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Assessment of myocardial "blush" by either Myocardial Blush Grade or TIMI Myocardial Perfusion Grade, is the angiographic method currently preferred to confirm myocardial tissue-level perfusion after primary percutaneous intervention. This review focuses on the utility of angiographic "blush" as a simple, widely available, and virtually costless technique for the immediate diagnosis of microvascular impairment at the time of acute catheterization. We comprehensively outline the available evidence behind the "blush," its use in clinical practice, and draw comparisons with other new technologies for assessment of microvascular integrity.

To the Editor: We propose an alternative explanation to the findings reported by Moccetti et al.1 First, numerous biomechanical explanations of contrecoup injury have been proposed, such as the positive pressure, negative pressure, rotational shear stress, and angular acceleration theories.2,3 These theories relate to transmission of the deceleration force to a soft organ from the surrounding hard structures (eg, brain–skull, lung–ribs). The injury described …

A 62-year-old female with supraventricular tachycardia underwent a contrast echocardiogram to assess left ventricular structure and function due to sub-optimal images on conventional imaging. Multi-pulse, phase inversion, low mechanical index imaging was used (left ventricular opacification), combined with bolus dosing of a perflutren microsphere (Definity®). In the parasternal short-axis view, during contrast imaging, flow within a septal coronary artery could be directly visualized. The corresponding coronary angiogram demonstrated prominent septal perforators arising from the LAD artery. By exploiting the non-linear oscillation properties of microbubbles and the linear oscillation properties of tissue, at low MI, contrast-specific imaging has the ability to enhance the contrast signal while suppressing the myocardial signal. This form of contrast imaging has high temporal and spatial resolution, enabling visualization of relatively small structures in real time. Clinical relevance of this finding includes the ability to enhance coronary blood flow evaluation, which would have utility in those studies where spectral Doppler is being used to evaluate coronary blood flow and coronary flow reserve and it may be beneficial in the identification of septal perforator arteries that should be injected with alcohol during percutaneous septal ablation for the management of hypertrophic obstructive cardiomyopathy.

We report a case of spontaneous coronary artery rupture (SCAR) in a 43-year-old male who presented with symptoms of sudden onset of chest pain and hemodynamic collapse. There were no abnormal electrocardiogram changes and serum troponin was not detected. Acute aortic dissection was suspected but urgent contrast computed tomography (CT) showed a large pericardial effusion with cardiac tamponade. This was later confirmed on trans-oesophageal echocardiogram. The SCAR was seen intra-operatively as an isolated perforation of the posterior descending artery. The patient was successfully managed with direct repair under cardiopulmonary bypass. Postoperative multi-detector dual-source 64-slice CT coronary angiography revealed normal coronary arteries with absence of atherosclerotic plaque in all coronary arterial segments. It is concluded that, though rare, a differential diagnosis of SCAR should be considered in cases of acute chest pain with cardiac tamponade in adult patients of all ages.

Cardiac perforation and device erosion are infrequent but potentially lethal complications of percutaneous occluder device insertion. Transthoracic and transesophageal echocardiography (TEE) and gated cardiac computed tomography are useful in detecting this complication. In particular, TEE can detect characteristic features to confirm the diagnosis before rapid surgical correction. Deficient superior-anterior rim and encroachment of the occluder device on the posterior atrial wall are risk factors for device erosion. TEE performed before device insertion with awareness of manufacturer's guidelines for atrial geometry and device sizing may reduce the occurrence of this serious complication.

paravalvular mitral regurgitation (mr) after mitral valve replacement may lead to heart failure and hemolysis. There are data to suggest that closure of paravalvular mitral regurgitant leaks confers an improved prognosis, with reduced hemolysis and improved functional status ([1][1]). These patients

Background The second-generation contrast agent Definity ® (a perflutren microsphere) became available in Australia in mid-2007. We describe the introduction of contrast echocardiography into a high-volume quaternary teaching hospital, performing over 16,000 echocardiograms per year. Workflow protocols were developed for patient selection, contrast administration, and image acquisition and analysis. Methods Data were prospectively collected for all contrast cases. Endocardial definition scores were derived by three independent observers before and after contrast administration, and statistically compared. Results 161 patients received contrast in the first 12 months of the contrast program. There was statistically significant improvement in endocardial definition scores after contrast administration ( p =0.0001), and reduction in inter-observer variability of wall motion assessment. A number of clinically significant findings (pseudoaneurysm, non-compaction, thrombus) were detected on contrast echo that were not apparent on standard 2D imaging. Adverse events were rare (0.6%) with no life-threatening events. Conclusions The introduction of a second-generation contrast agent into clinical workflow in a hospital echocardiography department resulted in a statistically significant improvement in endocardial definition, and safely provided diagnostic imaging in cases which were otherwise non-diagnostic. Inter-observer variability was reduced, and diagnostic yield increased. These results reflect previously published data, and indicate that contrast echocardiography is feasible in Australian clinical practice.

