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Congenital anomalies of the mitral valve are rare. A mitral arcade is defined as a fibrous continuity between the papillary muscles and the anterior mitral leaflet creating a hammock like suspension. We present images of a mitral anomaly that consists of a direct attachment of the anterolateral papillary muscle to the anterior mitral leaflet, which we have labeled as a "hemi-arcade." We discuss the surgical findings and review the available literature regarding a mitral "arcade". [ABSTRACT FROM AUTHOR]

Background and Aims: Bicuspid aortic valve (BAV) is the most common congenital heart anomaly. Lifetime morbidity and whether long-term survival varies according to BAV patient-sub-groups are unknown. This study aimed to assess lifetime morbidity and long-term survival in BAV patients in the community., Methods: The authors retrospectively identified all Olmsted County (Minnesota) residents with an echocardiographic diagnosis of BAV from 1 January 1980 to 31 December 2009, including patients with typical valvulo-aortopathy (BAV without accelerated valvulo-aortopathy or associated disorders), and those with complex valvulo-aortopathy (BAV with accelerated valvulo-aortopathy or associated disorders)., Results: 652 consecutive diagnosed BAV patients [median (IQR) age 37 (22-53) years; 525 (81%) adult and 127 (19%) paediatric] were followed for a median (IQR) of 19.1 (12.9-25.8) years. The total cumulative lifetime morbidity burden (from birth to age 90) was 86% (95% CI 82.5-89.7); cumulative lifetime progression to ≥ moderate aortic stenosis or regurgitation, aortic valve surgery, aortic aneurysm ≥45 mm or z-score ≥3, aorta surgery, infective endocarditis and aortic dissection was 80.3%, 68.5%, 75.4%, 27%, 6% and 1.6%, respectively. Survival of patients with typical valvulo-aortopathy [562 (86%), age 40 (28-55) years, 86% adults] was similar to age-sex-matched Minnesota population (P = .12). Conversely, survival of patients with complex valvulo-aortopathy [90 (14%), age 14 (3-26) years, 57% paediatric] was lower than expected, with a relative excess mortality risk of 2.25 (95% CI 1.21-4.19) (P = .01)., Conclusion: The BAV condition exhibits a high lifetime morbidity burden where valvulo-aortopathy is close to unavoidable by age 90. The lifetime incidence of infective endocarditis is higher than that of aortic dissection. The most common BAV clinical presentation is the typical valvulo-aortopathy with preserved expected long-term survival, while the complex valvulo-aortopathy presentation incurs higher mortality., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

There is emerging evidence that the cardiac interatrial septum has an important role as a thromboembolic source for ischemic strokes. There is little consensus on treatment of patients with different cardiac interatrial morphologies or pathologies who have had stroke. In this paper, we summarize the important background, diagnostic, and treatment considerations for this patient population as presented during the Federation of American Societies for Experimental Biology (FASEB) Virtual Catalytic Conference on the Cardiac Interatrial Septum and Stroke Risk, held on December 7, 2022. During this conference, many aspects of the cardiac interatrial septum were discussed. Among these were the embryogenesis of the interatrial septum and development of anatomic variants such as patent foramen ovale and left atrial septal pouch. Also addressed were various mechanisms of injury such as shunting physiologies and the consequences that can result from anatomic variants, as well as imaging considerations in echocardiography, computed tomography, and magnetic resonance imaging. Treatment options including anticoagulation and closure were addressed, as well as an in-depth discussion on whether the left atrial septal pouch is a stroke risk factor. These issues were discussed and debated by multiple experts from neurology, cardiology, and radiology., (© 2023 Federation of American Societies for Experimental Biology.)

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure. By providing circulatory support, VA-ECMO gives treatments time to reach optimal efficacy or may be used as a bridge to a more durable mechanical solution for patients with acute cardiopulmonary failure. It is commonly used when a readily reversible etiology of decompensation is identified with very strict inclusion criteria for extracorporeal cardiopulmonary resuscitation use. We present a unique case in which VA-ECMO/extracorporeal cardiopulmonary resuscitation was used after cardiac arrest with pulseless electrical activity in a patient with recurrent lymphoma of the left thigh with recent autologous stem cell transplant., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Published by Elsevier Inc.)

The diagnosis of cardiac device infection and, more importantly, accurate localization of the infection site, such as defibrillator pocket, pacemaker lead, along the peripheral driveline or central portion of the left ventricular assist device, prosthetic valve ring abscesses, and perivalvular extensions, remain clinically challenging. Although transthoracic and transesophageal echocardiography are the first-line imaging tests in suspected endocarditis and for assessing hemodynamic complications, recent studies suggest that cardiac computed tomography (CT) or CT angiography and functional imaging with 18 F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) with CT (FDG PET/CT) may have an incremental role in technically limited or inconclusive cases on echocardiography. One of the key benefits of FDG PET/CT is in its detection of inflammatory cells early in the infection process, before morphological damages ensue. However, there are many unanswered questions in the literature. In this document, we provide consensus on best practices among the various imaging studies, which includes the detection of cardiac device infection, differentiation of infection from inflammation, image-guided patient management, and detailed recommendations on patient preparation, image acquisition, processing, interpretation, and standardized reporting., Competing Interests: Funding Support and Author Disclosures Dr Nieman acknowledges support from the NIH (NIH R01- HL141712; NIH R01 - HL146754); has received unrestricted institutional research support from Siemens Healthineers, Bayer, HeartFlow Inc; has provided consulting for Siemens Medical Solutions USA; and has equity in Lumen Therapeutics, which are all unrelated to this work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Renal dysfunction is frequently encountered in patients with aortic prosthesis degeneration requiring valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR). The effect of VIV TAVR on renal function in patients with bioprosthetic aortic regurgitation (AR) and stenosis (AS) is unknown., Objectives: The aims of this study were to describe the change in renal function after VIV TAVR and to compare differences in renal function changes in those with predominant prosthetic regurgitation compared to stenosis., Methods: All VIV TAVR between June of 2014, and October 2019 (n = 141) at a single institution were reviewed. Baseline renal function parameters including estimated glomerular filtration rate (eGFR) were compared with post-discharge follow-up values in both prosthetic AR and AS patient groups. Linear regression analysis was performed to determine correlates of renal function change., Results: Mean baseline eGFR was lower in the AR group (55 SD21 vs. 64 SD24 ml/min/1.73 m 2 p = 0.0495). At post-discharge follow-up there was an increase in mean eGFR in the AR group which was not present in the AS group (8 SD12 vs. 0 SD11 ml/min/1.73 m 2 respectively p = 0.0006). There were strong correlations between change in creatinine (β = -0.57, R 2  = 0.64, p < 0.0001) and BUN (β = -0.61, R 2  = 0.51, p < 0.0001), and pre-procedure values in the AR group., Conclusions: Patients who underwent VIV TAVR for AR experienced significant improvement of renal function at post-discharge follow-up. More advanced renal dysfunction at baseline was associated with greater improvement in renal function at post discharge in AR patients., Competing Interests: The authors report no relationships that could be construed as a conflict of interest., (© 2022 The Author(s).)

