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Intravenous microbubble contrast agents are frequently used during ultrasound imaging to improve endocardial border detection, enhance Doppler signals, differentiate thrombi from tumors or define vascular anatomy. Dobutamine stress echocardiography (DSE) with or without addition of atropine is a standard technique for evaluation of coronary artery disease. Noncontrast or contrast-enhanced DSE is generally considered a safe procedure. We report what appears to be the first case of new-onset seizure activity following perflutren microbubble contrast injection during dobutamine-atropine stress echocardiography. On the basis of this single occurrence, we are only able to demonstrate a temporal, but not a causal relationship between the administration of microbubble echo contrast and onset of seizure. We do not suggest withholding administration of microbubble contrast when clinically indicated. However, increased vigilance in monitoring for seizure development in patients receiving microbubble contrast seems warranted.

Cholesterol emboli syndrome is a relatively rare, but potentially devastating, manifestation of atherosclerotic disease. Cholesterol emboli syndrome is characterized by waves of arterio-arterial embolization of cholesterol crystals and atheroma debris from atherosclerotic plaques in the aorta or its large branches to small or medium caliber arteries (100–200 μm in diameter) that frequently occur after invasive arterial procedures. End-organ damage is due to mechanical occlusion and inflammatory response in the destination arteries. Clinical manifestations may include renal failure, blue toe syndrome, global neurologic deficits and a variety of gastrointestinal, ocular and constitutional signs and symptoms. There is no specific therapy for cholesterol emboli syndrome. Supportive measures include modifications of risk factors, use of statins and antiplatelet agents, avoidance of anticoagulation and thrombolytic agents, and utilization of surgical and endovascular techniques to exclude sources of cholesterol emboli.

A 74-year-old man with a history of chest radiation for Hodgkin's disease in 1971, coronary artery disease, status post-coronary artery bypass grafting, and mitral valve repair in 2007 was referred for evaluation of aortic stenosis after presenting with acutely decompensated congestive heart failure. Transthoracic echocardiography demonstrated the left ventricular (LV) ejection fraction of 35%, severe tricuspid regurgitation, calcified trileaflet aortic …

A 77-year-old woman with a history of internal cardiac defibrillator (ICD) placement 5 years earlier was referred for transoesophageal echocardiography (TOE) to evaluate mitral regurgitation. An electrocardiogram revealed ventricular pacing with unexpected right bundle …

Combinations of DL-alpha-difluoromethylornithine (DFMO; eflornithine; Ornidyl) with either suramin or melarsen oxide were found to be effective against acute laboratory model infections with Trypanosoma brucei rhodesiense. We used clinical isolates known to be resistant to these drugs when used singly. An infection with a melarsen oxide-refractory isolate was cured by a combination of low-dose DFMO (0.5% in the drinking water) plus low-dose suramin (1 mg/kg of body weight given intraperitoneally). Another strain, moderately resistant to arsenical drugs, was cured with combinations of 4% DFMO with 5 mg of melarsen oxide per kg. Furthermore, a combination of DFMO (2% in the drinking water) and suramin (20 mg/kg) provided a 100% cure rate in a central nervous system model, although the same doses of these drugs used singly were completely ineffective. The synergism of DFMO and suramin against an acute infection was improved when suramin was given at the end of the DFMO administration. No adverse interactions were observed when high doses of DFMO combined with high doses of suramin were administered to uninfected mice. These results suggest that combinations of DFMO and suramin should be examined clinically for activity in arsenical-drug-refractory cases of East African sleeping sickness.

Libman-Sacks endocarditis (LSE) is a common manifestation of valve disease in antiphospholipid syndrome. Mitral valve LSE is characterized by verrucous vegetations on the atrial surfaces of valve leaflets. In this report, mitral valve LSE was visualized by real time 3D transesophageal echocardiography (TEE). 3D TEE provides a unique en face view of the mitral valve akin to a surgical or autopsy view that allows for an accurate determination of the size, shape, and location of the vegetations.

