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Dehiscence of a prosthetic heart valve or excessive rocking during the cardiac cycle is thought to preclude percutaneous paravalvular leak closure. However, surgical repair of paravalvular leak is associated with recurrent dehiscence and poor outcomes. We present the case of a symptomatic 74-year-old man in whom we performed percutaneous anchoring, involving multiple plugs and multimodal imaging, to stabilize a rocking mitral valve and close a substantial paravalvular leak caused by dehiscence. To our knowledge, using this technique to correct both conditions is novel.

Objectives In this study, the authors hypothesized that intraprocedural improvement of pulmonary venous (PV) waveforms are predictive of improved outcomes. In this report, they analyzed intraprocedural invasive and echocardiographic changes with respect to rehospitalization and mortality. Background The effects of hemodynamic changes during percutaneous mitral valve repair (PMVR) with MitraClip (Abbott Vascular, Santa Clara, California) are incompletely characterized. Methods The authors retrospectively reviewed records and intraprocedural transesophageal echocardiograms of 115 consecutive patients (age 76 ± 12 years) who underwent PMVR for mitral regurgitation (MR) from May 2013 to January 2017 at Emory University Hospital. They assessed intraprocedural PV waveforms for improvement in morphology, measured change in MR grade by semiquantitative methods, evaluated invasive changes in left atrial pressure (LAP) and V-wave, and compared with 30-day and 1-year rehospitalization and all-cause mortality. Results Ninety-three cases (80%) had PV waveforms before and after clip placement sufficient for analysis, of which 67 (73%) demonstrated intraprocedural improvement in PV morphology and 25 (27%) did not. At 24 months, 57 (85%) of those with PV improvement were living, compared with only 10 (40%) of those without improvement. Proportional hazards models demonstrated a significant survival advantage in those with PV improvement (hazard ratio [HR]: 0.28, 95% confidence interval [CI]: 0.08 to 0.93, p = 0.038). By multivariable analysis, PV improvement predicted reduced 1-year cardiac rehospitalization (odds ratio [OR]: 0.18, p = 0.044). Intraprocedural assessment of MR grade and invasive hemodynamics did not consistently predict mortality and rehospitalization. Conclusions PV waveforms are important markers of procedural success after PMVR. Our data show intraprocedural PV waveforms may predict rehospitalization and mortality after PMVR. A larger, multicenter cohort will be important to clarify this relationship.

The management of patients with valvular heart disease is increasingly reliant on multimodal cardiac imaging. In patients with severe aortic stenosis considered for transcatheter aortic valve replacement, careful pre-procedural planning with multimodal imaging is necessary to avoid and prevent complications during the procedure. During or immediately after the procedure, rapid echocardiographic assessment is important to assess the new valve's function and manage major complications. Echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging all share important roles in the post-procedural evaluation of abnormal transcatheter valve function. This review discusses the use of multimodal imaging for predicting, detecting, and managing complications after TAVR.

Objectives The aim of this study was to compare outcomes of transcatheter intervention (TI) versus surgical intervention (SI) for paravalvular leak (PVL). Background Data comparing the treatment of PVL with TI and SI are limited. Methods A retrospective cohort study was conducted comparing baseline characteristics, procedural details, and 1-year survival in consecutive patients who underwent TI or SI for moderate or greater PVL from 2007 to 2016. The primary outcome was a composite of death, reintervention for PVL, or readmission for congestive heart failure–related symptoms at 1 year. Results Of 114 patients, 56 underwent TI and 58 underwent SI. PVL locations were mitral, aortic, and pulmonary in 69 (60.5%), 39 (34.2%), and 6 (5.3%) patients, respectively. At baseline, TI patients were older (age 71 vs. 62 years; p = 0.010) and had fewer cases of active endocarditis (0.0% vs. 25.9%, p Conclusions In this study, TI for PVL closure had comparable 1-year clinical outcomes with SI, even after adjusting for differences in baseline characteristics, with less in-hospital morbidity and 30-day rehospitalization. Although further study is needed, these findings support the increased implementation of TI for PVL closure at experienced institutions.

