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We present this case of a 22-year-old woman with congenital heart disease as the youngest reported patient, to the best of our knowledge, to successfully undergo treatment of medically refractory torrential tricuspid regurgitation with the MitraClip system as an adjunct to guideline directed therapy. (Level of Difficulty: Advanced.), Graphical abstract, We present this case of a 22-year-old woman with congenital heart disease as the youngest reported patient, to the best of our knowledge, to…

A 72 year-old mountain bicyclist suffered a biking accident. The following week, he presented to the emergency room with abdominal pain, where he was treated for superior mesenteric artery thrombosis and new-onset atrial fibrillation. Two months later, he presented with intermittent left scapular pain that radiated to the chest. Pharmacologic stress testing revealed a large reversible perfusion defect in the anterior wall with an ejection fraction of 41%. Left heart catheterization showed narrowing of the distal left main coronary artery and the proximal left anterior descending (LAD) and circumflex arteries, by what appeared to be external compression. Follow-up CT angiogram demonstrated two sinus of Valsalva aneurysms (SOVA) originating from the left and right coronary cusps. A transesophageal echocardiogram confirmed these findings and showed tremendous thrombus within the larger aneurysm. The patient was admitted to cardiothoracic surgery. Troponin was elevated to 0.16 μg/L, with EKG showing 1 mm ST-segment depressions in V4-6, prompting treatment for a non-ST segment myocardial infarction. He underwent complex surgery involving thrombus extraction and closure of the SOVA with pericardial patch repair, and coronary artery bypass grafting of the LAD and obtuse marginal arteries. After a prolonged ICU course in which the patient was managed for cardiogenic shock, he was discharged to a hospital equipped with a rehabilitation facility. Unfortunately, he developed profound lactic acidosis from ischemic bowel and passed away. SOVA are rare lesions that arise from congenital or acquired etiologies, such as this patient’s biking accident. Multi-modality imaging is important for quantifying size and anatomy. Unruptured SOVA can present as embolic phenomenon from thrombus, valvular regurgitation, or chest pain from compression of the coronary arteries. Rupture is a highly morbid condition, and so urgent referral to cardiothoracic surgery is recommended.

The ratio of transmitral early filling velocity to early diastolic strain rate (E/eʹsr) has recently emerged as a novel and accurate non-invasive measure of left ventricular (LV) filling pressure. This systematic review and meta-analysis aimed to give an overview of the possible clinical implications of E/eʹsr. We conducted a systematic review and meta-analysis of all studies involving E/eʹsr. Of 598 identified studies, 16 met our inclusion criteria. Studies involving E/eʹsr either investigated its prognostic value (n = 9) or its correlation with invasively measured LV filling pressure (n = 7). The pooled meta-analysis showed a significant correlation between E/eʹsr and pulmonary capillary wedge pressure (PCWP) measured invasively across the studies assessing this relationship (Cohen’s d = 3.90 95% CI [2.38–6.39], p

National audience; Background: Atrial fibrillation is the most common arrhythmia in post-industrialized populations. Older age, hypertension, obesity, chronic inflammation, and diabetes are significant atrial fibrillation risk factors, suggesting that modern urban environments may promote atrial fibrillation.Objective: Here we assess atrial fibrillation prevalence and incidence among tropical horticulturalists of the Bolivian Amazon with high levels of physical activity, a lean diet, and minimal coronary atherosclerosis, but also high infectious disease burden and associated inflammation.Methods: Between 2005–2019, 1314 Tsimane aged 40–94 years (52% female) and 534 Moseten Amerindians aged 40–89 years (50% female) underwent resting 12-lead electrocardiograms to assess atrial fibrillation prevalence. For atrial fibrillation incidence assessment, 1059 (81% of original sample) Tsimane and 310 Moseten (58%) underwent additional ECGs (mean time to follow up 7.0, 1.8 years, respectively).Findings:Only one (male) of 1314 Tsimane (0.076%) and one (male) of 534 Moseten (0.187%) demonstrated atrial fibrillation at baseline. There was one new (female) Tsimane case in 7395 risk years for the 1059 participants with >1 ECG (incidence rate = 0.14 per 1,000 risk years). No new cases were detected among Moseten, based on 542 risk years.Conclusion: Tsimane and Moseten show the lowest levels of atrial fibrillation ever reported, 1/20 to ~1/6 of rates in high-income countries. These findings provide additional evidence that a subsistence lifestyle with high levels of physical activity, and a diet low in processed carbohydrates and fat is cardioprotective, despite frequent infection-induced inflammation. Findings suggest that atrial fibrillation is a modifiable lifestyle disease rather than an inevitable feature of cardiovascular aging.

This article highlights our current understanding of bicuspid aortic valve (BAV) syndrome and how genetics, pathology, imaging features, and clinical symptoms direct the clinical management, surveillance, and intervention of those with BAV. While randomized data and guidelines are lacking, transcatheter therapies are routinely used for BAV stenosis in medical centers throughout the world. Guidelines suggest that younger patients age less than 50 years undergo surgical aortic valve replacement (AVR) with a mechanical valve and the elderly > 70 years of age receive a bioprosthetic valve. For the age group 50–70 years, either option should be considered. Decision on type of intervention depends on specific features such as presence of stenosis or regurgitation, if there is any associated aortopathy, comorbid illnesses, contraindications, and patient preference. We have learned that the decision to intervene and mode of intervention is best achieved by a multidisciplinary valve team. Despite improvement in our understanding of BAV and the advancement of novel therapies particularly for BAV stenosis, much is still to be learned about the optimal treatment of BAV disease in the current era.