A 55-year-old woman was diagnosed with endocarditis involving the aortic valve and resulting in moderate aortic insufficiency. Transesophageal and transthoracic echocardiography demonstrated an unusually accentuated diastolic anterior motion of the anterior mitral valve leaflet toward the interventricular septum. The anterior leaflet remained within a few millimeters of the septum throughout diastole, with a narrow jet of aortic insufficiency separating the anterior leaflet from the septum. We hypothesize that the particularly long anterior mitral leaflet was drawn toward the septum during diastole due to the Venturi effect of the aortic insufficiency jet within a narrow ventricular outflow tract. This accentuated diastolic anterior motion may be a diastolic correlate of systolic anterior motion of the mitral valve.

Cholesterol embolization syndrome refers to embolization of the contents of an atherosclerotic plaque (primarily cholesterol crystals) from a proximal large-caliber artery to distal small to medium arteries causing end-organ damage by mechanical plugging and an inflammatory response. Synonyms used in the medical literature include atheromatous embolization, cholesterol crystal embolization, and atheroembolism. Cholesterol embolization syndrome should be distinguished from the related and much more common syndrome of arterio-arterial thromboembolism in which fragments of a thrombus that forms atop an atheromatous plaque in the aorta or a large artery travel distally and occlude medium to large arteries.1 Cholesterol embolization syndrome is generally characterized by a multitude of small emboli (showers of microemboli) occurring over time. This is in contrast to arterio-arterial thromboembolism, which is usually characterized by an abrupt release of 1 or a few large emboli, leading to severe ischemia of target organs. Cholesterol embolization syndrome has a variety of clinical presentations. Cholesterol emboli originating in the descending thoracic and abdominal aorta may lead to renal failure, gut ischemia, and emboli to the skeletal muscles and the skin. Dermatologic manifestations (most commonly livedo reticularis and blue toe syndrome) are usually confined to the lower extremities but may extend to the abdomen and the chest. Cholesterol emboli originating in the ascending aorta may in addition cause neurological damage that is typically diffuse and due to small infarcts. Cholesterol embolization syndrome is also characterized by a nonspecific acute inflammatory response leading to constitutional symptoms (such as fever and malaise) and abnormalities in laboratory tests (such as hypereosinophilia and elevated erythrocyte sedimentation rate). These manifestations will be discussed in detail later in the text. Danish physician Fenger and his colleagues appear to have provided the first description of atheroembolism in the Danish medical brochure Ugeskrift for Laeger (Doctors’ Weekly).2 In 1844, they …

Atrial fibrillation is a common, clinically significant arrhythmic disorder that results in increased risk of morbidity and mortality in affected patients. Atrial fibrillation is more prevalent among men compared with women and the risk for developing atrial fibrillation increases with advancing age. Ischaemic stroke is the most common clinical manifestation of embolic events from atrial fibrillation. While anticoagulation treatment is the preferred treatment, unfortunately, many patients have contraindications for anticoagulation treatment making this option unavailable to them. Previous data have shown that most thrombi that form in association with non-valvular atrial fibrillation occur in the left atrial appendage (LAA). It has been suggested that isolating the LAA from the body of the left atrium might reduce the risk of embolic events and that LAA obliteration may be a treatment option for patients with atrial fibrillation who are not candidates for anticoagulation treatment. Several procedures have been developed for isolation of the LAA, including surgical procedures as well as catheter-based ones. In this paper, we will review the currently available techniques, emphasizing the catheter-based ones. We will examine the increasing role of real-time three-dimensional transoesophageal echocardiography for appropriate screening and patient selection for these procedures, intra-procedural guidance, and follow-up care.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 25-year-old man with a history of atrioventricular (AV) canal defect repair in childhood underwent transesophageal echocardiography that revealed left atrial appendage morphology of the right atrial appendage (A) and a

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 49-year-old woman with exertional chest pain and a systolic murmur at the right upper sternal border radiating to both carotids had a hypercontractile left ventricle (LV) and a 77 mm Hg peak pressure gradient between the LV