Primary cardiac tumors are rare, and most are benign. Intimal sarcomas are among the rarest of the malignant cardiac tumors; they are aggressive and associated with a poor prognosis. Whereas transesophageal echocardiography has been instrumental in evaluating cardiac masses, other imaging methods, such as cardiac magnetic resonance, have proved invaluable in accurately characterizing these masses. We present the case of a 49-year-old woman in whom we diagnosed a primary intimal sarcoma of the left atrial appendage, and we discuss the importance of multimodal imaging in the evaluation and diagnosis of cardiac masses.

Transcatheter mitral valve replacement may cause fatal left ventricular outflow tract (LVOT) obstruction due to septal displacement of the anterior mitral leaflet. “Geometric obstruction” from the transcatheter valve can be predicted by calculating the “neo-LVOT” on 3-dimensional computed

Objective We investigated radioprotective strategies for the interventional echocardiographer (IE) during structural heart interventions in comparison with the interventional cardiologist (IC). Background Structural heart interventions are expanding in complexity with increased reliance on IE. Recent reports have demonstrated concerning exposure and higher radiation to the IE. Methods We monitored 32 structural interventions - 19 transcatheter aortic valve replacements (TAVR), 6 transcatheter mitral valve repairs, 5 paravalvular leak closures, and 2 atrial septal defect closures. Seventeen utilized transesophageal echocardiography (TEE) while 15 used transthoracic echocardiography (TTE). Members of the IC and IE teams wore multiple dosimeters on different sites of the body to measure radiation dose to the total body, lens of the eye, and hand. During each case, IE utilized dedicated radiation shielding. Results Mean doses were higher for the primary IC than the primary IE: IC#1-99, 222, 378; IE#1-48, 52, 416 (body, lens, and hand doses in μSv). IE radioprotective strategies were able to reduce body and lens doses compared to IC during both TTE and TEE-guided procedures. Hand equivalent dose remained higher for the IE driven by exposure during TEE-guided procedures (IC#1 294 vs. IE#1 676 μSv). In a subgroup using radioprotective drapes during TTE-guided TAVR, IC dose was reduced without effect on the IE. Conclusions Radiation exposure during structural heart interventions is concerning. With dedicated shielding, IE received lower doses to the body and lens than IC. Further optimization of structural suite design and shielding is needed.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare but serious sequela of endocarditis or valve replacement surgery. Because open-heart surgery is a high-risk treatment option, alternative methods are sought. We present the case of a 77-year-old man with a noninfected mechanical mitral valve whose pseudoaneurysm was repaired by introducing an occluder device into the defect by a transapical approach. Upon follow-up imaging, the defect was successfully closed. We conclude that percutaneous closure of pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a viable alternative to surgery and that a transapical approach is an appropriate method of access.

Speckle-tracking left ventricular global longitudinal strain (GLS) assessment may provide substantial prognostic information for hypertrophic cardiomyopathy (HCM) patients. Reference values for GLS have been recently published. We aimed to evaluate the prognostic value of standardized reference values for GLS in HCM patients. An analysis of HCM clinic patients who underwent GLS was performed. GLS was defined as normal (more negative or equal to −16 %) and abnormal (less negative than −16 %) based on recently published reference values. Patients were followed for a composite of events including heart failure hospitalization, sustained ventricular arrhythmia, and all-cause death. The power of GLS to predict outcomes was assessed relative to traditional clinical and echocardiographic variables present in HCM. 79 HCM patients were followed for a median of 22 months (interquartile range 9–30 months) after imaging. During follow-up, 15 patients (19 %) met the primary outcome. Abnormal GLS was the only echocardiographic variable independently predictive of the primary outcome [multivariate Hazard ratio 5.05 (95 % confidence interval 1.09–23.4, p = 0.038)]. When combined with traditional clinical variables, abnormal GLS remained independently predictive of the primary outcome [multivariate Hazard ratio 5.31 (95 % confidence interval 1.18–24, p = 0.030)]. In a model including the strongest clinical and echocardiographic predictors of the primary outcome, abnormal GLS demonstrated significant incremental benefit for risk stratification [net reclassification improvement 0.75 (95 % confidence interval 0.21–1.23, p < 0.0001)]. Abnormal GLS is an independent predictor of adverse outcomes in HCM patients. Standardized use of GLS may provide significant incremental value over traditional variables for risk stratification.

