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Objectives This study evaluated utilization of stress echocardiography (SE) at our institution, the impact of the updated 2011 appropriate use criteria (AUC) on appropriateness ratings, correlation of AUC to radiology benefits managers' (RBM) pre-certification guidelines and the effect of temporal trends and an AUC-based educational project on appropriateness. Background The AUC for SE have been developed to improve efficiency of utilization and promote optimal patient care. Methods We classified the appropriateness of 209 SEs from 2008 using the original and updated AUC. We also performed pre-authorization determinations on these SEs using the guidelines of 2 RBMs. We then classified and compared the appropriateness of 209 SEs from 2011 using the updated criteria to that of the 2008 cohort. Finally, we rated and compared 111 SEs requested by cardiologists after an educational project to 111 SEs referred before the intervention. Results Overall, nearly one-third of SEs were requested for inappropriate indications. Using 2011 AUC, the original ratings of 52 (25%) studies by AUC 2008 were changed and the number of unclassified SE decreased from 20 (9.6%) to 2 (1%). Correlation between RBM pre-authorization determination and AUC ratings was substantial for the first RBM (κ = 0.625) and fair for the second (κ = 0.358). However, 12.9% and 41.9% of studies classified as appropriate or uncertain by the AUC would not have received pre-authorization according to the guidelines of the first and second RBMs, respectively. Referrals of inappropriate SE did not decrease over time or with an educational intervention. Conclusions The revisions in the updated AUC improve their clinical application by encompassing nearly all indications for SE. The limited correlation between AUC ratings and RBM determinations suggests a need for greater consistency. The large number of SE requested for inappropriate indications at our institution did not decrease with time or education.

Background: This study evaluates the effects of performing real time three-dimensional transesophageal echocardiography in addition to conventional two-dimensional transesophageal echocardiography on diagnostic confidence. Methods: Operator diagnostic confidence in addressing clinical questions posed by the referral was scored using a five-point scale for two-dimensional transesophageal echocardiography alone and the combination of two-dimensional and real time three-dimensional transesophageal echocardiography in 136 consecutive patients undergoing examination in an academic hospital. Results: Mean diagnostic confidence score was higher for the combined studies compared to two-dimensional transesophageal echocardiography alone (4.5 vs. 4.1, P < 0.001)). The addition of real time three-dimensional transesophageal echocardiography increased diagnostic confidence score in 45 (33.1%) patients, and the percentage of studies with total diagnostic confidence rose from 40.4% with two-dimensional transesophageal echocardiography alone to 65.4% after performing real time three-dimensional transesophageal echocardiography. Type of clinical indication was associated with improved score by the combined exams (P < 0.004). The addition of real time three-dimensional transesophageal echocardiography was most likely to improve diagnostic confidence score in studies performed to assess valve disease (56.1%) and least likely in examinations performed for intracardiac infection (14.9%). The location (anterior or posterior) of the primary cardiac pathology was not associated with improved score by the combined studies (P = 0.498). Conclusions: The addition of real time three-dimensional transesophageal echocardiography to two-dimensional transesophageal echocardiography increases diagnostic confidence in examinations routinely performed in an academic practice. Further studies of the impact of real time three-dimensional transesophageal echocardiography on patient management, outcomes and displacement of or need for downstream testing are warranted. (Echocardiography 2011;28:235-242)

A 39-year-old female had cor triatriatum (CT) detected as an incidental finding on transthoracic echocardiography performed to evaluate chest pain. By conventional two- and real time three-dimensional transesophageal echocardiography, the CT membrane had a communicating orifice connecting the accessory and main left atrial chambers that measured 1.3 × 0.8 cm. The resting mean transmembrane gradient was 2 mm Hg. The postexercise mean transmembrane gradient and pulmonary artery pressure were 6 and 40 mm Hg. Extrapolating from cutoff values for postexercise gradients and pulmonary pressures in patients with mitral stenosis, we advised deferring surgery and close clinical and echocardiographic follow up. (Echocardiography 2010;27:E132-E136)

Epicardial fat plays a role in cardiovascular diseases. Because of its anatomic and functional proximity to the myocardium and its intense metabolic activity, some interactions between the heart and its visceral fat depot have been suggested. Epicardial fat can be visualized and measured using standard two-dimensional echocardiography. Standard parasternal long-axis and short-axis views permit the most accurate measurement of epicardial fat thickness overlying the right ventricle. Epicardial fat thickness is generally identified as the echo-free space between the outer wall of the myocardium and the visceral layer of pericardium and is measured perpendicularly on the free wall of the right ventricle at end-systole. Echocardiographic epicardial fat thickness ranges from a minimum of 1 mm to a maximum of almost 23 mm. Echocardiographic epicardial fat thickness clearly reflects visceral adiposity rather than general obesity. It correlates with metabolic syndrome, insulin resistance, coronary artery disease, and subclinical atherosclerosis, and therefore it might serve as a simple tool for cardiometabolic risk prediction. Substantial changes in echocardiographic epicardial fat thickness during weight-loss strategies may also suggest its use as a marker of therapeutic effect. Echocardiographic epicardial fat measurement in both clinical and research scenarios has several advantages, including its low cost, easy accessibility, rapid applicability, and good reproducibility. However, more evidence is necessary to evaluate whether echocardiographic epicardial fat thickness may become a routine way of assessing cardiovascular risk in a clinical setting.

