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Obstructive sleep apnea (OSA) imposes an afterload burden on the left ventricle and increases the pressure gradient across the aortic wall. Thus, OSA may increase the risk for aortic dissection (AD).This study enrolled 40 subjects with acute AD from four institutions; 37 completed the modified Berlin Questionnaire and 31 underwent attended overnight polysomnography. Aortic diameter was measured on a computed tomography scan at seven locations from the sinotubular junction to the diaphragm.Twenty-seven subjects had type A dissection; 13 had type B. In those who had polysomnography apnea-hypopnea index (AHI) ranged from 0.7 to 89. Prevalence of OSA (AHI ≥ 5) was 61%. Nocturnal presentation (10 p.m.-7 a.m.) did not differ by presence/absence of OSA. The modified Berlin Questionnaire was not predictive of the presence of OSA. Among type A subjects with polysomnography (n = 23), aortic diameters at all locations were greater in the OSA group though differences were not statistically significant. Summating aortic diameters at the seven locations also yielded a numerically larger mean value in the OSA group versus the non-OSA group.In this sample of patients with acute dissection, OSA was prevalent but was not associated with a nocturnal presentation. The presence of underlying OSA may be associated with larger aortic diameters at the time of dissection compared to patients without OSA. Though differences did not meet statistical significance the current series is limited by small numbers.

Nonalcoholic fatty liver disease (NAFLD) and cardiovascular diseases are both highly prevalent conditions around the world, and emerging data have shown an association between them. This review found several longitudinal and cross-sectional studies showing that NAFLD was associated with coronary artery disease, cardiac remodeling, aortic valve remodeling, mitral annulus valve calcifications, diabetic cardiomyopathy, diastolic cardiac dysfunction, arrhythmias, and stroke. Although the specific underlying mechanisms are not clear, many hypotheses have been suggested, including that metabolic syndrome might act as an upstream metabolic defect, leading to end-organ manifestations in both the heart and liver. Management of NAFLD includes weight loss through lifestyle interventions or bariatric surgery, and pharmacological interventions, often targeting comorbidities. Although there are no Food and Drug Administration–approved nonalcoholic steatohepatitis-specific therapies, several drug candidates have demonstrated effect in the improvement in fibrosis or nonalcoholic steatohepatitis resolution. Further studies are needed to assess the effect of those interventions on cardiovascular outcomes, the major cause of mortality in patients with NAFLD. In conclusion, a more comprehensive, multidisciplinary approach to diagnosis and management of patients with NAFLD and cardiovascular diseases is needed to optimize clinical outcomes.

Mitral annular calcification (MAC) has been reported as a possible cause of systolic anterior motion (SAM) of the mitral valve and dynamic left ventricular outflow tract (LVOT) obstruction. While morphologic features predisposing to SAM in other clinical settings have been described, patients with MAC+SAM have not been systematically investigated. We hypothesized that bulky calcium deposits in the mitral annulus could displace the valve towards the septum thus promoting development of SAM.We studied 30 patients with severe MAC who had SAM with septal contact. Three comparator groups (matched for age and sex) were developed: 30 controls without MAC or SAM, 30 with severe MAC but no SAM, and 30 with SAM but no MAC.Significant differences were found across groups for mitral valve coaptation point- septal distance (CSD), anterior mitral leaflet (AML) length, LV diastolic dimension, and EF. Comparing all MAC subjects (n=60) with controls, CSD was less (20.5±4.1 vs. 23.2±3.7 mm, p=0.003) and EF higher (67.7±7.8 vs. 60.9±6.4%, p0.0001) in MAC patients. Within MAC subjects AML was longer (21.9±3.0 vs. 17.4±2.2 mm, p0.0001) and CSD was smaller (18.0±2.7 vs. 23.1±3.6 mm, p0.0001) when SAM was present despite similar height of the calcium bar in the two MAC groups (12.4±2.9 vs. 11.1±3.1 mm, p=0.11). Regression analysis confirmed AML length and CSD as independent predictors of SAM. MAC+SAM patients also had more echocardiographic risk factors for SAM (acute aorto-mitral angle, small LVOT, long AML, small CSD, and presence of a septal bump) than MAC/no-SAM patients (3.4±0.9 vs. 1.8±1.0, p0.0001).Bulky MAC appears to contribute to dynamic LVOT obstruction when it accumulates in such a way that the mitral valve is displaced anteriorly towards the septum. However, other features are also associated with SAM in these patients, particularly a long AML. A combination of morphologic features and favorable hemodynamics may be needed to for SAM to develop in patients with severe MAC.

Nonalcoholic fatty liver disease (NAFLD) is an increasingly common condition that is believed to affect >25% of adults worldwide. Unless specific testing is done to identify NAFLD, the condition is typically silent until advanced and potentially irreversible liver impairment occurs. For this reason, the majority of patients with NAFLD are unaware of having this serious condition. Hepatic complications from NAFLD include nonalcoholic steatohepatitis, hepatic cirrhosis, and hepatocellular carcinoma. In addition to these serious complications, NAFLD is a risk factor for atherosclerotic cardiovascular disease, which is the principal cause of death in patients with NAFLD. Accordingly, the purpose of this scientific statement is to review the underlying risk factors and pathophysiology of NAFLD, the associations with atherosclerotic cardiovascular disease, diagnostic and screening strategies, and potential interventions.

PURPOSE Heart valve calcification (VC) is associated with increased cardiovascular risk, but the hemodynamic and functional profile of patients affected by VC has not been fully explored. METHODS The study population was formed by consecutive unselected patients included in seven echocardiographic laboratories in a 2-week period. A comprehensive echocardiographic examination was performed. VC was defined by the presence of calcification on at least one valve. RESULTS Population was formed of 1098 patients (mean age 65 ± 15 years; 47% female). VC was present in 31% of the overall population. Compared with subjects without VC, VC patients were older (60 ± 14 vs 75 ± 9; P

