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Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.

Purpose To evaluate the relationship between maternal left ventricular systolic function, utero-placental circulation, and risk of adverse neonatal outcomes in women with cardiac disease. Methods 119 women managed in the pregnancy heart clinic (2019–2021) were identified. Women were classified by their primary cardiac condition. Adverse neonatal outcomes were: low birth weight ( 20 weeks’ gestation). Parameters of left ventricular systolic function (global longitudinal strain, radial strain, ejection fraction, average S’, and cardiac output) were calculated and pulsatility index was recorded from last growth scan. Results Adverse neonatal outcomes occurred in 28 neonates (24%); most frequently in valvular heart disease (n = 8) and cardiomyopathy (n = 7). Small-for-gestational-age neonates were most common in women with cardiomyopathy (p = 0.016). Early pregnancy average S’ (p = 0.03), late pregnancy average S’ (p = 0.02), and late pregnancy cardiac output (p = 0.008) were significantly lower in women with adverse neonatal outcomes than in those with healthy neonates. There was a significant association between neonatal birth-weight centile and global longitudinal strain (p = 0.04) and cardiac output (p = 0.0002) in late pregnancy. Pulsatility index was highest in women with cardiomyopathy (p = 0.007), and correlated with average S’ (p p = 0.03) in late pregnancy. Conclusion Women with cardiac disease may not tolerate cardiovascular adaptations required during pregnancy to support fetal growth. Adverse neonatal outcomes were associated with reduced left ventricular systolic function and higher pulsatility index. The association between impaired systolic function and reduced fetal growth is supported by insufficient utero-placental circulation.

The guideline provides a practical step-by-step guide in order to facilitate high-quality echocardiographic studies of patients with aortic stenosis. In addition, it addresses commonly encountered yet challenging clinical scenarios and covers the use of advanced echocardiographic techniques, including TOE and Dobutamine stress echocardiography in the assessment of aortic stenosis.

To evaluate the relationship between maternal left ventricular systolic function, utero-placental circulation, and risk of adverse neonatal outcomes in women with cardiac disease.119 women managed in the pregnancy heart clinic (2019-2021) were identified. Women were classified by their primary cardiac condition. Adverse neonatal outcomes were: low birth weight ( 2500 g), small-for-gestational-age ( 10th birth-weight centile), pre-term delivery ( 37 weeks' gestation), and fetal demise ( 20 weeks' gestation). Parameters of left ventricular systolic function (global longitudinal strain, radial strain, ejection fraction, average S', and cardiac output) were calculated and pulsatility index was recorded from last growth scan.Adverse neonatal outcomes occurred in 28 neonates (24%); most frequently in valvular heart disease (n = 8) and cardiomyopathy (n = 7). Small-for-gestational-age neonates were most common in women with cardiomyopathy (p = 0.016). Early pregnancy average S' (p = 0.03), late pregnancy average S' (p = 0.02), and late pregnancy cardiac output (p = 0.008) were significantly lower in women with adverse neonatal outcomes than in those with healthy neonates. There was a significant association between neonatal birth-weight centile and global longitudinal strain (p = 0.04) and cardiac output (p = 0.0002) in late pregnancy. Pulsatility index was highest in women with cardiomyopathy (p = 0.007), and correlated with average S' (p 0.0001) and global longitudinal strain (p = 0.03) in late pregnancy.Women with cardiac disease may not tolerate cardiovascular adaptations required during pregnancy to support fetal growth. Adverse neonatal outcomes were associated with reduced left ventricular systolic function and higher pulsatility index. The association between impaired systolic function and reduced fetal growth is supported by insufficient utero-placental circulation.

Background Little literature exists regarding the syndrome of inappropriate sinus tachycardia during pregnancy. We aimed to further understand the natural history of inappropriate sinus tachycardia in pregnancy, and to explore maternal and fetal outcomes. Methods A retrospective, observational cohort analysis of 19 pregnant women who presented with inappropriate sinus tachycardia. Results 42% attended the emergency department on more than one occasion with symptoms of inappropriate sinus tachycardia; 32% required hospital admission and 26% required pharmacological therapy. There were no maternal deaths, instances of heart failure or acute coronary syndrome, and no thromboembolic or haemorrhagic complications during pregnancy. Rates of caesarean section were similar to the background rate of our unit (32% and 27%, respectively). Rates of induction were notably elevated (58% vs 25%). Conclusion Inappropriate sinus tachycardia in pregnancy is associated with high rates of hospitalization and induction of labour, which may not be mandatory given the clinical findings in this group of women.