To determine whether pulmonary arterial hypertension (PAH) and pulmonary venous hypertension (PVH) can be differentiated noninvasively, we reviewed data on 44 patients with pulmonary artery systolic pressure greater than or equal to 40 mm Hg by echocardiography and cardiac catheterization performed within 7 days of each other. Based on left ventricular end-diastolic pressure or pulmonary capillary wedge pressure, 20 patients were classified as having PVH and 24 as having PAH. Early (E) and late (A) diastolic mitral inflow velocities, deceleration time, early diastolic mitral annular velocity (E'), and E/A and E/E' ratios were remeasured in the two groups. Compared with patients with PAH, those with PVH had significantly higher E (107.8 +/- 27.3 vs 65.0 +/- 24.0 cm/s, P < .001), E/A (2.4 +/- 1.0 vs 0.9 +/- 0.4, P < .001), and E/E' (14.3 +/- 4.3 vs 5.1 +/- 1.9, P < .001), and significantly lower A (55.5 +/- 33.5 vs 74.1 +/- 20.8 cm/s, P < .001), E' (8.0 +/- 2.5 vs 13.1 +/- 3.6 cm/s, P = .001), and deceleration time (148.5 +/- 49.0 vs 192.3 +/- 41.9 milliseconds, P = .003). The area under receiver operating characteristic curve was 97% for E/E' and 91% for E/A. Optimal cutoff for diagnosing PVH was 9.2 for E/E' (sensitivity 95%, specificity 96%) and 1.7 for E/A (sensitivity 75%, specificity 91%). PAH and PVH may be differentiated by readily obtainable conventional and tissue Doppler parameters.

To evaluate the effects of age and pulmonary hypertension on phasic right atrial function we measured right atrial volumes at 3 different points in the cardiac cycle in 57 healthy subjects and 33 patients with pulmonary arterial hypertension. Right atrial reservoir function was assessed by systolic filling volume and passive and active emptying by passive and active emptying volume and fraction of total emptying. We compared these phases of right atrial function in 30 healthy subjects

Epicardial fat assessed using echocardiography is associated with abdominal visceral adipose tissue and cardiovascular risk factors. Because of its location, epicardial fat may directly affect the coronary vasculature and myocardium through local secretion of bioactive molecules. This study examines the effects of weight loss after bariatric surgery on epicardial adipose tissue in patients with severe obesity. Clinical data and echocardiograms of 23 patients with severe obesity who had echocardiograms recorded before and 8.3 +/- 3.7 months after undergoing bariatric surgery were retrospectively reviewed. Epicardial fat thickness was measured as the hypoechoic space anterior to the right ventricle in both the parasternal long- and short-axis views, and an average was obtained. At baseline, patients had increased epicardial fat compared with normal-weight controls matched for age, gender, and ethnicity (5.3 +/- 2.4 vs 3.0 +/- 1.1 mm, p0. 001). Epicardial fat thickness was associated with the patient's initial weight in severely obese patients (r = 0.51, p = 0.011). Patients lost an average of 40 +/- 14 kg after surgery. Epicardial fat thickness decreased from 5.3 +/- 2.4 to 4.0 +/-1.6 mm (p = 0.001). Change in epicardial fat correlated with initial epicardial fat thickness measured using echocardiography (r = 0.71, p0.001). In conclusion, epicardial fat thickness decreases in severely obese patients who have substantial weight loss after bariatric surgery. Measuring epicardial fat thickness using echocardiography may be useful to monitor visceral fat loss with weight reduction therapies.

This study examined the relation between arterial compliance of the lower extremities and aerobic capacity in patients with a broad spectrum of cardiovascular risk but without overt coronary heart disease (CHD). Local arterial compliance was noninvasively measured in the thigh and calf in 104 men and 99 women using air plethysmography. Subjects also underwent maximal exercise treadmill testing as a measure of aerobic capacity. In univariate analysis, age (r = -0.49, p0.001), systolic blood pressure at rest (r = -0.27, p0.001), pulse pressure (r = -0.39, p0.001), total cholesterol (r = -0.25, p0.001), triglycerides (r = -0.025, p0.001), non-high-density lipoprotein cholesterol (r = -0.23, p0.001), high-sensitivity C-reactive protein (r = -0.21, p = 0.002), and low-density lipoprotein cholesterol (r = -0.15, p = 0.03) all demonstrated a significant inverse association with treadmill time. Thigh and calf compliance demonstrated a significant positive association with treadmill time (r = 0.48, p0.001; r = 0.46, p0.001). In multivariate analysis, thigh compliance (p = 0.003), age (p0.001), gender (p = 0.005), and triglycerides (p = 0.017) were independent predictors of treadmill time. In conclusion, thigh compliance measured with a simple-to-use, fully automated device independently predicts aerobic fitness in patients with a wide range of cardiovascular risk but without CHD.

Objectives The purpose of this study was to determine whether digoxin use is associated with increased flow cytometric markers of endothelial cell and platelet activation in patients with nonvalvular atrial fibrillation (AF). Background Increased intracellular calcium is a key event in platelet activation, and several studies have demonstrated that digitalis activates platelets in vitro . Intracellular calcium also is a key regulator of endothelial cell function, and endogenous digitalis-like substances have been shown to affect biologic processes in endothelial cells. Methods We studied 30 patients with nonvalvular AF. We measured the levels of (1) platelet expression of P-selectin (CD62P), (2) platelet microparticles (PMP); and (3) endothelial microparticles (EMP) identified by anti-CD31 (EMP31) and by anti-E-selectin antibodies (EMP62E). Results Patients who were taking digoxin (n = 16; mean digoxin level=0.93 ng/dL) did not demonstrate any significant differences in clinical or echocardiographic characteristics compared with patients not taking digoxin (n = 14). Patients taking digoxin had significantly increased levels of CD62P expression in platelets and platelet-leukocyte conjugates and markedly increased markers of endothelial activation: EMP62E and EMP31. After adjusting for potential confounders (including age, congestive heart failure, coronary artery disease, ejection fraction, antiplatelet, β-blocker, and calcium channel blocker use), the differences persisted. Conclusions Digoxin use in patients with AF is associated with increased levels of endothelial and platelet activation. If digitalis activates endothelial cells and platelets at pharmacologic doses, use of digitalis in conditions such as AF could predispose to thrombosis and vascular events.