Pulmonary hypertension (PH) is an underdiagnosed and potentially fatal condition. The utility of screening for PH in hospitalized patients undergoing echocardiography is unknown. The goal of this study was to determine the prevalence of undiagnosed pulmonary hypertension (PH) and probable pulmonary arterial hypertension (PAH) in hospitalized patients undergoing echocardiography for any indication. All hospitalized patients undergoing echocardiography were identified and echocardiographs reviewed prospectively for the presence of a tricuspid regurgitant (TR) jet. Electronic medical records (EMR) of patients with a TR jet ≥ 3 m/s were reviewed for identifiable causes of pulmonary hypertension. Patients with no identifiable cause were classified as presumptive World Health Organization (WHO) Group 1 PH (also known as PAH). These PAH patients were compared to other PH patients for baseline demographic characteristics and comorbidities as well as 30-day readmission and mortality. The admitting physicians of patients classified as PH were advised to consider further evaluation including right heart catheterization. We reviewed 4417 consecutive echocardiograms and identified 448 with a TR jet ≥ 3 m/s. Of these 448 patients with PH, 47 were identified as “presumptive PAH” and the other 401 as having PH belonging to WHO Groups 2–5. Presumptive PAH represented 1% of screened echocardiograms and 10.5% of those identified to have an elevated TR jet. Of the patients identified as presumptive PAH, 8 underwent further evaluation including a right heart catheterization, where 5 were confirmed to have PAH. Kaplan–Meier analysis revealed 30-day readmission was higher among those classified as PAH. Our data shows that pulmonary hypertension, as defined by TR jet ≥ 3 m/s, is frequently encountered in hospitalized patients undergoing echocardiography for any reason. A careful review of echocardiogram findings and clinical history suggested 10.5% of those with PH (and 1% of all screened patients) may meet the criteria for PAH. Considering PH is a fatal condition which is frequently missed, a hospital screening program seems feasible.

Transcatheter valve-in-valve replacement has become a viable option for patients with degenerated bioprosthetic valves at high risk for redo surgery. We report a case of a patient who had degenerated mitral and tricuspid bioprosthesis causing severe tricuspid and mitral regurgitation. We performed simultaneous mitral and tricuspid valve-in-valve replacement via a transfemoral approach. Although the data on performing both valve-in-valve procedures are limited, this case demonstrated that these procedures can be safely done as a single procedure.

Myocardial scar burden impacts prognosis in patients with coronary artery disease who have experienced a myocardial infarction (MI). This has been demonstrated by late gadolinium enhancement cardiac magnetic resonance. Clinical experience with echocardiography suggests that the reflected ultrasound signal is enhanced in infarcted myocardial segments. Scar imaging with an ultrasound multipulse scheme (eScar) has been preliminarily validated in prior studies.To assess whether scar burden, as detected by eScar, is associated with implantable cardioverter-defibrillator (ICD) shocks in post-MI patients.We retrospectively selected 50 post-MI patients with an ejection fraction35% who received an ICD for primary prevention and subsequently had at least one appropriate shock (cases). These were compared with 50 post-MI patients, matched for clinical variables and ejection fraction, who never experienced an appropriate defibrillator shock (controls). Subjects were assessed with the eScar technique at the time of implantation or during follow-up.An eScar was present in ≥1 segment in 40 of 50 (80%) cases vs 26 of 50 (52%) controls and was associated with appropriate ICD shocks (P = .004). Receiver operating characteristic curve analysis, using a threshold of ≥3 segments by eScar, showed an area under the curve (AUC) of 0.715. On models including clinical and echocardiographic variables, eScar remained significantly associated with ICD shocks (P = .050 or P = .033 depending on the model). Adding eScar to a multivariate logistic regression model including indexed left ventricular end-systolic volume led to an increase in AUC from 0.734 to 0.782 (P = .049), while substituting indexed left ventricular end-diastolic volume for indexed left ventricular end-systolic volume resulted in a nonsignificant increase in AUC from 0.747 to 0.785 (P = .098).Presence and extent of eScar were independently associated with appropriate ICD shocks in this study of patients with prior MI and reduced ejection fraction. However, the addition of eScar assessment to the clinical multivariable model that included also indexed left ventricular end-diastolic volume did not provide significant incremental value.

Mitral annular calcification (MAC) is increasingly encountered, particularly among the elderly and those with chronic kidney disease, and is often associated with a transvalvular gradient. In contrast to rheumatic mitral stenosis relatively little is known about mitral stenosis due to MAC. We aimed to clarify whether exercise limitation in this group is primarily due to valvular obstruction or ventricular dysfunction resulting from multiple comorbidities. 20 patients with severe MAC (bulky calcium deposits which restricted leaflet motion) were submitted to supine bicycle exercise, measuring Doppler and echocardiographic parameters at baseline and during exercise. They were compared 1:1 to subjects matched for age, sex, and left ventricular wall thickness. At baseline MAC subjects had higher mean mitral valve gradients (MVG) than comparison subjects (7.5 ± 3.8 vs 1.6 ± 0.8 mm Hg, p 60 mm Hg. MAC subjects also had relative chronotropic incompetence. Patients with severe MAC and a transvalvular gradient experience large increases in MVG and pulmonary pressure with exercise, similar to what has been described in rheumatic mitral stenosis. MAC may be an under-recognized cause of dyspnea and exercise intolerance in older patients.

Mitral stenosis is classically caused by rheumatic disease (RMS). However, degenerative mitral stenosis (DMS) is increasingly encountered, particularly in developed countries with aging populations. The aim of this study was to compare clinical and echocardiographic characteristics between the 2 entities. One hundred fifteen patients with DMS were identified from an echocardiographic database in the United States and compared with 510 patients with RMS from Seoul, Korea. All subjects had a mitral valve area (MVA) ≤2.5 cm2 by continuity equation but were otherwise unselected. Patients with DMS were older and had more hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease than those with RMS. Atrial fibrillation was more common in RMS patients. Mean mitral valve gradient was slightly lower in DMS versus RMS (7.63 ± 3.67 vs 8.50 ± 4.23 mm Hg, p = 0.04) but MVA was strikingly higher in the DMS group (1.35 ± 0.41 vs 0.95 ± 0.38 cm2, p

BACKGROUND Distinguishing cardiac from noncardiac causes of dyspnea is clinically important, and a reliable noninvasive measure of left atrial pressure (LAP) is needed. Subtracting the peak systolic gradient between left ventricle (LV) and left atrium (LA) from the central systolic blood pressure (BP) should provide this measure. Using a commercially available blood pressure system incorporating applanation tonometry and bedside echocardiography, we tested this hypothesis in a broad spectrum of patients. METHODS A total of 75 stable patients, scheduled for right heart catheterization for any reason, were included. Central systolic pressure was measured by a Sphygmocor® tonometry system; peak LV-LA gradient was calculated as 4*(peak mitral regurgitation (MR) velocity)2 . Microbubble contrast was used as needed to augment the MR signal. LAP estimates using central BP were compared with wedge pressure as were LAP estimates using brachial BP. RESULTS Left atrial pressure estimates using central BP showed a good correlation with wedge pressure (r2 = 0.774, P

