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SARS-CoV-2 vaccine–associated myocarditis/myocardial injury should be evaluated in the contexts of COVID-19 infection, other types of viral myocarditis, and other vaccine-associated cardiac disorders. COVID-19 vaccine–associated myocardial injury can be caused by an inflammatory immune cell infiltrate, but other etiologies such as microvascular thrombosis are also possible. The clinical diagnosis is typically based on symptoms and cardiac magnetic resonance imaging. Endomyocardial biopsy is confirmatory for myocarditis, but may not show an inflammatory infiltrate because of rapid resolution or a non-inflammatory etiology. Myocarditis associated with SARS-COVID-19 vaccines occurs primarily with mRNA platform vaccines, which are also the most effective. In persons aged >16 or >12 years the myocarditis estimated crude incidences after the first 2 doses of BNT162b2 and mRNA-1273 are approximately 1.9 and 3.5 per 100 000 individuals, respectively. These rates equate to excess incidences above control populations of approximately 1.2 (BNT162b2) and 1.9 (mRNA-1273) per 100 000 persons, which are lower than the myocarditis rate for smallpox but higher than that for influenza vaccines. In the studies that have included mRNA vaccine and SARS-COVID-19 myocarditis measured by the same methodology, the incidence rate was increased by 3.5-fold over control in COVID-19 compared with 1.5-fold for BNT162b2 and 6.2-fold for mRNA-1273. However, mortality and major morbidity are less and recovery is faster with mRNA vaccine–associated myocarditis compared to COVID-19 infection. The reasons for this include vaccine-associated myocarditis having a higher incidence in young adults and adolescents, typically no involvement of other organs in vaccine-associated myocarditis, and based on comparisons to non-COVID viral myocarditis an inherently more benign clinical course.

BACKGROUND The association, if any, between the effective regurgitant orifice (EROA) to left ventricular end-diastolic volume (LVEDV) ratio and 1-year mortality is controversial in patients undergoing mitral transcatheter edge-to-edge repair (m-TEER) with the MitraClip™ system. The objective is to determine the association between EROA/LVEDV and 1-year mortality among patients undergoing m-TEER with MitraClip™. METHODS In patients with severe secondary (functional) mitral regurgitation (MR), we analyzed registry data from 11 centers using generalized linear models with the generalized estimating equations approach. RESULTS We studied 525 patients with secondary MR who underwent m-TEER in 11 centers. Most patients were male (63%) and were NYHA class III (61%) or IV (21%). MR was caused by ischemic cardiomyopathy in 51% of patients. EROA/LVEDV values varied widely with median=0.19 mm2/mL, interquartile range [0.12,0.28] mm2/mL, and 187 (36%) patients had values

Transesophageal echocardiography (TEE) has experienced tremendous increase in interest and demand alongside the rapid growth of transcatheter structural cardiac interventions. TEE instruction prolongs the procedure, increasing the risk of probe malfunction from overheating and patient complications from prolonged sedation. Echocardiographic simulation programs have been developed to hone the procedural skills of novice operators in a time-unrestricted, low-pressure environment before they perform TEEs on real patients. Simulators likely benefit training in interventional TEE for the same reasons. We searched PubMed, basic Google, and Google Scholar for currently marketed TEE simulators, including foreign as well as US companies. We queried the vendors regarding features of the simulators that pertain to effective instructional design for diagnostic TEE. We also queried regarding the simulators' applicability to training in interventional TEE. The vendors' responses are reported here. In addition, we discuss the specific training needs for structural heart interventions, for which echocardiographic simulation could be a powerful educational tool. Lastly, we discuss the role of simulation for formative and summative assessment, and the advances required to improve training in complex procedures within the field of interventional echocardiography.

SARS CoV-2 enters host cells via its Spike protein moiety binding to the essential cardiac enzyme angiotensin-converting enzyme (ACE) 2, followed by internalization. COVID-19 mRNA vaccines are RNA sequences that are translated into Spike protein, which follows the same ACE2-binding route as the intact virion. In model systems, isolated Spike protein can produce cell damage and altered gene expression, and myocardial injury or myocarditis can occur during COVID-19 or after mRNA vaccination. We investigated 7 COVID-19 and 6 post-mRNA vaccination patients with myocardial injury and found nearly identical alterations in gene expression that would predispose to inflammation, coagulopathy, and myocardial dysfunction.

The pulmonary valve (PV) has historically been ignored by imaging studies. Disorders of the PV encountered in adult cardiac patients are increasingly encountered due to advanced care of patients with congenital heart disease and associated PV diseases. Despite advances in PV imaging, multiple challenges remain when it comes to obtaining high quality PV images. While 2D TTE is the usual initial imaging tool for PV, excellent views of the PV annulus and its one or two leaflets are obtained in less than half of patients. The 3D echocardiography en face view allows all three leaflets to be evaluated concurrently, as well as assessments of the RV outflow tract and main pulmonary artery, which has improved quantitative assessment of PV diseases. Increasing image quality and experience with live/real time 3D TEE amplifies its utility in accurate evaluation and helps guide and monitor successful percutaneous PV interventions. 2D TTE remains the first line diagnostic tool; however, 3D TTE and 3D TEE provide better image quality which increases diagnostic accuracy and guidance to therapy. In this review article, we stress improvement in 3D echocardiography and its role in diagnostic and therapeutic options for PV diseases.