Abnormalities of peripheral arterial compliance are clinically useful markers of atherosclerosis and risk of vascular events. Local peripheral arterial compliance can be easily and accurately assessed in the clinic by computer-controlled pulse volume recordings (air plethysmography). The purpose of this study was to investigate the relationship between clinical cardiovascular risk factors, a surrogate of atherosclerotic burden, and peripheral arterial compliance in the thigh and calf determined by quantification of local pulse volume recordings in patients undergoing coronary angiography. Peripheral arterial compliance in the thigh and calf was measured in 346 patients undergoing diagnostic cardiac catheterization at 4 centers. Demographic and cardiovascular risk factor data were collected, and their relationship to local arterial compliance examined using a new device that assesses maximal local arterial volume change in an extremity segment. Pulse volume recordings detected decreased local arterial compliance in the thigh associated with a history of hypertension (p< 0.0001), diabetes mellitus (p = 0.0001), and hyperlipidemia (p = 0.0007). In the calf, this arterial compliance measure was associated with a history of hypertension (p < 0.0001) and diabetes mellitus (p = 0.002). Females had lower arterial compliance than males in the thigh (p = 0.003) and calf (p

A 43-year-old male with recurrent cerebral infarctions and high titers of antiphospholipid antibodies was found to have a thrombus in his left ventricular outflow tract by transthoracic echocardiography. This thrombus disappeared after less than 24 hours of intravenous heparin therapy due to resolution or asymptomatic embolism. Left ventricular thrombi in patients with antiphospholipid syndrome and rapid disappearance of left ventricular thrombi with heparin therapy are infrequently reported occurrences. (ECHOCARDIOGRAPHY, Volume 20, January 2003)

We describe an unusual case of orthodeoxia platypnea syndrome exacerbated by right ventricular inflow obstruction due to iatrogenic steroid-induced adipose deposition in cardiac tissues. A 68-year-old man on long-term prednisone therapy for eosinophilic pneumonia presented with progressive dyspnea worsened by bending forward. By using pulse oximetry, he was noted to have positional hypoxemia. Transthoracic echocardiogram demonstrated normal right-sided pressures but severe right to left shunting through a patent foramen ovale. Transesophageal echocardiogram showed a large patent foramen ovale, severe lipomatous hypertrophy of the interatrial septum, and massive adipose deposition in the pericardium causing compression of the right ventricular inflow tract. The patient underwent percutaneous closure of the patent foramen ovale, which resulted in the resolution of symptoms and hypoxemia. This case is unique because long-term steroid use resulted in reverse Lutembacher physiology and clinical orthodeoxia platypnea syndrome by inducing lipomatous hypertrophy of the interatrial septum and compression of the right atrium.

Importance Whether culture-expanded mesenchymal stem cells or whole bone marrow mononuclear cells are safe and effective in chronic ischemic cardiomyopathy is controversial. Objective To demonstrate the safety of transendocardial stem cell injection with autologous mesenchymal stem cells (MSCs) and bone marrow mononuclear cells (BMCs) in patients with ischemic cardiomyopathy. Design, setting, and patients A phase 1 and 2 randomized, blinded, placebo-controlled study involving 65 patients with ischemic cardiomyopathy and left ventricular (LV) ejection fraction less than 50% (September 1, 2009-July 12, 2013). The study compared injection of MSCs (n=19) with placebo (n = 11) and BMCs (n = 19) with placebo (n = 10), with 1 year of follow-up. Interventions Injections in 10 LV sites with an infusion catheter. Main outcomes and measures Treatment-emergent 30-day serious adverse event rate defined as a composite of death, myocardial infarction, stroke, hospitalization for worsening heart failure, perforation, tamponade, or sustained ventricular arrhythmias. Results No patient had a treatment-emergent serious adverse events at day 30. The 1-year incidence of serious adverse events was 31.6% (95% CI, 12.6% to 56.6%) for MSCs, 31.6% (95% CI, 12.6%-56.6%) for BMCs, and 38.1% (95% CI, 18.1%-61.6%) for placebo. Over 1 year, the Minnesota Living With Heart Failure score improved with MSCs (-6.3; 95% CI, -15.0 to 2.4; repeated measures of variance, P=.02) and with BMCs (-8.2; 95% CI, -17.4 to 0.97; P=.005) but not with placebo (0.4; 95% CI, -9.45 to 10.25; P=.38). The 6-minute walk distance increased with MSCs only (repeated measures model, P = .03). Infarct size as a percentage of LV mass was reduced by MSCs (-18.9%; 95% CI, -30.4 to -7.4; within-group, P = .004) but not by BMCs (-7.0%; 95% CI, -15.7% to 1.7%; within-group, P = .11) or placebo (-5.2%; 95% CI, -16.8% to 6.5%; within-group, P = .36). Regional myocardial function as peak Eulerian circumferential strain at the site of injection improved with MSCs (-4.9; 95% CI, -13.3 to 3.5; within-group repeated measures, P = .03) but not BMCs (-2.1; 95% CI, -5.5 to 1.3; P = .21) or placebo (-0.03; 95% CI, -1.9 to 1.9; P = .14). Left ventricular chamber volume and ejection fraction did not change. Conclusions and relevance Transendocardial stem cell injection with MSCs or BMCs appeared to be safe for patients with chronic ischemic cardiomyopathy and LV dysfunction. Although the sample size and multiple comparisons preclude a definitive statement about safety and clinical effect, these results provide the basis for larger studies to provide definitive evidence about safety and to assess efficacy of this new therapeutic approach. Trial registration clinicaltrials.gov Identifier: NCT00768066.

T ransesophageal echocardiography (TEE) has become a valuable modality for the diagnosis and management of diseases of the thoracic aorta. This procedure has also contributed greatly to our understanding of the pathogenesis of these disorders. When compared to other technologies that are used to evaluate the thoracic aorta, TEE has the unique advantages of portability and the ability to obtain high-resolution images of the normal and pathologic anatomy of the three layers of the aortic wall and the aortic lumen. In part one of this two-part article, the case-based review will focus on the use of TEE in the acute aortic syndrome (aortic dissection, aortic intramural hematoma [AIH], and penetrating atherosclerotic ulcer [PAU]) of the aorta. In part two, atherosclerotic disease of the aorta as a source of systemic emboli, and traumatic diseases of the aorta will be discussed. The two parts serve to update previous reviews in this continuously evolving field.1–5 Case Report 1