Background: Mitral annular calcification (MAC) is an increasingly encountered cause of mitral stenosis. As opposed to rheumatic disease, in MAC the commissures are typically open. In some cases the leaflet tips remain freely mobile while in others they are restricted. We sought to determine if mean mitral valve gradient (MVG) is associated with the minimal area in the MAC tunnel or the area at the leaflet tips. Methods: High quality 3D TEE datasets were acquired in 10 subjects with severe bulky MAC. Custom 2D cut planes were created at the mitral valve inlet, the narrowest portion of the MAC tunnel, and at the leaflet tips (figure 1), and compared with MVG by continuous wave Doppler. Results: Area at the annular inlet ranged from 5.4 - 11.0 cm 2 (mean 8.2). The smallest area within the tunnel ranged from 1.3 - 4.0 cm 2 (mean 2.4) while the smallest area at the leaflet tips ranged from 1.0 - 2.6 cm 2 (mean 1.6). MVG ranged from 3 - 14 (mean 8) mm Hg. As annular inlet area decreased MVG increased (r 2 = 0.49, p = 0.024). Similarly, as minimum tunnel area decreased MVG increased (r 2 = 0.54, p = 0.015; figure 2). There was a no significant relation between MVG and smallest leaflet area (r 2 = 0.17, p = 0.23). There was also no association between degree or distribution of MAC, and MVG or smallest tunnel area. Conclusions: In subjects with severe MAC and a resting gradient across the valve, obstruction to flow occurs at the annular inlet and within the calcium tunnel. In contrast to rheumatic mitral stenosis, valve area at the leaflet tips does not appear to determine the MVG.

Background: Obstructive sleep apnea (OSA) imposes an afterload burden on the left ventricle and increases the pressure gradient across the intrathoracic aorta. This might increase the likelihood of aortic dissection (AD). We hypothesized that patients with acute AD would have a high prevalence of previously undiagnosed OSA and a largely nocturnal presentation. Methods: 40 consecutive, consenting subjects with acute AD who survived to hospital discharge were collected from 4 institutions. Mean age was 57 (range 28-75), 24 were male. 25 had type A dissection and 15 type B. 37 completed the modified Berlin Questionnaire and 30 had attended overnight polysomnography. Presenting CT scans had aortic diameter measured at a) the sinotubular junction b) ascending aorta c) origin of innominate d) mid-arch e) origin of left subclavian f) mid-descending aorta g) level of diaphragm; CT scans at 3 months were available in 24 subjects. Results: AHI ranged from 0 - 89; prevalence of OSA (defined by apnea-hypopnea index [AHI] > 5) was 63%. There were no differences in aortic diameter at any level comparing OSA vs non-OSA, regardless of AHI cutoff (>5, >15, >30; figure). Over time aortic diameter decreased at the level of the sinotubular junction and ascending aorta (expected - due to surgery). Whether dissection occurred during overnight hours (10 PM - 7 AM) did not differ by presence/absence of OSA (regardless of AHI cutoff). In those with high-risk Berlin questionnaires (>=2 categories positive) 10/21 (48%) dissections occurred during sleeping hours vs 2/13 (15%) in low risk Berlin group (p = 0.08, Fisher’s exact test). Conclusions: Among patients with acute AD the prevalence of OSA was high. Aortic diameters, however, were not different according to level of AHI. Presence of OSA defined by polysomnography was not associated with a nocturnal presentation in this sample.

Background Systolic anterior motion (SAM) of the mitral valve (MV) can develop after mitral valve repair with placement of an annuloplasty ring. It is occasionally seen in patients with mitral annular calcification (MAC) but mechanisms have not been carefully delineated. Using 2-dimensional echocardiography we explored morphologic parameters which may contribute to SAM in patients with MAC. Hypothesis We hypothesized that in cases of MAC where SAM is present there would be anterior displacement of the valve by the posterior annular calcification. Methods From our echocardiographic database we identified 20 patients with severe MAC who also had SAM with definite septal contact. Each subject was paired with 2 controls free of MAC and 1 control with severe MAC but no SAM. All controls were matched for age, sex, BSA, and septal wall thickness (±1.5 mm). 2-D echocardiographic measurements were taken from the parasternal long-axis (PLAX), apical 3-chamber and apical 4-chamber views. Results MAC+SAM vs MAC no-SAM. Three notable differences were observed: MAC+SAM patients, as compared with MAC no-SAM, had a smaller left ventricular outflow tract (LVOT), longer anterior mitral leaflet, and greater displacement of the MV coaptation point towards the interventricular septum (Figure 1). Median values for these 3 factors were determined using the no-MAC controls; each MAC subject was then scored for number of factors exceeding those values. MAC+SAM patients had a mean score of 2.7 vs 1.1 for MAC no-SAM patients. By combining anterior mitral leaflet length and coaptation point-septal distance as a ratio we could effectively separate MAC+SAM vs MAC no-SAM when >0.9 with one exception (Figure 2). We also observed a smaller anteroposterior annular dimension in the MAC+SAM group. MAC no-SAM vs no-MAC. Comparing these groups there were no differences in LVOT diameter or coaptation-septal distance; effective anterior mitral leaflet length was smaller in MAC no-SAM subjects vs no-MAC controls while anteroposterior dimension of the annulus was larger. Conclusions SAM develops in a subset of patients with severe calcification of the mitral annulus. These patients have a smaller anteroposterior annular dimension, possibly due to severe MAC. Other notable differences characterize MAC patients with SAM from those without. The LVOT is smaller, the effective anterior mitral leaflet length is longer, and the point of leaflet coaptation is displaced towards the septum. Using the ratio of anterior mitral leaflet length/coaptation point-septal distance in this study sample effectively separated those MAC patients with SAM from those without. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Aims Sex-specific thresholds of aortic valve calcification (AVC) have been proposed and validated in Caucasians. Thus, we aimed to validate their accuracy in Asians. Methods and results Patients with calcific aortic stenosis (AS) from seven international centres were included. Exclusion criteria were ≥moderate aortic/mitral regurgitation and bicuspid valve. Optimal AVC and AVC-density sex-specific thresholds for severe AS were obtained in concordant grading and normal flow patients (CG/NF). We included 1263 patients [728 (57%) Asians, 573 (45%) women, 837 (66%) with CG/NF]. Mean gradient was 48 (26–64) mmHg and peak aortic velocity 4.5 (3.4–5.1) m/s. Optimal AVC thresholds were: 2145 Agatston Units (AU) in men and 1301 AU in women for Asians; and 1885 AU in men and 1129 AU in women for Caucasians. Overall, accuracy (% correctly classified) was high and comparable either using optimal or guidelines’ thresholds (2000 AU in men, 1200 AU in women). However, accuracy was lower in Asian women vs. Caucasian women (76–78% vs. 94–95%; P 0.41) with regards to AS haemodynamic severity. Conclusion AVC thresholds defining severe AS are comparable in Asian and Caucasian populations, and similar to those proposed in the guidelines. However, accuracy of AVC to identify severe AS in Asians (especially women) is sub-optimal. Therefore, the use of AVC-density is preferable in Asians.