An Expert Panel of the National Lipid Association reviewed the evidence related to the use of coronary artery calcium (CAC) scoring in clinical practice for adults seen for primary prevention of atherosclerotic cardiovascular disease. Recommendations for optimal use of this test in adults of various races/ethnicities, ages and multiple domains of primary prevention, including those with a 10-year ASCVD risk

Objectives To determine if there is a difference in rates of surgical complications among patients who have reperitonealization of mesh versus no reperitonealization at time of sacrocolpopexy. Methods This was a retrospective cohort study of all patients who underwent sacrocolpopexy at an academic medical center between 2008 and 2017. The medical record was reviewed for the operative method of sacrocolpopexy, concomitant surgeries, intraoperative or postoperative complications, and readmissions. Groups were compared on whether mesh was reperitonealized under pelvic peritoneum or not. Results A total of 209 patients underwent sacrocolpopexy, with mesh reperitonealization performed in 115 (55%). Demographics were similar in both groups, except race/ethnicity and stage of prolapse. The majority (190 [91%]) of surgeries included concomitant procedures. A total of 18 intraoperative or postoperative complications (8.6%) were recorded. Relative risk of complication with mesh reperitonealization is 0.81 (95% confidence interval, 0.1-1.70). Complications for subjects without mesh reperitonealization included 4 cystostomies, 1 urethrotomy, 3 postoperative ileuses, and 1 small bowel obstruction. Among subjects with mesh reperitonealization, complications included 5 cystotomies, 2 proctotomies, 1 ureteral obstruction, and 1 small bowel obstruction. Rates of hospital readmission among both groups were not significantly different, with 3.2% of subjects without mesh reperitonealization versus 3.5% of mesh reperitonealization patients (P = 0.91) (relative risk, 1.09; 95% confidence interval, 0.38-2.56). Conclusions There is no significant difference in rates of complications or readmissions among patients with and without mesh reperitonealization at time of sacrocolpopexy. The only intraoperative complication solely attributed to mesh closure was a case with ureteral obstruction at time of reperitonealization.

With the increasing frequency of catheter-based interventions in congenital heart disease and structural heart disease, the use of fusion imaging has become a major enhancement for understanding complex anatomy and facilitating key steps in interventional procedures. Because transesophageal echocardiography and fluoroscopy are displayed in different visual perspectives, the interventional cardiologist must mentally reregister the images from the two modalities during the procedure. Echocardiography-fluoroscopy fusion (EFF) imaging displays the x-ray and ultrasound overlay images in the same visual perspective. This new technology allows for enhanced team communication, improved visual guidance, and more efficient navigation. The purpose of this review is to describe the EFF imaging technology, current uses of EFF imaging in congenital and structural heart disease, and future directions that will enhance this unique imaging technology to guide interventional procedures.

Purpose: Mitral Regurgitation (MR) can cause left ventricular dilation (remodeling). Reverse remodeling describes improved volumes after intervention. Reverse remodeling carries favorable prognosis, but not all MitraClip patients undergo reverse remodeling. We hypothesized pre-procedural global longitudinal strain (preGLS) will predict reverse remodeling one-year post MitraClip in all-cause MR patients. Methods: Of the 189 MitraClips performed at our institution between 2007-2019, 57 patients had complete echocardiographic data,. Echocardiograms 0-120 days prior to and 6-24 months after procedure were retrospectively reviewed. Reverse remodeling was defined as reduction in end diastolic volume (EDV). Results: In 20 sample echocardiograms, intra and inter-reader GLS variability was r=0.95 and r=0.90, respectively. Our population consisted of 55.2% female, 12.3% functional , 61.4% degenerative and 26.3% mixed mitral regurgitation. A reduction in EDV was demonstrated in 38 patients (67%). EDV, ESV, LAVi, and RVSP significantly decreased post-clip (all p

Acquisition costs and cost-effectiveness have limited access and recommendations to use proprotein convertase subtilisin/kexin type 9 (PCSK9)-inhibiting monoclonal antibodies (mAbs). Recently, prices were reduced by 60% for alirocumab and evolocumab. This statement systematically reviewed subgroup analyses from statin and PCSK9 mAb trials to identify higher risk groups for which PCSK9 mAbs at the new price could be considered a reasonable (

BACKGROUND The effects of edge-to-edge percutaneous mitral valve repair on the shape and size of the mitral annulus and its relation to mitral regurgitation (MR) have not been well characterized. We evaluated acute changes in mitral annular shape and dimensions, and their effect on MR severity, in patients with functional and degenerative MR following MitraClip® . METHODS Patients that underwent MitraClip® between January 2013 and May 2016 at our institution were retrospectively reviewed. EXCLUSIONS inadequate images, prior mitral valve repair, and rapid atrial fibrillation. Intra-procedure TEE 3D images acquired prior to and after implantation of MitraClip® were analyzed using software to model the mitral valve apparatus. RESULTS Of seventy-eight patients that underwent MitraClip® procedure, 60 were eligible. Mean age was 78.3 ± 11 years. Severe MR (4+) was present in 37 patients, moderately/severe MR (3+) in 23. All patients achieved MR reduction to ≤2. 3D annular circumference, bicommissural diameter, and anteroposterior diameter had a significant size reduction after MitraClip® . None of the mitral annular measures had significantly different mean change between the large and small MR change groups at the 0.05 significance level. CONCLUSIONS In patients with functional or degenerative MR, the MitraClip® significantly affect mitral annular dimensions; however, these changes do not correlate with the immediate MR reduction.