The syndrome of inappropriate sinus tachycardia (IST) is a well-described and generally benign condition outside pregnancy. There is, however, little information in the literature about IST during pregnancy and nothing about the likely mechanism in such cases. Equally there is a paucity of information about the effects on maternal and fetal well-being in patients who develop IST during pregnancy. Here, we describe the case of a woman who developed IST for the first time during pregnancy. We have first given a brief clinical summary of events and then follow this with the patient's personal account which she has written herself specifically for this case report. We believe that this case highlights some of the important issues associated with the condition when it occurs during pregnancy. We hope that the publication of this case report will increase the awareness of IST during pregnancy. This is important as we believe that the correct diagnosis and understanding of the condition and its consequences will allow clinicians to manage women afflicted by the condition empathetically and appropriately.

Capillary malformation–arteriovenous malformation (CM–AVM) is a newly recognized clinical entity caused by mutation of the RASA1 gene, which encodes p120-RasGAP. Here we describe, for the first time, a patient with CM–AVM presenting during the late stages of pregnancy with pulmonary “capillary level” microvascular shunt, worsening cutaneous capillary malformations, and gross fluid overload. Sequencing revealed a novel mutation of the RASA1 gene involving a frameshift mutation in the RASGAP domain of RASA1. This report extends our current genetic and clinical understanding of CM–AVM. © 2013 Wiley Periodicals, Inc.

Ischemic stroke in younger people is common, and often remains unexplained. There is a well-documented association between unexplained stroke in younger people, and the presence of a patent foramen ovale. Therefore, in the absence of a clear cause of stroke, the heart is often assessed in detail for such lower risk causes of stroke. This usually involves imaging with a transesophageal echo, and investigation for a right-to-left shunt. An understanding of the anatomy of the atrial septum, and its associated abnormalities, is important for the stroke neurologist charged with decision making regarding appropriate secondary prevention. In this paper, we review the development and anatomy of the right heart with a focus on patent foramen ovale, and other associated abnormalities. We discuss how the heart can be imaged in the case of unexplained stroke, and provide examples. Finally, we suggest a method of investigation, in light of the recent European Association of Echocardiography guidance. Our aim is to provide the neurologist with an understanding on how the heart can be investigated in unexplained stroke, and the significance of abnormalities detected.

Background: Stroke is often unexplained in younger adults, although it is often associated with a patent foramen ovale (PFO). The reason for the association is not fully explained, and mechanisms other than paradoxical embolism may be involved. Young stroke patients with PFO have more atrial vulnerability than those without PFO. It is plausible that stretching of the interatrial septum may disrupt the interatrial conduction pathways causing interatrial block (IAB). IAB is associated with atrial fibrillation, dysfunctional left atria and stroke. Methods: Electrocardiogram (ECG) characteristics of prospectively recruited young patients (≤55 years of age) with unexplained stroke (TOAST and A-S-C-O) were compared with control data. All stroke cases underwent bubble contrast transthoracic and transoesophageal echography. IAB was defined as a P-wave duration of ≧110 ms. ECG data were converted to electronic format and analysed in a blind manner. Results: Fifty-five patients and 23 datasets were analysed. Patients with unexplained stroke had longer P-wave duration (p = 0.013) and a greater prevalence of IAB (p = 0.02) than healthy controls. Case status was an independent predictor of P-wave duration in a significant multivariate model. There was a significant increase in the proportion of cases with a PFO with IAB compared with cases without PFO and with controls (p = 0.005). Conclusions: Young patients with unexplained stroke, particularly those with PFO, exhibit abnormal atrial electrical characteristics suggesting atrial arrhythmia or atrial dysfunction as a possible mechanism of stroke.