Dramatic changes in the management of acute myocardial infarction (AMI) have occurred in the past decade. While previous management strategies were primarily supportive, current strategies focus on achieving and maintaining patency of the infarct-related artery restoring blood flow to jeopardized myocytes, preserving left ventricular function, and preventing recurrences and complications in addition to promoting healing. Restoration of blood flow can be achieved pharmacologically with thrombolytic agents or mechanically with percutaneous transluminal coronary angioplasty (PTCA). Early use of antiplatelet agents and anticoagulants helps maintain patency of the infarct-related arteries and prevents thromboembolic complications. Administration of beta-blockers and angiotensin enzyme inhibitors are more specific means of conserving myocardium and preserving ventricular function. Additionally, several strategies for preventing arrhythmias such as prophylactic lidocaine use and routine long-term suppression of premature ventricular contractions with antiarrhythmic drugs are no longer routinely advocated. Basically, in the era prior to the eighth decade of this century, the primary direction of the therapeutic strategy for AMI was to reduce the oxygen demands in the infarcted myocardium; whereas in the subsequent years, the emphasis shifts to improvement in oxygen delivery, via thrombolysis, PTCA, and coronary artery bypass graft surgery. These interventional changes, when added to greater sophistication in the use of drugs to reduce oxygen demands, resulted in significant lowering of myocardial mortality.

This study evaluated utilization of stress echocardiography (SE) at our institution, the impact of the updated 2011 appropriate use criteria (AUC) on appropriateness ratings, correlation of AUC to radiology benefits managers' (RBM) pre-certification guidelines and the effect of temporal trends and an AUC-based educational project on appropriateness.The AUC for SE have been developed to improve efficiency of utilization and promote optimal patient care.We classified the appropriateness of 209 SEs from 2008 using the original and updated AUC. We also performed pre-authorization determinations on these SEs using the guidelines of 2 RBMs. We then classified and compared the appropriateness of 209 SEs from 2011 using the updated criteria to that of the 2008 cohort. Finally, we rated and compared 111 SEs requested by cardiologists after an educational project to 111 SEs referred before the intervention.Overall, nearly one-third of SEs were requested for inappropriate indications. Using 2011 AUC, the original ratings of 52 (25%) studies by AUC 2008 were changed and the number of unclassified SE decreased from 20 (9.6%) to 2 (1%). Correlation between RBM pre-authorization determination and AUC ratings was substantial for the first RBM (κ = 0.625) and fair for the second (κ = 0.358). However, 12.9% and 41.9% of studies classified as appropriate or uncertain by the AUC would not have received pre-authorization according to the guidelines of the first and second RBMs, respectively. Referrals of inappropriate SE did not decrease over time or with an educational intervention.The revisions in the updated AUC improve their clinical application by encompassing nearly all indications for SE. The limited correlation between AUC ratings and RBM determinations suggests a need for greater consistency. The large number of SE requested for inappropriate indications at our institution did not decrease with time or education.

Background The aims of this study were to evaluate the relationship of the CHA 2 DS 2 -VASc score and risk categories with transesophageal echocardiographic (TEE) risk factors for thromboembolism and to compare the CHA 2 DS 2 -VASc and CHADS 2 risk stratification schemes with respect to their ability to predict these risk factors in a multiethnic US population with nonvalvular atrial fibrillation. Methods Transesophageal echocardiograms of 167 patients (mean age, 66.3 ± 11.6 years; 146 men [87%]; 100 whites [60%]; 40 Hispanics [24%]; 27 blacks [16%]) with nonvalvular atrial fibrillation were retrospectively reviewed for smoke, sludge, thrombus, and left atrial appendage (LAA) emptying velocity ≤20 cm/sec. The patients' CHA 2 DS 2 -VASc and CHADS 2 risk scores and categories were also calculated. Results Any LAA abnormality, smoke, sludge, thrombus, and abnormal LAA emptying velocity were present in 45%, 38%, 13%, 3%, and 22% of patients, respectively. Heart failure ( P P P = .013 for age 65–74 vs ≤64 years), and diabetes ( P = .019) were independent predictors of LAA abnormalities, while ethnicity was not. The prevalence of TEE risk factors for thromboembolism increased with increasing CHA 2 DS 2 -VASc score and risk category. The CHADS 2 risk categories of 35 patients (21%) were upgraded by the CHA 2 DS 2 -VASc scheme. Using the latter scheme, fewer patients were classified as at intermediate risk compared with the CHADS 2 system (21 [13%] vs 46 [28%]). Patients classified as at low risk by either scheme had almost no TEE risk factors. Of 30 intermediate-risk patients by CHADS 2 score upgraded to high risk using CHA 2 DS 2 -VASc score, eight (27%) had at least one TEE risk factor for thromboembolism. C-statistics, sensitivity, and specificity for predicting any LAA abnormality were 0.607 (95% confidence interval, 0.549–0.665), 92.0%, and 28.9% for CHA 2 DS 2 -VASc score and 0.685 (95% confidence interval, 0.615–0.755), 81.3%, and 54.2% for CHADS 2 score. Conclusions CHA 2 DS 2 -VASc score is associated with TEE risk factors for thromboembolism in a multiethnic US population. Compared with CHADS 2 score, it has increased sensitivity, decreased specificity, and lower ability for predicting TEE risk factors in this population.

Transesophageal echocardiography was indicated for evaluation of mitral valve pathology in a patient with a Zenker's diverticulum. However, transesophageal echocardiography is potentially dangerous and therefore relatively contraindicated in such patients. Our gastroenterologist directly intubated the esophagus with a fiberoptic endoscope and introduced an overtube through which transesophageal echocardiography was performed without incident.

The medical complications of cocaine abuse are being encountered by clinicians with increasing frequency. The cardiovascular manifestations of cocaine abuse include chest pain, myocardial ischemia and infarction, congestive heart failure, arrhythmias, infective endocarditis, and aortic dissection. The pathogenesis of these cardiovascular complications has not been fully elucidated but may be related to a combination of the sympathomimetic and membrane anaesthetic effects of cocaine. We present these concepts in a case discussion format.