This vignette illustrates a classic case of congenital mitral stenosis (Ruckman-VanPraagh type 1) presenting in adulthood and demonstrates the benefits of multimodality cardiac imaging prior to successful surgical intervention.

Pulmonary thromboembolism (PE) is the third most frequent cause of cardiovascular death after ischaemic heart disease and stroke. In fatal PE, 2/3 of patients die within first hour of presentation. There is a clinical impetus to rapidly recognize, risk-stratify and appropriately treat patients with acute severe PE. Current recommendations present conflicting classification systems, and there is often some confusion in the clinical evaluation and management of patients with acute severe PE. This review presents a series of real clinical cases, which illustrate the available treatment options, ranging from conservative therapy to thrombolysis through to percutaneous catheter fragmentation and open surgical embolectomy. We evaluate the evidence for the various strategies and propose an algorithm for clinicians with a focus on early risk stratification and timely referral. This is particularly relevant to regional and remote centres, as well as secondary and tertiary institutions.

Chromobacterium violaceum infection is uncommon but potentially fatal, with a clinical picture similar to melioidosis but with different antibiotic sensitivities and treatment. This infection can involve any organ, but we believe this is the first reported case of C. violaceum endocarditis.

We describe a series of cases referred to our institution with working diagnoses of chronic thrombo-embolic pulmonary hypertension (CTEPH) for consideration of surgical pulmonary thrombo-endarterectomy (PTE). Investigations in two cases revealed extrinsic compression of the pulmonary arteries from massive mediastinal lymphadenopathy (mediastinal fibrosis) due to underlying sarcoidosis. Angioplasty and stenting of the pulmonary arteries were performed in all cases with sustained haemodynamic and functional improvement. This highlights the value of new imaging modalities in delineating causes of pulmonary hypertension, and demonstrates an interventional approach for selected cases.

A 39-year-old man was referred with a history of progressive shortness of breath, NYHA class II, for further evaluation. Clinical examination revealed prominent V-waves in the jugular venous pulse, a parasternal heave and a soft systolic murmur at the left sternal edge. Respiratory function tests were normal and d-dimer was negative. Echocardiography demonstrated severe RV dilation, severe tricuspid regurgitation and an apically displaced septal leaflet of the tricuspid valve typical of Ebstein's anomaly (see online supplementary appendix movie 1). An abnormality was noted attached to the atrial aspect of the tricuspid valve on transthoracic and transoesophageal imaging (Figure 1A, B as well as online …

Dabigatran is an oral direct thrombin inhibitor licensed for use by the Food and Drug Administration.1,2 This novel anticoagulant is effective and approved for prevention of stroke and systemic embolism in nonvalvular atrial fibrillation (AF) and prevention of venous thromboembolism in adults receiving elective total hip or knee replacement surgery.1,2 These images present a cautionary account of failed dabigatran anticoagulation in a patient with valvular AF: an indication for which its use has not been approved. A 50-year-old female with severe rheumatic mitral stenosis underwent open mitral valvotomy under cardiopulmonary bypass 25 years prior. On subsequent annual surveillance, she remained asymptomatic and her mitral stenosis remained moderate on echocardiography with a mean transmitral gradient of 8 mm Hg. Permanent AF was previously diagnosed 12 months earlier, and she was commenced on warfarin and metoprolol. She had stable anticoagulation monitoring, no bleeding complications, and normal renal function, but was needle-phobic with psychological …

chronicelevationofLApressure,withdilatationdefinedas a LA volume≥34mL/m2. Increased LA pressure was estimated using transmitral flow and tissue Doppler imaging at the lateral border of the mitral annulus; LA pressure elevation was defined as E/e′ ≥ 12. Pulmonary systolic pressure was estimated by standard criteria according to the ASE guidelines and PH was defined as a PA pressure ≥40mmHg. Results:Therewere94 sclerodermasubjectsof age32–82 years (14 males) who were in sinus rhythm and had no or mild valvular disease. Thirty-five (37%) subjects had LA dilatation, 12 (13%) had E/e′ ≥ 12, and 13 (14%) had PH. In subjects with PH, three had LA dilatation and two had increased E/e′. In subjects with increased E/e′, nine (75%) had LA dilatation. In subjects with LA dilatation, nine (26%) had increased E/e′. Conclusion: In scleroderma, LAdilatation and elevation of LA pressure are common in subjects with and without PH. Therefore, LA pressure elevation may not only contribute to elevation of pulmonary pressure in PHbut could also be a cause of dyspnoea in patients without PH. doi:10.1016/j.hlc.2011.05.447