The risk prediction of future cardiovascular events is mainly based on conventional risk factor assessment by validated algorithms, such as the Framingham Risk Score, the Pooled Cohort Equations and the European SCORE Risk Charts. The identification of subclinical atherosclerosis has emerged as a promising tool to refine the individual cardiovascular risk identified by these models, to prognostic stratify asymptomatic individuals and to implement preventive strategies. Several imaging modalities have been proposed for the identification of subclinical organ damage, the main ones being coronary artery calcification scanning by cardiac computed tomography and the two-dimensional ultrasound evaluation of carotid arteries. In this context, echocardiography offers an assessment of cardiac calcifications at different sites, such as the mitral apparatus (including annulus, leaflets and papillary muscles), aortic valve and ascending aorta, findings that are associated with the clinical manifestation of atherosclerotic disease and are predictive of future cardiovascular events. The aim of this paper is to summarize the available evidence on clinical implications of cardiac calcification, review studies that propose semiquantitative ultrasound assessments of cardiac calcifications and evaluate the potential of ultrasound calcium scores for risk stratification and prevention of clinical events.

Estimation of right atrial (RA) or central venous pressure (CVP) is a critical component of a comprehensive transthoracic echocardiographic (TTE) examination. We hypothesize that continuous inflow from the inferior vena cava (IVC) into the RA is a surrogate for low/normal CVP and can be reliably imaged in standard echocardiographic parasternal short and right ventricular inflow views. We retrospectively studied 200 patients who underwent right heart catheterization (RHC) within 8 hours of TTE between 2012 and 2016, and selected 60 patients in whom the continuous wave Doppler beam incidentally interrogated IVC inflow into RA during evaluation of the tricuspid valve. From these studies, we sought an uninterrupted Doppler wave (DW) inflow signal. CVP on RHC were then compared in patients with continuous and interrupted DW. Other TTE and RHC parameters were also noted and compared in these 2 groups. The average time interval between TTE and RHC was 266 ± 151 minutes. Of 60 patients (males = 39 (65%); age 63 ± 14 years), 12 patients (20%) had continuous DW and 48 (80%) had interrupted DW inflow signal from IVC into the RA. Of the 12 patients with continuous flow, 11 had RA pressure of ≤7 mm Hg. Similarly, of 48 patients with interrupted flow, RA pressure was >7 mm Hg in 45, and less than ≤7 mm Hg in 3 patients (two-sided p value 0.0001). The continuous DW signal predicted RA of ≤7 mm Hg with a sensitivity and specificity of 98% and 78%, respectively. Additionally, when combined with IVC size and collapsibility (normal-sized collapsible IVC), the sensitivity and specificity of DW signal to predict RA of ≤ 7 mmHg were enhanced to 94% and 92%, respectively. In conclusion, IVC flow pattern can be reliably studied to estimate CVP in standard echocardiographic views. Continuous and interrupted IVC flow predicts normal and elevated RA pressure, respectively.

Graphical abstract, Highlights • EA is a distinct entity on echocardiography. • Accessory pathways are commonly seen with EA. • Mahaim fiber tachycardia is a rare accessory pathway–mediated tachycardia.

Background: Acute Kidney Injury as a complication of cardiac catheterization is associated with increased length of hospital stay and mortality. In recent years, the use of the radial artery for cardiac catheterization is increasing in frequency. Objective: The objective of this concise review was to evaluate the method of cardiac access site and its impact on Acute Kidney Injury following cardiac catheterization. Methods: After a thorough search on Medline, Google Scholar and PubMed, we included all the literature relevant to Acute kidney injury following transradial and transfemoral cardiac catheterization. Results: While acute kidney injury was caused due to a variety of reasons, it was important to consider each case on an individual basis. We found a trend towards increased use of transradial approach in patients at high risk of developing kidney injury. However, limitations such as operator experience, anatomical challenges and so on do exist with this approach. Conclusion: Transradial access offers several advantages to a patient at high risk of acute kidney injury undergoing cardiac catheterization. Further large studies are needed to establish this trend in the years ahead.

Carcinoid heart disease is the collective term for all cardiac manifestations in patients who have carcinoid syndrome. Carcinoid heart disease has a multifactorial pathophysiology, and the right side of the heart is usually involved. Symptoms and signs vary depending upon the affected cardiac components; most typical is right-sided heart failure secondary to diseased tricuspid and pulmonary valves. Despite no single ideal diagnostic test, strong suspicion, coupled with serologic and imaging results, usually enables diagnosis. Advances in imaging, such as speckle-tracking echocardiography and cardiac magnetic resonance, have improved the diagnostic yield. Treatment is challenging, warrants a multidisciplinary approach, and can be medical or surgical depending on the cardiac manifestations. Investigators are exploring the therapeutic use of monoclonal antibodies and new somatostatin analogues. In this review, we cover current knowledge about the pathophysiology, diagnosis, and treatment of carcinoid heart disease.

Echocardiographic calcifications are associated with major adverse cardiovascular events (MACE). A recently described semiquantitative Global Cardiac Calcium Score (GCCS) has been associated with mortality and stroke, with increasing scores associated with increasing risk. This score assigns points for calcium in the aortic root and valve, mitral valve and annulus, and submitral apparatus, with additional points for restricted leaflet mobility. We tested the hypothesis that the GCCS could improve prediction of MACE beyond traditional risk scores. This was a retrospective study of 216 subjects from a general echocardiography database (mean age 59 ± 15; 51% male). Follow-up was 3.8 ± 1.7 years. The Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) were applied to each patient. Mean GCCS was 3.2 ± 2. In the total cohort, GCCS predicted MACE (myocardial infarction, stroke, all-cause mortality), even after adjusting for FRS (odd ratio 1.19, p = 0.03). There were 106 subjects (49%) in the low-risk FRS group, 71 (33%) in the intermediate-risk group, and 39 (18%) in the high-risk group. GCCS ≥3 was associated with increased MACE (vs3) in the low-risk group (p = 0.03), while GCCS3 was associated with decreased MACE (vs ≥3) in the high-risk group (p = 0.04). When applied to the PCE risk estimate (dichotomized at7.5% vs ≥7.5%) the GCCS similarly refined risk prediction. In conclusion, the semiquantitative GCCS appears to be a marker of additional unaccounted risk factors; it is easily applied and can further stratify risk of MACE beyond traditional FRS or PCE estimates.