Background: Investigational transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR) has shown promise as an alternative to surgery, but factors influencing outcomes, optimal patient selection, and procedural timing remain incompletely defined. Given the limitations of determining TR severity by conventional echocardiography, our objectives were to determine whether invasive right atrial (RA) pressures performed during the procedure are related to patient outcomes., Methods: This study was a retrospective review of patients who underwent off-label tricuspid TEER using MitraClip (Abbott Vascular, Menlo Park, CA) for significant TR at a single institution. Intraprocedural mean RA pressure, RA peak V-wave, RA pressure nadir, and systolic increase in RA pressure (XV height) were recorded., Results: Thirty-eight patients underwent tricuspid TEER; 33 underwent concomitant mitral TEER for mitral regurgitation. The study cohort was 39% female with a mean age of 78.6±14.3 years. Median follow-up was 339 days (interquartile range, 100-601). Any reduction in mean RA pressure, RA peak V-wave, RA nadir, and XV height occurred in 74%, 82%, 45%, and 87% of patients, respectively. At 1 year, event-free survival was 47%. Postprocedure XV height correlated with TR severity as determined by echocardiography ( P <0.0001). The highest quartile of postprocedure XV height (>8 mm Hg) had worse event-free survival compared with those who had concluding XV height ≤8 mm Hg ( P =0.02). Attainment of a concluding XV height less than or equal to median value was associated with a lower creatinine the next day (1.27±0.47 versus 1.64±0.47 mg/dL, P =0.04)., Conclusions: Intraprocedural XV height correlates with TR severity after tricuspid TEER, and lower concluding pressures are associated with improved outcomes. Analysis of RA pressures may serve as a complementary tool for the evaluation of disease severity and procedural guidance.

Background: The predictors and clinical significance of increased Doppler-derived mean diastolic gradient (MG) following transcatheter edge-to-edge mitral valve repair (MVTEER) remain controversial., Objective: We sought to examine baseline correlates of Doppler-derived increased MG post-MVTEER and its impact on intermediate-term outcomes., Methods: Patients undergoing MVTEER were analyzed retrospectively. Post-MVTEER increased MG was defined as >5 mmHg or aborted clip implantation due to increased MG intraprocedurally. Baseline MG and 3D-guided mitral valve area (MVA) by planimetry were retrospectively available in 233 and 109 patients., Results: 243 patients were included; 62 (26%) had MG > 5 mmHg post-MVTEER or aborted clip insertion, including 7 (11%) that had aborted clip implantation. Mortality occurred in 63 (26%) during a median follow up of 516 days (IQR 211, 1021). Increased post-MVTEER MG occurred more frequently in females (44% vs. 16%, p <  0.001), those with baseline MVA <4.0 cm 2 (71% vs. 16%), baseline MG ≥4 mmHg (61% vs. 20%), or multiple clips implanted (33% vs. 21%, p = 0.04). Increased post-MVTEER MG was associated with increased subsequent mortality compared to those with normal gradient (HR 1.91 95% CI 1.15-3.18 p = 0.016) as was aborted clip insertion compared to all others (HR 5.23 95% CI 2.06-13.28 p <  0.001)., Conclusions: Smaller baseline MVA and increased baseline MG are associated with increased MG post-MVTEER and patients with a Doppler-derived post-MVTEER MG >5 mmHg suffered excess subsequent mortality. In high risk patients considered for MVTEER, identification of those at risk of iatrogenic mitral stenosis with MVTEER is important as they may be optimally treated with alternate surgical or transcatheter therapies., (© 2021 Wiley Periodicals LLC.)

