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Background Aortic stenosis severity is defined by the calculated aortic valve area (AVA) using the Doppler-derived continuity equation (CE; AVACE = 0.785 x (LVOTd)2 x LVOT VTI/AV VTI (LVOTd = left ventricular outflow tract diameter; AV = aortic valve; VTI = velocity-time integral)). The LVOTd is the “Achilles heel” due to limitations of conventional 2D imaging and unstandardized measurement sites (0.5–1cm “apical” in the LVOT (LVOTdApi) vs “annulus” level (LVOTdAnn)) with no consensus even in recent guidelines. Geometrical differences in the LVOT and annulus of bicuspid (BAV) and tricuspid (TAV) aortic valves are further confounders. There remains a paucity of evidence to guide best practice. Erroneous LVOTd values will result in inaccurate AVACE estimations, triggering inappropriate intervention, or inaction. Purpose To define the optimal LVOTd by transthoracic echocardiography (TTE; LVOTdApi vs LVOTdAnn by 2D vs 3D) for AVACE calculation, and to identify factors accounting for any observed differences between BAVs and TAVs. AVA measured by 3D TTE planimetry (AVA3D) was the reference standard. Methods TTEs with 3D datasets of the AV complex in patients with BAVs and TAVs were included. 2D-LVOTdApi and 2D-LVOTdAnn were measured from 2D parasternal long-axis images. 3D-LVOTd values were calculated from the measured circumference, area, and average of minor/major dimensions at the “apical” (3D-LVOTdApi-Circ; 3D-LVOTdApi-Area; 3D-LVOTdApi-Ave) and “annulus” (3D-LVOTdAnn-Circ; 3D-LVOTdAnn-Area; 3D-LVOTdAnn-Ave) levels using multiplanar reconstruction. LVOTVTI and AVVTI were traced from standard spectral Doppler waveforms. The ratio of minor:major dimensions was used as an eccentricity index (EI) of the “apical” (EIApi) and “annulus” (EIAnn) sites. Results 53 BAVs and 52 TAVs were included. Mean BAV-AVA3D and TAV-AVA3D were 3.48±0.93cm2 and 3.41±0.69cm2 respectively. In BAVs, estimated AVACE using 3D-LVOTdApi-Circ (3.43±1.05cm2; Intraclass correlation (ICC) 0.971) and 3D-LVOTdAnn-Circ (3.40±1.01cm2; ICC 0.968) correlated best with AVA3D. Conversely in TAVs, 3D-LVOTdApi-Area (3.29±0.69cm2; ICC 0.983) and 3D-LVOTdAnn-Area (3.24±0.70cm2; ICC 0.975) performed optimally. 3D-LVOTdApi-Circ and 3D-LVOTdAnn-Circ overestimated TAV-AVA3D due to the greater ellipticity of the “apical” and “annulus” sites in TAVs (TAV vs BAV: EIApi 0.78 vs 0.83, P=0.04; EIAnn 0.84 vs 0.90, P Conclusions The “apical” LVOT and “annulus” are more circular in BAVs where 3D circumference (3D-LVOTdApi-Circ or 3D-LVOTdAnn-Circ) yielded the best AVACE. The more elliptical geometry in TAVs resulted in 3D area (3D-LVOTdApi-Area or 3D-LVOTdAnn-Area) the preferred technique. Resolving the quandary of measurement site, 2D-LVOTdAnn is favored over 2D-LVOTdApi for both BAVs and TAVs.

Acute myopericarditis in the developed world is ascribed predominantly to viral infections. Enteroviruses and adenoviruses are commonly implicated but are not routinely tested for, as the condition is self-limiting and has a good prognosis. However, we recently encountered two cases of acute myopericarditis associated with concomitant Streptococcus pyogenes [group A Streptococcus (GAS)] pharyngotonsillitis. A microbiological aetiology was pursued because of the severity of the upper respiratory tract infection and associated systemic illness rather than to explain the myopericarditis per se. We report these two cases and review the literature of this potentially under-recognized condition. In the absence of features of rheumatic fever, we hypothesize a toxin-mediated process as opposed to an immune-mediated one. We suggest that perhaps all patients with myopericarditis be assessed for GAS pharyngitis.