Background: Renal dysfunction is an important predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) dysfunction is implicated as one of the explanations for worsening renal function in cardiorenal syndrome. Novel right heart catheterization (RHC) parameters such as pulmonary artery pulsatility index (PAPi) and right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP) have been found as predictors of RV dysfunction. However, most studies investigating these parameters have been done in the setting of myocardial infarction or left ventricular assist device implantation, with limited data on these metrics in patients with HFpEF. Objective: The purpose of this study was to determine whether novel RHC parameters such as RA:PCWP and PAPi correlate with long-term renal outcomes among patients with HFpEF. Methods: A retrospective single-center study of adult patients with a documented diagnosis of heart failure who had RHC was performed between January 2006 and December 2010 at Einstein Med ical Center Philadelphia. Selected patients also had a serum B-type natriuretic peptide level ≥100 pg/mL and a PCWP ≥15 mm Hg. Patients with an ejection fraction < 50%, including those with recovered ejection fraction, and end-stage renal disease were excluded. Results: A total of 81 patients with a clinical diagnosis of HFpEF were identified who met the inclusion criteria. On multivariate analysis, after adjusting for age, sex, race, diabetes, hypertension, and cardiac index, PAPi was associated with long-term estimated glomerular filtration rate (eGFR) (β = 3.43, 95% CI = 0.635–6.23, p = 0.017), and RA:PCWP showed a trend towards significance (β = 14.81, 95% CI = –0.096–29.73, p = 0.051). The results were unchanged after further adjustment for eGFR at the time of RHC. Conclusion: Novel hemodynamic indices obtained by RHC may have predictive value for long-term renal dysfunction in patients with HFpEF.

Aortic stenosis (AS) is common and increasing in prevalence as the population ages. Using computed tomography (CT) to quantify aortic valve calcification (AVC) it has been reported that men have greater degrees of calcification than women among subjects with severe AS. These data, however, were derived in largely Caucasian populations and have not been verified in non-Caucasian subjects. This retrospective study identified 137 patients with severe AS who underwent valve replacement and had CT scans within 6 months prior to surgery. AVC scores were compared between men and women, both in the entire sample and in racial subgroups. 52% of subjects were male and 62.8% were non-Caucasian. Mean AVC score for the entire cohort was 3062.08±2097.87 with a range of 428-13,089. Gender differences in aortic valve calcification were found to be statistically significant with an average AVC score of 3646±2422 in men and 2433±1453 in women (p=0.001). On multivariate analysis, gender remained significantly associated with AVC score both in the entire sample (p=0.014) and in the non-Caucasian subgroup (p=0.008). Mean AVA was significantly greater in males than females but this difference disappeared when AVA was indexed to BSA (p=0.719). AVA was not different between racial groups (p=0.369). In this research we observed that among subjects with severe AS men have higher AVC scores than women regardless of racial background. This is consistent with previous studies in predominantly Caucasian populations.

Introduction Study aims were to compare hemodynamics and viscous energy dissipation (VED) in 3D printed mitral valves–one replicating a normal valve and the other a valve with severe mitral annular calcification (MAC). Patients with severe MAC develop transmitral gradients, without the commissural fusion typifying rheumatic mitral stenosis (MS), and may have symptoms similar to classical MS. A proposed mechanism relates to VED due to disturbed blood flow through the diseased valve into the ventricle. Methods A silicone model of a normal mitral valve (MV) was created using a transesophageal echocardiography dataset. 3D printed calcium phantoms were incorporated into a second valve model to replicate severe MAC. The synthetic MVs were tested in a left heart duplicator under rest and exercise conditions. Fine particles were suspended in a water/glycerol blood analogue for particle image velocimetry calculation of VED. Results Catheter mean transmitral gradients were slightly higher in the MAC valve compared to the normal MV, both at rest (3.2 vs. 1.3 mm Hg) and with exercise (5.9 vs. 5.0 mm Hg); Doppler gradients were 2.7 vs. 2.1 mm Hg at rest and 9.9 vs 8.2 mm Hg with exercise. VED was similar between the two valves at rest. During exercise, VED increased to a greater extent for the MAC valve (240%) versus the normal valve (127%). Conclusion MAC MS is associated with slightly increased transmitral gradients but markedly increased VED during exercise. These energy losses may contribute to the exercise intolerance and exertional dyspnea present in MAC patients.

Pulmonary hypertension (PH) is an underdiagnosed and potentially fatal condition. The utility of screening for PH in hospitalized patients undergoing echocardiography is unknown. The goal of this study was to determine the prevalence of undiagnosed pulmonary hypertension (PH) and probable pulmonary arterial hypertension (PAH) in hospitalized patients undergoing echocardiography for any indication. All hospitalized patients undergoing echocardiography were identified and echocardiographs reviewed prospectively for the presence of a tricuspid regurgitant (TR) jet. Electronic medical records (EMR) of patients with a TR jet ≥ 3 m/s were reviewed for identifiable causes of pulmonary hypertension. Patients with no identifiable cause were classified as presumptive World Health Organization (WHO) Group 1 PH (also known as PAH). These PAH patients were compared to other PH patients for baseline demographic characteristics and comorbidities as well as 30-day readmission and mortality. The admitting physicians of patients classified as PH were advised to consider further evaluation including right heart catheterization. We reviewed 4417 consecutive echocardiograms and identified 448 with a TR jet ≥ 3 m/s. Of these 448 patients with PH, 47 were identified as "presumptive PAH" and the other 401 as having PH belonging to WHO Groups 2-5. Presumptive PAH represented 1% of screened echocardiograms and 10.5% of those identified to have an elevated TR jet. Of the patients identified as presumptive PAH, 8 underwent further evaluation including a right heart catheterization, where 5 were confirmed to have PAH. Kaplan-Meier analysis revealed 30-day readmission was higher among those classified as PAH. Our data shows that pulmonary hypertension, as defined by TR jet ≥ 3 m/s, is frequently encountered in hospitalized patients undergoing echocardiography for any reason. A careful review of echocardiogram findings and clinical history suggested 10.5% of those with PH (and 1% of all screened patients) may meet the criteria for PAH. Considering PH is a fatal condition which is frequently missed, a hospital screening program seems feasible.