[Figure][1] ![Figure][1] [Video 1][2] Parasternal Long-Axis View on Two-Dimensional Transthoracic Echocardiography Demonstrating the Pericardial Cyst. ![Figure][1] [Video 2][3] Parasternal Short-Axis View on Two-Dimensional Transthoracic Echocardiography Demonstrating the

We describe a patient with an infrequent combination of variants in both the right and the left coronary arterial ostia, namely a combination of two separate right coronary artery (RCA) ostia from the aorta, and an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). To our knowledge, such a combination has not been previously reported. Based on published statistics for individual variants, such a combination is expected to occur approximately once for every 500,000 to one million live births. ALCAPA and dual RCA anatomy was characterized in our patient by echocardiography, conventional angiography, and multidetector computed tomography before and after Takeuchi repair.

It is commonly postulated that neurologic complications of atrial myxomas are due to either direct tumor embolization or mycotic aneurysm of cerebral vasculature or rupture of mycotic aneurysms of cerebral arteries. However, the authors report the case of 63-year-old woman with a large left atrial myxoma whose progressive left-sided weakness was due to a different neurologic mechanism, namely, multiple bleeding cavernous malformations, which were visualized by magnetic resonance imaging of the brain. Cerebral cavernous malformations coexist with mesenchymal anomalies of other organs, including the liver, kidneys, and retinas. To the best of the authors' knowledge, this is only the second reported case of coexistent cerebral cavernous malformations and atrial myxoma.

We report the case of an enormous right atrial hemangioma in an asymptomatic 42-year-old woman. The diagnosis was made by echocardiogram after the patient was found to have an abnormal EKG during a routine medical exam. The hemangioma is the largest described in English literature. The tumor was surgically resected and the patient did well postoperatively. In this case report, we discuss the discovery of the tumor and treatment of our patient. A brief discussion of cardiac hemangiomas follows.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 78-year-old man with bioprosthetic aortic valve replacement presented with leg edema. Two-dimensional transthoracic echocardiography revealed a high-velocity systolic jet entering the right atrium (RA)

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 26-year-old man with a history of carcinoid and small-bowel resection presented with shortness of breath. Physical examination revealed a pulsatile liver, leg edema, and a holosystolic murmur at the

We report a case of a 52-year-old man with multiple myeloma and rapidly progressive heart failure who died unexpectedly from a probable arrhythmia. Postmortem examination revealed infiltrative amyloid cardiomyopathy, a rare cause of predominantly diastolic myocardial disease. Cardiac amyloidosis should be considered in any patient presenting with congestive heart failure, preserved systolic function, and a discrepancy between a low QRS voltage on electrocardiography and an apparent left ventricular hypertrophy on sonogram. The pattern of left ventricular diastolic dysfunction changes during the course of amyloidosis and the classically described restrictive physiology occurs only in advanced stages of the disease.

Introduction A plentiful arterial circulation is required for an effective myocardial function during both systole and diastole. This supply/demand coupling is accomplished through regional matching of the arterial supply to a particular portion of the myocardium. Arterial circulation of the heart consists of two parts: (1) large epicardial coronary arteries which serve as conduit vessels, and (2) medium-size and small intramyocardial coronary arterioles which serve as resistance vessels regulating the amount of coronary flow according to myocardial metabolic needs. Perturbation in any portion of this arterial tree will lead to a regional myocardial dysfunction. Acute coronary syndrome (ACS) is the clinical manifestation of a diminished coronary arterial blood supply in either conduit or resistance coronary vessels that is most commonly caused by atherosclerosis. In this chapter, we will discuss the epicardial circulation; the anatomy and function of resistance vessels will be discussed in Chapter 5.