Background Most previous studies on diastolic function in diabetics are confounded by coexisting ischemic heart disease, obesity and hypertension. Therefore, there may be advantages in studying patients with diabetes mellitus in developing nations where confounding variables are less prevalent. The aim of this study was to assess the effect of type-2 diabetes mellitus on left ventricular diastolic function in normotensive subjects in Nigeria. Methods One-hundred-twenty-two patients with type-2 diabetes mellitus aged 35–74 years with a mean age of 55.30 ± 8.53 years were studied. Patients with blood pressure ≥ 140/90 mmHg or on treatment for hypertension were excluded from the study. Ninety-one healthy volunteers aged 40–75 years with a mean age of 55.30 ± 8.56 years were recruited as normal controls. Transthoracic echocardiography was performed in all subjects to assess their left ventricular diastolic filling pattern by analyzing mitral and pulmonary flow velocities. Results Seventy-one (58%) of the type-2 diabetic subjects had evidence of impaired relaxation, 9 (7%) had pseudonormal filling and 7 (6%) had a restrictive filling pattern. Only 29% of the diabetics had a normal filling profile compared to 58% of the normal controls (c 2 = 19.4, p=0.0002). Conclusions The result of the study shows that Nigerian type-2 diabetics have impaired left ventricular filling compared with normal subjects independent of confounding factors such as obesity and blood pressure. Therefore, not only Caucasians, African Americans and Asians but also African diabetic subjects suffered from diastolic dysfunction.

Community participation and empowerment are core principles underpinning the Healthy Cities movement. By providing an overview of theory and presenting the relevant findings of evaluations, this article explores how cities in the WHO European Healthy Cities Network have integrated community participation and empowerment within their development. Reflecting the inclusion of public participation and empowerment within the designation criteria for project cities, the evaluation of Phase III in 2002 demonstrated that community participation continues to be a high priority in most project cities. One-third of cities regularly consulted with large parts of their populations and another third undertook occasional consultations. Nearly 80% of cities had mechanisms for community representatives to participate in decision-making; and more than two-thirds of cities had initiatives explicitly aimed at empowering local people. Subsequent research carried out during 2005 further highlighted the centrality of public participation to the Healthy Cities movement. It found that all project cities continued to support community involvement. Community participation is an essential part of the process of good local governance, and empowerment remains at the heart of effective health promotion. To be meaningful, these processes must be seen as fundamental values of Healthy Cities and so must be developed as an integral part of long-term strategic development.

SAS for what was until a recently a fatally progressive disease without surgery. But these patients often have a poor functional reserve and are prone to significant morbidity if any complication arises. This case illustrates themultiple cardiac and vascular complications that can result from TAVI. It emphasises the importance of a multi-disciplinary approach to appropriately select patients in whom possible morbidity may be avoided.

A comparison was performed of the environmental impacts of using phosphogypsum versus conventional fill materials (e.g., from borrow pits) for road construction. The study compared a hypothetical roadway with an actual roadway in Florida; the two facilities differed only in that phosphogypsum was employed as fill material instead of conventional materials. The effect of the two construction approaches on the plant and animal communities was considered, as was the impact on the surface and ground water. A summary was made of the comparative impacts, and a comparison matrix was constructed using integral numbers to depict impacts ranging from -5 (most impact) to 0 (none) to + 5, showing most benefit of the part of the project on a given resource. Values were subjective, based upon investigators' experience. Four categories (plant and animal communities, water quality, water resources, and air quality) were considered. The cumulative total was +12 for phosphogypsum and -6 for conventional fill material.