We describe the role of three-dimensional echocardiography in the assessment of the aortic valve and the aorta. The manuscript is heavily illustrated with figures and movie clips.

Introduction: Transseptal puncture (TSP) is an essential step in percutaneous structural heart interventions, such as the MitraClip® procedure. Radiation exposure is a hazard for Interventional Cardiologists, Echocardiographers, and patients. Advancements in shielding and radiation equipment have reduced this exposure, but further reduction is desired. EchoNav® (Philips) fuses fluoroscopy and echocardiography resulting in a single multimodal image display. Prior studies demonstrated reduced time to TSP with use of EchoNav® but failed to show significant reduction in radiation. We hypothesized that increased experience using EchoNav® would further decrease TSP time and radiation dose. Methods: Single center, retrospective analysis evaluated 202 patients undergoing MitraClip® procedure pre and post-EchoNav® from 6/2010 to 12/2019: 8 pre and 194 post. We measured time to TSP and radiation exposure by Air Kerma and dose area product (DAP). For the post-EchoNav® cases, we evaluated these variables by 2-year time periods to examine change over time. Results: Comparing pre and post-EchoNav ® procedures, time to TSP was non-significantly reduced overall (40.00±14.95 to 33.63±15.92, p=0.23). However, post-EchoNav ® had a decreasing trend (48.00±28.39, 43.47±15.86, 28.45±11.94, 27.55±10.64; R 2 =0.89, p =0.009) that was significantly less than pre-EchoNav ® by the third time period (40.00±14.95 vs 28.45±11.94, p=0.05) and remained less in the fourth (40.00±14.95 vs 27.55±10.64, p=0.03). Radiation was reduced post-EchoNav ® by both DAP (264.52±150.03 to 109.00±97.68) (p=0.02) and Air Kerma (1472.92±883.50 to 582.49±485.28) (p=0.05). Significant radiation reduction occurred by the third time period for Air Kerma (1472.92±883.50 vs 494.12±413,79, p=0.03) and second time period for DAP (264.52±150.03 to 127.51±110.35, p=0.03). Conclusion: These results suggest that use of EchoNav® has a learning curve, but ultimately reduces time to TSP and radiation.

The growth of transcatheter structural heart disease interventions has created a subspecialty of interventional imagers who focus on preprocedural planning and the periprocedural guidance of these complex cases. In particular interventional imagers who focus on periprocedural guidance have developed a specific expertise in interventional transesophageal echocardiography (iTEE). This nascent field has challenges in training, reimbursement, and occupational hazards which are unique to this field. This review encompasses the evolution of iTEE, current challenges, and future opportunities.

Increased catheter-based interventions in congenital and structural heart disease require imaging modalities to be oriented in the same visual perspective. The use of echocardiography-fluoroscopy fusion (EFF) imaging has been developed for better characterization of complex anatomy and to facilitate key steps in interventional procedures. This review will detail the technology behind EFF, the differences between the two ultrasound fusion systems, and essential features of EFF imaging in congenital and structural heart disease interventions.

Diagnosis, prognosis, treatment, and development of new therapies for diseases or syndromes depend on a reliable means of identifying phenotypes associated with distinct predictive probabilities for these various objectives. Left ventricular ejection fraction (LVEF) provides the current basis for combined functional and structural phenotyping in heart failure by classifying patients as those with heart failure with reduced ejection fraction (HFrEF) and those with heart failure with preserved ejection fraction (HFpEF). Recently the utility of LVEF as the major phenotypic determinant of heart failure has been challenged based on its load dependency and measurement variability. We review the history of the development and adoption of LVEF as a critical measurement of LV function and structure and demonstrate that, in chronic heart failure, load dependency is not an important practical issue, and we provide hemodynamic and molecular biomarker evidence that LVEF is superior or equal to more unwieldy methods of identifying phenotypes of ventricular remodeling. We conclude that, because it reliably measures both left ventricular function and structure, LVEF remains the best current method of assessing pathologic remodeling in heart failure in both individual clinical and multicenter group settings. Because of the present and future importance of left ventricular phenotyping in heart failure, LVEF should be measured by using the most accurate technology and methodologic refinements available, and improved characterization methods should continue to be sought.

Previous studies demonstrated that men were more likely to have plaque rupture and are at greater risk for myocardial infarction and stroke than women. We evaluated differences in carotid plaque characteristics by MRI between men and women with mild-moderate atherosclerosis and elevated ApoB levels. One hundred eighty-two subjects (104 men and 78 women) with CAD or carotid stenosis (≥ 15% by ultrasound), ApoB ≥ 120 mg/dL and carotid MRI scan were included. Percent wall volume (%WV) was calculated as (wall volume/total vessel volume) × 100%. Three major plaque compositions, fibrous tissue (FT), calcification (CA) and lipid rich necrotic core (LRNC), were identified and quantified using published MRI criteria. Adventitial and plaque neovascularization as fractional plasma volume (Vp) and permeability as transfer constant (Ktrans) were analyzed using kinetic modeling. These characteristics were compared between men and women. Men, compared to women, were younger (54 ± 8 vs. 58 ± 8 years, p = 0.01), had higher rate of previous MI (46 vs. 26%, p = 0.005) but lower proportions of metabolic syndrome (37 vs. 59%, p = 0.003). After adjusting for between-gender differences, men were significantly more likely to have LRNC (OR 2.22, 95% CI 1.04–4.89, p = 0.04) and showed significantly larger %LRNC than women (diff = 4.3%, 95% CI 1.6–6.9%, p = 0.002), while %WV, FT, and CA were similar between men and women. There were no statistically significant differences in adventitial and plaque Vp or Ktrans. Men were significantly more likely to have LRNC and had larger LRNC than women. However, men and women showed relatively similar levels of adventitial and plaque neovascularization and permeability. Trial registration: NCT00715273 at ClinicalTrials.gov. Registered 15 July 2008, retrospectively registered.