Aims: To assess prospectively (1) the incidence of early anthracycline-induced cardiotoxicity; (2) the best predictor for identifying individuals at risk of developing functional cardiotoxicity; and (3) the most sensitive standard echocardiographic measure for the detection of anthracycline-induced changes in left ventricular (LV) function. Methods: Sixty-seven consecutive patients (45 male, mean age 50±18 years) requiring doxorubicin-containing chemotherapy were enrolled. Clinical and echocardiographic assessments occurred before they received any anthracycline, after low-dose anthracyclines and 1–3 months after completion of their chemotherapy. Results: Twenty six percent of patients without significant pre-existing cardiac disease developed cardiotoxicity. The parameter that best predicted the development of functional cardiotoxicity was the change in EF between baseline and low dose with an area under the curve of 0.92. The Tei index detected declines in LV function earlier in the course of treatment with anthracyclines and to a greater significance than any other standard echocardiographic measurement but did not predict functional cardiotoxicity. Conclusions: All patients receiving potential cardiotoxic chemotherapy should be under the care of a cardiologist and have their EF monitored closely.

Objectives: The usefulness of the implantable loop recorder (ILR) with improved atrial fibrillation (AF) detection capability (Reveal XT) and the factors associated with AF in the setting of unexplained stroke were investigated. Methods: A cohort study is reported of 51 patients in whom ILRs were implanted for the investigation of ischemic stroke for which no cause had been found (cryptogenic) following appropriate vascular and cardiac imaging and at least 24 hours of cardiac rhythm monitoring. Results: The patients were aged from 17 to 73 (median 52) years. Of the 30 patients with a shunt investigation, 22 had a patent foramen ovale (73.3%; 95% confidence interval [CI] 56.5%–90.1%). AF was identified in 13 (25.5%; 95% CI 13.1%–37.9%) cases. AF was associated with increasing age ( p = 0.018), interatrial conduction block ( p = 0.02), left atrial volume ( p = 0.025), and the occurrence of atrial premature contractions on preceding external monitoring ( p = 0.004). The median (range) of monitoring prior to AF detection was 48 (0–154) days. Conclusion: In patients with unexplained stroke, AF was detected by ILR in 25.5%. Predictors of AF were identified, which may help to target investigations. ILRs may have a central role in the future in the investigation of patients with unexplained stroke.

We report the case of a 77 year-old Caucasian woman with a past medical history of breast cancer who presented to our institution with a five-week history of progressive shortness of breath associated with abdominal distension, anorexia, change in bowel habit and cough. She had an ejection systolic murmur and a pansystolic murmur radiating to the axilla, a raised jugular venous pressure, abdominal distension with shifting dullness and hepatomegaly 16 cm below the costal margin. Blood results revealed a normocytic anemia with deranged liver function tests, renal impairment and a raised C-reactive protein. Chest radiograph demonstrated a raised right hemidiaphragm (Fig. 1A). Transtho

Assessment of the left ventricle may be the primary objective in a peroperative TEE study (especially for noncardiac surgery), in ventilated patients or in patients “resistant” to ultrasound via the transthoracic approach (due to body habitus). In other studies, it is secondary, but a very important objective. Whether a primary or secondary objective, it is necessary to have a systematic approach to ensure the appropriate images are obtained.

The aortic valve (AV) is a semi lunar valve and, like the mitral valve, lies close to the esophagus allowing excellent visualization with TEE. The valve itself consists of 3 cusps (right, left, and noncoronary) attached to a fibrous annulus, and unlike the atrio-ventricular valves, it does not have any anchoring supports (e.g., chordae tendinae) to maintain the integrity. The integrity is dependant mainly on the annulus geometry and the ratio of annulus: cusp area. The annulus geometry is affected by the inter-ventricular septum and proximal aortic root, and pathologies of either can alter the annular shape and cause incompetence of the valve. There is about 30% overlap of each cusp with its neighbor, and the total cusp area must exceed the cross sectional area of the annulus in order to maintain competency with a normal ratio being greater than 1.6:1; any pathology that decreases cusp area or increases annular area will therefore lead to incompetence and regurgitation through the valve.

The fully developed human left atrium (LA) consists of the true atrial septum, a superior smooth walled portion, and an inferior trabeculated portion. The smooth walled portion is larger and originates embryologically from the pulmonary veins that combine to form a common pulmonary vein before becoming integrated with the inferior portion of the left atrium. The trabeculated portion of the adult LA is confined to the appendage (LAA) and is all that remains is of the primitive left atrium.