Introduction: Myocardial Mechanics in Hypertrophic Cardiomyopathy: Is There a Difference between Subtypes? Objectives: We compared global longitudinal strain (GLS) derived by 2-dimensional speckle tracking echocardiography (STE) using the EchoPAC workstation (GE, Horton, Norway) in HCM patients categorised according to the distribution of hypertrophy. Methods: We prospectively assessed GLS in 86 HCM patients attending a quaternary cardiomyopathy clinic: 53 with asymmetrical septal hypertrophy (ASH), 21 with concentric hypertrophy (cHCM) and 12 with apical hypertrophy (ApHCM). Overall group differences were assessed with one-way ANOVA with the post-hoc Tukey test for three-way comparisons. To correct for the impact of afterload, the analysis was repeated for patients with no evidence of dynamic left ventricular obstruction either at rest or post Valsalva manoeuvre (n1⁄4 54). Results: Mean age was 49 15 years; 68 % were males. Mean age was similar in ASH, cHCM and ApHCM groups respectively (48 13 vs. 51 15 vs. 49 19 years). There was a significant difference between the 3 groups in the GLS: ApHCM (-12.8 2.6%) vs. ASH (-16.9 3.6%) vs. cHCM (-18.4 2.7%), one-way ANOVA P

Background: The wide application of Percutaneous Coronary Intervention (PCI) has increased the number of patients transferred from hospitals without cardiac catheterisation facilities (“spokes”) to thoseequippedwith them (“hubs”). This “hub and spoke” networked model of care has increased demand for acute beds at “hub” hospitals. Aim: To evaluate a protocol used to select patients who are at low risk of adverse events after a PCI for return transfer to the “spoke” hospital on the same day as their procedure. Method: From 2007 to 2009, patients sent from CampbelltownHospital (“spoke”) to Liverpool Hospital (“hub”) for PCI were assessed. To be eligible for entry into this study, patients were required to have a groin closure device placed at the end of their PCI. They were then 356

The Cordis stent is a flexible, highly radioopaque intracoronary stent engineered from a single Tantalum filament folded into a sinusoidal helical coil. It is premounted on a semicompliant balloon expandable stent delivery system. From September 1995-March 1996, 147 Cordis stents were deployed in 105 patients (aged 58+/-12 yr, 71% male). Clinical indications for stenting were unstable angina in 59 (55%), stable angina in 41 (38%), and acute myocardial infarction in 7 (7%). The target vessel was the right coronary artery in 45%, the left anterior descending in 31%, and the circumflex artery in 22%. One stent was deployed in a vein graft, and one stent was deployed in a left internal mammary artery graft. Stent deployment was achieved in all but one patient. Acute in-stent thrombosis occurred in 3 patients (2.9%). Two of these patients required urgent coronary artery bypass surgery. Subacute stent thrombosis occurred in 2 patients (1.9%). Minimum lumen diameter increased from 0.70+/-0.41 mm to 3.50+/-0.60 mm following stent placement. All patients received aspirin. Eighty-one patients (77%) received ticlopidine, and 4 patients (4%) received warfarin therapy. The mean hospital stay was 3.4+/-2.3 days. Six-month follow-up angiography was performed on 50 out of 55 eligible patients at one of the two institutions involved in this study. Computer-assisted quantitative coronary angiography defined a restenosis rate of 26%. Repeat revascularization was required in 8 patients (14.5%) at 6-mo follow-up. The Tantalum Cordis intracoronary stent is an effective and safe means of treating coronary lesions, even in patients with unstable ischemic syndromes. Acute and subacute rates of in-stent thrombosis were acceptable, and the long-term angiographic restenosis rates and need for repeat revascularization were favorable.

A total of 147 stents were implanted (in overlapping manner in 76% of vessels) in a single coronary artery in 59 patients (60 vessels, 97 lesions, 2.45 stents/vessel) over a period of 18 mo using high pressure stent deployment without ultrasound guidance. The indications for stenting were suboptimal percutaneous transluminal coronary angioplasty (PTCA) result (45%), primary prevention of restenosis (44%), acute closure (10%), and restenosis after plain balloon angioplasty (1%). One patient required emergency coronary artery bypass grafting (CABG) (extensive dissection), and one required early intervention with plain balloon angioplasty and intracoronary urokinase for stent thrombosis. There were no deaths. Thirteen patients had recurrence of angina within 6 mo and angiograms were performed in all. These showed intrastent restenosis in nine (all had successful repeat plain balloon angioplasty), development of new disease in other vessels along with restenosis close to the stent in the target vessel in one (underwent elective CABG) and normal angiograms with widely patent stents in three. Forty-five patients (77%) remained free of recurrent angina and 25 of these had follow-up angiograms (56%) at a mean of 172 days, two showing restenosis. Thus, the restenosis rate per patient in the symptomatic group (angiographic follow-up in 100%) was 77% and in the asymptomatic group (angiographic follow-up in 56%) was 8%. The restenosis rate in the subgroup with bailout stenting (n = 6) was 20% (angiographic follow-up in 83%). The overall restenosis rate per patient was 32% (overall angiographic follow-up in 66%). During the 6-mo follow-up period, one patient underwent elective CABG (1.7%), one sustained a non-Q myocardial infarction (1.7%), nine had repeat PTCA to the target vessel (15.5%), and there were no deaths. The event-free survival rate was 77%. Multiple stent implantation aided by high pressure stent deployment without ultrasound guidance and with adjunctive optimal antiplatelet therapy without oral anticoagulation seems to be a useful and effective revascularisation strategy to deal with long lesions and acute dissections with a high procedural success rate. The restenosis rate is acceptable and is not appreciably high as reported in previous studies from the "warfarin era."