Computed tomographic (CT) coronary calcium scoring has been established by large prospective, population-based studies as the single best noninvasive predictor of atherosclerotic cardiovascular risk available today. The calcium score correlates highly with the total burden of coronary atherosclerosis demonstrated at autopsy. It adds significantly to traditional risk calculators such as the Framingham Risk Calculator or the Pooled Cohort Equations. The 2018 U.S. Cholesterol Guidelines endorse the use of CT coronary calcium scoring to refine risk estimates in the intermediate range of 7.5%–20% over 10 years. Most, but not all, adults with calcium scores of zero can reasonably elect to avoid or defer statin therapy, but repeating the calcium score should be considered in 5 to 10 years. Discussants at this roundtable urge that coronary calcium scoring be offered to many more adults than currently receiving this test, including those with borderline 10-year risk in the range of 5%–7.5%. CT coronary angiography is a procedure based on intravenous contrast injection, mostly used in low-risk patients with chest pain. In British guidelines, CT angiography is preferred over stress testing for initial assessment of suspected coronary symptoms. Carotid ultrasound evaluating both the carotid intima-media thickness and presence of plague is less predictive than coronary calcium scoring for overall atherosclerotic risk but more predictive for stroke risk.

BACKGROUND The present study designed to evaluate feasibility of transesophageal echocardiographic (TEE) imaging of the pulmonary valve (PV) at the transaortic upper esophageal (TAUE) window. We hypothesized that patients with larger aorta would be more likely to have visualization of the PV from this TAUE window. METHODS 2D TEE images of the PV were prospectively acquired by one operator at the TAUE window looking through the aortic arch. Patients were divided into four groups based on image quality of PV (group 1, not visualized; group 2, barely visualized; group 3, sufficient visualization; group 4, excellent visualization). Clinical, echocardiographic, and radiologic parameters were collected. RESULTS A total of 212 consecutive patients (54 ± 14 years, 63.7% male) were enrolled. Group distribution was as follows: group 1, n = 60 (28.3%); group 2 n = 39 (18.4%); group 3, n = 27 (12.7%); group 4, n = 86 (40.6%). There were no differences between groups' baseline clinical characteristics. There was a weak although statistically negative correlation between PV image quality and aortic arch dimension (r = -0.17 P = 0.01). There was a stronger positive correlation between PV thickness (r = 0.38 P

3D TEE is often used to guide structural heart disease interventions (SHDI). Depth perception plays a crucial role for navigation and placement of interventional devices. In this study, a novel rendering technique, mimicking the normal human visual world, called pseudo-illumination is evaluated and

Catheter interventions in congenital and structural heart disease have increased in complexity and rely on advanced transesophageal echocardiography (TEE) guidance. The different spatial reference frames of TEE and fluoroscopy necessitate mental co-registration of the images during the procedure.

Acquired type of LV to RA shunt (Gerbode defect) is rare form of intracardiac shunt which is due to complications of invasive cardiac procedures, endocarditis, trauma or myocardial infarction. Increasing invasive and recurrent cardiovascular procedures have led to more acquired cases of what used to be a predominant congenital heart defect. Advanced cardiac imaging techniques and awareness of this rare pathology may account for the increased number of case reports in the last two decades Advanced cardiac imaging tools such as cardiac CT, MRI and Real-time 3D echocardiography provide definitive diagnosis and anatomic characterization of the shunt. Real-time 3D echocardiography is an imaging technique with arguably the most advantages. It is not only a diagnostic tool; it has also become an integral part of percutaneous and surgical treatment. Although surgical repair is the usual treatment for this shunt, percutaneous catheter-based closure has seen significant success as a less invasive treatment in selected patients in the last decade. In summary, a beneficial side effect of the increasing frequency of acquired Gerbode defect has been the corresponding development of newer diagnostic tools and less invasive treatments. This article presents etiologic, diagnostic and treatment changes of acquired LV-RA shunts over the last two decades.

Diagnosis, prognosis, treatment, and development of new therapies for diseases or syndromes depend on a reliable means of identifying phenotypes associated with distinct predictive probabilities for these various objectives. Left ventricular ejection fraction (LVEF) provides the current basis for combined functional and structural phenotyping in heart failure by classifying patients as those with heart failure with reduced ejection fraction (HFrEF) and those with heart failure with preserved ejection fraction (HFpEF). Recently the utility of LVEF as the major phenotypic determinant of heart failure has been challenged based on its load dependency and measurement variability. We review the history of the development and adoption of LVEF as a critical measurement of LV function and structure and demonstrate that, in chronic heart failure, load dependency is not an important practical issue, and we provide hemodynamic and molecular biomarker evidence that LVEF is superior or equal to more unwieldy methods of identifying phenotypes of ventricular remodeling. We conclude that, because it reliably measures both left ventricular function and structure, LVEF remains the best current method of assessing pathologic remodeling in heart failure in both individual clinical and multicenter group settings. Because of the present and future importance of left ventricular phenotyping in heart failure, LVEF should be measured by using the most accurate technology and methodologic refinements available, and improved characterization methods should continue to be sought.