Background: Iatrogenic mitral stenosis is a known limitation of transcatheter edge-to-edge mitral valve repair (TMVr), but determinants of increased postprocedural mean diastolic gradient (MG) are not well defined. The aim of this study was to determine correlates of increased post-TMVr MG or aborted clip implantation due to increased MG., Methods: Procedural three-dimensional transesophageal echocardiographic (TEE) data sets of 112 patients who underwent TMVr were retrospectively analyzed. Three-dimensional TEE mitral valve area (MVA) planimetry and mitral annular calcification (MAC) were quantified using multiplanar reconstruction. When MAC extension into the mitral leaflets was present, MAC with leaflet calcification (MAC-LC) length was recorded as the maximum distance from the mitral annulus to the most distal leaflet calcification. Increased MG after TMVr, measured on intraprocedural TEE imaging, was defined as ≥5 mm Hg or aborted clip implantation due to increased MG., Results: Baseline MVA was 5.9 ± 1.7 cm 2 , baseline MG was 2.1 ± 1.2 mm Hg, and MAC-LC length was 4.0 ± 4.5 mm. Thirty-two patients (29%) had increased post-TMVr MG. Risk for increased post-TMVr MG was 86%, 28%, and 14% in patients with baseline MVA < 4.0, 4.0 to 6.0, and >6.0 cm 2 , respectively (P < .001). In patients with baseline MVA 4.0 to 6.0 cm 2 , concurrent baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm was associated with higher risk for increased post-TMVr MG (53% vs 12%, P = .002). In patients with baseline MVA < 4.0 and >6.0 cm 2 , the risk for increased post-TMVr MG was similar in the presence or absence of baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm (P > .05 for both)., Conclusions: Patients with baseline three-dimensional TEE MVA < 4.0 cm 2 are at high risk for increased post-TMVr MG. Additionally, patients with borderline MVA (4.0-6.0 cm 2 ) and concurrent MAC-LC length ≥ 6 mm or baseline MG ≥ 4 mm Hg are at moderate risk for increased MG after TMVr., (Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to define the 2-dimensional and Doppler echocardiographic hemodynamics associated with each Society for Cardiovascular Angiography and Interventions (SCAI) stage, and to determine their association with mortality., Background: The SCAI shock stages classification stratifies mortality risk in cardiac intensive care unit (CICU) patients, but the echocardiographic and hemodynamic parameters that define these SCAI shock stages are unknown., Methods: Unique CICU patients admitted from 2007 to 2015 who had a transthoracic echocardiogram within 1 day of CICU admission were included. Echocardiographic variables were evaluated as a function of SCAI shock stage. Multivariable logistic regression determined the association between echocardiographic parameters with adjusted hospital mortality., Results: We included 5,453 patients with a median age of 69.3 years (interquartile range: 58.2 to 79.0 years) (37% women), and a median left ventricular ejection fraction (LVEF) of 50% (interquartile range: 35% to 61%). Higher SCAI shock stages were associated with lower LVEF and worse systemic hemodynamics. Hospital mortality was higher in patients with LVEF <40%, cardiac index <1.8 l/min/m 2 , stroke volume index <35 ml/m 2 , cardiac power output <0.6 W, or medial early mitral valve inflow velocity to early diastolic annular velocity (E/e') ratio >15 (particularly in SCAI shock Stages A to C). After multivariable adjustment, only stroke volume index <35 ml/m 2 (adjusted odds ratio: 2.0; 95% confidence interval: 1.4 to 3.0; p < 0.001) and E/e' ratio >15 (adjusted odds ratio: 1.52; 95% confidence interval: 1.04 to 2.23; p = 0.03) remained associated with higher hospital mortality., Conclusions: Noninvasive 2-dimensional and Doppler echocardiographic parameters correlate with the SCAI shock stages and improve risk stratification for hospital mortality in CICU patients. Low stroke volume index and high E/e' ratio demonstrated the strongest association with hospital mortality., Competing Interests: Funding support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Transcatheter edge-to-edge repair with MitraClip is only approved for treatment of mitral regurgitation but is increasingly used to treat concomitant tricuspid regurgitation (TR) due to its common coexistence and association with poor outcomes. This study aimed to describe the learning curve associated with the challenge of off-label treatment of concomitant TR., Methods: This is a retrospective review of initial and consecutive patients who underwent combined edge-to-edge repair of mitral and tricuspid valves (TVs) at our institution from August 2017 to October 2019., Results: Repair of both valves with MitraClip was performed in 22 patients (median age 81.5 years, 32% female). Mean procedure time was 176 ± 47 min; mean fluoroscopy time was 65 ± 24 min. Procedure duration in the first tertile was significantly longer (223 ± 13 min) than in the third tertile (143 ± 23 min, p = .0003). Median number of total clips placed per case was 3; in 15 patients (68%), the anterior and septal leaflets of the TV were clipped. The average changes in mean right atrial (RA) and left atrial (LA) pressures were -1.7 ± 2.5 mmHg (p = .0080) and -3.2 ± 4.6 mmHg (p = .0045), respectively. The average changes in RA and LA V-wave heights were -3.3 ± 4.0 mmHg (p = .0009) and -8.1 ± 9.9 mmHg (p = .038), respectively. There was a significant trend toward decreasing residual TR over the course of the series (p = .046). At 30 days, survival was 100% and mean NYHA class decreased from 2.8 to 1.8 (p < .0001)., Conclusions: Combined edge-to-edge tricuspid and mitral valve repair is safe and feasible. With experience, procedure duration and residual TR decreased., (© 2020 Wiley Periodicals, Inc.)

Background: A significant proportion of patients with aortic stenosis (AS) have discordance in severity by mean gradient/peak velocity and aortic valve area. Low gradient aortic stenosis (LG-AS) is defined when the aortic valve area is < 1 cm 2 consistent with severe AS and mean aortic gradient is < 40 mmHg consistent with non-severe AS. LG-AS represents a diagnostic and therapeutic challenge., Purpose of Review: To summarize the different categories, diagnosis, management, and prognosis of LG-AS. LG-AS is classified as classical (ejection fraction (EF) < 50%, indexed stroke volume (SVi) < 35 ml/m 2 ), paradoxical (EF > 50%, SVi < 35 ml/m 2 ), pseudo-severe (moderate AS with reduced EF), or normal flow low gradient AS., Recent Findings: Recent findings emphasize the importance of low-dose dobutamine stress echocardiography and CT calcium score in the assessment of aortic valve. In addition, flow reserve (increase in SV > 50%) can be evaluated during dobutamine stress echocardiography and helps predict perioperative prognosis. Patients with LG-AS have better survival with aortic valve replacement (AVR) compared to medical therapy, irrespective of presence or absence of flow reserve. Some recent studies suggest that transcatheter aortic valve replacement (TAVR) may be superior to surgical AVR for patients with a lack of contractile flow reserve or those with paradoxical LG-AS, but further investigation is needed to clarify optimal treatment. The role of TAVR in patients with moderate AS and reduced EF is also under investigation.