Background Visual assessment of mitral regurgitation (MR) severity by color Doppler can be difficult, especially in eccentric jets. Examination of the proximal flow acceleration signal (PISA) on the ventricular side of the mitral valve can be helpful but, is not always intuitive. We describe a color signal ("splay") on the atrial side of the valve that can often be helpful in recognizing significant MR. Methods Clinical echocardiograms were reviewed to obtain two data sets: 100 patients with reported mild MR and another 100 with reported severe MR. All echocardiograms were reviewed to confirm that MR was truly mild or severe. Splay was defined as a non-physiologic arc of color (figure) centered at the point where the MR jet emerges into the atrium. Results Splay was present in the large majority of severe MR cases (table). It was seen across 3 vendors’ machines and was present with normal and reduced EF as well as primary and secondary MR. Color scale and transducer frequency did not differ according to presence or absence of splay, but gain was higher when splay was present (57.5 ± 6.8 vs 55.2 ± 6.1, p = 0.04). In mild MR patients, splay was present on fewer frames and had lesser dimensions vs severe MR. Splay was particularly prevalent in patients with wall hugging jets (28/30, 93%). Conclusions The splay signal occurs as a side lobe artifact, at the point where a high energy MR jet emerges into the left atrium. Its presence often indicates significant MR and may be a useful clue in highly eccentric jets which are otherwise difficult to grade. Table 1 Mild MR Severe MR P value Splay Present (%) 18 82 Abstract P1577 Figure. Splay Image

Background The authors describe a previously unreported Doppler signal associated with mitral regurgitation (MR) as imaged using transthoracic echocardiography. Horizontal “splay” of the color Doppler signal along the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign. Methods Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocardiography as less than moderate. The splay signal was present on at least one standard transthoracic view in each case. To better characterize the splay signal, two groups were created from existing clinically driven transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR. Results Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection fraction, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions compared with severe MR. Color scale did not differ between subjects with and those without splay, but color gain was higher when splay was present (P = .04). Machine settings were further explored in a single subject with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it. Conclusions The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely generated as a side-lobe artifact due to a high-flux regurgitant jet.

To determine whether calcifications of the coronary arteries (coronary artery calcium 0 to 4 score), or extending the assessment also to cardiac valves and thoracic aorta (overall calcium 0 to 8 score), as seen on computed tomography for attenuation correction during stress-scintigraphy (SPECT-CT), are associated with total mortality and non-fatal myocardial infarction. We aimed to assess whether these calcifications added to the prognostic value of SPECT imaging.The presence/amount of calcium in the coronary arteries, but also in the heart valves and aorta, has been associated with cardiovascular (CV) and all-cause mortality. This information can be obtained during SPECT-CT examinations, where low resolution CT images are co-registered for attenuation correction of myocardial perfusion, but then discarded.Clinical data were collected on 353 consecutive patients submitted to stress SPECT-CT between Sept 2010 and Oct 2012, for suspected coronary artery disease (CAD). Follow-up data on outcomes were collected retrospectively.Mean age was 72 and 58% were male. Mean follow-up was 6.4 years, during which 48 subjects died (15 from CV causes) and 10 had non-fatal myocardial infarction (MI). Reversible perfusion defects were detected in 55 patients (15.6%), 39 of whom (11%) hadmild defects. The presence of a calcium score 1 in the attenuation correction images was the strongest univariate predictor of all-cause death or MI (hazard ratio 7.21, p .001). On multivariate analysis, controlling for age, gender and myocardial perfusion defects an overall calcium score 2 remained a predictor of all-cause death or non-fatal MI (hazard ratio 4.12, p .001).Visual assessment of coronary or overall coronary, cardiac and aortic calcium in the CT images used for attenuation correction during SPECT-CT is feasible and reproducible. It was strongly associated with all-cause death and MI, even after controlling for clinical variables and myocardial perfusion data. This simple visual calcium assessment does not add additional costs or radiation, and may significantly improve risk-assessment of patients with suspected CAD undergoing SPECT-CT.Calcium in the coronary arteries, heart valves and aorta has been associated with worse prognosis. We sought to determine whether assessment of such calcifications on computed tomography images (co-registered for myocardial perfusion attenuation correction and then discarded) are independently associated with long-term outcome on top of available data. We enrolled 353 consecutive patients, referred for suspected coronary artery disease. An overall calcium score 1 in the attenuation correction images was the strongest univariate (hazard ratio 7.21, p .001) and multivariate predictor of all-cause death or non-fatal MI (hazard ratio 4.12, p .001), even after controlling for clinical variables and myocardial perfusion data.

Background The presence and amount of calcium in the coronary arteries, but also in the heart valves and aorta, has been clearly associated with cardiovascular and all-cause mortality and this information might be prognostically useful during SPECT-CT examinations, where CT images are co-registered for attenuation correction of myocardial perfusion, but then discarded. Objectives This study sought to determine whether the assessment of calcifications of the coronary arteries, cardiac valves and thoracic aorta in the computed tomography images co-registered for attenuation correction during stress-scintigraphy (SPECT-CT) is associated with long-term mortality and cardiac events on top of other available data. Methods Baseline data were collected prospectively on 353 consecutive patients, referred for suspected coronary artery disease (CAD) with no previously known CAD who underwent stress SPECT-CT between Sept 2010 and Oct 2012. Retrospective analysis was performed on follow-up data for outcomes. Results Patients (mean age 72 years. 58% males) had a mean follow-up of 6.4 years, during which 48 died (15 from cardiovascular causes) and 10 had a non-fatal myocardial infarction (MI). Reversible myocardial perfusion defects were detected in 55 patients (15.6%), 39 of whom (11%) had more than mild defects. The presence of an overall visual calcium score >1 in the attenuation correction images was the most strong univariable (hazard ratio 8.99, p Multivariable models Clinical + SPECT + Overall Calcium Ischemic Cardiac Events HR CI (95%) p-value χ2 Age 1.058 1.0234 to 1.093 0.0008 Male gender 1.63 0.88 to 3.024 0.1183 Fixed perfusion defect 3.924 1.63 to 9.426 0.0022 Overall Calcium >1 4.765 2.2 to 10.32 Kaplan-Meier Conclusions Visual assessment of coronary or overall coronary, cardiac and aortic calcium in the CT images used for attenuation correction during SPECT-CT is feasible, reproducible and strongly associated with hard cardiac events and all-cause death, beyond clinical variables and myocardial perfusion data. This incredibly easy visual calcium assessment does not require additional costs or radiation and may heavily impact on better risk-assessment of patients with suspected CAD undergoing SPECT-CT.

