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The incidence of cardiac injury after blunt chest trauma is difficult to determine and ranges from 8% to 76%. Moreover, the clinical presentation varies tremendously without a real gold standard to exclude or document cardiac involvement. Electrocardiogram as a single test is not sensitive or specific for diagnosing cardiac contusion. Furthermore, creatine kinase MB is non-reliable in the setting of severe trauma involving the liver, intestines or diaphragm. Although troponins T and I are highly specific for cardiac injury, their sensitivity in the setting of trauma is poor. The echocardiogram is very useful in the evaluation of trauma patients with suspected cardiac involvement. However, poor windows in the setting of chest and lung injuries and in intubated patients might be a major problem limiting the accuracy of transthoracic echocardiogram. On the other hand, transesophageal echocardiogram seems to be more sensitive and specific in trauma patients and should be the test of choice in patients with high clinical suspicion for blunt cardiac trauma.

Transesophageal echocardiography has significantly improved the detection of vegetative lesions, including those associated with indwelling central venous lines. However, in certain cases, the increased mobility of these lesions as well as the presence of indwelling catheters obscure the precise delineation of their origin and the detection of attachment to adjacent structures. We report a case of right-sided endocarditis in which the use of contrast was instrumental to the comprehensive evaluation of the lesion and to subsequent patient management.

Background: The feasibility and value of transthoracic dobutamine stress echocardiography (DSE) in patients scheduled for bariatric surgery has not been investigated., Methods: We evaluated 611 patients (86.6% female, 42 +/- 10 years, 136 +/- 18 kg, BMI 48.0 +/- 6.1 kg/m2) referred for DSE prior to surgery between February 2000 and July 2005. Mortality and major cardiovascular events (cardiac death, acute coronary syndrome, and urgent revascularization) were recorded 30-days postoperatively and at 6 months., Results: Adequate baseline imaging quality was achieved in 590 patients (96.6%), with use of echocardiographic contrast agents in 426 patients (72.2%); the remaining 21 patients (3.4%) were referred for alternative preoperative testing. There were no serious adverse events during DSE, which was negative in 545 patients (92.4%). The test was inconclusive in 38 patients (6.4%), requiring alternative investigations, and positive in 7 patients (1.2%). Eventually, 595 patients proceeded to surgery: 539 with DSE-based risk stratification and 56 with risk stratification based on alternative testing. Laparoscopic procedures were employed in 77.0% of patients. There were 3 perioperative deaths, all attributed to sepsis (perioperative mortality 0.50%), but no major cardiovascular events at 30-days. One patient (evaluated prior to surgery with alternative testing) experienced an acute coronary syndrome during the following 6 months (event rate 0.17%)., Conclusion: Transthoracic DSE is feasible and safe in morbidly obese patients undergoing bariatric surgery; implementation of echocardiographic contrast agents allows for adequate imaging quality in the majority of these patients. However, the very low risk of contemporary bariatric procedures questions the need for routine preoperative stress testing in asymptomatic patients.

Background: Pacemakers and implantable cardioverter-defibrillators (ICDs) are established therapies for life-threatening cardiac arrhythmias. Biventricular pacemakers (BiVP) can improve heart failure in selected patients as well., Objective: This study sought to investigate the impact of gender and race on rates of implantation of pacemakers and ICDs in patients with reduced left ventricular ejection fraction (LVEF)., Methods: Data were obtained from ADVANCENT, a prospective multicenter registry enrolling patients with LVEF < or = 40% between June 2003 and November 2004. a total of 26,264 patients from 106 us centers were enrolled. the mean age was 66.4 years; 71.5% were male and 81.9% were white; 10,394 subjects (39.6%) had devices implanted., Results: The overall rate of device implantation was higher in white subjects compared with nonwhite subjects (41.1% vs 32.5%, P <.0001). This was also true for the rates of implantation of all types of ICDs (28.6% vs 23.9%, P <.0001) and BiVP (11.2% vs 7.7%, P <.0001). After adjusting for age, gender, LVEF, New York Heart Association class, coronary artery disease, QRS duration, comorbidities, type of referring physician, and insurance type, nonwhite race remained an independent negative predictor of implantation of any device (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.791 to 0.927), and any ICD (OR 0.88, 95% CI 0.817 to 0.964). Female gender was also independently associated with decreased implantation of any device (OR 0.70, 95% CI 0.66 to 0.76), and any ICD (OR 0.60, 95% CI 0.55 to 0.64)., Conclusion: In this large cohort with reduced LVEF, minorities and women were significantly less likely to receive device implants. These findings were most pronounced in nonwhite women, and could not be explained by disparities in demographic or clinical characteristics.

Atrial fibrillation (AF) is the most common sustained arrhythmia and a leading cause of stroke. Warfarin reduces the incidence of thromboemboli and is recommended for most patients with AF. However, oral anticoagulation is contraindicated or not tolerated by a significant percentage of patients with AF. Occlusion of the left atrial appendage, the major source of emboli in atrial fibrillation, has been shown to be a potential alternative to warfarin in patients with AF who have contraindications to anticoagulation. In this article, we describe the current percutaneous left atrial appendage occlusion devices, their safety in recent trials, and their potential role in stroke prevention in AF.