Introduction The human heart, being almost exclusively dependent on aerobic metabolism, requires a constant supply of oxygen to avoid tissue injury. Even at rest, the human myocardium extracts almost the entire oxygen content of the passing blood. This results in extremely low resting oxygen saturation in the coronary sinus, the final repository of the coronary blood (35% at rest; 25% at peak exercise). Therefore, the primary means of increasing oxygen delivery to the myocardium is through augmentation of coronary blood flow. From rest to maximal physical exertion, coronary flow increases up to fivefold.1 Although the pressure in the epicardial coronary arteries may vary significantly, the precapillary pressure in the myocardium is held almost constant at 45 mmHg thanks to autoregulation accomplished through dynamic changes in the arteriolar resistance.2 Due to this autoregulation, a narrowing in an epicardial coronary artery has to be very severe (about 90% diameter loss) for the stenosis to become clinically evident at rest; blood supply limitation with exercise become evident when the stenosis reaches 70%. Once the epicardial stenosis reaches a critical level, the loss of myocardial function and the development of clinical signs and symptoms proceed in an orderly fashion. This stepwise process is referred to as ischemic cascade.3 It starts with an intramyocardial perfusion defect and progresses through a diminished left ventricular diastolic function, a decreased myocardial contractility, an increased left ventricular end-diastolic pressure, ST-segment changes, and ends, occasionally, with angina pectoris (Fig. 4.1). Intramyocardial perfusion defects are the earliest sign of limitations in the coronary blood supply and can be detected by either myocardial contrast echocardiography (MCE) or nuclear imaging. MCE is discussed elsewhere in this textbook. In this

Intermediate and short stumpy bloodstream forms of Trypanosoma brucei brucei are transitional stages in the differentiation of mammal-infective long slender bloodstream forms into the procyclic forms found in the midgut of the tsetse vector. Although the mitochondria of the proliferative long slender forms do not accumulate rhodamine 123, the mitochondria of the transitional forms attain this ability thus revealing the development of an electromotive force (EMF) across the inner mitochondrial membrane. The EMF is inhibited by 2,4-dinitrophenol, rotenone and salicylhydroxamic acid but not by antimycin A or cyanide. Consequently, NADH dehydrogenase, site I of oxidative phosphorylation, is the source of the EMF and the plant-like trypanosome alternative oxidase (TAO) supports the electron flow serving as the terminal oxidase of the chain. Although the TAO is present in the long slender forms as well, it serves only as the terminal oxidase for electrons from glycerol-3-phosphate dehydrogenase. The data presented here, combined with older data, lead to the conclusion that the mitochondria of transitional intermediate and short stumpy forms likely produce ATP. This putative production is either by F1F0 ATPase driven by the complex I proton pump or by mitochondrial substrate level phosphorylation, or most likely by both. These conclusions contrast with the previously held dogma that all bloodstream form mitochondria are incapable of ATP production.

A 59-year-old woman with hypertension presented with right flank pain. Magnetic resonance imaging of the abdomen revealed a 9 cm × 8 cm right renal mass and a filling defect (tumour extension) in the inferior vena cava (IVC), with protrusion into the right atrium (Figure 1). Figure 1) Magnetic resonance imaging of the abdomen showing a 9 cm × 8 cm right renal mass and a filling defect (tumour extension) in the inferior vena cava (thin arrow) with protrusion into the right atrium (thick arrow) Transthoracic echocardiography showed a large mobile mass (Figure 2) protruding from the IVC into the right atrium. The patient underwent radical right nephrectomy and excision of the mass from the IVC and right atrium. Microscopic examination of the renal mass and its intracaval and intracardiac extension demonstrated renal cell carcinoma of clear cell type. The patient remained stable on follow-up examination. Figure 2) Transthoracic echocardiogram showing a large mobile mass (arrow) protruding from the inferior vena cava (IVC) into the right atrium. Ao Ascending aorta; RV Right ventricle Malignant renal tumours represent approximately 2% of all malignant neoplasms (1). Patients with renal cell carcinoma and extension into the atrium have a significantly worse prognosis than those with other levels of vena caval involvement (2). Echocardiography plays an important role in diagnosing tumour clot extension into the right heart through the IVC.