Background: The prognostic significance of diastolic blood pressure (DBP) and resting heart rate (RHR) in patients with hemodynamically significant aortic regurgitation (AR) is unknown., Objectives: This study sought to investigate the association of DBP and RHR with all-cause mortality in patients with AR., Methods: Consecutive patients with ≥ moderate to severe AR were retrospectively identified from 2006 to 2017. The association between all-cause mortality and routinely measured DBP and RHR was examined., Results: Of 820 patients (age 59 ± 17 years; 82% men) followed for 5.5 ± 3.5 years, 104 died under medical management, and 400 underwent aortic valve surgery (AVS). Age, symptoms, left ventricular ejection fraction (LVEF), LV end-systolic diameter-index (LVESDi), DBP, and RHR were univariable predictors of all-cause mortality (all p ≤ 0.002). When adjusted for demographics, comorbidities, and surgical triggers (symptoms, LVEF, and LVESDi), baseline DBP (adjusted-hazard ratio [HR]: 0.79 [95% confidence interval: 0.66 to 0.94] per 10 mm Hg increase, p = 0.009) and baseline RHR (adjusted HR: 1.23 [95% confidence interval: 1.03 to 1.45] per 10 beat per min [bpm] increase, p = 0.01) were independently associated with all-cause mortality. These associations persisted after adjustment for presence of hypertension, medications, time-dependent AVS, and using average DBP and RHR (all p ≤ 0.02). Compared with the general population, patients with AR exhibited excess mortality (relative risk of death >1), which rose steeply in inverse proportion (p nonlinearity = 0.002) to DBP starting at 70 mm Hg and peaking at 55 mm Hg and in direct proportion to RHR starting at 60 bpm., Conclusions: In patients with chronic hemodynamically significant AR, routinely measured DBP and RHR demonstrate a robust association with all-cause death, independent of demographics, comorbidities, guideline-based surgical triggers, presence of hypertension, and use of medications. Therefore, DBP and RHR should be integrated into comprehensive clinical decision-making for these patients., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Patient selection for transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging because of heterogenous mitral valve pathology and highly variable anatomy. The aim of this study was to investigate whether quantitative three-dimensional (3D) transesophageal echocardiographic modeling parameters are associated with optimal mitral regurgitation (MR) reduction in patients undergoing TMVR., Methods: Fifty-nine patients underwent 3D transesophageal echocardiography during TMVR. Volumetric data sets were retrospectively analyzed using mitral valve quantitative 3D modeling software (Mitral Valve Navigator). Optimal MR reduction was defined as less than moderate residual MR. Logistic regression was used to correlate 3D transesophageal echocardiographic quantitative data to procedural success., Results: Thirty-five patients had primary MR, 24 had mixed or secondary MR, and all patients had grade ≥ 3/4 MR before the procedure. Optimal MR reduction was achieved in 40 of 59 patients (68%). Univariate correlates of optimal MR reduction in patients with primary MR were lower mitral leaflet tenting volume (P = .049) and lower tenting height (P = .025); tenting height < 3 mm and tenting volume < 0.7 mL were associated with increased likelihood of optimal MR reduction (92% vs 48% [P = .01] and 81% vs 47% [P = .03], respectively). In mixed or secondary MR, annular height ≥ 5.5 mm was associated with increased likelihood of optimal MR reduction (94% vs 38%; P = .03). During follow-up, redo TMVR or surgical mitral valve replacement occurred exclusively in patients with suboptimal anatomy defined by 3D transesophageal echocardiography (10% vs 0%, P = .045)., Conclusions: Quantitative 3D echocardiographic data are associated with favorable response to TMVR and could help optimize patient selection., (Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years., Methods: We retrospectively reviewed unique CICU admissions at the Mayo Clinic from January 2007 to April 2018. Comorbidities, severity of illness scores, discharge diagnosis codes and CICU procedures and therapies were recorded, and temporal trends were assessed using linear regression and Cochran-Armitage trend tests. Trends in adjusted hospital mortality over time were assessed using multivariable logistic regression., Results: We included 12,418 patients with a mean age of 67.6 years (including 37.7% females). Temporal trends in the prevalence of several comorbidities and discharge diagnoses were observed, reflecting an increase in the prevalence of non-coronary cardiovascular diseases, critical care diagnoses, and organ failure (all P ≪ .05). The use of several CICU therapies and procedures increased over time, including mechanical ventilation, invasive lines and vasoactive drugs (all P ≪ .05). A temporal decrease in adjusted hospital mortality was observed among the subgroup of patients with (adjusted OR per year 0.97, 95% CI 0.94-0.99, P = .023) and without (adjusted OR per year 0.91, 95% CI 0.85-0.96, P = .002) a critical care discharge diagnosis., Conclusions: We observed an increasing prevalence of critical care and organ failure diagnoses as well as increased utilization of critical care therapies in this CICU cohort, associated with a decrease in risk-adjusted hospital mortality over time., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aims: Bicuspid aortic valve (BAV) and mitral valve prolapse (MVP) are common but the prevalence and significance of coexistent conditions are unknown. This study investigated the prevalence, phenotypic expression, and clinical significance of coexistent MVP-BAV., Methods and Results: Retrospective comparison of MVP-BAV and MVP-tricuspid aortic valve (TAV) prevalence including de novo echocardiographic analysis of all MVP-BAV patients between 2005 and 2015 was performed. The community prevalence of MVP-BAV was 2.7% vs. 3.4% for MVP-TAV (P = 0.45). Posterior mitral leaflet (PML)-MVP was the most common phenotype in both BAV and TAV (P = 0.38), but anterior mitral leaflet (AML)-MVP was twice more prevalent in BAV (31% vs. 15%, P < 0.0001). Among 130 subjects with coexistent MVP-BAV (81% men, 51 ± 16 years old), 31 (24%) exhibited AML:PML length ratio ≥3:1, termed large-AML prolapse (LAP-BAV), who had predominant BAV regurgitation when compared with those with non-LAP-BAV (P ≤ 0.001). An extreme phenotype of LAP-BAV with giant-AML prolapse and diminutive PML (GAP-BAV) was identified in 18/130 (14%) subjects. Compared with posterior-MVP-BAV, GAP-BAV patients were younger (42 ± 15 vs. 64 ± 12 years, P < 0.0001), had larger aortic annulus (28 ± 3 vs. 26 ± 2 mm, P = 0.01), and 61% had ≥ moderate BAV regurgitation (vs. 16%, P = 0.0007). Mitral repair occurred in 37/130 (28%) subjects. After median follow-up 5.5 months (4-83), 4/5 (80%) GAP-BAV patients required redo surgery for recurrent mitral regurgitation vs. 2/31 (6%) for non-LAP-BAV (P = 0.001)., Conclusion: The community prevalence of coexistent MVP-BAV is comparable to MVP-TAV and their most common phenotype is posterior-MVP. However, anterior-MVP is twice as prevalent in MVP-BAV. A large-AML phenotype (LAP-BAV) with predominant BAV regurgitation affects 24% of MVP-BAV patients. An extreme phenotype of anterior-MVP (GAP-BAV) affects 14% of BAV patients; characterized by exceptionally large AML, diminutive PML, high mitral and aortic regurgitation prevalence, and high mitral repair failure rate., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Purpose: To assess trends in life support interventions and performance of the automated Acute Physiology and Chronic Health Evaluation (APACHE) IV model at mortality prediction compared with Oxford Acute Severity of Illness Score (OASIS) in a contemporary cardiac intensive care unit (CICU)., Methods and Materials: Retrospective analysis of adults (age ≥ 18 years) admitted to CICU from January 1, 2007, through December 31, 2015. Temporal trends were assessed with linear regression. Discrimination of each risk score for hospital mortality was assessed with use of area under the receiver operating characteristic curve (AUROC) values. Calibration was assessed with Hosmer-Lemeshow goodness-of-fit test., Results: The study analyzed 10,004 patients. CICU and hospital mortality rates were 5.7% and 9.1%. APACHE IV predicted death had an AUROC of 0.82 (0.81-0.84) for hospital death, compared with 0.79 for OASIS (P < .05). Calibration was better for OASIS than APACHE IV. Increases were observed in CICU and hospital lengths of stay (both P < .001), APACHE IV predicted mortality (P = .007), Charlson Comorbidity Index (P < .001), noninvasive ventilation use (P < .001), and noninvasive ventilation days (P = .02)., Conclusions: Contemporary CICU patients are increasingly ill, observed in upward trends in comorbid conditions and life support interventions. APACHE IV predicted death and OASIS showed good discrimination in predicting death in this population. APACHE IV and OASIS may be useful for benchmarking and quality improvement initiatives in the CICU, the former having better discrimination., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Ventricular-annular decoupling is thought to exist in all degenerative myxomatous mitral valve (MV) diseases. However, the annular physiology of degenerative MV disease may differ when severe mitral regurgitation (MR) presents at different stages. The aim of this study was to assess differences in mitral annular physiology and surgical effects between early- and late-stage severe MR., Methods: Three-dimensional (3D) transesophageal echocardiography was performed before and after MV surgery in 74 patients with degenerative MV disease, including 57 with early-stage severe MR (without left ventricular remodeling) and 17 with late-stage MR (with left ventricular remodeling). A control group comprised 46 patients without MV disease. Novel 3D MV software was used to evaluate mitral annular dynamics. The degree of annular saddle shape was calculated as the ratio of annular height (AH) to lateromedial diameter (LM). Ventricular-annular decoupling was defined as insufficient systolic AH/LM compared with the control group., Results: Prebypass 3D measurements demonstrated that systolic AH/LM in the early-stage group (0.19 ± 0.04) was similar to that in the control group (0.21 ± 0.05; P = .101), while systolic AH/LM in the late-stage group (0.17 ± 0.04) was lower than that in the control group (P = .011). Postbypass comparison showed saddle shape accentuation in the early-stage group (0.20 ± 0.04), similar to that in the control group (P = .3127); the mitral annulus remained flat in the late-stage group (0.17 ± 0.03; P = .004)., Conclusions: Ventricular-annular decoupling, present in the late-stage group, was absent in the early-stage group. MV repair surgery did not disrupt mitral annular saddle shape in the early-stage group; however, it failed to correct annular dysfunction in the late-stage group. Sequential 3D transesophageal echocardiographic analysis provides comprehensive mitral annular evaluation beyond conventional two-dimensional parameters for determining stages of severe MR., (Copyright © 2018 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether systolic or diastolic dysfunction on transthoracic echocardiogram (TTE) predicts mortality after out-of-hospital cardiac arrest (OHCA)., Methods: Retrospective cohort study of 173 OHCA subjects undergoing targeted temperature management who underwent TTE during hospitalization. Univariate analysis and multivariate logistic regression were used to determine associations between TTE measurements of systolic and diastolic function and systemic hemodynamics with all-cause mortality., Results: Mean age was 61.6 ± 12.4 years (72.7% male) and initial rhythm was shockable in 89%. Hospital mortality was 30.6%. Mean LVEF was 40% and was not different in hospital survivors (p = 0.81). TTE parameters reflecting systolic function and systemic hemodynamics did not predict hospital mortality. Medial mitral E/e' ratio was associated with hospital mortality, with an optimal cut-off > 13 (p = 0.002). After multivariate adjustment, medial mitral E/e' ratio remained predictive of hospital mortality (OR 1.11, 95% CI 1.03-1.20, p = 0.004). Subjects with a medial mitral E/e' ratio > 13 had higher mortality during long-term follow-up (p < 0.001 by log-rank)., Conclusions: Diastolic dysfunction (higher medial mitral E/e' ratio) on TTE independently predicted mortality after OHCA; systolic dysfunction and TTE hemodynamic parameters did not. This reflects a novel use of Doppler TTE to predict outcomes after OHCA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose of Review: Cardiac sarcoidosis (CS) is associated with significant morbidity and mortality. The diagnosis of CS is challenging and typically one that is only entertained after many other conditions have been ruled out. A high index of suspicion is necessary in order to correctly determine appropriate testing for the disease. Transthoracic echocardiography is the most readily available imaging modality available to help establish a diagnosis in a potential patient. However, no one echocardiographic feature is pathognomonic., Recent Findings: On echocardiography, unusual wall motion abnormalities, which do not fit a classic coronary distribution, along with diastolic dysfunction may alert one to the presence of cardiac sarcoid, particularly in the right clinical context. Myocardial strain imaging on echocardiography may increase the sensitivity of identifying cardiac sarcoidosis. Alternative imaging with cardiac magnetic resonance imaging or positron emission tomography have become more frequently utilized to establish a diagnosis of CS. Cardiac sarcoidosis remains a difficult condition to diagnose. However early diagnosis is critical to decrease the associated high mortality. Endomyocardial biopsy is highly specific but lacks sensitivity due to the patchy nature of the granulomatous deposition. Thus, imaging plays a role in diagnosis as well as for follow-up. Echocardiography remains an hallmark during the workup for CS. Decreased sensitivity of echocardiography has facilitated the use of other techniques to establish the presence of CS.