It has previously been demonstrated that the ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) is a significant predictor of cardiac events in specific patient populations. The utility of this measurement to predict cardiovascular events in a general population has not been evaluated.A total of 1238 participants in a general population study underwent a health examination including echocardiography where global longitudinal strain (GLS) and E/e'sr were determined. The primary endpoint was the composite of incident heart failure (HF), acute myocardial infarction (AMI) or cardiovascular death (CVD). During follow-up (median 11 years), 140 (11.3%) participants reached the composite endpoint. E/e'sr was associated with adverse outcome [HR 1.17 95% CI (1.13-1.21); P 0.001, per 10 cm increase]. After multivariable adjustment for echocardiographic and clinical parameters, E/e'sr remained an independent predictor of the composite endpoint [HR 1.08, 95% CI (1.02-1.13); P = 0.003] as opposed to E/e' [HR 1.03, 95% CI (0.99-1.06); P = 0.11 per 1 unit increase]. Global longitudinal strain modified the relationship between E/e'sr and outcome (P for interaction = 0.015). E/e'sr was a stronger predictor in participants with good systolic function as determined by GLS (GLS 18%) after multivariable adjustment, when compared to participants with reduced systolic function (GLS 18%) [HR 1.28 95% CI (1.06-1.54); P = 0.011, and HR 1.08 95% CI (1.02-1.14); P = 0.012, respectively). E/e'sr provided incremental information [Harrell's C-index: 0.839 (0.81-0.87) vs. 0.844 (0.82-0.87); P = 0.045] beyond the SCORE risk chart.In the general population, E/e'sr provides independent and incremental prognostic information regarding cardiovascular morbidity and mortality. Additionally, E/e'sr is a stronger predictor of cardiac events than E/e'.

The geometries and sizes of persistent iatrogenic atrial septal defects (IASDs) after transseptal puncture during catheter-based mitral valve clip insertion (MVCI) have not been detailed. In this study, 11 IASDs were investigated in 10 patients who underwent MVCI using a guide catheter (24Fr proximally and 22Fr at the atrial septum). The diameters of the long and short axes and the area at maximum and minimum during a cardiac cycle were measured after MVCI using real-time 3-dimensional (RT3D) transesophageal echocardiography (TEE). A circular shape was assumed on 2-dimensional TEE, resulting in an area calculation of π × (dimension/2)(2). The anatomic geometries of IASDs were visualized in a 3-dimensional en face view of the atrial septum. Furthermore, 1 month after MVCI, IASDs were evaluated using echocardiography. The IASDs had a variety of irregular geometries. The mean long-axis diameter was 1.0 ± 0.24 cm, the mean short-axis diameter was 0.51 ± 0.22 cm, and the mean area was 0.40 ± 0.24 cm(2) on RT3D TEE. The diameters and area changed significantly between the maximal and minimal values during the cardiac cycle. Importantly, 2-dimensional TEE underestimated the maximal diameters of IASDs (0.54 ± 0.17 vs 1.0 ± 0.24 cm by RT3D TEE, p0.01) and the maximal areas of IASDs (0.25 ± 0.15 vs 0.40 ± 0.23 cm(2) by RT3D TEE, p0.05). One month after MVCI, the smallest and the second smallest IASDs had closed, and the other 9 remained open. In conclusion, RT3D TEE is useful to assess the irregular geometries of IASDs created during MVCI.

Background: Left atrial (LA) size reflects diastolic burden and is a prognostic parameter of common cardiovascular death. However, the association between LA size and function and pulmonary hypertension (PH) in coronary artery disease (CAD) has not been well investigated. We hypothesized that LA size and function are associated with PH in CAD. Methods: One hundred seven patients with CAD were studied. LA size was determined in three different methods; namely, LA volume index (LAV), LA area index, and LA dimension. LAV total emptying fraction was also determined. Pulsed Doppler E, A, E/A, DT, tissue Doppler E′, A′, and E/E′ were measured. Pulmonary artery systolic pressure (PASP) was estimated. Results: All LA size parameters are significantly associated with PH. LAV emptying fraction, age, E, E/A, E/E′, and A′ were also associated with PH significantly. CAD patients with PH showed larger LA size, higher E, E/A, and E/E′ and lower LAV emptying fraction, A and A′ than CAD patients without PH. Multivariate regression analysis revealed that maximum LAV, E, E/A ratio, and age were independent predictors of PH. Maximum LAV > 35.6 mL/m2 predicted PASP > 40 mmHg with a sensitivity of 83.9% and specificity of 62.2%. Conclusion: LAV is associated with PH in CAD patients. (Echocardiography 2012;29:535-540)

Aims To investigate the use of atropine to achieve target heart rate (THR) and rate pressure product (RPP) during supine bicycle exercise stress echocardiography (SBESE) to increase the number of diagnostic stress tests. Methods and results Forty-four patients that were unable to achieve THR or RPP during SBESE performed to evaluate ischaemia were given 0.4–1.2 mg of atropine to augment THR and RPP. After atropine (0.7 ± 0.3 mg) the maximum heart rate (HR) achieved was 133 (±16) bpm, mean THR was 82% (±8%), and average RPP was 22 716 (±4915) b/min × mmHg. Of the patients with a non-diagnostic SBESE, with the use of atropine 80% of those patients achieved a diagnostic test. There were no major adverse affects from the administration of atropine. Conclusion The use of atropine to augment the HR or RPP during SBESE (i) is safe; (ii) enables the assessment of ischaemia at peak effort; and (iii) allows assessment of exercise haemodynamics in patients with sub-maximal exercise capacity and chronotropic incompetence.

