4%) who underwent 113 procedures. One patient (0.9%, 95% CI 0.02% to 4.9%) experienced two MAEs within the first 30 days: need for cardiovascular surgery and in-hospital neurological death. Three other patients underwent in-hospital pericardiocentesis due to a hemopericardium. Average follow-up was 9.8 months. Two patients experienced stroke. No migration or mobile thrombus was noted on transesophageal echocardiogram at one and six months after device implantation. Conclusions Closing the LAA using the PLAATO system is feasible and can be performed at acceptable risk. It may become an alternative in patients with AF and a contraindication for lifelong anticoagulation treatment.

In the present study, we examined the relationships between whole brain volume (WBV), subcortical hyperintensities (SH), indices of cardiac disease and cognitive function in nondemented cardiac patients with evidence of mild cerebrovascular disease. A total of 27 individuals with evidence of cardiac disease underwent neuropsychological examination, neuroimaging, and cardiac assessment. Cognition was assessed with the Dementia Rating Scale-2 (DRS). WBV and SH were quantified using a semi-automated thresholding program based on MRI. Correlational analyses revealed that WBV predicted performance on the overall DRS score, the attention subscale and the initiation/perseveration scale. SH were significantly associated with performance on the attention subscale, and the initiation/perseveration subscale. Regression analyses revealed that SH accounted for most of the variance in the initiation/perseveration scale, whereas WBV accounted for most of the variance in the attention scale. The only cardiac structural or functional variable related to the neurological indices was aortic diameter, which was strongly related to both neuroimaging variables, as well as performances on the DRS attention and initiation/perseveration subscales. Our results highlight the importance of overall brain parenchyma in determining cognitive status among patients at risk for cognitive decline and suggest that select indices of structural cardiac morphology may be related to the early phases of cerebrovascular disease and cognitive status.

The present study examined the relationship between multiple blood pressure (BP) indices and white matter hyperintensities (WMH) in a sample of 39 older adults with cardiovascular disease (CVD). Resting BP was measured using an automated monitor every 10 min for 2 h. WMH were quantified on FLAIR images and separate indices were generated for neocortical, periventricular and subcortical brain regions. Correlation analyses revealed systolic BP variability was related to neocortical and total WMH. A function of systolic BP variability and average diastolic pressure showed the strongest relationships, including significant correlation to neocortical, subcortical and total WMH. No BP index was related to WMH in periventricular regions. Exploratory analyses showed only the function of systolic BP variability and average diastolic pressure predicted total WMH, whereas as age, CVD conditions and psychosocial factors did not. These findings demonstrate BP variability is an important contributor to WMH in older adults with CVD and suggests it may have differential relationships to WMH in different brain regions. Additional studies are needed to examine the role of autoregulatory systems in the development of WMH, particularly those using beat-to-beat measures of BP.