The use of bioprosthetic valves for mitral valve disease has been increasingly popular with both patients and physicians, and current practice uses these valves for increasingly younger patients. However, these valves are known to degenerate over time. Historically, reoperation was the only recourse for a failing bioprosthetic valve. Today, however, percutaneous options exist with the use of transcatheter valve implantation. Determining candidacy for this less invasive option requires careful evaluation with echocardiography. This review is focused on the echocardiographic evaluation required pre-, intra-, and postprocedurally during transcatheter mitral valve insertion., (Copyright © 2018 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Aim: Reversible myocardial dysfunction is common after out-of-hospital cardiac arrest (OHCA). The aim of this study was to determine if changes on serial transthoracic echocardiography (TTE) can predict long-term mortality in OHCA subjects., Methods: This is a single-center historical cohort study of OHCA subjects undergoing targeted temperature management who received >1 TTE during hospitalization. Two-dimensional and Doppler parameters of systolic and diastolic function were compared between paired TTE. Univariate analysis was used to determine associations between TTE parameters and all-cause mortality., Results: Fifty-nine patients were included; mean age was 59.4 ± 11.2 years (75% male). Initial rhythm was shockable in 90%. Initial TTE was done a median of 10.4 h after admission and repeat TTE was done 5.7 ± 4.1 days later. Between TTE studies, there were significant increases in left ventricular ejection fraction (LVEF, from 32% to 43%), cardiac output, stroke volume, and other Doppler-derived hemodynamic parameters, while systemic vascular resistance decreased (all p < 0.001). Systolic function and hemodynamic parameters on initial TTE were not associated with follow-up mortality. Patients who died during follow-up (n = 16, 27%) had smaller increases in LVEF and cardiac output-derived hemodynamic parameters than long-term survivors (p < 0.05)., Conclusions: Significant changes in systolic function and hemodynamic parameters occur on serial Doppler TTE after OHCA, consistent with reversible post-arrest myocardial dysfunction. The magnitude of those changes is greater in long-term survivors, emphasizing that the degree of recovery from post-arrest myocardial dysfunction may be more important than its initial severity., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Despite its high prevalence, little is known about mechanisms of mitral regurgitation in degenerative mitral valve disease apart from the leaflet prolapse itself. Mitral valve is a complex structure, including mitral annulus, mitral leaflets, papillary muscles, chords, and left ventricular walls. All these structures are involved in physiological and pathological functioning of this valvuloventricular complex but up to now were difficult to analyze because of inherent limitations of 2-dimensional imaging. The advent of 3-dimensional echocardiography, computed tomography, and cardiac magnetic resonance imaging overcoming these limitations provides new insights into mechanistic analysis of degenerative mitral regurgitation. This review will detail the contribution of quantitative and qualitative dynamic analysis of mitral annulus and mitral leaflets by new imaging methods in the understanding of degenerative mitral regurgitation pathophysiology., (© 2018 American Heart Association, Inc.)