DL-alpha-Difluoromethylornithine is an enzyme-activated inhibitor of ornithine decarboxylase and an antagonist of polyamine metabolism that has been successful in clinical trials against West African sleeping sickness caused by Trypanosoma brucei gambiense. Its potential for use against the more virulent East African form of the disease, caused by T. brucei rhodesiense, is not certain. We examined 14 East African clinical isolates from the Kenya Trypanosomiasis Research Institute strain bank plus 2 established isolates for susceptibility to DL-alpha-difluoromethylornithine and to standard trypanocides. Seven of 16 strains were partially or totally refractory to DL-alpha-difluoromethylornithine in our test system. Four strains were also refractory to arsenical drugs, and five were refractory to diamidines. The results indicate that other novel agents or combinations of established agents may be needed for chemotherapy of East African disease.

Asymptomatic subclavian vein occlusion following insertion of a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) is not uncommon. We report a case of a dual-chamber PPM in a patient with an unrecognized left subclavian vein occlusion who developed massive left arm edema following ipsilateral implantation of an arteriovenous (AV) hemodialysis graft. We recommend that patients with pre-existing PPM or ICD leads who are in need of vascular access for hemodialysis should have the AV shunts placed in the contralateral arm. If this is unavoidable, then preoperative subclavian vein screening for patency should be mandatory, even in asymptomatic patients. Sonography is an appropriate initial test in such a situation. © 2007 Wiley Periodicals, Inc. J Clin Ultrasound, 2008

It is well recognized that patients with severe left ventricular (LV) systolic dysfunction develop pulmonary venous hypertension or postcapillary pulmonary hypertension, which leads to an increase in pulmonary vascular resistance (PVR) and right ventricular (RV) systolic failure. It is often underrecognized, however, that patients with heart failure with preserved LV ejection fraction and diastolic dysfunction may also develop postcapillary pulmonary hypertension with elevated PVR leading to RV systolic failure. This form of biventricular failure is a result of diastolic failure on the left in patients with preserved LV ejection fraction and systolic failure on the right. At this time, there are no randomized trials or guidelines addressing the management of patients with diastolic heart failure with and without resultant RV failure. The authors review the pathophysiology, clinical presentation, and suggested treatment of this underrecognized clinical entity.

We present a case of a high brachiocephalic artery extending as far superiorly as the thyroid gland. Recognition of this rare anomaly is necessary to avoid potential catastrophic hemorrhage or other complications during percutaneous and surgical procedures on the trachea and neck.

We present a case of AIDS-related Burkitt's type cardiac lymphoma in a middle-aged woman with Epstein-Barr virus infection and profound immunodeficiency. The original features of our case include left ventricular location, female sex, and the use of contrast echocardiography to help establish the diagnosis. © 2007 Wiley Periodicals, Inc. J Clin Ultrasound, 2007

Takayasu's arteritis (TA) is a granulomatous vasculitis of medium and large arteries, which most often presents as pulseless disease due to widespread arterial stenoses. Only the minority of TA patients have aortic valve insufficiency, which is due to aortic root dilatation following aortitis and aneurysm formation. No other cardiac valve is involved. We report a case of Takayasu's disease-related severe aortic insufficiency (AI) in a Filipino woman, which necessitated aortic valve replacement. It is important to consider TA in the differential diagnosis of AI in young women, particularly those with early-onset systemic hypertension and pulse deficits. Early diagnosis and therapy of TA can improve outcomes.

ObjectiveWe discuss the CT findings in a case of pulmonary embolism complicated by paradoxical embolism in a patient with a patent foramen ovale and atrial septal aneurysm.ConclusionWhen confronted with a case of pulmonary embolism on CT, besides evaluating the extent of pulmonary artery occlusion, the radiologist should examine the cardiovascular system to identify any unsuspected underlying or associated conditions.

To the best of our knowledge, acute decompensated left-sided heart failure with preserved left ventricular ejection fraction in a patient with scleroderma has not been previously reported. We describe a patient with severe pulmonary hypertension due to limited scleroderma in whom nesiritide led to marked reductions in pulmonary arterial and capillary wedge pressure as well as resolution of symptoms and pulmonary edema. Subsequent epoprostenol use was associated with an increase in pulmonary capillary wedge pressure and a recurrence of pulmonary edema. Thus, nesiritide may be the preferred agent in scleroderma patients with severe pulmonary hypertension and preserved left ventricular systolic function since epoprostenol may lead to adverse hemodynamic effects.