Gerbode defect and sinus of Valsalva aneurysm fistula are congenital and acquired forms of intracardiac shunt. The increasing prevalence of invasive, recurrent cardiovascular procedures cause tissue damage and has led to more iatrogenic and acquired cases of predominantly congenital shunt over time. We report 2 cases of acquired intracardiac fistula precisely defined by Real time three-dimensional transesophageal echocardiography (3DTEE). The first case is a 70-year-old male with Gerbode defect after second aortic valve replacement surgery due to prosthetic valve endocarditis and the other case is a 41-year-old male with sinus of Valsalva aneurysm fistula between aorta and right atrium post subclinical infective endocarditis. Advanced cardiac imaging techniques such as cardiac computerized tomography, MRI and Real time three-dimensional (3D) echocardiography help to precisely detect intracardiac fistula and provide detailed anatomic and physiologic information. The relatively low cost, lack of radiation exposure, portability and guiding characteristic make real time 3DTEE an imaging technique with arguably the most advantages. Surgical repair is the usual treatment for intracardiac shunt, and percutaneous catheter-based closure is a less invasive alternative.

Pluripotent stem cells provide a potential solution to current epidemic rates of heart failure by providing human cardiomyocytes to support heart regeneration. Studies of human embryonic-stem-cell-derived cardiomyocytes (hESC-CMs) in small-animal models have shown favourable effects of this treatment. However, it remains unknown whether clinical-scale hESC-CM transplantation is feasible, safe or can provide sufficient myocardial regeneration. Here we show that hESC-CMs can be produced at a clinical scale (more than one billion cells per batch) and cryopreserved with good viability. Using a non-human primate model of myocardial ischaemia followed by reperfusion, we show that cryopreservation and intra-myocardial delivery of one billion hESC-CMs generates extensive remuscularization of the infarcted heart. The hESC-CMs showed progressive but incomplete maturation over a 3-month period. Grafts were perfused by host vasculature, and electromechanical junctions between graft and host myocytes were present within 2 weeks of engraftment. Importantly, grafts showed regular calcium transients that were synchronized to the host electrocardiogram, indicating electromechanical coupling. In contrast to small-animal models, non-fatal ventricular arrhythmias were observed in hESC-CM-engrafted primates. Thus, hESC-CMs can remuscularize substantial amounts of the infarcted monkey heart. Comparable remuscularization of a human heart should be possible, but potential arrhythmic complications need to be overcome.

Objective— The relationship between air pollution and cardiovascular disease may be explained by changes in high-density lipoprotein (HDL). Approach and Results— We examined the cross-sectional relationship between air pollution and both HDL cholesterol and HDL particle number in the MESA Air study (Multi-Ethnic Study of Atherosclerosis Air Pollution). Study participants were 6654 white, black, Hispanic, and Chinese men and women aged 45 to 84 years. We estimated individual residential ambient fine particulate pollution exposure (PM 2.5 ) and black carbon concentrations using a fine-scale likelihood-based spatiotemporal model and cohort-specific monitoring. Exposure periods were averaged to 12 months, 3 months, and 2 weeks prior to examination. HDL cholesterol and HDL particle number were measured in the year 2000 using the cholesterol oxidase method and nuclear magnetic resonance spectroscopy, respectively. We used multivariable linear regression to examine the relationship between air pollution exposure and HDL measures. A 0.7×10 − 6 m − 1 higher exposure to black carbon (a marker of traffic-related pollution) averaged over a 1-year period was significantly associated with a lower HDL cholesterol (−1.68 mg/dL; 95% confidence interval, −2.86 to −0.50) and approached significance with HDL particle number (−0.55 mg/dL; 95% confidence interval, −1.13 to 0.03). In the 3-month averaging time period, a 5 μg/m 3 higher PM 2.5 was associated with lower HDL particle number (−0.64 μmol/L; 95% confidence interval, −1.01 to −0.26), but not HDL cholesterol (−0.05 mg/dL; 95% confidence interval, −0.82 to 0.71). Conclusions— These data are consistent with the hypothesis that exposure to air pollution is adversely associated with measures of HDL.

Lipid lowering, particularly with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors ("statins"), reduces the risk of cardiovascular disease. Patients with chronic liver disease present challenges to the use of lipid medications. In the case of most liver disorders, the concern has been one of safety. There is evidence that most lipid-lowering medications can be used safely in many situations, although large outcomes trials are lacking. This review examines lipid physiology and cardiovascular risk in specific liver diseases and reviews the evidence for lipid lowering and the use of statins in chronic liver disease.

Understanding opportunities to reduce dyslipidemia before, during, and after pregnancy has major implications for cardiovascular disease risk prevention for the entire population. The best time to screen for dyslipidemia is before pregnancy or in the early antenatal period. The differential diagnosis of hypertriglyceridemia in pregnancy is the same as in nonpregnant women except that clinical lipidologists need to be aware of the potential obstetric complications associated with hypertriglyceridemia. Dyslipidemia discovered during pregnancy should be treated with diet and exercise intervention, as well as glycemic control if indicated. A complete lipid profile assessment during each trimester of pregnancy is recommended.