Conclusion:Aconservative approachwith non-invasive management of selected elderly patients with NSTEMI is not associated with increased unplanned readmissions to hospital with ACS. http://dx.doi.org/10.1016/j.hlc.2013.05.107

length (inferolateral + anteroseptal) showed a significant difference (p< 0.0001) between UE (46.71± 2.75mm) and CE (57.74± 2.60). Conclusion: Despite exposure to destructive hydrodynamic forces, CE is feasible in an ovine VV ECMO model. CE results in significantly improved EDS and increased length of visualised endocardium. http://dx.doi.org/10.1016/j.hlc.2013.05.454

Aim: We aimed to characterise regional center emergency catheterisation referrals for ST elevationmyocardial infarction (STEMI) or cardiac arrest (CA). Methods: A single institution prospective database of STEMI/CA patients was interrogated to identify these patients and descriptive statistics derived. Findings: Sixty-five (65) patients were identified (2008 to February 2012). The following baseline characteristics were present: age 60± 13 years (mean± standard deviation), 82% male, 66% post-fibrinolysis, 7% CA, and 15% shocked. Percutaneous intervention (PCI) was performed in 89% (success 98%). Balloonpumpswereused in 9%.Two patients received urgent bypass surgery. One patient had the final diagnosis not STEMI. The hospital mortality was: 7.7%. The median distance from the institution of referring site was 138 (72,240) km with range 6–597 km. A map is shown below (point size scaled to referral number). The average time from onset of symptoms to cath lab arrival (CLA) was 5.8 h. This time was correlated with distance (p< 0.05). It explained only 19% of the variation. The day of week and time of day of CLA are shown in the second viously been assessed in the era of primary percutaneous coronary intervention (PCI). We sought to determine the validity of the TRS in both male and female ST Elevation Myocardial Infarction (STEMI) patients who have undergone early field triage. Methods: This was a single centre retrospective cohort study identifying consecutive STEMI patients presenting for primary-PCI via field triage between May 2004 and December 2010. Unpaired t-tests were used to determine significant demographic differences in males and females. Linear regression analysis was used to determine the correlation of the TRS with the endpoints of 30 day majoradverse cardiacevents (MACE)andmedianhospital length of stay (LOS). Results: 329 patients presented with STEMI via field triage, of which 248 (75.4%)weremale and 81 (24.6%)were female. Women were more likely to be older (73.2 vs 68.2, p< 0.0001), hypertensive (60.5% vs 44.9%, p< 0.05), show signsofpulmonaryoedemaatpresentation (17.5%vs7.6%, p< 0.05) andhaveahigherTRS (4.90 vs 3.14,p< 0.0001). The TRS was predictive of MACE (R2 = 0.57, p< 0.02) and hospital LOS (R2 = 0.79, p< 0.001) in the entire cohort. The TRS was found to be predictive of MACE and hospital LOS in males (R2 = 0.57, p< 0.02; R2 = 0.87, p< 0.0001 respectively) as well as females (R2 = 0.58, p< 0.02; R2 = 0.66, p< 0.02 respectively). Conclusion: The TRS is a useful prognostic tool in

Saphenous vein graft interventions are recognised as high risk procedures for adverse outcomes. We present a case of a ruptured vein graft causing a focal hematoma that led to pulmonary artery compression and cardiogenic shock without the classical signs of tamponade. Multi-modality imaging revealed the aetiology and the hematoma resolved after the patient received cardio-pulmonary resuscitation during attempted percutaneous drainage. Localized pulmonary artery compression is a rare complication of percutaneous coronary interventions (PCI). Its recognition and management are discussed, with the importance of early detection and urgent invasive management emphasized.