We present a patient with cardiac involvement by a metastatic high-grade pleomorphic sarcoma. The tumor metastasized to the endocardium of the left ventricle as well as the lungs, adrenal glands, and thoracolumbar spine. The sarcoma obstructed the left ventricular outflow tract. Approximately 5 months after diagnosis, despite chemotherapy, our patient died suddenly. The exact cause of death is unknown, but presumably cardiac in origin.

Background and Purpose: The objective of our study was to evaluate magnetic resonance imaging (MRI) and echocardiographic characteristics that would identify patients with cryptogenic ischemic stroke (IS) and transient ischemic attack (TIA) who subsequently developed paroxysmal atrial fibrillation (PAF) on mobile cardiac outpatient telemetry (MCOT). Methods: All patients with cryptogenic IS or TIA seen at the Emory University Hospital and Emory University Hospital Midtown from January 1, 2009, to June 30, 2013, who underwent MCOT were included in this analysis. Location (cortical, high subcortical, or neither) of current and prior strokes on MRI and left atrial (LA) functional and anatomical echocardiographic parameters were evaluated to determine their association with subsequent detection of PAF. Results: Of 132 patients, 17 (13%) had evidence of newly diagnosed PAF on MCOT (mean duration of monitoring = 25 days). The presence (vs absence) of ≥1 cortical infarct on baseline MRI was a significant predictor of identifying PAF (odds ratio: 5.2, 95% confidence interval: 1.3-19; P = .01). On baseline echocardiography, patients who had PAF (vs non-PAF) had significantly higher mean LA diameters (4.2 vs 3.7 cm, P = .03) and lower tissue Doppler velocity (a’; 5.5 vs 13.5 cm/s, P = .03). In receiver operating characteristic analysis, the ratio of LA volume index to the septal Doppler velocity (LAVI/a’) of >4.6 was associated with a higher likelihood of PAF. Combining MRI with echocardiographic variables did not improve the predictive ability beyond echocardiography alone. Conclusion: Although the presence of cortical-based infarcts on MRI in patients with cryptogenic IS or TIA increases the likelihood of detecting PAF on MCOT, LA functional and anatomic parameters alone best predicted which patients subsequently had PAF.

The differential diagnosis of a lateral neck mass includes a number of possible etiologies. While jugular venous aneurysms and pseudoaneurysms are rare entities, they should be considered in the differential diagnosis of a pulsatile lateral neck mass. We present a case of an idiopathic jugular venous pseudoaneurysm and its association with worsening tricuspid regurgitation in a patient with heart failure with preserved ejection fraction.

Primary malignant cardiac tumors are rare. Among these tumors, cardiac plasmacytoma is extremely rare and is the subject of few case reports. We present the case of a 73-year-old man who had isolated cardiac plasmacytoma 26 years after successful treatment of an axillary plasmacytoma. Multiple imaging methods—including echocardiography, cardiac magnetic resonance, and positron-emission tomography/computed tomography—were valuable and complementary to each other in this patient's diagnosis and optimal management. His case illustrates the use of these techniques in the successful diagnosis and treatment of a rare clinical entity, cardiac plasmacytoma.

A 56-year-old woman presented to the cardiology clinic with a 7-day history of dyspnea and chest pressure. An echocardiogram showed a flail posterior mitral valve leaflet, and subsequent left heart catheterization showed complete occlusion of the first obtuse marginal coronary artery. Further investigation demonstrated the culprit lesion to be ischemic partial rupture of the posteromedial papillary muscle. Timely recognition of this condition allowed for an optimal clinical outcome. In this Cardiology Grand Rounds, the authors further describe the above presentation of ischemic partial papillary muscle rupture and provide a brief review of the pathophysiology, diagnosis and treatment of this condition.