OBJECTIVES To determine the impact of routine preoperative cystourethroscopy on the surgical management of urinary incontinence and pelvic organ prolapse. METHODS Retrospective review of consecutive women undergoing surgery for urinary incontinence and/or pelvic organ prolapse at a tertiary referral urogynecology center to determine whether the routine use of preoperative cystourethroscopy changed the surgical management. Patients with other indications for cystourethroscopy were excluded. RESULTS A total of 283 consecutive charts were reviewed of which 235 met inclusion criteria. Five patients accounted for 6 abnormal findings on preoperative cystourethroscopic examination including 2 bladder calculi, 2 lesions suspicious for neoplasm, and 2 cases of absent unilateral ureteric efflux. In only one case (0.5%) was the surgical plan altered. CONCLUSION The routine use of preoperative cystourethroscopy in low-risk patients being prepared for surgery for urinary incontinence and pelvic prolapse is not required when no other indications for cystourethroscopy exist.

OBJECTIVE To evaluate outcomes of robot-assisted sacrocolpopexy (RSCP) and sacrocervicopexy (RCSP). METHODS We conducted a prospective study of women undergoing RSCP or RCSP between June 2008 and January 2010. RESULTS A total of 85 cases (48 RSCP and 37 supracervical hysterectomy with concomitant RCSP) were performed: 33% (28/85) for stage II, 54% (46/85) for stage III, and 13% (11/85) for stage IV pelvic organ prolapse (POP). Six weeks postoperatively, 96% (80/83) had stage 0, 2.4% (2/83) had stage I, and 1.2% (1/83) had stage II POP (P < 0.001). Six months postoperatively, 77% (24/31) had stage 0, 6.5% (2/31) had stage I, and 16% (5/31) had stage II POP (P < 0.001). Mean surgical time, estimated blood loss, and length of hospital stay was 194 ± 54 minutes, 49 ± 48 cm, and 1.6 ± 0.72 days, respectively. There were 2 cases of mesh erosion (2.3%), both in the RSCP group. CONCLUSIONS RSCP and RCSP are effective, efficient, and safe procedures.

Our aim was to determine what effect access to robotic technology had on our approach to managing apical pelvic support defects.This was a retrospective chart review of 187 pelvic floor reconstructive surgeries performed for the 18 months prior to (time period 1: January 2007 to July 2008) and following (time period 2: July 2009 to December 2009) the introduction of the robot. Chi-square was used to compare percentages, and analysis of variance (ANOVA) was used to compare demographic data among groups.Overall, 187 procedures were performed for apical prolapse during the study period: 61 in time period 1 and 126 in time period 2. Following the introduction of robotic technology, a significant change from vaginal to abdominal reconstruction occurred. Uterosacral ligament suspension declined from 67 % to 22 % (p0.0001), whereas sacrocolpopexy increased from 25 % (15/61) to 66 % (83/126) (p0.0001). The rate of abdominal sacrocolpopexy, however, declined from 25 % (15/61) to 2 % (2/126) over the two time periods (p0.0001).The introduction of robotic technology significantly affected the surgical procedure and mode of surgical access for repair of apical pelvic support defects.

The evaluation of cardiac masses is often a challenge for cardiac imaging techniques. The traditional standby has been two-dimensional echocardiography (2DE). Real time three-dimensional echocardiography (RT3DE) offers incremental value for the evaluation of intracardiac masses by providing more accurate assessment of the size and shape of the mass as well as in some cases, composition of the mass. RT3DE aids with the relationship between the mass and adjacent structures. Therefore, here we discuss the subject of RT3DE evaluation of cardiac masses is reviewed and discussed in detail.

Aortic pseudoaneurysms (APSAs) are an uncommon but serious complication of aortic surgery with potentially fatal complications if left untreated. Operative repair is associated with significant morbidity and mortality. Percutaneous APSA repair may reduce the risk of these complications and represents an alternative option for patients. We report our experience with percutaneous intervention for the treatment of APSAs.We retrospectively reviewed all patients at our institution who underwent percutaneous APSA repair with Amplatzer septal occluders and vascular plugs between January 2004 and September 2014. Ten patients are included in this study, representing our first cases of percutaneous APSA repair. Follow-up was performed with serial computed tomographic angiography. The primary outcome was the success rate of device deployment. Secondary outcomes included success rate of complete APSA exclusion, postprocedural symptoms, and periprocedural and postprocedural complications. Mean clinical follow-up time was 12 months (range, 5-30 months) and mean imaging follow-up time was 29 months (range, 14-52 months). Device deployment was successful in all patients, although 2 patients required reintervention due to device malposition and the discovery of additional defects on postprocedure CT angiography. There were no periprocedural or postprocedure complications. Long-term follow-up imaging was available for 7 patients and revealed complete APSA exclusion in 4 patients. One out of the remaining 3 patients ultimately required operative intervention.Percutaneous APSA repair can be performed safely with a good procedural success, albeit with variable long-term results. This procedure may be considered as an alternative to surgical repair in select patients.