The mitral valve is so named due to its appearance that resembles a bishops’ miter. Transesophageal echocardiography and the mitral valve (that sits only 5–10 cm from the transducer with nothing but blood between them) were made for each other with the spatial and temporal resolution of the technique allowing the valve with its complex structure and motion to be perfectly described. Assessment of the mitral valve (MV) is, therefore, one of the commonest indications for TEE and should be undertaken in all patients being evaluated for (preoperatively) or undergoing (perioperatively) MV surgery. The MV is one of the atrio-ventricular valves (the tricuspid valve being the other one) and has an anterior and a posterior leaflet. The posterior leaflet has clefts that divide it into 3 scallops (P1, P2, and P3); the anterior leaflet has no such scallops, but is described as having three regions that reflect those of the posterior leaflet (A1, A2, and A3 respectively). In addition to the points of apposition along the leaflets, there are anterior (adjacent to A1/P1) and posterior (adjacent to A3/P3) commissures. The nonleaflet apparatus consists of the saddle-shaped mitral annulus, the chordae tendinae (primary chordae attached to the free edges of the leaflets, secondary and tertiary chordae attached to body of leaflets), and papillary muscles (anterior: chordae attached to lateral aspects of leaflets; posterior: chordae attached to medial aspects of leaflets).

The right ventricle (RV) comprises a main pumping chamber and an infundibulum. The infundibulum (or right ventricular outflow tract [RVOT]) acts as a conduit between the main chamber of the RV and the pulmonary valve (PV). The shape of the main chamber is somewhere between triangular and crescenteric with anterior and inferior (diaphragmatic) free walls and the interventricular septum. By convention the labeling of the septal segments of the RV follow those of the left ventricle. The anterior and inferior walls are, however, divided into basal and apical segments only. As with the left ventricle the assessment of the RV should include chamber size, wall thickness and ventricular function, but because of its’ geometric complexity, this is more of a qualitative than completely quantitative exercise when using transesophageal two dimensional imaging. Chamber size is important because dilatation is the end point of almost all pathologies that affect the RV whether the process involves volume overload, pressure overload or a primary myopathic process.

Primary Cardiac Lymphoma (PCL) is defined as a non-Hodgkin's lymphoma involving only the heart and/or pericardium. Diagnosis of this rare disease is particularly difficult due to its nonspecific clinical manifestations. In this review the role of echocardiography in the early diagnosis of PCL is assessed, moreover we report an improvement in the outcome of PCL related to increased availability and utilization of echocardiography.

Objective We sought to study the relative effect on left ventricular (LV) and right ventricular (RV) function of low-dose anthracycline-containing chemotherapy regimes. Methods A total of 23 patients (mean age 48 ± 20 years) underwent echocardiographic examinations before any anthracycline had been administered and then after low-dose anthracycline (doxorubicin 50-125 mg/m 2 ). The Tei index was used to compare the relative effects on RV and LV function. Results Anthracycline administration was significantly associated with an increase in the LV Tei index (0.38 ± 0.12 vs 0.46 ± 0.16, P = .02). There was no significant change in the RV Tei index (0.19 ± 0.10 vs 0.20 ± 0.10, P = .72). Comparing the relative effect on global LV and RV function the change in LV Tei was significantly greater than the change in RV Tei (0.07 ± 0.13 vs 0.01 ± 0.09, P = .044). Conclusions Low-dose anthracycline administration has a significant negative impact on LV function but does not affect RV function.

) prompted karyotype testing which con-firmed mosaic Turner syndrome.Otherwise, she had had poorly controlled hyper-tension for many years and was currently being pre-scribed labetalol for presumed primary hypertension.Her blood pressure remained elevated at 158/104mm Hg, but attempts to add other antihypertensivemedications had not been tolerated due to trouble-some side effects. Echocardiography had previous-ly shown a bicuspid aortic valve, but no left ventricu-lar hypertrophy or other structural abnormality.Due to concerns about potential secondarycauses for hypertension, she proceeded to magneticresonance imaging of her aorta. This indeed de-monstrated a post-ductal interrupted aorta (Fig. 1)with extensive collateralization and enlargement ofthe internal mammary arteries (Fig. 2). Currently,she is awaiting surgical repair of the interruptedaorta with fertility treatment postponed until aftersurgery.Cardiovascular disease is the commonest causeof death in Turner syndrome, with life expectancyreduced by approximately ten years [1, 2]. Aorticvalve disease (particularly bicuspid valve morpho-logy) and aortic coarctation are the commonest car-diovascular anomalies. Aortic root dilatation, aor-tic dissection, hypertension, mitral valve prolapse