Left ventricular outflow tract (LVOT) obstruction is a life-threatening complication of transcatheter mitral valve replacement (TMVR), caused by septal displacement of the mitral valve leaflet. Laceration of the anterior mitral valve leaflet to prevent outflow tract obstruction (LAMPOON) is an

Background— Coronary artery bypass graft (CABG) surgery has been performed frequently for symptomatic coronary atherosclerotic heart disease for more than 30 years. However, uncertainty exists regarding the relationship between long-term survival after CABG and readily available clinical correlates of mortality. Methods and Results— We studied outcome at 20 years by age, sex, and other variables in 3939 patients who had CABG surgery from 1973 to 1979 in the Emory University System of Healthcare. Twenty-year survival, freedom from myocardial infarction, and freedom from repeat CABG were 35.6% (95% confidence interval [CI], 33.9% to 37.3%), 66.6% (95% CI, 64.6% to 68.6%), and 59.1% (95% CI, 56.9% to 61.5%). Multivariate correlates of late mortality were age (hazard ratio [HR], 1.46 per 10 years), female sex (HR, 1.21), hypertension (HR, 1.44), angina class (HR, 1.07 per class increase of 1), prior CABG (HR, 1.72), ejection fraction (HR, 1.07 per 10-point decrease), number of vessels diseased (HR, 1.11 per 1-vessel increase), and weight (HR, 1.04 per 10 kg). Twenty-year survival by age was 55%, 38%, 22%, and 11% for age 70 years at the time of initial surgery. Survival at 20 years after surgery with and without hypertension was 27% and 41%, respectively. Similarly, 20-year survival was 37% and 29% for men and women. Conclusions— Symptomatic coronary atherosclerotic heart disease requiring surgical revascularization is progressive with continuing events and mortality. Clinical correlates of mortality significantly impact survival over time and may help identify long-term benefits after CABG.

Background Significant paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) confers a worse prognosis. Symptoms related to significant PVL may be difficult to differentiate from those related to other causes of heart failure. Cardiovascular magnetic resonance (CMR) directly quantifies valvular regurgitation, but has not been extensively studied in symptomatic post-TAVR patients. Methods CMR was compared to qualitative (QE) and semi-quantitative echocardiography (SQE) for classifying PVL and prognostic value at one year post-imaging in 23 symptomatic post-TAVR patients. The primary outcome was a composite of all-cause death, heart failure hospitalization, and intractable symptoms necessitating repeat invasive therapy; the secondary outcome was a composite of all-cause death and heart failure hospitalization. The difference in event-free survival according to greater than mild PVL versus mild or less PVL by QE, SQE, and CMR were evaluated by Kaplan-Meier survival analysis. Results Compared to QE, CMR reclassified PVL severity in 48% of patients, with most patients (31%) reclassified to at least one grade higher. Compared to SQE, CMR reclassified PVL severity in 57% of patients, all being reclassified to at least one grade lower; SQE overestimated PVL severity (mean grade 2.5 versus 1.7, p = 0.001). The primary and secondary outcomes occurred in 48% and 35% of patients, respectively. Greater than mild PVL by CMR was associated with reduced event-free survival for the primary outcome (p 20%) had a higher incidence of adverse events.

Supracristal ventricular septal defect (SCVSD), a defect of the infundibular portion of the interventricular septum just below the right aortic cusp, occurs more frequently in Eastern Asian populations. SCVSD may be complicated by right sinus of Valsalva aneurysm (SoVA). We present the case of a 26-year-old male of Korean descent with a history of a childhood murmur who was referred to our institution for progressive heart failure symptoms. He was diagnosed with SCVSD and ruptured right SoVA based on history, physical exam, and echocardiography including three-dimensional transesophageal echocardiography with reconstructed surgical views. The patient underwent SCVSD closure, SoVA excision, and valve-sparing aortic root replacement. We reviewed the echocardiography literature regarding SCVSD and SoVA, and analyzed contemporary literature of SoVA and its relationship with SCVSD. We conclude that a higher prevalence of ruptured SoVA in Eastern Asians is likely related to a higher prevalence of underlying SCVSD in this population.