Purpose: Point-of-care ultrasonography has been increasingly used in the care of critically ill patients; however, reports on its use during active resuscitation are limited. The aim of this study was to investigate the true impact of focused cardiac ultrasound (FCU) during the management of sepsis with early (6-h) resuscitation., Methods: A prospective pilot observational study was conducted at an academic medical center from March 2011 through July 2012. Patients undergoing resuscitation for severe sepsis or septic shock were prospectively enrolled at medical and combined medical-surgical intensive care units. Patients underwent a 10-min FCU examination when echocardiography was not part of their care plan. FCU was performed by sonographers and interpreted by cardiologists to minimize risks of inadequate image acquisition and misinterpretation. Intensivists completed surveys on their diagnostic and therapeutic plans before and after receiving FCU information., Results: Of the 30 patients enrolled, 18 (60%) were male and the median age was 61 years [interquartile range (IQR) 50-71 years]. Median central venous oxygen saturation and lactate levels were 59.6% (IQR 53.1-66.2%) and 2.7 mmol/L (IQR 1.2-4.1 mmol/L), respectively. Clinical assessment by intensivists before FCU commonly failed to correctly estimate ventricular function; specifically, left ventricular in 12 patients [40%, 95% confidence interval (CI) 25-58%] and right ventricular function in 15 patients (50%, 95% CI 33-67%). Intensivists' therapeutic plans changed in eight cases (27%, 95% CI 14-44%) after FCU information became available. The most common changes were fluid management and imaging tests. Intensivists' confidence in their therapeutic plans improved for 11 patients (37%, 95% CI 22-55%)., Conclusion: FCU is a valuable examination tool during early resuscitation of severe sepsis and septic shock.