Cardiac ultrasound is a useful diagnostic modality for the evaluation of cardiac masses and tumors. However, normal cardiac structures and normal variants can mimic masses with both transthoracic echocardiography and transesophageal echocardiography. We report two patients in whom a redundant mitral leaflet simulated cardiac tumor attached to the mitral valve by transesophageal echocardiography. (ECHOCARDIOGRAPHY, Volume 11, May 1994)

Accessory mitral valve tissue is a rare cause of intracardiac mass and subvalvular left ventricular outflow tract obstruction. The preoperative diagnosis of this congenital anomaly has been facilitated by transthoracic two-dimensional and Doppler echocardiography. However, transthoracic two-dimensional echocardiography cannot identify or correctly diagnose all cases of accessory mitral valve tissue. We report a patient in whom an intracardiac mass detected by transthoracic echocardiography was definitively diagnosed as accessory mitral valve tissue by transesophageal echocardiography. accessory mitral valve tissue, subaortic stenosis, transesophageal echocardiography, intracardiac mass

Although differences in the rate of utilization of invasive cardiac procedures between Veterans Affairs (VA) hospitals and other health care systems are present, noninvasive cardiac imaging use pattern has not been well studied. We evaluated the ability of the updated appropriateness use criteria (AUC) to determine utilization patterns of myocardial perfusion imaging (MPI) and compare use between an academic practice and a VA. One-hundred fifty stress/rest MPI studies in an academic practice and 150 at a VA hospital were retrospectively reviewed using the hierarchical approach published in the 2009 AUC. Less than 1% of studies were unclassified. A higher percentage of MPI were requested for inappropriate reason at the VA, although this difference was not statistically significant (P = .248). In the VA, non-physicians requested significantly more inappropriate studies than physicians (26.8% vs 20.1%; P

In response to growth in cardiac imaging, medical societies have published appropriateness use criteria (AUC) and payers have introduced preauthorization mandates, largely through radiology benefits managers (RBM). The correlation of algorithms used to determine preauthorization with the AUC is unknown. In addition, studies applying the 2007 AUC for transthoracic echocardiography revealed that many echocardiograms could not be classified. We sought to examine the impact of the revised 2010 AUC on appropriateness ratings of transthoracic echocardiograms previously classified by the 2007 AUC and the relationship of preauthorization determination to AUC rating.We reclassified indications for transthoracic echocardiography as appropriate, inappropriate, uncertain, or unclassifiable using the 2010 AUC in the same 625 patients previously reported using 2007 AUC. We also evaluated the relationship between preauthorization status by 2 RBM precertification algorithms and appropriateness rating by 2007 AUC.The appropriateness classification of 148 (24%) transthoracic echocardiograms was changed by the updated AUC (P.001). The number of unclassifiable echocardiograms was markedly reduced from 99 (16%) to 8 (1%), and more echocardiograms were classified as inappropriate (95 [15%] vs 45 [7%]) or uncertain (43 [7%] vs 0 [0%]). Limited correlation between the 2007 AUC rating and RBM preauthorization determinations was noted, with only moderate agreement with RBM no. 1 (90%, κ = 0.480, P.001) and poor agreement with RBM no. 2 (72%, κ = 0.177, P.001).The updated AUC (2010) provide enhanced clinical value compared with 2007 AUC. There is limited agreement between RBM preauthorization determination and 2007 AUC rating.

This study evaluates the effects of performing real time three-dimensional transesophageal echocardiography in addition to conventional two-dimensional transesophageal echocardiography on diagnostic confidence.Operator diagnostic confidence in addressing clinical questions posed by the referral was scored using a five-point scale for two-dimensional transesophageal echocardiography alone and the combination of two-dimensional and real time three-dimensional transesophageal echocardiography in 136 consecutive patients undergoing examination in an academic hospital.Mean diagnostic confidence score was higher for the combined studies compared to two-dimensional transesophageal echocardiography alone (4.5 vs. 4.1, P0.001)). The addition of real time three-dimensional transesophageal echocardiography increased diagnostic confidence score in 45 (33.1%) patients, and the percentage of studies with total diagnostic confidence rose from 40.4% with two-dimensional transesophageal echocardiography alone to 65.4% after performing real time three-dimensional transesophageal echocardiography. Type of clinical indication was associated with improved score by the combined exams (P0.004). The addition of real time three-dimensional transesophageal echocardiography was most likely to improve diagnostic confidence score in studies performed to assess valve disease (56.1%) and least likely in examinations performed for intracardiac infection (14.9%). The location (anterior or posterior) of the primary cardiac pathology was not associated with improved score by the combined studies (P = 0.498).The addition of real time three-dimensional transesophageal echocardiography to two-dimensional transesophageal echocardiography increases diagnostic confidence in examinations routinely performed in an academic practice. Further studies of the impact of real time three-dimensional transesophageal echocardiography on patient management, outcomes and displacement of or need for downstream testing are warranted.

EDITORIAL NOTE: This department offers stylized clinical presentations of current cardiovascular issues. Questions raised in each case history highlight key elements that are elaborated upon in the discussions that follow. (Chest 1993; 103:1877)

A 39-year-old female had cor triatriatum (CT) detected as an incidental finding on transthoracic echocardiography performed to evaluate chest pain. By conventional two- and real time three-dimensional transesophageal echocardiography, the CT membrane had a communicating orifice connecting the accessory and main left atrial chambers that measured 1.3 × 0.8 cm. The resting mean transmembrane gradient was 2 mm Hg. The postexercise mean transmembrane gradient and pulmonary artery pressure were 6 and 40 mm Hg. Extrapolating from cutoff values for postexercise gradients and pulmonary pressures in patients with mitral stenosis, we advised deferring surgery and close clinical and echocardiographic follow up.