Background: The optimal timing of revascularization in unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI) remains uncertain. We compared routine early revascularization (REV) versus selective late revascularization (SLR) strategies and divergence in the approach of cardiologists in the United States and Europe. Methods: Seventeen randomized controlled trials (RCTs) (15,812 patients) were extracted from PubMed, Cochrane Library, EMBASE and Web of Science databases. The data were pooled using the Der Simonian and Laird random-effect models and expressed as pooled risk ratios (RR) with 95% confidence intervals (95% CIs). Results: Overall, there was no difference in all-cause mortality (RR: 1.01, 95% CI: 0.95 - 1.08, P = 0.7), myocardial infarction (MI) (RR: 0.98, 95% CI: 0.79 - 1.22, P = 0.85) or coronary artery bypass grafting (CABG) (RR: 1.33, 95% CI: 0.92 - 1.91, P = 0.12) between REV and SLR strategy. There were trends of decreased incidence of MI in REV, 13.3% (1,029/7,704) vs. 15.1% (1,108/7,314) in SLR (P = 0.007), and rate of CABG was higher in REV, 4.9% (140/2,831) vs. 3.7% (105/2,819) in SLR (P = 0.031). There were trends of lower all-cause mortality in the combined US/international trials in both REV 8.4% (390/4,624) vs. 22.8% (908/3,975) (P < 0.001) and SLR 8% (359/4,421) vs. 24% (910/3,808) (P < 0.001) compared to the European trials. There were also trends of lower rates of MI in the European trials in the REV group 20% (623/3,080) vs. 25% (712/2,893) in SLR (P = 0.001) and higher rates of CABG in REV 8.3% (96/1,144) vs. 5.7% (67/1,165) in SLR (P = 0.02); however, there were no significant effects in the pooled RR ratios even after subgroup analysis between US/international trials and European trials. Conclusions: Despite having contemporary differences in the management approach towards UA/NSTEMI patients, no significant differences in trends were observed with REV strategy in US/international trials vs. European trials. J Clin Med Res. 2018;10(12):868-876 doi: https://doi.org/10.14740/jocmr3585w

A 76-year-old Korean woman presented with intermittent episodes of exertional hypoxia at the rehabilitation facility after a recent admission for ischaemic stroke. Clinical and diagnostic investigation confirmed the presence of platypnea-orthodeoxia syndrome (POS). Transoesophageal echocardiogram revealed a patent foramen ovale and hyperdynamic interatrial septum with right-to-left intracardiac shunt. Further diagnostic workup did not reveal right atrial hypertension, cirrhosis, pulmonary hypertension or any other extracardiac causes of right-to-left shunt. Positional preferential blood flow from inferior vena cava to the left atrium due to counterclockwise displacement of interatrial septum with age and posture was postulated to explain the atrial right-to-left shunt and the resultant POS. Closure was performed using a cribriform amplatzer occluder which improved her symptoms.

Objectives This study sought to evaluate mechanisms of effort intolerance in patients with rheumatic mitral stenosis (MS). Background Combined stress echocardiography and cardiopulmonary testing allows assessment of cardiac function, hemodynamics, and oxygen extraction (A–Vo2 difference). Methods Using semirecumbent bicycle exercise, 20 patients with rheumatic MS (valve area 1.36 ± 0.4 cm2) were compared to 20 control subjects at 4 pre-defined activity stages (rest, unloaded, anaerobic threshold, and peak). Various echocardiographic parameters (left ventricular volumes, ejection fraction, stroke volume, mitral valve gradient, mitral valve area, tissue s′ and e′) and ventilatory parameters (peak oxygen consumption [Vo2] and A–Vo2 difference) were measured during 8 to 12 min of graded exercise. Results Comparing patients with MS to control subjects, significant differences (both between groups and for group by time interaction) were seen in multiple parameters (heart rate, stroke volume, end-diastolic volume, ejection fraction, s′, e′, Vo2, and tidal volume). Exercise responses were all attenuated compared to control subjects. Comparing patients with MS and poor exercise tolerance ( Conclusions In patients with rheumatic MS, exercise intolerance is predominantly the result of restrictive lung function, chronotropic incompetence, limited stroke volume reserve, and peripheral factors, and not simply impaired valvular function. Combined stress echocardiography and cardiopulmonary testing can be helpful in determining mechanisms of exercise intolerance in patients with MS.

Background and Aim Diastolic wall strain (DWS) has been proposed as a simple noninvasive measure of left ventricular (LV) stiffness. This study investigated DWS as a possible predictor of mortality in severe aortic stenosis (AS). Methods 138 patients with severe AS (indexed aortic valve area [AVA] 55%) were included. 52 patients (38%) had aortic valve interventions or poor image quality (n=5) and were excluded leaving 86 in the study group (84±8 years, 70% female, 69% African American). DWS was defined as (LVPWs−LVPWd)/LVPWs where LVPWs=left ventricular posterior wall thickness in systole and LVPWd=left ventricular wall thickness in diastole. Results Follow-up extended 2.0±1.9 years (median 1.6 years). Mean DWS for the group was 0.21±0.11 (normal=0.4±0.07). In patients who died, DWS was significantly lower than in survivors (0.18±0.09 vs 0.24±0.11, P=.02). By contrast, traditional measures of diastolic dysfunction did not predict death. Regression analysis showed DWS predicted death even after adjusting for age, sex, race, indexed AVA, symptoms (angina, shortness of breath, dizziness, syncope), and clinical factors (creatinine, smoking, diabetes, hypertension, hyperlipidemia) (HR 2.5 [95% CI 1.02-5.90], P

Combining echocardiography and cardiopulmonary stress testing allows noninvasive assessment of hemodynamics, and oxygen extraction (A-VO 2 difference). We evaluated mechanisms of effort intolerance in patients with heart failure with borderline (40% to 49%) left ventricular ejection fraction (EF) (HF and Borderline Ejection fraction). We included 89 consecutive patients with HF and Borderline Ejection fraction (n = 25; 63.6 ± 14 years, 64% men), control subjects (n = 22), patients with HF with preserved EF (n = 26; EF ≥50%), and patients with HF with reduced EF (n = 16; 2 ] and A-VO 2 difference) were measured at 4 predefined activity stages. Effort-induced functional MR was frequent and more prevalent in HF and Borderline Ejection fraction than in all the other types of HF. In multivariable analysis heart rate response (p 2 difference (p = 0.02), stroke volume (p = 0.002), and right ventricle end-systolic area were the only independent predictors of exercise capacity in HF and Borderline Ejection fraction but peak EF was not. In HF and Borderline Ejection fraction exercise intolerance is predominantly due to chronotropic incompetence, peripheral factors, and limited stroke volume reserve, which are related to right ventricle dysfunction and functional MR but not to left ventricular ejection fraction. Combined testing can be helpful in determining mechanisms of exercise intolerance in HF and Borderline Ejection fraction.