This present case pertains to a 48-year-old woman with a history of antiphospholipid syndrome, who presented with progressive fatigue, generalized weakness, and orthopnea acutely. She had a prior diagnosis of antiphospholipid syndrome with recurrent deep vein thromboses (DVTs) and repeated demonstration of lupus anticoagulants. She presented in cardiogenic shock with markedly elevated troponin and global myocardial dysfunction on echocardiography, and cardiac catheterization revealed minimal disease. Cardiac magnetic resonance imaging was performed, which revealed findings of perfusion defects and microvascular obstruction, consistent with the pathophysiology of catastrophic antiphospholipid syndrome (CAPS). Diagnosis was made based on supportive imaging, including head magnetic resonance imaging (MRI) revealing multifocal, acute strokes; microvascular thrombosis in the dermis; and subacute renal infarctions. The patient was anticoagulated with intravenous unfractionated heparin and received high-dose methylprednisolone, plasmapheresis, intravenous immunoglobulin, and one dose each of rituximab and cyclophosphamide. She convalesced with eventual myocardial recovery after a complicated course. The diagnosis of CAPS relies on the presence of (1) antiphospholipid antibodies and (2) involvement of multiple organs in a microangiopathic thrombotic process with a close temporal association. The myocardium is frequently affected, and heart failure, either as the presenting symptom or cause of death, is common. Despite echocardiographic evidence of myocardial dysfunction in such patients, MRIs of CAPS have not previously been reported. This case highlights the utility in assessing the involvement of the myocardium by the microangiopathic process with MRI. Because the diagnosis of CAPS requires involvement in multiple organ systems, cardiac MRI is likely an underused tool that not only reaffirms the pathophysiology of CAPS, but could also clue clinicians in to the possibility of a diffuse thrombotic process., (© The Author(s) 2015.)

Background: Pathogenic causes of acute hypoxemic respiratory failure (AHRF) can be difficult to identify at early clinical presentation. We evaluated the diagnostic utility of combined cardiac and thoracic critical care ultrasonography (CCUS)., Methods: Adult patients in the ICU were prospectively enrolled from January through September 2010 with a Pao2/Fio2 ratio < 300 on arterial blood gas (ABG) analysis within 6 h of a new hypoxemic event or the ICU admission. Focused cardiac and thoracic CCUS was conducted within 6 h of ABG testing. Causes of AHRF were categorized into cardiogenic pulmonary edema (CPE), ARDS, and miscellaneous causes after reviewing the hospitalization course in electronic medical records., Results: One hundred thirty-four patients were enrolled (median Pao2/Fio2 ratio, 191; interquartile range, 122-253). Fifty-nine patients (44%) received a diagnosis of CPE; 42 (31%), ARDS; and 33 (25%), miscellaneous cause. Analysis of CCUS findings showed that a low B-line ratio (proportion of chest zones with positive B-lines relative to all zones examined) was predictive of miscellaneous cause vs CPE or ARDS (receiver operating characteristic area under the curve [AUC], 0.82; 95% CI, 0.75-0.88). For further differentiation of CPE from ARDS, left-sided pleural effusion (> 20 mm), moderately or severely decreased left ventricular function, and a large inferior vena cava minimal diameter (> 23 mm) were predictive of CPE (AUC, 0.79; 95% CI, 0.70-0.87)., Conclusions: Combined cardiac and thoracic CCUS assists in early bedside differential diagnosis of ARDS, CPE, and other causes of AHRF.

Objectives: Cleft-like indentations (CLI) are deep separations between scallops of the mitral posterior leaflet observed in myxomatous mitral valve disease (MMVD), but their diagnosis, mechanisms and implications are unknown. Using 3D transoesophageal echocardiography (3DTOC), we aimed at assessing diagnostic accuracy and defining mechanisms of CLI in patients undergoing surgery for MMVD., Methods: 3DTOC of mitral valve was acquired in 49 patients with MMVD and severe regurgitation prior to valve repair. Qualitative review compared 3DTOC diagnosis of CLI with surgical inspection. Mitral, annular and leaflet dimensions were quantified with dedicated software and compared between those with and without CLI., Results: Diagnosis of CLI was made by 3DTOC in 17 (35%) while none was identified by 2D and was confirmed in 15 (88%) by surgical inspection. Mechanistically, LV diameters and mitral regurgitant volume (RVol) were similar with and without CLI (p>0.49). Conversely, mitral annulus was smaller with CLI (anteroposterior diameter 42.2±7.1 vs 47.0±7.5 mm, p=0.04; circumference 133±16 vs 148±19 mm, p=0.009; area 1289±326 vs 1619±427 mm(2), p=0.008). Prolapse volume tended to be smaller with CLI (1.9±1.2 vs 4.0±4.3 mL, p=0.06) involving single posterior scallop at surgery (82% vs 44%, p=0.007) with smaller 3DTOC leaflet area (1574±409 vs 2019±652 mm(2), p=0.01). During valve repair, surgical closure of all surgically diagnosed CLI was required., Conclusions: Posterior leaflet CLI are frequent in MMVD, are identified by 3DTOC with high accuracy and require closure during valve repair. CLI are mechanistically not related to excess annular enlargement or excess prolapse. Conversely, CLI occur in the context of single scallop prolapse with tissue paucity causing excess separation of scallops. These 3DTOC data enhance diagnostic and mechanistic comprehension of the diversity of MMVD phenotypical presentation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Fibro-elastic deficiency (FED) and diffuse myxomatous degeneration (DMD) are phenotypes of degenerative mitral valve disease defined morphologically. Whether physiological differences in annular and valvular dynamics exist between these phenotypes remains unknown., Methods and Results: We performed triple quantitation of cardiac remodeling and of mitral regurgitation severity and of annular and valvular dimensions by real-time 3-dimensional-transesophageal-echocardiography. Forty-nine patients with degenerative mitral valve disease classified as FED (n=31) and DMD (n=18) by surgical observation showed no difference in age (65±10 versus 59±13; P=0.5), body surface area (2.0±0.2 versus 2.0±0.2 m(2); P=0.5), left ventricular and atrial dimensions (all P>0.55), and mitral regurgitation regurgitant orifice (P=0.62). On average, annular dimensions were larger in DMD versus FED, but height was similar resulting in lower saddle shape. Dynamically, annular DMD versus FED display poorer contraction and saddle-shape accentuation in early systole and abnormal enlargement, particularly intercommissural, in late-systole (all P<0.05). Valvular dynamics showed stable valvular area in systole in FED versus considerable systolic increased area in DMD (P<0.001). Prolapse height and volume increased little throughout systole in FED versus marked increase in DMD (P<0.001)., Conclusions: Our novel observations show that FED and DMD, although both labeled myxomatous, display considerable physiological phenotypic differences. In DMD, the annular increased size and profoundly abnormal dynamics demonstrate DMD-specific annular degeneration compared with the enlarged but relatively normal FED annulus. DMD does not incur more severe mitral regurgitation, despite larger prolapse and valve redundancy, underscoring potential compensatory role of tissue redundancy of DMD (or aggravating role of tissue paucity of FED) on mitral regurgitation severity., (© 2015 American Heart Association, Inc.)