Septic cardiomyopathy is commonly encountered in patients with severe sepsis and septic shock. This study explores whether novel global and segmental echocardiographic markers of myocardial deformation, using two-dimensional speckle tracking, are associated with adverse sepsis outcomes. We conducted a retrospective observational feasibility study, at a tertiary care centre, of patients admitted to the ICU with a diagnosis of sepsis who underwent an echocardiogram within the first week of sepsis diagnosis. Data were collected on chamber dimensions, systolic and diastolic function, demographics, haemodynamics, and laboratory parameters. Global and segmental left ventricular longitudinal strain (LVLS) and tissue mitral annular displacement (TMAD) were assessed on 12 left ventricular segments and six mitral annulus segments in apical views, respectively. We explored associations of abnormal LVLS and TMAD with duration of mechanical ventilation, hospital length of stay, and mortality. Fifty-four patients were included. Global LVLS was not associated with any of the primary study endpoints. However, reduced systolic LVLS of the basal anterior segment was associated with in-hospital mortality. There was a suggestion that patients with a reduced global TMAD were associated with an increased risk of mortality and a short length of hospital stay but these associations were not statistically significant. Reduced global LVLS was associated with lower ejection fraction. Reduced global TMAD was associated with reduced global and segmental LVLS, reduced left ventricular ejection fraction, and increased left ventricular end-systolic and end-diastolic volumes. Speckle-tracking echocardiography can be performed feasibly in patients in sepsis. Global and segmental left ventricular deformation indices are associated with ejection fraction. Further studies need to evaluate the ability of these new indices to predict sepsis outcomes.

The aim of this study was to describe the clinical characteristics and mortality of patients with conflicting diastolic function during follow-up. Up to 30% of patients have conflicting diastolic function by echo Doppler and therefore cannot be classified into a distinct diastolic dysfunction category of stage 1, 2 or 3. Using our established echocardiography data base, we studied a cohort of 250 subjects with conflicting diastolic function. Each individual was compared to two controls with normal diastolic and systolic function. The pre-specified goal of the analysis was a 6-year follow-up. Patients with conflicting diastolic function were more likely to have diabetes, hypertension, and established coronary artery disease. The Cox proportional hazards model determined that the risk of death was significantly higher for conflicting patients compared to patients with normal diastolic parameters (HR: 1.83; 95% CI: 1.32–2.53), P

We present two cases of cor triatriatum, a rare congenital anomaly that consists of a membrane that divides the left atrium into two chambers. The first case involves an older adult man admitted for evaluation of left-sided weakness attributed to stroke. The second is a case of a middle-aged woman with dyspnea. Both patients had transthoracic echocardiograms as a part of their initial evaluation, which revealed abnormal structures in the left atrium, and both subsequently underwent transesophageal echocardiography. During these exams, real-time 3D imaging was utilized to more completely define the pathology. (Echocardiography 2011;28:E125-E128)

To estimate whether variability in the size and ratios of the lower and upper abdomen exist in women undergoing robotic gynecologic surgery and whether demographic variables are significantly associated, and to determine the association between abdominal wall dimensions and supraumbilical robotic port placement.Prospective cohort study (Canadian Task Force classification II-2).University teaching hospital.Seventy-eight women undergoing robotic surgery between May 2008 and March 2009.Measurements from the symphysis pubis to the umbilicus (lower abdomen), umbilicus to the xyphoid process (upper abdomen), and distance between the anterior superior iliac crests were obtained at surgery. A multiple linear regression model was created to determine the relationships between abdominal wall measurements, demographic variables, and need for supraumbilical robotic port placement.Fifty-six white and 22 black women were enrolled. Mean lower abdominal length was significantly affected by body mass index (BMI) (p.001) and race (p = .006), with white women having longer measurements (17.1 cm vs 15 cm). Mean lower abdominal width was independent of age (p = .95) or race (p = .98), but was significantly correlated with BMI (p.001). Mean upper abdominal length correlated with BMI (p.001) and age (p = .03) but not race (p = .13). Ratios of bottom to top were significantly affected by race (p = .002) and age (p = .008) but not BMI (p = .07). Adjustments to port placement above the umbilicus were made in 44 of the 74 women (59.5%). Those who required supraumbilical port placement had a significantly shorter mean (SD) distance between the symphysis pubis and the umbilicus (14.99 [1.36] vs 18.55 [2.21]; p.001).Significant variability in abdominal wall anatomy exists in women undergoing robotic gynecologic surgery, and the need for supraumbilical robotic port placement is common.

An incorrect transseptal puncture (TSP) position can lead to difficulties during clip navigation and placement for mitral valve (MV) repair. We investigated the height difference of optimal TSP positions as measured by 2D echo compared to a 3D approach using an investigational Philips EchoNavigator

Background It is well known that cardiovascular disease is the number one killer of men and women in the United States and in many parts of the developed world. However, early detection of atherosclerosis remains a challenging area of research and development. Stress echo and myocardial perfusion studies were not designed to be screening tests and the majority of literature using these tests is in populations with a high probability of disease. It must be emphasized that negative stress echo and stress MPI tests only imply a lack of flow limiting disease; they do not indicate lack of atherosclerotic disease. It is important to remember that when these tests are "negative," the implication is favorable short-term prognosis rather than any implication regarding lack of disease. In contrast, carotid intima-media thickness (CIMT) scanning protocols can detect atherosclerotic disease in early and asymptomatic stages. For a number of reasons reviewed in this article, CIMT may be a more optimal screening and risk-stratifying technology: CIMT directly visualizes vasculature unlike biomarkers such as LDL cholesterol, hsCRP, or PLA2. Methods We performed medline searches for original articles and reviews of carotid IMT from 1985 to the present. We particularly emphasized large multi-center epidemiologic studies of the natural history of patients with carotid IMT measurements. Conclusion There is substantial evidence that CIMT is a suitable surrogate for the coronary tree. CIMT is also (along with coronary calcium scoring) recognized by the American Heart Association as a surrogate marker for coronary artery disease. A recent commentary by Stein, et al reviewed the comparison of CIMT to coronary calcium scoring, with favorable findings for CIMT especially in the healthy young and middle-aged populations, as well as women and African American individuals where coronary calcification has more limited utility. Recent findings of the Multi-Ethnic Study of Atherosclerosis indicate further that increased CIMT predicted CVD events in individuals without coronary calcification.