Coronary CT Angiography (CTCA) has high sensitivity to exclude coronary artery disease (CAD), but recent large trials compared mainly to SPECT. Whether CTCA has advantages over exercise treadmill ECG (ExECG) is unclear. Randomized, prospective, single-center study in a large academic Australian

two-, three-, and four-chamber views. TDI (expressed as average of septal and lateral values) and GLS were analysed using EchoPac. Results: Mean BP of the study group was 136± 20/78± 10mmHg, 35 (70%) had hypertension, 21 (42%) had diabetes. As mandated, average e′ velocity was low (4.6± 0.9 cm/s) however mean GLS was relatively preserved at −17.8± 2.7%. Ten patients (20%) had GLS>−16%, and three patients (6%) had GLS>−14%. There was no significant correlation between GLS and either septal or lateral e′. GLS was weakly correlated to both s’ (r= 0.36, p= 0.01) and s’ integral (r= 0.42, p< 0.01). Conclusion: In a population with a high prevalence of cardiovascular risk factors and markedly abnormal e′ velocities (but preserved LVEF) the majority of patients had normal 2D strain values and the two parameters were unrelated. GLS and e′ are not equivalent methods for the identification of subclinical myocardial dysfunction. This may have important practical significance. http://dx.doi.org/10.1016/j.hlc.2013.05.395

Background: Pressure recovery (PR) has been shown to occur distal to a stenotic aortic valve and its magnitude is primarily influenced by the diameter of the aortic root. It has only recently been appreciated that PRmay be clinically important in correctly classifying aortic stenosis (AS) severity. We sought to investigate the potential change in peak instantaneous pressure gradients (PSG) and indexed aortic valve area (AVAI) when accounting for pressure recovery. Methods:Retrospectivedatabase interrogationbetween 2007 and 2012 detected 82 consecutive patients diagnosed with severe native valve AS using current criteria (PSG≥ 64mmHg/peak transaortic velocity ≥4m/s, or AVAI≤ 0.6 cm/m2). Thirty patients were excluded due to left ventricular dysfunction (LVEF≤ 50%), atrial fibrillation, other severe valvular lesions, and another six due to suboptimal image quality, leaving 46 patients for analysis. The aortic root diameter was measured at the level of the sinus of Valsalva and incorporated into previously published formula. Statistical analysis was performed using Fisher’s exact test. Results: The mean pressure recovery gradient was 14± 5mmHg (range 6–25mmHg). The percentage of patients reclassified from severe to nonsevere AS using pressure recovery adjustedAVAIwas 17.4%and44%when using the PSG instead. A significantly higher proportion of patients were re-classified if BSA>2 (63%; P< 0.02). Conclusion:Depending on criteria used, accounting for pressure recovery appears tobe an important determinant to accurately classify AS. We suggest to routinely account for pressure recovery in the echo laboratory.

The number of stress echocardiograms increased during the same time: exercise-SE by 3.0% per quarter (p< 0.001), dobutamine-SE by 2.5% per quarter (p< 0.001). For both thiswas a continuing trend since 2010 (seefigure). Conclusions: The inclusion of CTCA in the Medicare Benefits Schedule did not lead to a significant reduction in rebate claims for invasive coronary angiography or stress echocardiography in Australia. Introduction of CTCA did not affect the pre-existing trend toward increasing utilisation of stress echocardiography. http://dx.doi.org/10.1016/j.hlc.2013.05.463