Background Although transthoracic echocardiography and two-dimensional transesophageal echocardiography (TEE) identify cardiac myxomas with high sensitivity, anatomic and morphologic information is often incomplete. Real-time three-dimensional (3D) TEE is increasingly being used in general clinical practice. However, the use of real-time 3D TEE for the assessment of atrial myxomas has not been described. Methods This case series of 10 patients with left atrial myxomas undergoing two-dimensional and real-time 3D TEE. Results Correlative pathologic findings demonstrate that 3D imaging accurately identifies these tumors and provides detailed morphologic description of the tumors, which may have clinical importance. Conclusions Because the 3D TEE is real time and can be performed preoperatively in the operating room, the surgeon may gain a better understanding of the nature and location of the tumor.

Background: Carcinoid heart disease (CHD) is a rare cause of valvular heart disease and carries a poor prognosis. CHD has a unique morphology and echocardiographic features that predominantly involve right-sided valvular structures. The diagnosis of CHD is usually made by two-dimensional transthoracic echocardiography (TTE). With the superior spatial resolution of real time three-dimensional transesophageal echocardiography (3DTEE), structural changes that occur in patients with CHD-associated valvular heart disease can be examined in greater detail. We undertook this study to examine the incremental value of 3DTEE in the diagnosis of CHD. Methods: A total of four patients with CHD underwent TTE, transesophageal echocardiography (TEE), and 3DTEE as part of their routine clinical evaluation. Results: TTE and TEE for all four patients revealed thickened, fibrosed, retracted, and malcoapted tricuspid leaflets with wide-open tricuspid valve regurgitation. 3DTEE en face imaging of the tricuspid valve demonstrated the characteristic morphologic features of CHD more clearly in all four patients. Conclusions: 3DTEE provides substantial incremental value over TTE in the assessment of characteristic CHD pathology and thus enhances the echocardiographic diagnosis of CHD. (Echocardiography 2010;27:1098-1105)

Diastolic heart failure is increasing in prevalence. Although the pathophysiology is incompletely understood and current therapeutic strategies are limited, identification of diastolic dysfunction is important. We review the role of contemporary techniques with echocardiography and cardiac magnetic resonance imaging (CMRI) in the assessment of diastolic dysfunction. Cardiac catheterization is the criterion standard for demonstrating impaired relaxation and filling by making direct measurements; however, echocardiography has replaced it as the most clinically used tool. By evaluating mitral inflow pulsed-wave Doppler with and without the Valsalva maneuver, isovolumetric relaxation time, pulmonary venous flow Doppler, color M-mode velocity propagation, tissue Doppler imaging, and speckle tracking, echocardiography is considered an accurate method for diagnosis and grading diastolic dysfunction. Evaluation of diastolic function can also be performed by CMRI. Mitral valve inflow velocities, early deceleration time, and pulmonary vein flow velocities are diastolic parameters that can be measured by phase-contrast CMRI. Cardiac magnetic resonance imaging steady-state gradient echo can evaluate functional dimensions for time-volume curves; and myocardial tagging can assess ventricular diastolic "untwisting," which may be important for improved pathophysiologic understanding. Studies have compared echocardiography and CMRI for diagnosing diastolic dysfunction in small patient groups with similar results. Cardiac magnetic resonance imaging can now provide clinically relevant data regarding the underlying cause of diastolic dysfunction and offers promise to gain mechanistic insights for therapeutic strategy development and clinical trial planning.

Objectives The aim of this study was to evaluate the interobserver agreement of proximal isovelocity surface area (PISA) and vena contracta (VC) for differentiating severe from nonsevere mitral regurgitation (MR). Background Recommendation for MR evaluation stresses the importance of VC width and effective regurgitant orifice area by PISA measurements. Reliable and accurate assessment of MR is important for clinical decision making regarding corrective surgery. We hypothesize that color Doppler-based quantitative measurements for classifying MR as severe versus nonsevere may be particularly susceptible to interobserver agreement. Methods The PISA and VC measurements of 16 patients with MR were interpreted by 18 echocardiologists from 11 academic institutions. In addition, we obtained quantitative assessment of MR based on color flow Doppler jet area. Results The overall interobserver agreement for grading MR as severe or nonsevere using qualitative and quantitative parameters was similar and suboptimal: 0.32 (95% confidence interval [CI]: 0.1 to 0.52) for jet area–based MR grade, 0.28 (95% CI: 0.11 to 0.45) for VC measurements, and 0.37 (95% CI: 0.16 to 0.58) for PISA measurements. Significant univariate predictors of substantial interobserver agreement for: 1) jet area–based MR grade was functional etiology (p = 0.039); 2) VC was central MR (p = 0.013) and identifiable effective regurgitant orifice (p = 0.049); and 3) PISA was presence of a central MR jet (p = 0.003), fixed proximal flow convergence (p = 0.025), and functional etiology (p = 0.049). Significant multivariate predictors of raw interobserver agreement ≥80% included: 1) for VC, identifiable effective regurgitant orifice (p = 0.035); and 2) for PISA, central regurgitant jet (p = 0.02). Conclusions The VC and PISA measurements for distinction of severe versus nonsevere MR are only modestly reliable and associated with suboptimal interobserver agreement. The presence of an identifiable effective regurgitant orifice improves reproducibility of VC and a central regurgitant jet predicts substantial agreement among multiple observers of PISA assessment.