Background: An electronic Acute Coronary Syndrome (ACS) referral and triage system in South East Queensland links two tertiary and ten non-metropolitan hospitals using a web-based application. Methods: We sought to analyse patient demographics, triage category and ACS presentation between 01/01/2007 and 31/12/2010. Baseline characteristics were collected: gender, age, bodymass index (BMI), diabetes andsmoking history. Triage and ACS category were collected. Comparisons were made between those transferred and not transferred. Results: 4845 patientswere referred ofwhom4021 (83%) were transferred. There was no statistical difference for mean age 66.6± 0.20 years or mean BMI 28.5± 0.09. The prevalence of diabetes was 17.58%. Those transferred were more likely to be male (64.5%, p= 0.046) and curr d ( l 1 o ( c w ( e N u

Conclusion:Our data underscore the value of recognising diabetes, a history of MI and presence of Troponin-T as risk factors for mortality in ESRD. There was no significant difference in mortality risk between dialysis and pre dialysis patients. doi:10.1016/j.hlc.2011.05.501

criteria. Pearson’s coefficient was used to determine correlation between the two methods for each category of TR. Results: 108 RHC studies were included for analysis. Pearson’s coefficient of correlation for each subgroup; overall cohort: 0.829 (p< 0.001), trivial or no TR (n= 25): 0.880 (p< 0.001), 1/4 TR (n= 37): 0.816 (p< 0.001), 2/4 TR (n= 33): 0.729 (p< 0.001), 3/4 or worse TR (n= 12): 0.936 (p< 0.001). Conclusion: There is good correlation between Fick and thermodilution measures of CO independent of the severity of TR. Small numbers limit the reliability of the observation of the excellent degree of correlation in severe TR. doi:10.1016/j.hlc.2011.05.372

Methods:All patients undergoingTAVI-C fromNovember 2008 to February 2010 were included in this study. Patients underwent detailed resting echo immediately prior to and one year post procedure. Objective clinical review including New York Heart Association (NYHA) functional class and Minnesota Living with Heart Failure Questionnaire (MLHFQ)wereperformedat the same time intervals. Results:Twenty-nine patientswith SSAS (22men, 83± 4 years) underwent TAVI-C. There was 100% procedural success with 14% one year mortality and a single rescue surgicalAVR.At one year, TAVI-C lead to an improvement NYHA class, quality of life and reduction in mean aortic gradient but no significant change in other measures of cardiac structure and function (see table). Conclusion: In selected patients with severe AS, TAVI leads to an improvement in NYHA functional class, quality of life and a reduction in mean aortic valve gradient at one year without any other significant impact on echo measures of cardiac function. Baseline 12 months p value MLHFQ score 39± 16 6± 6

Aim: We investigated the correlates of “door” to reperfusion time in the setting of an EmergencyMedicine (EM) Cardiology integrated primary angioplasty (PCI) service. Methods: Consecutive patients presenting through EM with initial diagnosis of STEMI referred for PCI were extracted from a prospective database (November 2007–March 2009). Multivariate linear regression was used to identify correlates for intervals: door to balloon time (DTB), door to lab time (DTL), lab to balloon time (LTB). The following variables were assessed: age, gender, presentation characteristics: day of week, time of day, weekend (WE), paramedic fast track (FT), presentation as cardiac arrest (CA), time interval of presentation: between midnight and 8 a.m. (EP); between 5p.m. to midnight period. Results: Eighty one (81) patients were identified. The baseline characteristics are as follows: age: 60± 13 years, male: 68 (84%), CA: 13 (16%), FT: 21 (26%), final diagnosis not STEMI: 12 (15%), PCI: 64 (79%). The time intervals are as follows (format: median (interquartile range) minutes): symptom to presentation: 113 (63,228), DTB: 73.5 (53, 98), DTL 37 (18, 44), LTB: 32 (26, 37), symptom to balloon: 227 (139, 336). The positive correlates for DTB were WE (p< 0.05) and EP (p< 0.05). FT was negatively correlated (p< 0.05). The average effect (minutes) on DTB was as follows: WE: +25, EP: +30, FT: −25. There were no significant associations between any of the variables and LTB.WE, EP and FT were correlates of DTL (which included patients with no PCI) with the corresponding average effects: +23, +22, −31min. CA was not correlated with any intervals (median: without 73, with 72min). Conclusions: Weekend and early presentations (midnight to 8 a.m.) are associated with approximately 25–30min delay in door to balloon time. Paramedic fast-tracking reduces door to balloon time by 25min. Presentation as cardiac arrest was not associated with delay to lab or reperfusion.