OBJECTIVE Transesophageal echocardiography (TEE)-guided cardioversion is an established strategy for managing atrial arrhythmias and is commonly used as an alternative to the conventional approach of administering several weeks of anticoagulation before cardioversion. However, the safety of this approach depends on the exclusion of left atrial appendage (LAA) thrombi with a high level of diagnostic confidence. The objective of this case series is to explore the use of real-time 3-dimensional (RT3D) TEE in the precardioversion evaluation of patients with complex anatomy in their LAAs. METHODS We used RT3D TEE to further assess the LAAs of 3 patients being evaluated for cardioversion who had inconclusive 2-dimensional (2D) TEE studies because of complex anatomic variants of the LAA. We imaged the LAA using the 3D zoom mode and rotated this image to view the LAA en face from the perspective of its ostium. Further cropping was performed as needed. RESULTS In all 3 patients, the additional views of the appendage obtained by RT3D TEE were decisive in excluding contraindications to cardioversion. The unique en face view of the LAA acquired with 3D TEE, which was previously unobtainable using 2D TEE, was particularly useful. In 1 patient, a bilobed LAA mimicked a thrombus. In 2 other patients, prominent pectinate muscles masqueraded as thrombi. CONCLUSIONS Three-dimensional TEE is valuable for the precardioversion evaluation of patients with complex anatomic variants of the LAA.

We compared adherence to appropriateness criteria for transthoracic echocardiography in a Veterans Administration Medical Center (VAMC) and an academic practice and, within the VAMC, between physicians and mid-level providers. We reviewed 201 outpatient echocardiograms performed in the laboratory of an academic practice and 424 outpatient and inpatient studies performed at a VAMC. Echocardiographic examinations requested for indications addressed in the criteria were considered classified, and those for indications not addressed were considered unclassified. Classified studies were further rated as appropriate or inappropriate. Of 625 echocardiograms reviewed, 99 (16%) were unclassified. Approximately 80% of the indications for these could be assigned to 4 categories. Of the remaining 526 echocardiograms, indications were appropriate in 481 (91.4%) and inappropriate in 45 (8.6%). Among classified outpatient studies at the VAMC, mid-level providers requested significantly more studies for inappropriate indications than physicians (16.0% vs 7%, P = .024). There was no significant difference in the frequency of outpatient studies requested for inappropriate indications by VAMC and academic practice physicians (7.0% vs 9.5%, P = .558). The appropriateness criteria perform reasonably well at evaluating variations in use of echocardiography between health care systems and providers. The large majority of studies are requested for appropriate indications, although there is room for improvement.

Compared to non-Hispanic Whites, African American men have less intra-abdominal visceral adipose tissue (VAT) relative to total fat mass despite having a higher risk of obesity-related diseases. This study explores whether this racial pattern of VAT distribution extends to the intrathoracic VAT.We used two-dimensional transthoracic echocardiography to measure pericardial and maximum and minimum epicardial fat thickness anterior to the right ventricle in 50 African American and 106 non-Hispanic White men, aged 40-75 years, consecutively referred for echocardiography for standard clinical indications. Age, coronary risk factors, height, and weight were recorded, and body mass index (BMI) was calculated. The two groups were compared with respect to pericardial and maximum, minimum, and average epicardial fat thicknesses.Among non-Hispanic Whites, pericardial and minimum epicardial fat measured at the mid-rightventricular wall were higher by 37% and 69%, respectively, than among African Americans (5.2+/-3.1 mm vs 3.8+/-3.1 mm, P.011; 2.2+/-1.6 mm vs 1.3+/-1.2 mm, P.001). Maximum epicardial fat along the distal right ventricular wall was 19% greater in non-Hispanic Whites, but this difference was not statistically significant (4.3+/-2.6 mm vs 3.6+/-2.0 mm, P=.133). The average epicardial fat measured at two sites was 26% greater in non-Hispanic Whites (2.9+/-2.0 mm vs 2.3+/-1.3 mm, P=.019).Among men referred for echocardiography, non-Hispanic Whites have more epicardial and pericardial fat than do African Americans. Echocardiography may be a useful research tool for investigating VAT distribution and its relationship to cardiovascular risk.

The association of ethnic ancestry with coronary artery calcifications suggests that mitral annulus calcification may also vary with ethnicity. We sought to compare prevalence and clinical correlates of mitral annulus calcification in non-Hispanic Whites, Hispanics, and African Americans.This was a retrospective study of 857 patients age 40-75 years that included 217 (25%) African Americans, 349 (41%) Hispanics, and 291 (34%) non-Hispanic Whites referred for echocardiography. Multiple logistic regression was used to determine the interrelationships between mitral annulus calcification, risk factors, and ethnicity.Mitral annulus calcification was detected in 181 (21.1%) patients including 35 (16.1%) African Americans, 80 (22.9%) Hispanics, and 66 (22.7%) non-Hispanic whites. In univariate analysis, patients with mitral annulus calcification were older and more likely to have hypertension, diabetes, dyslipidemia, smoking history, and two or more risk factors than were those without calcification. In multivariate analysis, age and smoking history were independent predictors of mitral annulus calcification; dyslipidemia and diabetes were borderline significant predictors; and after adjusting for the remaining variables in the model, ethnicity was not an independent significant predictor of mitral annulus calcification.In a retrospective study of middle-aged and elderly African Americans, non-Hispanic Whites, and Hispanics referred for echocardiography, mitral annulus calcification is common in all three major ethnic groups but not significantly associated with ethnic ancestry.

Objective: Echocardiographic epicardial adipose tissue is a new index of cardiac and visceral adiposity with great potential as a diagnostic tool and therapeutic target. In this study, we sought to provide threshold values of echocardiographic epicardial fat thickness associated with metabolic and anthropometric risk factors. Methods and Procedures: Epicardial fat thickness was measured in 246 consecutive white subjects (120 women, 126 men, median age 46 years (30–65), median BMI 32 kg/m2 (22–52), median waist circumference 100.5 cm (85–140)), who underwent routine transthoracic echocardiogram for standard clinical indications. Metabolic syndrome (MetS), Insulin resistance, BMI, and waist circumference categories were identified and epicardial fat was calculated. Results: Among 246 subjects, 58% had MetS. These subjects showed median values of epicardial fat thickness of 9.5 and 7.5 mm (in men and women, respectively), significantly higher than those found in subjects without MetS (no MetS) (P < 0.001). Receiver operating characteristics (ROC) analysis showed that epicardial fat thickness of 9.5 and 7.5 mm maximize the sensitivity and specificity to predict MetS, in men and women, respectively. In separate analyses, median epicardial fat thickness values of 9.5 and 7.5 mm were cutoff points associated with high abdominal fat in men and women, respectively. When insulin sensitivity was considered separately, epicardial fat thickness of 9.5 mm was associated with insulin resistance. Discussion: Median values of 9.5 and 7.5 mm should be considered the threshold values for high-risk echocardiographic epicardial fat thickness in white men and women, respectively. Echocardiographic epicardial fat measurement may be of help for cardiometabolic risk stratification and therapeutic interventions targeting the fat.