ObjectivesThis study aimed to determine the prevalence of dilation and abnormal elastic properties of aortic root in first-degree relatives (FDRs) of bicuspid aortic valve (BAV) patients.BackgroundEvidence indicates that BAV is a genetic disorder. Although FDRs of affected individuals have an increased prevalence of BAV, their risk of aortic root abnormalities is unknown.MethodsWe studied dimensions as well as the elastic properties of the ascending aorta in 48 FDRs with morphologically normal tricuspid aortic valves, 54 BAV patients, and 45 control subjects using 2-dimensional echocardiography.ResultsThe prevalence of aortic root dilation was 32% in FDRs and 53% in BAV patients, whereas all control subjects showed normal aortic dimensions (p < 0.001). The FDRs and BAVs had significantly lower aortic distensibility (1.7 ± 1.4 × 10−3mm Hg and 1.4 ± 2.0 × 10−3mm Hg vs. 2.5 ± 1.6 × 10−3mm Hg, p < 0.001) and greater aortic stiffness index (26.7 ± 25.8 and 55.9 ± 76.8 vs. 18.7 ± 40.1, p = 0.001) compared with control subjects. This difference remained significant in subjects without aortic root dilation or hypertension (p = 0.002 and p = 0.004, respectively).ConclusionsThe aortic root is functionally abnormal and dilation is common (32%) in first-degree relatives of patients with BAV. Screening of FDRs by transthoracic 2-dimensional echocardiography should be considered for detection of aortic valve malformation and dilated ascending aorta.

Background: Tissue synchronizing imaging (TSI) allows visual detection of asynchronous myocardial contraction. Although it is a screening tool for the detection of left ventricular (LV) dyssynchrony, its use as a qualitative method to assess dyssynchrony has not been studied. We evaluated the correlation of the visual assessment of dyssynchrony using TSI with quantitative assessment, the value of visual assessment to predict reverse remodeling to cardiac resynchronization therapy (CRT). Methods: Echocardiograms from 100 consecutive patients were retrospectively evaluated. We compared visual TSI assessment with the qualitative assessment of dyssynchrony obtained by tissue Doppler imaging (TDI). The utility of visual assessment as a predictor of response to CRT was evaluated in 43 patients. Results: In 86% of the cases, visual assessment was possible, and reproducibility was unrelated to observer experience. Each grade of visual dyssynchrony corresponded to a range of values of time to peak velocity (TPV) gradient (p < 0.001). Grade ≥1 dyssynchrony by visual assessment had 90% sensitivity and 95% specificity to identify ≥65 ms TPV gradient of LV opposing walls, and 93% sensitivity and 70% specificity to predict reverse LV remodeling. Conclusion: LV dyssynchrony may be visually assessed by TSI, which can also predict reverse LV remodeling.

CRT causes reduction in MR due to left ventricular (LV) remodelling, but determinants of clinically meaningful MR reduction acutely after CRT have not been evaluated.We evaluated echocardiographic predictors of significant reduction in functional mitral regurgitation (MR) by cardiac resynchronisation treatment (CRT).35 patients withor= moderate to severe MR underwent CRT for presence of electrical and/or mechanical dyssynchrony. Significant reduction in MR post-CRT was defined as reduction to less than moderate MR (MR jet area/left atrial area25%, group 1) on follow-up echocardiogram at 1.7 (SD 2.8) months post-CRT.Significant MR reduction of 62% (28%) from baseline MR occurred in 18 patients vs 22% (16%) in the remaining patients (group 2), p0.01). Follow-up left ventricular ejection fraction (LVEF) was 0.43 (0.09) in group 1 patients vs 0.29% (0.1%) in group 2 patients (p0.001). On multivariate analysis, time to peak strain in the mid inferior segment was the only significant predictor of MR reduction post-CRT (p = 0.008, OR = 1.023 (CI 1.006 to 1.041). The sensitivity and specificity of the combined variable of time to peak strain of400 ms in the mid inferior segment and peak negative strain ofor=9% and 8% in the basal and mid posterior segments, respectively, to predict follow-up MR was 88% and 93% respectively and positive and negative predictive value was 94% and 87%.In patients with cardiomyopathy and significant MR, the presence of delayed longitudinal strain in the mid inferior LV segment along with preserved negative systolic strain in the basal and mid posterior segments predicts substantial reduction in MR post-CRT.

Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

Background: Accurate assessment of aortic valve area (AVA) is important for clinical decision-making in patients with aortic valve stenosis (AS). The role of three-dimensional echocardiography (3D) in the quantitative assessment of AS has not been evaluated so far. Objectives: To evaluate the reproducibility and accuracy of real-time three-dimensional echocardiography (RT3D) and 3D-guided two-dimensional planimetry (3D/2D) for assessment of AS, and compare these results with those of standard echocardiography and cardiac catheterisation (Cath). Methods: AVA was estimated by transthoracic echo-Doppler (TTE) and by direct planimetry using transoesophageal echocardiography (TEE) as well as RT3D and 3D/2D. 15 patients underwent assessment of AS by Cath. Results: 33 patients with AS were studied (20 men, mean (SD) age 70 (14) years). Bland–Altman analysis showed good agreement and small absolute differences in AVA between all planimetric methods (RT3D vs 3D/2D: −0.01 (0.15) cm 2 ; 3D/2D vs TEE: 0.05 (0.22) cm 2 ; RT3D vs TEE: 0.06 (0.26) cm 2 ). The agreement between AVA assessment by 2D–TTE and planimetry was −0.01 (0.20) cm 2 for 3D/2D; 0.00 (0.15) cm 2 for RT3D; and −0.05 (0.30) cm 2 for TEE. Correlation coefficient r for AVA assessment between each of 3D/2D, RT3D, TEE planimetry and Cath was 0.81, 0.86 and 0.71, respectively. The intraobserver variability was similar for all methods, but interobserver variability was better for 3D techniques than for TEE (p Conclusions: The 3D echo methods for planimetry of the AVA showed good agreement with the standard TEE technique and flow-derived methods. Compared with AV planimetry by TEE, both 3D methods were at least as good as TEE and had better reproducibility. 3D aortic valve planimetry is a novel non-invasive technique, which provides an accurate and reliable quantitative assessment of AS.