An 89-year-old woman was admitted to the hospital with dyspnea, renal failure, and atrial fibrillation with rapid ventricular response. Transthoracic ([Figure 1A][1], [Online Video 1][2]) and transesophageal echocardiograms ([Figures 1B to 1D][1], [Online Videos 2][3] and [3][4]) showed severe

Aortic valve abscesses (AVAs) are a devastating complication of aortic valve endocarditis. Over 8 years, 25 patients were diagnosed with AVA by transesophageal echo (TEE). Management and outcomes were then analyzed. Eleven (44%) AVAs involved prosthetic valves, and 6 (24%) occurred in congenitally malformed valves. Twenty patients (80%) underwent surgical intervention; the rest were treated medically. Eleven (44%) of the patients died [6 (30%) surgery patients and all the medical patients]. Eight of 11 (73%) patients who died were culture positive for Staphylococcus aureus. All patients with congenitally malformed aortic valves underwent surgical intervention and survived. We conclude that: (1) despite advances in therapy and diagnosis, patients with AVAs have a high mortality rate; (2) prognosis with AVA is especially poor when S aureus is the infectious organism; (3) patients with AVAs in congenitally malformed valves have a great outcome with surgery; (4) patients treated medically have a very poor prognosis; earlier identification by TEE may be critical to improving survival.

Eighteen patients (3 men and 15 women; mean age 63 years) with right-sided tumors were evaluated by both transthoracic and transesophageal echocardiography from 1989 to 1996. The indications for echocardiographic studies included evaluation for a presumed mass and further evaluation of ventricular function and valvular function. Fifteen patients had right atrial tumors. These included 5 hypernephromas, 4 myxomas, 2 angiosarcomas, 1 lipoma, 1 cavernous hemangioma, 1 hepatoma, and 1 chondrosarcoma. Three patients had right ventricular (RV) tumors: 1 metastatic olfactory neuroblastoma, a leiomyosarcoma, a chondrosarcoma, and a fourth patient had infiltration of the RV free wall of unknown etiology. Biopsy of either right atrial or RV masses was performed with transesophageal echocardiographic guidance in 2 patients, and allowed histologic diagnosis before surgical resection. These findings indicate that tumors are more often found in the right atrium than in the right ventricle, and females predominate. Most tumors arising within the right atrium are benign, whereas those extending into the right atrium from outside are malignant. RV tumors are rarely encountered; when present, they are likely to be malignant.

Fulminant myocarditis is an uncommon diagnosis characterized by cardiac failure preceded by symptoms of a viral illness. Presentation can frequently mimic acute myocardial infarction. The electrocardiographic changes are frequently nonspecific, but include ST segment elevation and T wave changes, as well as conduction abnormalities. We report the case of a patient with fulminant myocarditis that presented with sinus rhythm, a conduction system abnormality, and severe ST segment elevation mimicking ventricular tachycardia. Myocarditis should be considered in young persons with unexplained heart failure and similar electrocardiographic abnormalities.

Based on a case of suspected ischemic heart disease we review hiatal hernia causing chest pain. Rest echocardiography images were suggestive of cardiac mass in the left atrium. Dobutamine stress echocardiogram was negative for inducible ischemia. Multi-slice computed tomography of the chest was performed showing that a large hiatal hernia was present compressing on the left atrium. Multimodality imaging is necessary for suspected mass compressing the heart, causing chest discomfort.

This report shows that transesophageal echocardiography can detect thoracic pathology, in this case esophageal sarcoma, as well as cardiac and aortic abnormalities. Transesophageal echocardiography can help differentiate cardiac from aortic or other intrathoracic pathology when the patient's history and physical examination do not provide enough information. (J Am Soc Echocardiogr 2000;13:619-21.)