Background: Cardiovascular (CVS) death is the leading cause of mortality in patients with end stage chronic kidney disease (CKD). We wished to investigate the incremental value of contemporary measures of echocardiographic left ventricular (LV) assessment over standard baseline demographic features. Methods: We followed 183 patients (57.4% male, 61.2% dialysis) with stage 4/5 kidney disease for a mean of 7.8± 4.4 years. Forty-six (25%)patients diedof aCVScause within this time. Simpson’s ejection fraction (EF), global longitudinal strain (GLS) and radial strain (RS) were calculated. Nested Cox regression models were constructed to assess the predictive value of baseline variables and measures of LV myocardial mechanics for prediction of survival. Results: Mean EF was 44.6± 10.7%, GLS was −13.7± 4.1%, and RS 29.5± 18.3%. Receipt of a renal transplant (n= 70, 38.3%) was by far the strongest predictor of CVS outcome (hazard ratio HR=0.07; p< 0.01) and was not included in subsequent models. Other baseline predictors of CVS outcome (model χ2 = 45.5) were male gender (hazard ratio HR=2.48; p< 0.01), history of previous cardiac event (HR=3.2; p< 0.01), and knownperipheral arterial disease (HR=3.75; p< 0.01). The addition of GLS (HR=0.66; p< 0.05) and RS (HR=0.71; p< 0.05), but not EF, to the baseline model resulted in a significant increase in the predictive power of the model (model χ2 = 51.3 for GLS, 49.6 for RS, both p< 0.05). Conclusions: Baseline global longitudinal and radial strain is significant long term predictors of CVS outcome in patients with end stage CKD whereas EF is not. Incremental value is added to powerful baseline predictors of CVS outcome.

Background: Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) has been recommended to distinguish Tako-Tsubo cardiomyopathy (TTC) from either acute myocardial infarction or myocarditis. Method: Forty-four consecutive patients with confirmed Mayo Clinic criteria for TTC underwent CMR imaging at 1.5 Tesla during the acute phase. LGE was quantitated at two signal thresholds (CircleCVi software) at >2 and >5 standard-deviations (SD)above reference myocardium, and compared to biomarkers. Findings: Mean door-to-CMR time was 57 h. Eighteen patients (41%) had LGE >2SD localised to the area of abnormal wall motion, representing 28.9 ± 11.2% LV mass. In 16 of these 18 patients (89%) LGE was >5 SD above normal myocardium, representing 12.1 ± 10% LV mass. Mean troponin was significantly higher in LGE positive patients (2.5 ± 1.8 vs 4.4 ± 6.9, p = 0.001). Mean ejection fraction (EF) by CMR was 45 ± 8.7% in LGE-negative, and 40 ± 7.1 in LGE-positive patients (p = 0.37). Recovery of segmental function was confirmed at follow-up, mean EF was 59% in both groups. Conclusion: LGE was present in 41% of cases of TTC, 89% of which had intense enhancement >5 SD above normal myocardium. Presence of LGE was associated with worse myocardial injury in the acute setting, with no difference in recovery of function.

Background: In 2010 the American Society of Echocardiography (ASE) changed the guidelines for the transthoracic echocardiographic (TTE) assessment of right atrial pressure (RAP). This study sought to assess the accuracy of simultaneous TTE measurements of RAP using both the new and old guidelines as compared to the gold standardassessmentof invasive rightheart catheterisation (RHC). Methods: Patients undergoing RHC assessment of RAP had samedayTTEderived IVCdiameter and collapsibility measurements performed. The echo guided assessment of RAP was calculated using the new and old ASE guidelines. In patients with atrial fibrillation (AF), the average of fivemeasurements was used. Echocardiographers were blinded to the invasive data. Results: 100 patients were prospectively recruited and RAP calculated for whole cohort (males = 44%). Rhythm: Sinus 76%, AF 16%, paced 8%. RAP≥ 10mmHg=55%. Measurements (mean±SD): age = 58.2± 13.6 years. Weight = 79± 19.4 kg. Time between 55% RHC and TTE=140± 112.5min. Mean pulmonary artery pressure = 34.1± 15mmHg. RAP on RHC=10.1± 5.3 mmHg. RAP on TTE using old guidelines = 10.3± 5mmHg, correlation (r) with RHC=0.38 (p= 0.0001), Bland Altman mean −0.2 (1.96SDs=+11.2 to −11.6) mmHg. RAP on TTE using new guidelines = 7.6± 4.7mmHg, correlation (r) with RHC=0.45 (p< 0.0001), Bland Altman mean −2.5 (1.96SDs=+7.9 to −12.9)mmHg. Conclusion: As awhole group, the estimatedmeanRAP was similar between RHC and TTE using old and new guidelines but there was high variability in the individual measurements and poor correlation. Compared to the old guidelines, the new ASE guidelines are marginally more accurate. New guidelines for TTE derived estimation of RAP are required.