269 THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2005 VOL. 14 NO. 5 S is the leading cause of morbidity in the elderly and the third leading cause of mortality in the United States. Cardioembolic causes may account for approximately 15%–20% of all strokes.1 The potential sources of cardiogenic embolism include atrial fibrillation, left ventricular dysfunction, rheumatic heart disease, prosthetic heart valves, and less commonly, intracardiac tumors. The frequency of primary cardiac tumors is approximately 0.02%, corresponding to 200 tumors in one million autopsies.2 Cardiac papillary fibroelastoma (PFE) is the second most common primary cardiac tumor (myxoma being the most frequent). These benign endocardial tumors predominantly affect the cardiac valves, and account for 75% of all cardiac valvular tumors. This case illustrates detection and surgical removal of the PFE in a patient who presented with a transient ischemic attack. A 64-year-old woman with a history of treated systemic hypertension presented to the emergency department complaining of a new right facial droop and difficulty speaking, which she noticed upon arising from sleep. She denied any prior neurologic events. Cardiac exam revealed a decrescendo grade II/IV diastolic murmur along the left sternal border with no radiation. Computed tomography of the head and bilateral carotid ultrasound exams were unremarkable. A two-dimensional transthoracic echocardiogram and a subsequent transesophageal echocardiogram (Figure 1) showed trace aortic regurgitation and a 1.3 × 0.8 cm rounded mobile mass on the Images in Geriatric Cardiology

We report a case of a 56-year-old man with traumatic aortic rupture (TAR) sustained in a motor vehicle accident diagnosed by helical computed tomography, aortography, and transesophageal echocardiography. A large majority of patients with TAR never make it to the hospital, and for those who do, a timely diagnosis is critical for survival. We discuss the merits and pitfalls of the three imaging modalities.

1. Siersema PD, Homs MY, Haringsma J, et al. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc 2003;58:356-61. 2. Shim CS. Esophageal stenting in unusual situations. Endoscopy 2003; 35:S14-8. 3. Shim CS, Cho YD, Moon JH, et al. Fixation of a modified covered esophageal stent: its clinical usefulness for preventing stent migration. Endoscopy 2001;33:843-8. 4. Gelbmann CM, Ratiu NL, Rath HC, et al. Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy 2004;36:695-9. 5. Kozarek RA, Raltz S, Marcon N, et al. Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial. Gastrointest Endosc 1997;46:156-60. 6. Wu WC, Katon RM, Saxon RR, et al. Silicone-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature. Gastrointest Endosc 1994;40:22-33. 7. Siersema PD, Hop WC, van Blankenstein M, et al. A new design metal stent (Flamingo stent) for palliation of malignant dysphagia: a prospective study. The Rotterdam Esophageal Tumor Study Group. Gastrointest Endosc 2000;51:139-45.

Heart murmurs, a common finding in dental patients, are of major concern to dental professionals because certain dental procedures occasionally can induce severe cardiovascular complications. Murmurs may indicate existing heart disease that is a risk factor for infective endocarditis following a dental procedure, as well as more severe heart conditions such as congenital heart disease, atrial fibrillation or congestive heart failure.This review article is based on data published in peer-reviewed journals, including practice guidelines published by major dental and medical professional organizations.Echocardiography is the primary means of evaluating heart murmurs, and all dental professionals should become familiar with major aspects of an echocardiogram. Understanding the medical evaluation and assessment of a heart murmur fosters better communication with other health care professionals and results in improved patient care.Beyond the need to administer antibiotic prophylaxis, the dentist also needs to address the underlying causes of a patient's heart murmur. By providing dental care to such patients, oral health care providers become part of the patient's overall health care team.

We present a case of a 46-year-old man with advanced acquired immunodeficiency syndrome and congenitally bicuspid aortic valve endocarditis caused by methicillin- and gentamicin-resistant Staphylococcus aureus. Endocarditis led to root abscess formation, a complete heart block, and fistulous tract formation between the ascending aorta and the right ventricle. Although perivalvular abscess is not an unusual complication of native valve endocarditis, a fatal fistulous communication between the ascending aorta and the right ventricle is exceedingly rare.