Summary: A total of 3000 patients have had cardiac catheterization in the Andreas Gruentzig Cardiovascular Laboratory of the Emory Clinic. The purpose of this presentation is to describe the patient population selected for this procedure and our experience with this group. The concept of catheterization as an outpatient is attractive from the standpoint of cost savings and time conservation. Safety has been questioned. We have found that this technique can be performed safely in carefully selected outpatients. Careful selection attempted to eliminate those with unstable symptoms, recent myocardial infarction, severe diabetes, and renal failure. Small catheters were used to minimize the potential for bleeding. Excellent opacification of vessels was obtained with these catheters. Despite careful screening we found 2.2% had significant left main obstruction, 10.8% had triple-vessel disease, 16.0% had double-vessel disease, and 23.5% had single-vessel disease, and a similar percentage had normal coronary arteriograms. Our patients experienced ventricular fibrillation on five occasions, there were two small cerebral emboli with reversible neurologic defects, two episodes of pulmonary edema, and two episodes of severe allergic reactions. Only three patients had significant groin bleeding at home that required compression of the site. We subsequently did angioplasty on 323 patients, performed cardiac surgery (mostly coronary bypass) on 187 patients, and admitted 18.2% of the entire group. We conclude that this procedure can be done safely in this carefully designed setting and it saves time and offers cost savings. Patient selection is very important to minimize potential emergency situations and complications. The laboratory must be carefully set up and provide a close relationship with a hospital capable of attending to any unexpected emergency.

The authors enrolled 95 patients with keratoconus and 96 matched controls in a cross-sectional study to determine if mitral valve prolapse and hypermobile joints occur with greater frequency in individuals with keratoconus than in individuals without keratoconus. The hypothesis that keratoconus may not be a distinct eye disease, but a nonspecific sign representing a more generalized systemic disorder, possibly a mild collagen tissue abnormality, was considered. M-mode and two dimensional echocardiography and cardiac auscultation detected no statistically significant difference in the prevalence of mitral valve prolapse in patients with keratoconus compared with controls. Formal, systematic examination of five joints also failed to detect a statistically significant difference in the prevalence of hypermobile joints in keratoconus patients and controls. However, as an ancillary finding, a significantly higher proportion of patients with keratoconus was found to have a history of hay fever than was the case with controls.

Development of left ventricular to coronary sinus fistula is a rare complication of mitral valve surgery. Three of the seven previously reported cases occurred following multiple valve replacement surgeries, all of which were thought to be secondary to a complication of surgery and all were treated with surgical closure of the fistula. We report a case of left ventricular to coronary sinus fistula occurring after two mitral valve replacement surgeries that was treated medically with favorable long-term results.

Cardiac nocardiosis is a rare disease that is nearly always associated with cardiac operation. We report the case of a patient with a 10-month history of intermittent fevers after coronary artery bypass operation who presented with progressive shortness of breath and fever. He was found to have a large aortic aneurysm secondary to Nocardia nova infection likely transmitted during his original bypass operation. This is the first reported case of Nocardia aortitis after coronary bypass operation and serves to alert physicians of this rare but serious postoperative complication.

Two unusual cases of large aneurysms, one located in the native right coronary artery and the other in a saphenous vein graft, are reported. Their size and mode of presentation as asymptomatic paracardiac masses on chest x‐ray films make them unique. It is proposed that these entities be considered as part of the differential diagnosis of paracardiac masses.

We report 3 patients who sustained intrathoracic esophageal perforations due to transesophageal echocardiography encountered during the past 2 years. Lack of suspicion of this complication led to delay in diagnosis. Surgical management led to survival of all 3 patients.

Closure of the fibrillating left atrial appendage has been recommended during mitral valve operations to help prevent thrombus formation and systemic embolization postoperatively. We report recanalization of the appendage orifice in 6 patients after surgical closure by pursestring suturing at the time of mitral valve replacement. Transesophageal echocardiography demonstrated disruption of the closure line and partial recanalization of the sutured orifice with relatively high velocity flow between the left atrial body and the appendage.

Coronary surgery is being performed increasingly in older patients who may have more extensive disease as well as other factors that may lead to more frequent complications and death. 1–3 Several studies have shown that the rate of complications and mortality in elderly patients are higher than in younger ones. 4–7 Advanced age has also been shown to correlate with late mortality after cardiac surgery. 8 Because of these data, there has been uncertainty as to use of cardiac surgery in older patients, especially in those aged ≥80 years. This report presents results of coronary artery bypass grafting both in hospital and at follow-up in patients aged ≥80.