Calcium deposits in the aortic valve and mitral annulus have been associated with cardiovascular events and mortality. However, there is no accepted standard method for scoring such cardiac calcifications, and most existing methods are simplistic. The aim of this study was to test the hypothesis that a semiquantitative score, one that accounts for all visible calcium on echocardiography, could predict all-cause mortality and stroke in a graded fashion.This was a retrospective study of 443 unselected subjects derived from a general echocardiography database. A global cardiac calcium score (GCCS) was applied that assigned points for calcification in the aortic root and valve, mitral annulus and valve, and submitral apparatus, and points for restricted leaflet mobility. The primary outcome was all-cause mortality, and the secondary outcome was stroke.Over a mean 3.8 ± 1.7 years of follow-up, there were 116 deaths and 34 strokes. Crude mortality increased in a graded fashion with increasing GCCS. In unadjusted proportional hazard analysis, the GCCS was significantly associated with total mortality (hazard ratio, 1.26; 95% CI, 1.17-1.35; P .0001) and stroke (hazard ratio, 1.23; 95% CI, 1.07-1.40; P = .003). After adjusting for demographic and clinical factors (age, gender, body mass index, diabetes, hypertension, dyslipidemia, smoking, family history of coronary disease, chronic kidney disease, history of atrial fibrillation, and history of stroke), these associations remained significant.The GCCS is easily applied to routinely acquired echocardiograms and has clinically significant associations with total mortality and stroke.

Epicardial adipose tissue (EAT) has been linked to coronary artery calcium deposits and atherosclerotic disease. Mitral annular (MAC) and aortic valve calcium (AVC) have also been associated with atherosclerosis. This study examined the possible relation between EAT thickness and valvular calcium deposits. We included 294 patients aged ≥65 years who had noncontrast computed tomography scans of the chest. Mean age was 76 ± 7 years; 47% were men. Using reconstructed images, EAT thickness was measured at various locations. MAC and AVC were quantified by Agatston technique. The sum of AVC and MAC was reported as the grand total score (GTS). Subjects were divided into 2 groups based on the value of GTS; GTS = 0, no cardiac calcification and GTS ≥1, cardiac calcification group. Epicardial fat (left and right atrioventricular grooves and superior interventricular groove) was significantly greater in the cardiac calcification group compared with the no cardiac calcification (all values, p

Calcific aortic stenosis is the most common lesion requiring valve replacement. Transcutaneous procedures (TAVR) are rapidly increasing yet detailed information on aortic valve and root anatomy are sparse. This study examined gated cardiac CT scans to make observations regarding the size and proportions of the valve leaflets, sinuses of Valsalva, and sinotubular junction. One hundred and fifty gated cardiac CT scans were performed for a variety of clinical indications. Area of each cusp (short axis plane) was measured along with sinus height (from leaflet base to sinotubular junction), sinus width (from central coaptation point to outer sinus edge), annular perimeter, perimeter at mid-sinus level, and perimeter at the sinotubular junction. The right coronary cusp was largest, the left cusp smallest, and the non-coronary cusp intermediate in size. Each cusp was larger in men than women, even after indexing for body surface area. By contrast, indexed sinus width and height did not differ between genders. No significant differences were noted between races. Annular perimeter did not vary by age while the mid-sinus perimeter and sinotubular junction perimeter increased with age (p=0.01, r2 =0.05 and p=0.002, r2 =0.07). Interestingly, the ratio of sinus height (average): annular radius was 1.69±0.18, very close to the “golden ratio” of 1.62 found throughout the natural world. This might be important for proper vortex formation in the sinuses.

BACKGROUND Accurately assessing volume status in acutely decompensated heart failure (ADHF) can be challenging. Inferior vena cava (IVC) dynamics by echocardiography allow indirect assessment of volume status in these patients. Recently introduced hand-held ultrasound devices are promising. We aimed to describe the clinical correlates of volume status assessment using a hand-held ultrasound device in ADHF. METHODS In this prospective study, we evaluated 106 patients admitted with ADHF. First scan was performed within 24 hours of admission and timed in reference to first dose of intravenous diuretic. Daily resting and inspiratory (sniff) IVC diameters were measured according to standard echocardiography methods during hospitalization including the day of discharge. IVC collapsibility index (IVC-CI = Maximum IVC diameter-Inspiratory IVC diameter/maximum diameter

Background Rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is crucial for appropriate management. Catheterization for a false STEMI activation has risks including exposure to contrast agent and radiation, increased healthcare costs and delay in treatment of the primary medical condition. Patients and methods This was a single center retrospective study including all 'cath alerts' between January 2012 and December 2015. 'Cath alert' is a term used to activate the interventional cardiology team when STEMI is suspected by the emergency department physicians based on review of the initial ECG. We reviewed all STEMI alerts to understand ECG differences between true and false STEMI. Results Our study population (N = 361) included 221 (61%) men and 140 (39%) women, with average age 60 ± 4.2 years. Among the 361 STEMI alerts, 82 (22.7%) did not have acute coronary syndrome. Common ECG causes of misdiagnosis included left ventricular hypertrophy (LVH, found in 40/82, 49%), early repolarization changes (20/82, 24%), right bundle branch block (RBBB) (13/82, 16%), and Brugada pattern (3/82, 4%). Multivariate regression analysis showed that LVH and RBBB were independent predictors of nonacute coronary syndrome false STEMI (odds ratio: 0.54; 95% confidence interval: 0.32-0.93; P = 0.03 for LVH, and odds ratio: 0.26, 95% confidence interval: 0.1-0.62, P = 0.004 for RBBB). Conclusion The incidence of false STEMI alerts was almost 23% at our center. This number might be reduced with additional training of emergency department physicians in ECG interpretation, and recognition of common causes of misdiagnosis such as LVH, early repolarization changes, RBBB, and Brugada pattern.