The rapid depletion of Pneumocystis carinii polyamines caused by in vitro exposure to DL-alpha-difluoromethylornithine (DFMO; also called eflornithine or Ornidyl) and the rapid repletion following removal of this drug suggested that the in vivo efficacy of DFMO against P. carinii pneumonia (PCP) may be limited by troughs in drug concentration resulting from the schedule of administration. This led to the prediction that, compared with the response to the standard animal protocol of administering DFMO in drinking water, the response of a rat model of PCP to DFMO would be lessened by bolus administration and improved by continuous infusion. These predictions were confirmed. Intraperitoneal bolus administration of up to 3 g of DFMO kg of body weight-1 was completely ineffective, although this dose has been shown to be effective when given in the drinking water. Conversely, continuous infusion improved the response against PCP seven- to ninefold over the response to drinking water administration. These findings suggest that, compared with the standard clinical investigational protocol for treatment of PCP with DFMO given in four divided daily doses, continuous infusion combined with monitoring of drug concentrations in plasma may improve efficacy and/or reduce the already low rate of adverse effects.

We report a case of Gemella morbillorum mitral bioprosthetic valve endocarditis with perivalvular extension in a 44-year-old human immunodeficiency virus-positive man who is an active intravenous drug user together with review of all published cases. This is only the second reported case of Gemella morbillorum endocarditis in a patient with a prosthetic valve.

Catecholamine-induced cardiomyopathy due to chronic excess of endogenous catecholamines has been recognized for decades as a clinical phenomenon. In contrast, reports of myocardial dysfunction due to acute iatrogenic overdose are rare. A 35-year-old woman whose cervix uteri was inadvertently injected with 8 mg of epinephrine developed myocardial stunning that was characterized by severe hemodynamic compromise, profound, albeit transient, left ventricular systolic and diastolic dysfunction, and only modestly elevated biochemical markers of myocardial necrosis. Our case illustrates the serious consequences of medical errors that can be avoided through improved medication labeling and staff supervision.

Takayasu's arteritis is a chronic vasculitis of unknown etiology that typically occurs in women. It affects the aorta and its main branches, leading to either arterial stenoses or aneurysms. Here we report a case of a 42-year-old woman presenting with loss of peripheral vision in her left eye. On ultrasound imaging, she had distinctive findings of Takayasu's arteritis with marked circumferential thickening of the intimal-medial layer in the left common carotid artery and characteristic sparing of the carotid bulb and internal carotid artery. The diagnosis was further supported by computed topography findings of aneurysms in the subclavian artery and aorta. Awareness of these ultrasound findings may be of particular importance to many echocardiographers who are extending their practice into vascular imaging.

A 55-year-old woman was diagnosed with endocarditis involving the aortic valve and resulting in moderate aortic insufficiency. Transesophageal and transthoracic echocardiography demonstrated an unusually accentuated diastolic anterior motion of the anterior mitral valve leaflet toward the interventricular septum. The anterior leaflet remained within a few millimeters of the septum throughout diastole, with a narrow jet of aortic insufficiency separating the anterior leaflet from the septum. We hypothesize that the particularly long anterior mitral leaflet was drawn toward the septum during diastole due to the Venturi effect of the aortic insufficiency jet within a narrow ventricular outflow tract. This accentuated diastolic anterior motion may be a diastolic correlate of systolic anterior motion of the mitral valve.

Libman–Sacks endocarditis (LSE) is a common manifestation of valve disease in antiphospholipid syndrome. Mitral valve LSE is characterized by verrucous vegetations on the atrial surfaces of valve leaflets. In this report, mitral valve LSE was visualized by real time 3D transesophageal echocardiography (TEE). 3D TEE provides a unique en face view of the mitral valve akin to a surgical or autopsy view that allows for an accurate determination of the size, shape, and location of the vegetations. (Echocardiography 2012;29:E100-E101)