To characterize thallium-201 distribution in single-photon emission computed tomography (SPECT) cardiac images and polar bullseye maps, 100 patients with chronic systemic hypertension due to end-stage renal disease were studied and the results compared with those in 35 normotensive control subjects. Thallium-201 SPECT was performed after exercise in all control subjects and 70 hypertensive patients, and after intravenous dipyridamole in 30 patients. A frequent finding in hypertensive patients was a fixed decrease in the normal lateral-to-septal count density ratio in immediate thallium-201 SPECT images (1.02 +/- 0.10 vs 1.17 +/- 0.08 in control subjects, p less than 0.00001) and in 3-hour delayed images (1.02 +/- 0.11 vs 1.11 +/- 0.08 in control subjects, p less than 0.00001). No significant difference in count density ratio was present in patients undergoing treadmill versus diypridamole intervention. In 35 patients the count density ratio was greater than 2.0 standard deviations below the normal mean, creating the false impression of a fixed lateral defect (i.e., myocardial infarction). In 12 patients, myocardial wall thickness was measured at end-diastole by 2-dimensional echocardiography. Wall thickness was increased (greater than 11 mm) in all patients. The mean lateral-to-septal wall thickness ratio was 1.08 +/- 1.11; in no patient was the ratio less than 0.76 to indicate selective septal hypertrophy. The lateral-to-septal wall thickness and lateral-to-septal thallium-201 count density ratios correlated poorly (r = 0.43).(ABSTRACT TRUNCATED AT 250 WORDS)

The vast majority of left ventricular aneurysms (LVA) are secondary to coronary artery disease. The natural history of LVA is now better understood. The increasing use of noninvasive techniques has allowed earlier recognition and better appreciation of LVA genesis and pathophysiology. Improvements in surgical anesthesia and techniques have resulted in more successful LVA surgery. This article reviews the pathogenesis, natural history, and complications of LVA. Surgical indications and available treatment options in the management of patients with LVA and severe symptoms are presented. Left ventricular pseudoaneurysm (false aneurysm) will also be discussed.

Ruptured papillary muscle due to myocardial infarction was encountered in 14 patients during the period 1975-1983. Five of the 14 patients had a history of angina pectoris and two had a history of prior myocardial infarction. Eleven patients with myocardial infarction developed additional pain due to myocardial ischemia and/or a murmur of mitral regurgitation and pulmonary edema within a week, 3 others had a prolonged course with intermittent pain due to myocardial ischemia and breathlessness for longer periods and then deteriorated. Thirteen of our 14 patients developed a murmur and all but one had pulmonary edema on the chest x-ray. Five patients had infarction patterns on the electrocardiogram, the remainder of the patients had only ST- and T-wave changes. Echocardiograms showed fine flutter and notching of the anterior mitral leaflets and vigorous contractions of the left ventricle. Only one patient was demonstrated to have a papillary muscle tip prolapsing into the left atrium on two-dimensional echocardiography. Twelve patients underwent surgery and 8 survived. Seven patients had single-vessel coronary disease, 4 involving the circumflex system and 3 involving the right coronary system. Four of the 7 patients with single-vessel coronary disease survived surgery. Five patients went to surgery with the intra-aortic balloon pump in place and only 3 survived. Three others had the pump inserted intraoperatively and 2 of these survived. Six of 9 patients who had mitral valve replacement and coronary bypass survived. Ejection fraction ranged from 40 to 79%. Surgical survival did seem to be related to the extent of papillary muscle rupture, with the best results occurring in the group with a small portion of the tip ruptured. Seven patients had a stormy clinical course and required surgery within 10 days of rupture. Four of these 7 survived. It seems reasonable to believe that these patients who often have small infarction and limited coronary disease have good potential for survival. Our approach has been to move toward surgery once the diagnosis is made to avoid the sudden deterioration that frequently occurs. The surgical mortality in this group remains in the 30 to 40% range.

The electrocardiogram is often the key to the diagnosis of myocardial infarction. In order to use it effectively, the clinician must be aware of its limitations. Most importantly, it must be remembered that a single normal electrocardiogram does not exclude myocardial infarction. In addition, certain clinical entities mimic infarction electrocardiographically and others mask electrocardiographic evidence of infarction. These factors must be considered when the electrocardiogram is interpreted in order to provide the clinician with the best possible information about the patient.