Background: The percutaneous left atrial appendage transcatheter occlusion system (PLAATO) is an alternative to coumadin in patients with atrial fibrillation (AF) and contraindications to anticoagulation. It appears to be protective against stroke in intermediate follow-up studies., Hypothesis: The PLAATO system is protective against stroke and is safe in long-term follow-up., Methods: Eleven patients (age 72 +/- 9 years) enrolled in the PLAATO feasibility and safety trial at our institution were followed (36 +/- 1.4) months. All patients had contraindications to anticoagulation and had at least one risk factor for stroke. The predicted stroke risk for this cohort was 8.6% per year as calculated using the CHADS2 score (A validated scoring system assigning 1 point for CHF, hypertension, diabetes, and age >75 years, and 2 points for history of stroke). The primary end-point was the incidence of stroke, and secondary end points were complications related to PLAATO device and systemic embolic events., Results: There was one stroke during follow-up; the stroke risk in our population was 3% per year. Interestingly, the observed stroke risk in these patients after occluding the left atrial appendage is comparable to what would have been observed with warfarin. No systemic embolic events were noted in our cohort and no long term complications related to PLAATO were seen., Conclusion: The PLAATO device decreases the risk of stroke in a high-risk cohort of AF patients. Furthermore, the safety of this device is confirmed during this long-term follow-up study. A larger trial is needed to validate these findings.

Tissue Doppler imaging (TDI), is a new imaging tool that allows measurement of dyssynchrony. In several small studies, TDI predicted clinical response and reverse remodeling after cardiac resynchronization therapy (CRT). Moreover, it allowed detection of mechanical dyssynchrony in heart failure patients with narrow QRS. Using TDI, the selection criteria for CRT might be changed to include heart failure patients with narrow QRS. Furthermore, it will help predict responders to this therapy, hence decreasing the percentage of nonresponders and allowing a more cost-effective use of this new technology.

Transesophageal echocardiogram is a very safe procedure, however, it is not devoid of complications. We report a case of esophageal dissection complicating transesophageal echocardiogram in a 52-year-old man who was treated conservatively. Moreover, we review briefly the complications of transesophageal echocardiogram.

Background: Recent experimental and clinical data suggest that lowering serum lipid levels with statins may prevent or delay the process of restenosis. The purpose of this trial is to determine whether lipid levels relate to restenosis and/or whether statin therapy can prevent or delay the process of restenosis after intracoronary stenting., Methods: One hundred thirty-six patients who underwent single coronary artery stenting from June 1995 to June 1997 in our institution were included in the study. All these patients were followed for at least 9 months (mean 392+/-148 days) for major adverse cardiac events (MACE). We defined as MACE the occurrence of death, myocardial infarction, or need for target lesion revascularization. From this cohort, 103 patients had at least one lipid parameter from the lipid profile evaluated within 2 months from the date of the procedure. Patients who had the stent because of an acute myocardial infarction were included in the study only if their lipid profile was evaluated before or at least 6 weeks after the event. Patients with triglyceride levels above 500 had both triglyceride and low-density lipoprotein cholesterol levels excluded from the statistical analysis. Patients were divided into two groups based on lipid levels: normal (Group I; n=31) and elevated (Group II; n=72). Patient outcomes were also analyzed by statin therapy use., Results: There was no significant difference in MACE rates between the two groups when outcomes were analyzed by lipid levels (22.6% versus 20.8% P=0.8). Furthermore, outcomes were analyzed by use of statin therapy (Group III, n=53, on statin versus Group IV, n=50, on no statin). There was also no difference in MACE rates between the two groups (20.8% versus 22%; P=0.8)., Conclusion: The process of restenosis has unique features that differentiate it from atherosclerosis. Although lipid-lowering therapy is crucial in delaying the process of atherosclerosis, its role in the prevention of restenosis is yet to be proven.

Patent foramen ovale and/or atrial septal aneurysm occur in up to 20% of the general population, and have been linked to cryptogenic ischemic strokes in younger individuals. The pathophysiologic basis of this association remains unclear, with growing evidence suggesting a role for thrombosis and embolization. Aspirin and warfarin constitute the current mainstay of medical therapy, with a variety of secondary prevention studies assessing their impact on stroke recurrence. To date, the quality of published data preclude the development of strict recommendations, but a number of suggestions can be derived from available literature. Patients with isolated patent foramen ovale or atrial septal aneurysm and a first ischemic stroke respond well to either aspirin or warfarin therapy. On the other hand, oral anticoagulation seems to be the preferred medical therapy in higher-risk patients with both patent foramen ovale and atrial septal aneurysm or those with multiple strokes on aspirin. Percutaneous or surgical patent foramen ovale closures have been proposed as alternative therapies and seem effective in reducing stroke recurrence. In the absence of randomized, controlled trials comparing medical and invasive approaches, the adoption of a particular therapy should take into consideration the individual's preference, clinical presentation, risk profile, lifestyle, and the expertise of the local interventional and surgical teams.