Aims The 2007 ESC Taskforce for Cardiac Pacing advises ‘in well-selected cases, modern technology permits an early discharge policy, where the paced patient leaves hospital after a few hours.’ The pacing clinic at our institution was established in 2008, with a view to establishing a robust ambulatory elective pacing service. This study aimed to assess the feasibility, acceptability and safety of day-case pacemaker implantation from a single centre in its fifth year of operation. Methods The ambulatory pacing service was established in February 2009 and 100 consecutive day-case patients were asked to complete a questionnaire to report on the acceptability of the programme. Subsequently, 5 years into the service, review of prospectively collected data was undertaken to assess the safety and efficacy of the day-case programme. Results Between September 2009 and August 2011, 101 (38.5% of 262 pacemakers in total) underwent planned day-case procedure (median age 75, range 20–91; 72% male). One patient required overnight stay for pneumothorax during the procedure. Of the remaining patients, all were discharged on the same day, with 95% satisfied with same-day discharge. Hospital transport was required by 5%. At 6-week review, 100% reported satisfaction with day-case discharge, though 5% noted they would have preferred to stay in hospital to prevent burdening relatives. 100% reported receipt of satisfactory pre-discharge information and 98% had adequate analgesia. There were no adverse findings at the 6-week pacemaker review that would have been avoided by overnight stay at implantation. Since inception in 2008, 448 pacemakers have been implanted electively, of which 291 (65.0%) were planned elective day cases and a further 157 (35.0%) were planned overnight attendances by patient or physician preference. Of the planned day cases, 281 (96.6%) were successfully discharged on the day of procedure. Of the 10 patients that required overnight stay, 6 patients had pneumothoraces (3 required drainage), 1 had atrial lead displacement, 1 developed atrial arrhythmia and 2 had unrelated medical illnesses. Since the development of the ambulatory service, the proportion of day case procedures has been increasing year-on-year (figure 1) and in the current year, 88% have been discharged on the same day (table 1). Conclusions This 5 year single centre experience successfully illustrates the safety, efficacy and acceptability of a day case elective pacemaker service. We would suggest that overnight admission after elective pacemaker insertion should be the exception and the majority should be treated via an ambulatory care pathway, with a provision being made for 3% of planned elective day-cases to be admitted for complications. Future work should focus on the financial benefit of these advances.

Anthracyclines remain an essential component of treatment regimes for lymphoma. Increasing numbers of older patients are being offered potentially curative treatment for lymphoma and a corresponding increase in cases of cardiac toxicity might be expected. Upper limits for total doses of anthracycline are published, but there is little information on whether age predicts independently for cardiac susceptibility to anthracyclines. There is also little data on the effect of low doses of anthracycline on the heart. We have prospectively studied cardiac function in patients receiving Doxorubicin (DOX) for High Grade Non Hodgkin’s Lymphoma and Hodgkin’s disease. 28 patients are included: 18 male, 9 female aged 16 to 89 (median 59) years. Echocardiographic examinations were undertaken before and after patients received DOX at a median dose of 85 mg/m2 (50 mg/m2 to 150 mg/m2). The Left Ventricular (LV) Tei index was calculated in all cases as the sum of the isovolumetric contraction time and isovolumetric relaxation time divided by the ejection time. Higher values represent cardiac dysfunction and a rise post treatment was regarded as deterioration in LV function. For the group, there was a significant post treatment deterioration in LV function as measured by the Tei index: 0.400 ± 0.12 pre-treatment to 0.475 ± 0.16 post treatment (P = 0.0076). Multivariate analysis of age, pre-treatment Tei index and DOX dose (in this low range) revealed age to be the only significant predictor of deterioration in cardiac function after treatment (correlation coefficient 0.69, p < 0.0001). We conclude that measurable changes in cardiac function occur after very low doses of DOX and that these changes are more marked in older patients. Whether these changes will predict for further deterioration after higher doses of DOX and potentially predict for long term symptomatic cardiac dysfunction post therapy will require further study and follow up.