Introduction: Ischemic cardiomyopathy from coronary atherosclerosis is the leading cause of mortality in developed nations. However, the natural history of cardiovascular disease in contemporary pre-industrial man is not well described. The Tsimane of Bolivia are a forager-horticulturalist population in the western Amazonian basin with high levels of inflammation and a low prevalence of atherosclerosis risk factors. We sought to define the cardiovascular health of a contemporary pre-industrial population with high inflammation and low atherosclerotic risk factors. Methods: Two-Dimensional echocardiograms with Color and Doppler were obtained on 934 Tsimane over age 40. Echocardiograms were reviewed by 2 cardiologists following the American Society of Echocardiography guidelines for interpretation. Patients had baseline clinical evaluations including age, height, weight, blood pressure, and gender. Blood was obtained for serology for inflammatory markers. Results: The average age was 53 years (SD +/- 11; range 40-90 years). 455 (48.7%) were male. The prevalences of hypertension, diabetes, and smoking were 4.8%, 0.5%, and 1.3%, respectively. Mean LVEF was 66% (SD +/- 6.1). There were 4 males with LVEF less than 52% and 11 females with LVEF less than 54%. There was no measured LVEF less than 44%. Complete diastolic data was available in 910. Normal diastolic parameters were observed in 741 (81.4%). Mild diastolic dysfunction was found in 167 (18.3%) and moderate dysfunction in 2 (0.2%). No echocardiograms showed severe diastolic dysfunction. Serologic data showed elevated CRP, ESR, and IL-6 with low high density lipoprotein (HDL) and low density lipoprotein (LDL) Conclusions: In a pre-modern population with high inflammation and low atherosclerotic risk factors, cardiovascular systolic and diastolic dysfunction was a rare finding.

The feasibility and diagnostic accuracy of transesophageal pacing stress echocardiography for detection of inducible myocardial ischemia were evaluated in 161 patients 80 years of age or older (mean 84 +/- 3.9, range 80-97). The pacing time was 5.5 +/- 2.5 minutes with a total test time of 37 +/- 7 minutes. The mean achieved heart rate was 96 +/- 7% (83%-121%) of maximum predicted with an average rate pressure product of 21,560 +/- 5175 beats/min x mm Hg. There were minor adverse events in 8% of cases and no major complications occurred. Patient acceptance was high. When compared with myocardial single photon emission computed tomography, pacing stress echocardiography had a sensitivity of 89% and a specificity of 93% for the detection of myocardial ischemia, and 91% agreement (kappa = 0.80, P < .001). We demonstrate that pacing stress echocardiography is safe and accurate for detection of myocardial ischemia and, thus, a reliable substitute to exercise and pharmacologic stress testing in octogenarians.

This study compared the accuracy of cardiovascular diagnoses by medical students operating a small hand-carried ultrasound (HCU) device with that of board-certified cardiologists using standard physical examinations. Sixty-one patients (38% women; mean age 70 +/- 19 years) with clinically significant cardiac disease had HCU studies performed by 1 of 2 medical students with 18 hours of training in cardiac ultrasound and physical examinations by 1 of 5 cardiologists. Diagnostic accuracy was determined by standard echocardiography. Two-hundred thirty-nine abnormal findings were detected by standard echocardiography. The students correctly identified 75% (180 of 239) of the pathologies, whereas cardiologists found 49% (116 of 239) (p0.001). The students' diagnostic specificity of 87% was also greater than cardiologists' specificity of 76% (p0.001). For nonvalvular pathologies (115 findings), students' sensitivity was 61%, compared with 47% for cardiologists (p = 0.040). There were 124 clinically significant valvular lesions (111 regurgitations, 13 stenoses). Students' and cardiologists' sensitivities for recognizing lesions that cause a systolic murmur were 93% and 62% (p0.001), respectively. Students' sensitivity for diagnosing lesions that produce a diastolic murmur was 75%; cardiologists recognized 16% of these lesions (p0.001). The diagnostic accuracy of medical students using an HCU device after brief echocardiographic training to detect valvular disease, left ventricular dysfunction, enlargement, and hypertrophy was superior to that of experienced cardiologists performing cardiac physical examinations.

One hundred fifty patients with their first acute myocardial infarctions (AMIs) were studied. AMIs were confirmed by troponin levels, ST-segment elevation, or angiographic coronary occlusion. In 36% of patients (16 of 45) with left ventricular (LV) hypertrophy, the wall motion score index was normal, whereas in patients with no LV hypertrophy, only 18% (19 of 105) had no segmental wall motion abnormalities (p = 0.03). When adjusting for troponin level, the odds ratio for normal wall motion of patients with LV hypertrophy was 2.86 (95% confidence interval 1.26 to 6.50) compared with those with normal wall thickness. Consequently, normal LV wall motion by echocardiography in the setting of LV hypertrophy does not exclude AMI.