Ambient air pollution has been associated with heart failure morbidity and mortality. The mechanisms responsible for these associations are unknown but may include the effects of traffic-related pollutants on vascular or autonomic function.We assessed the cross-sectional relation between long-term air pollution, traffic exposures, and important end-organ measures of alterations in cardiac function-left ventricular mass index (LVMI) and ejection fraction-in the Multi-Ethnic Study of Atherosclerosis, a multicenter study of adults without previous clinical cardiovascular disease.A total of 3,827 eligible participants (aged 45-84 yr) underwent cardiac magnetic resonance imaging between 2000 and 2002. We estimated air pollution exposures using residential proximity to major roadways and interpolated concentrations of fine particulate matter (less than 2.5 microns in diameter). We examined adjusted associations between these exposures and left ventricular mass and function.Relative to participants living more than 150 m from a major roadway, participants living within 50 m of a major roadway showed an adjusted 1.4 g/m(2) (95% CI, 0.3-2.5) higher LVMI, a difference in mass corresponding to a 5.6 mm Hg greater systolic blood pressure. Ejection fraction was not associated with proximity to major roadways. Limited variability in estimates of fine particulate matter was observed within cities, and no associations with particulate matter were found for either outcome after adjustment for center.Living in close proximity to major roadways is associated with higher LVMI, suggesting chronic vascular end-organ damage from a traffic-related environmental exposure. Air pollutants or another component of roadway proximity, such as noise, could be responsible.

The association between ambient fine particulate matter (PM) air pollution [particles with aerodynamic diameter ≤ 2.5 μm (PM2.5)] and increased cardiovascular morbidity and mortality in epidemiologic studies (Dominici et al. 2006; Miller et al. 2007; Pope et al. 2002) has led to investigation of underlying mechanisms, which remain cryptic (Bhatnagar 2006). Several studies link ambient (especially combustion-derived) PM with increased vascular tone (Brook et al. 2002; Campen et al. 2005; Proctor et al. 2006), and animal studies showed possible involvement of sympathetic nervous system activation (Proctor et al. 2006) and vasoconstriction pathways (Bouthillier et al. 1998; Li et al. 2005). Evidence suggests that the effect of PM on vascular reactivity may be greater in individuals at risk for coronary artery disease (O’Neill et al. 2005). Human studies to date have provided limited insight into the mechanism of the vascular effects of PM, although recent evidence has documented enhanced exercise-induced ischemia with controlled exposure to diesel exhaust (DE) (Mills et al. 2007). DE is a complex mixture of particulate and gaseous pollutants that comprise a substantial and biologically active fraction of urban ambient air pollution (Health Effects Institute 1995) and is a very appropriate experimental model exposure, especially with the current interest in traffic-related air pollution. Evidence suggests that inhalation of DE is associated with perturbation in endothelial function (Campen et al. 2005; Mills et al. 2005; Tornqvist et al. 2007). We exposed young adults, healthy or with metabolic syndrome, to DE under controlled settings. Young adults with metabolic syndrome have increased subclinical atherosclerosis (Tzou et al. 2005) and are at increased risk for cardiovascular morbidity and mortality (Isomaa et al. 2001). We focused on individuals with metabolic syndrome because they might be more susceptible to DE effects. We hypothesized that DE inhalation would result in vaso-constriction and decreased endothelium-dependent flow-mediated dilation (FMD) of the brachial artery within 30 min of exposure. We also hypothesized that vascular effects of DE might be related to activation of the sympathetic nervous system or increased release of the endothelium-dependent vasoconstrictor endothelin-1 (ET-1).

Cardiomyocytes derived from human embryonic stem (hES) cells potentially offer large numbers of cells to facilitate repair of the infarcted heart. However, this approach has been limited by inefficient differentiation of hES cells into cardiomyocytes, insufficient purity of cardiomyocyte preparations and poor survival of hES cell-derived myocytes after transplantation. Seeking to overcome these challenges, we generated highly purified human cardiomyocytes using a readily scalable system for directed differentiation that relies on activin A and BMP4. We then identified a cocktail of pro-survival factors that limits cardiomyocyte death after transplantation. These techniques enabled consistent formation of myocardial grafts in the infarcted rat heart. The engrafted human myocardium attenuated ventricular dilation and preserved regional and global contractile function after myocardial infarction compared with controls receiving noncardiac hES cell derivatives or vehicle. The ability of hES cell-derived cardiomyocytes to partially remuscularize myocardial infarcts and attenuate heart failure encourages their study under conditions that closely match human disease.

Three-dimensional echocardiography (3DE) has made a dramatic transition from predominantly a research tool to a technology useful in everyday clinical practice. This article outlines the history of 3DE from its beginnings to the most current technology.

Heart failure is exceedingly prevalent in the United States and in other developed countries. Treatment regimens are complex and now include electrical therapy. Methods for evaluating left ventricular dyssynchrony using echocardiography rather than QRS duration have been developed, with tissue Doppler velocity parameters being the most popular. Real-time three-dimensional echocardiography is another novel method for dyssynchrony evaluation that has potential advantages over existing techniques. The authors describe their experience with three-dimensional echocardiography dyssynchrony evaluation and offer insights into the direction that this technology must move to improve results.