To determine whether the observed association between mitral annular calcification (MAC) and mortality is independent of the severity of coronary artery disease (CAD), we analyzed data from 134 male veterans (age 63 +/- 10 years) followed for 5 years who had undergone diagnostic coronary angiography and transthoracic echocardiography within 6 months of each other. Echocardiograms were retrospectively reviewed for the presence of MAC. The relation of MAC to all-cause mortality was analyzed using logistic regression, and odds ratios (OR) were calculated. MAC was present in 49 (37%) subjects. Over the 5-year follow-up period, 38 (28%) patients expired. Five-year survival was 80% for subjects without MAC and 56% for subjects with MAC (P = 0.003). MAC (OR = 3.16, 95% confidence interval [CI]= 1.43-6.96, P = 0.003), ejection fraction (OR = 0.76, 95% CI = 0.59-0.97, P = 0.02), and left main CAD (OR = 2.70, 95% CI = 1.11-6.57, P = 0.02) were significantly associated with mortality in univariate analysis. After adjusting for left ventricular ejection fraction, number of obstructed coronary arteries and the presence of left main coronary artery stenosis, MAC significantly predicted death (OR = 2.48, 95% CI = 1.09-5.68, P = 0.03). Similarly, after adjusting for predictors of MAC, including ejection fraction, age, diabetes, peripheral vascular disease, and heart failure, MAC remained a significant predictor of death (OR = 2.38, 95% CI = 1.02-5.58, P = 0.04). MAC also predicted death independent of smoking status, hypertension, serum creatinine, low density lipoprotein cholesterol, high density lipoprotein cholesterol, and C-reactive protein levels (OR = 3.98, 95% CI = 1.68-9.40, P = 0.001). MAC detected by two-dimensional echocardiography independently predicts mortality and may provide an easy-to-perform and inexpensive way to improve risk stratification.

Background Data about mitral annulus calcification (MAC) are sparse in Hispanics. We compare prevalence and clinical correlates of MAC in Hispanics and non-Hispanic whites. Methods We reviewed echocardiograms and clinical data of 337 Hispanics and 279 non-Hispanic whites, age 45 to 75 years. In cross-sectional data, prevalence and interrelationships of MAC, coronary heart disease (CHD), and risk factors were compared using multivariable logistic regression. Results In Hispanics, MAC was significantly associated with CHD (odds ratio [OR] = 2.06, confidence interval [CI] = 1.09-3.87), age (OR = 1.73, CI=1.21-2.49), female sex (OR = 1.87, CI=1.01-3.47), smoking (OR = 1.80, CI=1.01-3.24), and having multiple (>2) risk factors (OR = 3.43, CI=2.66-4.43). In non-Hispanic whites, MAC was associated with CHD (OR = 4.24, CI=2.00-8.98), age (OR = 2.87, CI=1.82-4.50), and having multiple risk factors (OR = 3.59, CI=2.7-4.77). There were no significant ethnic differences in prevalence of MAC. Conclusions Among Hispanics referred for echocardiography, MAC is associated with CHD and risk factors.

Pulse pressure (PP), a marker of arterial stiffness, predicts cardiovascular risk. We aimed to determine whether augmentation pressure (AP) derived from the aortic pressure waveform predicts major adverse cardiovascular events (MACE) and death independently of PP in patients with established coronary artery disease (CAD). We prospectively followed-up 297 males undergoing coronary angiography for 1186±424 days. Ascending aortic pressure tracings obtained during catheterization were used to calculate AP (difference between the second and the first systolic peak). Augmentation index (AIx) was defined as AP as a percentage of PP. We evaluated whether AP and AIx can predict the risk of MACE (unstable angina, acute myocardial infarction, coronary revascularization, stroke, or death) and death using Cox regression. All models evaluating AP included PP to assess whether AP adds to the information already provided by PP. Both AP and AIx significantly predicted MACE. The hazard ratio (HR) per 10 mm Hg increase in AP was 1.20 (95% confidence interval [CI], 1.08 to 1.34; P P =0.004). After adjusting for other univariate predictors of MACE, age, and other potential confounders, AP remained a significant predictor of MACE (HR per 10 mm Hg increase=1.19; 95% CI, 1.06 to 1.34; P =0.002), as did AIx (adjusted HR, 1.28; 95% CI, 1.09 to 1.50; P =0.003). AP was a significant predictor of death (HR per 10 mm Hg increase=1.18; 95% CI, 1.02 to 1.39; P =0.03). Higher AIx was associated with a trend toward increased mortality (HR=1.22; 95% CI, 0.98 to 1.52; P =0.056). Aortic AP predicts adverse outcomes in patients with CAD independently of PP and other risk markers.

To evaluate the effects of substantial weight loss on tissue Doppler imaging parameters of right ventricular (RV) and left ventricular (LV) systolic and diastolic function, we performed standard echocardiography and tissue Doppler imaging in 17 patients with severe obesity before and after gastric bypass. Patients lost 39 +/- 10 kg over 7.6 +/- 3.6 months. Adjusted LV mass decreased (134 +/- 41 to 119 +/- 31 kg/m, p = 0.031). After weight loss, the ratios of early-to-late diastolic mitral and tricuspid inflow velocities increased (1.3 +/- 0.2 to 1.6 +/- 0.5, p = 0.02; 1.0 +/- 0.1 to 1.6 +/- 0.3, p = 0.003). Early diastolic tissue Doppler velocities increased at both the lateral and septal mitral annulus (7.6 +/- 1.5 to 9.3 +/- 2.5 cm/s, p = 0.009; and 6.6 +/- 1.4 to 7.7 +/- 1.7 cm/s; p = 0.028, respectively) and for their 2-site average (7.2 +/- 1.0 to 8.5 +/- 1.7 cm/s, p = 0.007). Early diastolic tricuspid annular velocity increased (7.2 +/- 2.8 to 10.6 +/- 2.3 cm/s, p