The accuracy of a hand-carried cardiac ultrasound (HCCU) device for the diagnosis of valvular regurgitations using color-flow Doppler was assessed. One hundred twenty hospitalized patients with at least mild valvular regurgitation by standard echocardiography were evaluated by 2 cardiologists using HCCU. The HCCU operator identified 99% of clinically significant valvular regurgitations and assessed the severity correctly in 83% of cases. For mild regurgitation, the HCCU sensitivity and specificity were 82% and 93%, respectively, resulting in correct assessments of severity in 71% of cases. HCCU used by trained cardiologists has high sensitivity for the detection and accurate assessment of the severity of clinically relevant valvular regurgitation.

cardioembolic strokes are responsible for more than 20% of all ischemic strokes. The examination of atrial sources of cardioembolic strokes has focused almost exclusively on the left atrial appendage (LAA) and the pathophysiology of thrombus formation at this site is well understood. However

The aim of this study was to elucidate patent foramen ovale (PFO) morphology and the change of PFO size using real-time 3-dimensional (3D) transesophageal echocardiography (TEE). PFO is a 3D structure, and its shape changes during the cardiac cycle. Therefore, it may be difficult to estimate accurate PFO morphology using 2-dimensional (2D) TEE. The study included 50 patients with PFO who underwent 2D and 3D TEE. PFO heights (PHs) at entrance, mid, and exit were measured by 2D and 3D TEE. Systolic and diastolic areas were also measured by 3D TEE. PH by 3D TEE was larger than that by 2D TEE (entrance 0.32 ± 0.18 vs 0.21 ± 0.15 cm, p0.001; mid 0.25 ± 0.14 vs 0.15 ± 0.11 cm, p0.001; exit 0.19 ± 0.11 vs 0.11 ± 0.08 cm, p0.001). Systolic area was greater than diastolic area at each location (entrance 0.19 ± 0.17 vs 0.11 ± 0.11 cm(2), p = 0.001; mid 0.13 ± 0.11 vs 0.08 ± 0.06 cm(2), p = 0.001; exit 0.09 ± 0.09 vs 0.06 ± 0.05 cm(2), p = 0.01). Additionally, entrance area was greater than exit area in systole and diastole (systole 0.19 ± 0.17 vs 0.09 ± 0.09 cm(2), p0.001; diastole 0.11 ± 0.11 vs 0.06 ± 0.05 cm(2), p = 0.001). There were good correlations between PH by 3D TEE and PFO area (entrance r = 0.68, mid r = 0.71, exit r = 0.78) but weak correlations between PH by 2D TEE and PFO area (entrance r = 0.62, mid r = 0.50, exit r = 0.51). In conclusion, real-time 3D TEE could provide detailed and unique information on PFO morphology.

Real-time 3-dimensional (3D) transesophageal echocardiography (TEE) provides more accurate geometric information on the mitral valve (MV) than 2-dimensional (2D) TEE. The aim of this study was to quantify MV prolapse using real-time 3D TEE in patients with severe mitral regurgitation. In 102 patients with severe mitral regurgitation due to MV prolapse and/or flail, 2D TEE quantified MV prolapse, including prolapse gap and width in the commissural view. Three-dimensional TEE also determined prolapse gap and width with the use of the 3D en face view. On the basis of the locations of MV prolapse, all patients were classified into group 1 (pure middle leaflet prolapse, n = 50) or group 2 (involvement of medial and/or lateral prolapse, n = 52). Prolapse gap and prolapse width determined by 3D TEE were significantly greater than those by 2D TEE (all p values0.001). The differences in prolapse gap and prolapse width between 2D TEE and 3D TEE were significantly greater in group 2 than group 1 (Δ gap 1.3 ± 1.4 vs 2.4 ± 1.8 mm, Δ width 2.5 ± 3.0 vs 4.4 ± 5.1 mm, all p values0.01). The differences in prolapse gap and width between 2D TEE and 3D TEE were best correlated with 3D TEE-derived prolapse width (r = 0.41 and r = 0.74, respectively). Two-dimensional TEE underestimated the width of MV prolapse and leaflet gap compared to 3D TEE. Two-dimensional TEE could not detect the largest prolapse gap and width, because of the complicated anatomy of the MV. In conclusion, 3D TEE provided more precise quantification of MV prolapse than 2D TEE.

Background— The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results— This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ≤1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P r =0.83 and 0.53, respectively). Conclusions— 3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.

Left atrial (LA) size reflects diastolic burden and is a prognostic parameter of common cardiovascular death. However, the association between LA size and function and pulmonary hypertension (PH) in coronary artery disease (CAD) has not been well investigated. We hypothesized that LA size and function are associated with PH in CAD.One hundred seven patients with CAD were studied. LA size was determined in three different methods; namely, LA volume index (LAV), LA area index, and LA dimension. LAV total emptying fraction was also determined. Pulsed Doppler E, A, E/A, DT, tissue Doppler E', A', and E/E' were measured. Pulmonary artery systolic pressure (PASP) was estimated.All LA size parameters are significantly associated with PH. LAV emptying fraction, age, E, E/A, E/E', and A' were also associated with PH significantly. CAD patients with PH showed larger LA size, higher E, E/A, and E/E' and lower LAV emptying fraction, A and A' than CAD patients without PH. Multivariate regression analysis revealed that maximum LAV, E, E/A ratio, and age were independent predictors of PH. Maximum LAV35.6 mL/m(2) predicted PASP40 mmHg with a sensitivity of 83.9% and specificity of 62.2%.LAV is associated with PH in CAD patients.