Successful restoration of patency of the infarct-related artery is important in management of acute ST-segment elevation myocardial infarction (STEMI); however, it does not necessarily translate into the restoration of perfusion at the tissue level. In this study, we evaluate the prognostic role of qualitative and quantitative myocardial contrast echocardiography (MCE) in predicting cardiac events (after adjustment for cardiovascular risk factors) in STEMI patients undergoing reperfusion. Bedside resting real-time MCE using continuous infusion of diluted contrast agent (Definity) was performed within a median of 21.4 h from revascularization in STEMI. Myocardial perfusion on qualitative MCE was graded 1 = homogenous; 2 = partial/patchy; and 3 = absent. Perfusion score index (PSI) was calculated by adding the perfusion score in all segments divided by the total number of evaluable segments. Quantitative perfusion parameters [A, dB; β, sec(-1); and Aβ] were analyzed using a 17-segment model. Patients were followed for cardiac events including death; nonfatal myocardial infarction (MI); hospitalization for cardiac symptoms; coronary revascularization; or heart failure. Thirty-seven reperfused STEMI patients with a mean age of 64 years (range, 40-86 years) were enrolled and followed for a median of 1.4 years. Cardiac events occurred in 22 patients. Patients with cardiac events had a higher perfusion score index (PSI), and lower A, β and Aβ parameters compared to patients without events [1.84 ± 0.36 vs 1.39 ± 0.17 for PSI, P < 0.001; 0.57 ± 0.24 vs 0.85 ± 0.30 for A, P = 0.03; 0.34 ± 0.15 vs. 0.53 ± 0.17 for β, P = 0.002; and 0.21 ± 0.12 vs. 0.49 ± 0.32, for Aβ, P = 0.003; respectively]. A PSI value of 1.58 provided an area under the curve (AUC) of 0.873, while β of 0.423 and Aβ of 0.323 provided an AUC of 0.858 and 0.842, respectively. PSI and Aβ were independent predictors of cardiac events with an adjusted hazard ratio of 3.41 (1.19-12.27); and 4.19 (1.3-19.09), respectively. No contrast-related side effects were reported. Evaluation of perfusion in reperfused STEMI patients by qualitative and quantitative MCE (myocardial blood flow, Aβ) provides independent prediction of cardiac events.

Intra-operative transesophageal echocardiography (TEE) is a mature imaging technique which represents the premier surgical quality control instrument in the contemporary operating room. In adult cardiac surgery, management of valvular heart disease and related structural cardiac abnormalities derive the most benefit from perioperative echocardiography which includes pre-operative transthoracic echocardiography, intra-operative TEE and post-surgical echocardiographic surveillance. This review discusses the theoretical background upon which these imaging techniques are built-on, and offers a practical state-of-the-art guide on their application, emphasizing the importance of anatomic relationships, mechanisms of dysfunction and effective communication with our surgeons., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Echocardiography guidance for interventions in the catheterization laboratory allows for reduction in radiation exposure from fluoroscopy as well as superior anatomic definition and visualization. The additional information provided over fluoroscopy has translated into an increasing use during interventional procedures. Procedures such as transeptal puncture, percutaneous valvular interventions, myocardial biopsy, echo-guided pericardiocentesis and other interventions have evolved to a complexity level that requires combined echocardiographic and fluoroscopic guidance. Different imaging modalities are utilized in the catheterization laboratory including intracardiac echocardiography, two-dimensional (2D) or three-dimensional (3D) transthoracic echocardiography, and 2D or 3D transesophageal echocardiography. This review is intended to provide an overall summary of the impact echocardiography has had in the catheterization laboratory. We will describe how echocardiography is utilized to guide a diverse array of interventional procedures, emphasizing specific practical issues with respect to echocardiographic guidance of interventional procedures and also pointing out the limitations of echocardiography., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Cardiomyopathy is defined as a heterogeneous group of myocardial disorders with mechanical or electrical dysfunction. Identification of the etiology is important for accurate diagnosis, treatment and prognosis, but continues to be challenging. The ability of cardiac MRI to non-invasively obtain 3D-images of unparalleled resolution without radiation exposure and to provide tissue characterization gives it a distinct advantage over any other diagnostic tool used for evaluation of cardiomyopathies. Cardiac MRI can accurately visualize cardiac morphology and function and also help identify myocardial edema, infiltration and fibrosis. It has emerged as an important diagnostic and prognostic tool in tertiary care centers for work up of patients with non-ischemic cardiomyopathies. This review covers the role of cardiac MRI in evaluation of nonischemic cardiomyopathies, particularly in the context of other diagnostic and prognostic imaging modalities.