To determine whether structural features or concentrations of plasma lipoproteins are predictive of arterial compliance in healthy women versus healthy men, cohorts of 111 men and 112 women with a wide range of 10-year risks for coronary artery disease were selected using assessments based on the Framingham Heart Study. Age ranges were restricted to 35 to 69 years for men and 45 to 79 years for women. Lipid-lowering drugs or any evidence of vascular disease was cause for exclusion. Fasting lipoprotein analysis and arterial compliance measurements in thigh and calf were completed in all patients. Plasma triglyceride levels were the most powerful predictor of compliance in women. Weaker but significant relations were observed between plasma non-high-density lipoprotein cholesterol, apolipoprotein-B, and apolipoprotein-CIII. In contrast, the only significant predictor of compliance in men was body weight. Thus, the major lipid predictors of arterial stiffness in women are concentrations of triglyceride-rich lipoproteins. These results are consistent with previous findings that triglyceride measurements are more strongly related to clinical vascular events in women than in men.

We investigated right and left heart function in 51 patients with a body mass index of35 kg/m(2) who underwent evaluation for gastric bypass surgery using standard Doppler echocardiography and color tissue Doppler imaging. Left atrial diameter (3.7 +/- 0.5 vs 3.3 +/- 0.4 cm, p0.001), left ventricular end-diastolic diameter (5.0 +/- 0.6 vs 4.5 +/- 0.4 cm, p0.001), and left ventricular mass index (119 +/- 49 vs 76 +/- 26 g/m, p0.001) were increased in patients with severe obesity. Early diastolic mitral annular velocity (7.5 +/- 2.1 vs 9.6 +/- 3.0 cm/s, p0.001), early diastolic/late diastolic mitral annular velocity ratio (1.38 +/- 0.6 vs 1.94 +/- 1.3, p = 0.007), early diastolic tricuspid annular velocity (7.8 +/- 2.6 vs 9.5 +/- 2.4 cm/s, p = 0.002), early diastolic/late diastolic tricuspid annular velocity ratio (0.9 +/- 0.36 vs 1.1 +/- 0.4, p = 0.048), and mitral annular systolic velocity (5.7 +/- 1.3 vs 6.5 +/- 1.5 cm/s, p = 0.012) were significantly lower in obese patients. Early diastolic mitral inflow/mitral annular velocity ratio was increased in the obese (13.5 +/- 4.7 vs 9.1 +/- 3.6, p0.001). Tricuspid annular systolic velocities did not differ.

Peripheral arterial disease (PAD) is an underdiagnosed circulatory problem in the primary care setting. Individuals are at increased risk for cardiovascular disease; therefore, there is the need for a technique capable of early identification and detection of patients with PAD. The focus of this study was to compare the accuracy of a new operator-independent method of measuring ankle brachial index (ABI) with the traditional Doppler ultrasound method of determining ABI. In 246 limbs the authors compared ankle systolic pressures and ABI measured by a new automated oscillatory method called the ABIgram with those measured by standard Doppler ultrasound. In phase 1, the 2 methods for measuring ankle systolic pressure had a mean difference of 2 mm Hg with a standard deviation of 6.7 mm Hg. In phase 2 the mean difference was 3.1 mm Hg with a standard deviation of 5.1 mm Hg. Further, ABI as measured by the 2 methods fell within 1% and demonstrated a 5% error in reproducibility. These numbers pass the SP-10 standard for medical devices established by the FDA. The ABIgram module of the Vasocor ®Vascular Diagnostic Center offers primary care physicians the ability to rapidly obtain ABI measurements comparable to the standard technique. Further, the ABIgram may be operated by staff commonly found in the primary care setting.

Mitral annulus calcification may directly cause cerebrovascular accidents by serving as a source of calcific or thrombotic emboli. This hypothesis has been supported by recent reports of mobile components associated with mitral annulus calcification detected by echocardiography. Cardiovascular calcifications, including mitral annulus calcification, are common in end-stage renal disease and may develop and progress over a short period of time. We report two patients with mobile components associated with mitral annulus calcification and end-stage renal disease. Serial echocardiography documented that the mitral annulus calcification in these two patients had developed rapidly. Follow-up echocardiography in one patient demonstrated resolution of the mobile elements. (ECHOCARDIOGRAPHY, Volume 20, May 2003)

Atrial septal aneurysm and a dilated sinus of Valsalva were noted on echocardiography in a 30-year-old male with Wolff-Parkinson-White syndrome. The relative low probability of all three coexisting by chance alone suggests the possibility of a common developmental origin. (ECHOCARDIOGRAPHY, Volume 13, January 1996)

flow occurred across the left ventricular outflow tract with a peakgradient of 57.2 mmHg. Systolic anterior motion (SAM) couldnot be demonstrated by M mode echocardiography.It was suspected that the severe mitral insufficiency was secon-dary to the hyperdynamic left ventricular function and severe volu-me depletion. During echocardiographic monitoring, 1000 mL ofnormal saline was rapidly infused over a period of 30 minutes. Aprogressive slowing of the heart rate from 96 to 64 beats perminute, a decrease in outflow gradient (from 57.2 to 10.1 mmHg),and total resolution of the mitral insufficiency were documented(Fig.1a, 1b, 2a, and 2b).

A highly mobile left atrial mass was detected by transesophageal echocardiography in a patient with mediastinal lymphoma. Transesophageal echocardiography also demonstrated resolution of the mass following chemotherapy. (ECHOCARDIOGRAPHY, Volume 20, August 2003)

An 81-year-old woman developed symptomatic liver disease 3 weeks after beginning clopidogrel as adjunctive antiplatelet therapy for a coronary stent implantation. Symptomatic liver disease associated with short-term periprocedural administration of clopidogrel for coronary stenting has not been well described. The clinical significance of this event as well as a possible interaction between clopidogrel and other drugs metabolized by the cytochrome P450 2C9 pathways coadministered to this patient are discussed.