High performance liquid chromatography (HPLC) has been used to identify a fraction of aqueous sediment extract from Lake Starvation, Hillsborough County, Florida, that is responsible for inhibition of hydrilla growth. The fraction was separated on a Zorbax™ C18 preparative-scale column. The present study examines various lake sediment extracts and river water samples to determine the presence or absence of the inhibitor peak. The biologically active component is absent in certain rivers where hydrilla is prominent, but it is present in extracts of Lake Starvation and White Trout Lake sediments that are known to have hydrilla growth inhibiting properties. The implications of “fingerprinting” natural waters for hydrilla inhibitor through liquid chromatography are considered.

The choice of a lake rehabilitation technique can be assisted by laboratory experiments concerned with the composition and properties of the sediments. This work on Sawgrass Lake, Pinellas County, Florida, provides an example of the type of laboratory information that can be useful towards making decisions regarding the most effective restorative techniques. Experiments include chemical analysis of sediment (water content, organic content, pesticides, nutrients), rate of sediment compaction and rehydration at ambient conditions, and the effect of treatment with alum and other chemicals.

Aqueous extracts of peat‐like sediments from Lake Starvation, Hillsborough County, Florida, inhibit the growth of Hydrilla verticillata in laboratory systems. The extracts were obtained by autoclaving sediment in water, and it may be that this process degrades the sediment. Evidence is presented that the total organic content of the extract obtained is not substantially different from solutions obtained at much lower temperatures. Therefore, the use of autoclaving in the preparation of sediment extract would appear to produce a material similar to that possibly produced in the environments of selected lakes.

Aeration of artificial, model lake systems was studied as a tool to improve water quality and to control the growth of a nuisance aquatic weed, Hydrilla verticillata (L.F.) Royle, which has been recognized as a plant pest since the mid-1960s. Aeration decreased the growth of Hydrilla by 20% fresh weight and 18% dry weight on average after 21 days. The effect was due to the oxygenation of the water and not the mechanical effect of the bubbles, as verified by studies using pure nitrogen. Aeration also affected water quality. Inorganic carbon decreased; nitrate-nitrite-nitrogen decreased, more slowly in test systems than in control systems; dissolved oxygen increased to saturation within 24 h and pH increased 0.5–1.5 unit over the period of study. Phosphate-phosphorus concentration was unaffected. The concentrations of zinc, calcium and iron decreased as well. The effect of aeration upon Hydrilla growth appears to be correlated with a decrease of iron. After 7 days, iron concentrations decreased to less than 20 ppb. Iron toxicity is proposed as the mechanism responsible for creating a limiting condition for Hydrilla growth.

The growth of hydrilla (Hydrilla verticillata Royle) in lake water, Floridan aquifer waten and mixtures of the two water samples was studied. The water was sampled from Lake Hobbs that has been previously identified as a lake that has not been augmented with water from the Floridan Aquifer. Evidence is presented that adding water from the deep wells enhances growth of hydrilla.

Iron, added as (Fe-EDTA)-, was found stimulatory to V. spiralis at a concentration of 0.05 ppm. (Fe-EDTA)- had no effect upon growth of V. neotropicalis as measured by changes in dissolved oxygen and dry weight. Results are compared with those derived from similar studies with Hydrilla verticillata and Egeria densa. The implications of lake drawdown and aeration are discussed.