patients 26/63 (41.2%, p< 0.01) had a negative study. However 37 (58.7%) of elderly patients had a positive study and 20/37 (54%) patients required an invasive coronary angiogram. Conclusion: Elderly patients are more likely than younger cohort tohavesignificantCAD.However thereare still a good percentage of themwho have negative studies, thus avoiding an invasive coronary angiogram. http://dx.doi.org/10.1016/j.hlc.2013.05.421

Background:TheaccuracyofCoronaryCTAngiography (CCTA) is directly related to heart rate control. Previous studies show that at 21%of segments are unevaluable. Heart rate control also reduces radiation exposure through use of prospective gating or high-pitch scanning. The safety of “aggressive” heart rate control, using oral and intravenous metoprolol, has not been fully evaluated. Method: Retrospective review of all CCTA cases from a large, single centre institution. Data from all cases were logged into a prospective database including heart rate, DLP and effective dose, beta-blocker usage, and adverse events. Data were separated and analysed by calendar year, using the students’ T-test. Results: 4171 CCTA were performed from 02-02-2007 to 15-03-2012 (all-comers, excluding TAVI aortograms). Mean heart rate in 2009 was 63.9± 11, 64.2± 11 in 2010 Method:A review of all CE performed at our institution since August 2007 was undertaken, to identify incidence, demographics and predisposing factors for adverse reactions (AR) during CE. Results: 1129 CE were performed (2% total TTE) from August 2007 to March 2012. Mean age 60.5 years (range 15–96). Males = 760. Mean body mass index= 30.9. Exam type: resting TTE 667, stress TTE 454 (dobutamine stress 445). CE indication: inducible ischaemia (454), LV function/RWMA (413), thrombus (195) and morphology (59). Patient location: outpatient (797), inpatient (249),CCU (39), ICU (36). Contrast administration bolus (888), infusion (233). There were seven adverse reactions related to contrast (incidence 0.6%). Back or hip pain (5), headache (1), non-life threatening anaphylaxis (1). In five of seven cases, theTTEcouldbe continuedas theARwasonlymild, inone of seven the CE had to be terminated and in one of seven the anaphylaxis occurred after study completion. The AR group was not high risk/unwell patients with six of seven having normal LV systolic function, six of seven were outpatients, administration by bolus (4) and infusion (3). 137 cases were re-exposure CE with no AR in any of these. Conclusion: CE is safe with a low adverse event rate. Most ARweremild and usually did not influence test continuation. CE can be safely used across a broad range of patients and indications.

Background After ST-elevation myocardial infarction (STEMI), microvascular obstruction (MVO) can be assessed using semiquantitative angiographic "blush" scores subject to interoperator variability. Quantitative Blush Evaluator (QuBE) is a free computer-calculated algorithm that evaluates myocardial blush on a continuous scale with improved reproducibility. We aimed to compare QuBE with cardiovascular magnetic resonance (CMR) in detecting MVO and its severity. Methods Fifty-two STEMI treated with successful primary percutaneous coronary intervention were enrolled. Quantitative Blush Evaluator and electrocardiographic sum ST-segment resolution were blindly calculated. All patients underwent CMR 4 to 7 days after STEMI for assessment of infarct size (IS), myocardial salvage index, MVO (both as first-pass MVO and delayed-enhancement MVO [DE-MVO]), and presence of intramyocardial hemorrhage on T2-weighted sequences. Results Quantitative Blush Evaluator values were inversely related to IS ( R = −0.4, P = .008), DE-MVO ( R = −0.7, P R = −0.4, P = .002) and positively related to myocardial salvage index ( R = 0.4, P = .007). Moreover, patients with intramyocardial hemorrhage had significantly lower QuBE values (3.9, 3.5-8.0 vs 12.2, 8.2-16.0, P = .001) than those without. At receiver operating characteristic curve analysis, QuBE accounted for an area under the curve of 0.88 (95% CI 0.7-0.9, P = .001) for both DE-MVO and hemorrhage detection and performed significantly better than ST resolution. Conclusions Quantitative Blush Evaluator score correlates with IS and microvascular dysfunction by CMR and can be considered as an accurate tool for the assessment of MVO in clinical practice. Quantitative Blush Evaluator is a useful quantitative angiographic technique for the assessment of myocardial reperfusion after STEMI.

Background After ST-elevation myocardial infarction (STEMI), microvascular obstruction (MVO) can be assessed using angiographic myocardial ‘blush’ grade (MBG), subject to interoperator variability. Quantitative blush evaluator (QuBE) is a free computer-calculated algorithm, with improved reproducibility. We aimed to compare QuBE in detecting MVO and its severity in comparison to the gold standard, cardiovascular magnetic resonance (CMR).