The present study sought to elucidate the geometry of the left ventricular outflow tract (LVOT) in patients with aortic stenosis and its effect on the accuracy of the continuity equation-based aortic valve area (AVA) estimation. Real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) provides high-resolution images of LVOT in patients with aortic stenosis. Thus, AVA is derived reliably with the continuity equation. Forty patients with aortic stenosis who underwent 2-dimensional transthoracic echocardiography (2D-TTE), 2-dimensional transesophageal echocardiography (2D-TEE), and RT3D-TEE were studied. In 2D-TTE and 2D-TEE, the LVOT areas were calculated as π × (LVOT dimension/2)(2). In RT3D-TEE, the LVOT areas and ellipticity ([diameter of the anteroposterior axis]/[diameter of the medial-lateral axis]) were evaluated by planimetry. The AVA is then determined using planimetry and the continuity equation method. LVOT shape was found to be elliptical (ellipticity of 0.80 ± 0.08). Accordingly, the LVOT areas measured by 2D-TTE (median 3.7 cm(2), interquartile range 3.1 to 4.1) and 2D-TEE (median 3.7 cm(2), interquartile range 3.1 to 4.0) were smaller than those by 3D-TEE (median 4.6 cm(2), interquartile range 3.9 to 5.3; p0.05 vs both 2D-TTE and 2D-TEE). RT3D-TEE yielded a larger continuity equation-based AVA (median 1.0 cm(2), interquartile range 0.79 to 1.3, p0.05 vs both 2D-TTE and 2D-TEE) than 2D-TTE (median 0.77 cm(2), interquartile range 0.64 to 0.94) and 2D-TEE (median 0.76 cm(2), interquartile range 0.62 to 0.95). Additionally, the continuity equation-based AVA by RT3D-TEE was consistent with the planimetry method. In conclusion, RT3D-TEE might allow more accurate evaluation of the elliptical LVOT geometry and continuity equation-based AVA in patients with aortic stenosis than 2D-TTE and 2D-TEE.

The natural history of valvular aortic stenosis (AS) is characterized by a protracted symptom free period during which morbidity and mortality are very low. During this period the average decrease in the aortic valve area is about 0.1 cm2 per year (1-4), although it is impossible to predict the rate of progression in an individual patient. For this reason, regular clinical follow-up is standard of care in all patients with asymptomatic mild to moderate AS (1). The onset of symptoms such as: angina, syncope, or heart failure significantly changes prognosis, with an average survival of 60% at 1 year and has increased risk of sudden cardiac death (5-7).

Carcinoid heart disease (CHD) is a rare cause of valvular heart disease and carries a poor prognosis. CHD has a unique morphology and echocardiographic features that predominantly involve right-sided valvular structures. The diagnosis of CHD is usually made by two-dimensional transthoracic echocardiography (TTE). With the superior spatial resolution of real time three-dimensional transesophageal echocardiography (3DTEE), structural changes that occur in patients with CHD-associated valvular heart disease can be examined in greater detail. We undertook this study to examine the incremental value of 3DTEE in the diagnosis of CHD.A total of four patients with CHD underwent TTE, transesophageal echocardiography (TEE), and 3DTEE as part of their routine clinical evaluation.TTE and TEE for all four patients revealed thickened, fibrosed, retracted, and malcoapted tricuspid leaflets with wide-open tricuspid valve regurgitation. 3DTEE en face imaging of the tricuspid valve demonstrated the characteristic morphologic features of CHD more clearly in all four patients.3DTEE provides substantial incremental value over TTE in the assessment of characteristic CHD pathology and thus enhances the echocardiographic diagnosis of CHD.

Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is a relatively new imaging modality that is increasingly being used to characterize a variety of cardiac pathologic features. In the present study, we reviewed the 2-dimensional (2D) and 3D TEE images from our echocardiographic database to identify patients with valve perforations. A review of the 2D TEE images resulted in the identification of 11 valvular perforations (6 aortic valves, 4 mitral valves, and 1 tricuspid valve). A review of the 3D TEE images allowed for the identification of 15 valve perforations (7 aortic valves, 7 mitral valves, and 1 tricuspid valve), including 4 perforations that could not be diagnosed using 2D imaging alone. In conclusion, 3D TEE imaging provided added benefit to traditional 2D TEE imaging because of its ability to provide en face visualization of the cardiac valves, allowing improved identification and precise anatomic localization of the perforation.

The management strategy in asymptomatic patients with severe aortic stenosis (AS) is controversial. Aortic valve replacement has significant morbidity and mortality, while there is a risk for sudden cardiac death with conservative management. There is no consensus on the prognostic value of stress testing to stratify management. A pooled analysis of studies in patients with severe AS was performed to assess the prognostic value of stress testing for adverse events, including angina, dyspnea, acute heart failure, sudden death, and symptoms requiring aortic valve replacement. A search of published research was performed using the terms "stress test" and "asymptomatic aortic stenosis." A random-effects model was used to calculate pooled odds ratios and 95% confidence intervals. Data from 7 studies were included (491 patients with asymptomatic severe AS). None of the patients experienced any complications during or after stress testing. There were no sudden deaths in the patients with normal stress test results after 1 year of follow-up, while 5% with abnormal stress test results had sudden cardiac death. Overall, 52 of 253 patients (21%) with normal stress test results had adverse cardiac events, compared with 156 of 238 (66%) with abnormal stress test results (odds ratio 0.12, 95% confidence interval 0.07 to 0.21, p

Background: Bicuspid aortic valve (BAV) and dilated ascending aorta frequently coexist. 10% of first degree relatives (FDRs) of probands with BAV inherit a valvular abnormality, however there is limited data concerning the occurrence of dilated aortic root in families of affected subjects. We evaluated the prevalence of aortic root dilatation among FDRs with a tricuspid aortic valve. Methods: Aortic root dimensions were measured by 2D echocardiography in BAV probands (n=48), their FDRs (n = 49) and controls without structural heart disease matched by age and gender (n=44). Aortic root was measured at: annulus, sinuses of Valsalva, sino-tubular junction and proximal ascending aorta. The dimensions were indexed by body surface area (BSA). Presence of dilatation was determined using published confidence intervals relating normal aortic diameters to BSA and age. Results: Five subjects (10%) in FDR group were found to have BAV, thus they were included in BAV group. Indexed aortic diameter was significantly different in 3 groups namely BAV>FDR>Control at annulus (2.0±0.3, 1.7±0.2, 1.6±0.1, p . BAV subjects showed significantly larger dimensions in the ascending aorta compared to FDRs and controls (p Conclusions: There is high prevalence of aortic root dilatation in the FDRs of subjects with BAV despite having normal tricuspid aortic valve. This finding suggests that aortic root dilatation is another phenotypic manifestation of BAV disease that is inherited independent of BAV.

Background: Abnormal aorta dilatation and elastic properties have been documented in subjects with bicuspid aortic valve (BAV). 10% of first degree relatives (FDRs) of probands with BAV inherit this valvular abnormality. There is no data regarding the elastic properties of aortic root in family members of BAV subjects. We evaluated the elastic properties in FDRs with normal tricuspid aortic valves. Methods: Systolic and diastolic aortic root dimensions were measured by 2D echocardiography in BAV probands (n=48) their FDRs (n = 49) and controls without structural heart disease matched by age and gender (n=44) at sinuses of Valsalva level. In addition, systolic (SBP) and diastolic blood pressure (DBP) were measured to calculate aortic distensibility, stiffness index and strain. Results: Five subjects (10%) in FDR group were found to have BAV, thus they were included in BAV group. There was no difference in age, gender, SBP and DBP in the three groups. History of hypertension was less prevalent in FDRs when compared to BAV and controls (16% vs 43% and 33%, p=0.03). All three parameters of aortic elastic properties including distensibility ×10 −3 mmHg (1.2±1.0 and 1.5±1.1 vs 2.3±1.5, p ). Conclusions: Aortic root elastic properties are abnormal in the family members of subjects with BAV despite normal tricuspid aortic valve morphology. This finding supports the hypothesis that there is a common genetic basis for BAV and abnormal elastic properties of aorta.

Chlamydia pneumoniae has previously been associated with higher prevalence of valvular and cardiac calcifications.To investigate a possible association of seropositivity for C. pneumoniae and the presence of cardiac calcifications (mitral annular or aortic root calcification, and aortic valve sclerosis).We retrospectively analyzed serological data (immunoglobulin G TWAR antibodies) from the AZACS trial (Azithromycin in Acute Coronary Syndromes), and correlated the serological findings according to titer levels with the presence of cardiac calcifications as detected by transthoracic echocardiography.In 271 patients, age 69 +/- 13 years, who underwent both serological and echocardiographic evaluation, we found no significant association between the "calcification sum score" (on a scale of 0-3) in seropositive compared to seronegative patients (1.56 +/- 1.15 vs.1.35 +/- 1.15, respectively, P = 0.26). The median calcification sum score was 1 (interquartile range 0-3) for the seronegative group, and 2 (interquartile range 0-3) for the seropositive group (P = 0.2757). In addition, we did not find a significant correlation of any of the individual sites of cardiac calcification and C. pneumoniae seropositivity.Our findings suggest that past C. pneumoniae infection may not be associated with the pathogenesis of valvular and cardiac calcifications.

The association between the severity of arteriosclerosis in the thoracic aorta in patients with isolated aortic stenosis (AS) and with concomitant coronary artery disease (CAD) has been not evaluated. Therefore, the aim of our study was to compare the thoracic aortic atheroma extent and severity in patients with severe AS alone and with concomitant CAD by intraoperative transesophageal echocardiography.We retrospectively evaluated echocardiograms of 105 consecutive patients with severe degenerative AS who underwent aortic valve replacement. Sixty patients had concomitant CAD (AS/CAD) on coronary angiography and 45 had no CAD (AS alone). These patients were compared with 54 sex- and age-matched patients without AS or CAD. Aortic atheroma (localized intimal thickening of3 mm) prevalence and morphology in three segments of aorta were assessed with echocardiography.There were 62 men, mean age 75.3 +/- 9.4 years. No difference was observed in age, sex, and risk factors for arteriosclerosis other than hypercholesterolemia among AS/CAD, AS alone, and control groups (88%, 67%, 41%, respectively; p0.0001). The AS/CAD group had a significantly higher rate of aortic root calcification (68%, 36%, 26%, respectively; p0.0001) and aortic atheroma (ascending aorta [26%, 20%, 14%, respectively; p = 0.03]; aortic arch [78%, 36%, 30%, respectively; p0.0001]; descending aorta [72%, 42%, 29%, respectively; p0.0001]) than AS alone or control subjects. Patients with AS/CAD also had more complex atheromas in the aortic arch (48%, 20%, 7%, respectively; p0.0001). Significant differences in extension of aortic arteriosclerosis (presence of plaques in two or three segments) were observed among the groups (70%, 31%, 18%, respectively; p0.0001).Patients with severe AS and coexisting CAD have more extensive arteriosclerotic changes in the thoracic aorta compared with those with AS alone and control subjects. Preoperative evaluation of the thoracic aorta and more aggressive lipid therapy should be considered in these patients.