Minimalist transcatheter aortic valve replacement misses paravalvular regurgitation: Incidence and echocardiographic distribution of missed paravalvular regurgitation.

BACKGROUND: Paravalvular regurgitation (PVR) may be missed intraoperatively with transthoracic echocardiography (TTE) guided minimalist TAVR. We sought to determine the incidence and echocardiographic distribution of PVR missed on intra-op TTE, but detected on predischarge TTE. METHODS: From July 2015 to 2020, 475 patients with symptomatic severe native aortic stenosis underwent TTE-guided minimalist TAVR. Missed PVR was defined as predischarge PVR that was ≥1 grade higher than the corresponding intra-op PVR severity. PVR was classified as anterior or posterior on the four standard TTE views; parasternal short-axis (PSAX), parasternal long-axis (PLAX), apical 3-chamber (A3C), and 5-chamber (A5C). Location-specific risk of missed PVR was then determined. RESULTS: Mild or greater PVR was seen in 55 (11.5%) cases intra-op and 91 (19.1%) at predischarge, with no severe PVR. Among the 91 patients with ≥mild predischarge PVR, missed PVR was present in 42 (46.2%). Compared to the corresponding anterior jets, missed PVR rate was significantly higher for posterior jets in PLAX (62.5% vs. 25.0%, p = 0.005), A5C (56.9% vs. 25.0%, p = 0.009), PSAX (66.7% vs. 24.3%, 0.001), but not A3C (58.5% vs. 40.0%, p = 0.28). CONCLUSIONS: Intraoperative TTE-guided minimalist TAVR either misses nearly half of ≥mild PVR or underestimates PVR by ≥1 grade when compared to predischarge TTE. Posterior PVR jets are more likely to be missed. Transesophageal echo guidance may help minimize missing PVR. Further studies are warranted.

Mechanistic validation of the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging Guidelines for the assessment of diastolic dysfunction in heart failure with reduced ejection fraction.

BACKGROUND: The American Society for Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI) 2016 guidelines for assessment of diastolic dysfunction (DD) are based primarily on the effects of diastolic dysfunction on left ventricular filling hemodynamics. However, these measures do not provide quantifiable mechanistic information about diastolic function. The Parameterized Diastolic Filling (PDF) formalism is a validated theoretical framework that describes DD in terms of the physical properties of left ventricular filling. AIMS: We hypothesized that PDF analysis can provide mechanistic insight into the mechanical properties governing higher grade DD. METHODS: Patients referred for echocardiography showing reduced left ventricular ejection fraction (< 45%) were prospectively classified into DD grade according to 2016 ASE/EACVI guidelines. Serial E-waves acquired during free breathing using pulsed wave Doppler of transmitral blood flow were analyzed using the PDF formalism. RESULTS: Higher DD grade (grade 2 or 3, n = 20 vs grade 1, n = 30) was associated with increased chamber stiffness (261 ± 71 vs 169 ± 61 g/s2, p < 0.001), increased filling energy (2.0 ± 0.9 vs 1.0 ± 0.5 mJ, p < 0.001) and greater peak forces resisting filling (median [interquartile range], 18 [15-24] vs 11 [8-14] mN, p < 0.001). DD grade was unrelated to chamber viscoelasticity (21 ± 4 vs 20 ± 6 g/s, p = 0.32). Stiffness was inversely correlated with ejection fraction (r = - 0.39, p = 0.005). CONCLUSIONS: Higher grade DD was associated with changes in the mechanical properties that determine the physics of poorer left ventricular filling. These findings provide mechanistic insight into, and independent validation of the appropriateness of the 2016 guidelines for assessment of DD.

Association of Transthoracic Echocardiography Findings and Long-Term Outcomes in Patients Undergoing Workup of Stroke.

BACKGROUND: Transthoracic echocardiography (TTE) has become routine as part of initial stroke workup to assess for sources of emboli. Few studies have looked at other TTE findings such as ejection fraction, wall motion abnormalities, valve disease, pulmonary hypertension and left ventricular hypertrophy and their association with various subtypes of stroke, long-term outcomes of recurrent stroke, and all-cause mortality. METHODS AND RESULTS: Computed tomography and magnetic resonance imaging brain imaging and TTE reports were reviewed for 2464 consecutive patients referred for TTE as part of a workup for acute stroke between 1/1/01 and 9/30/07. Study patients were 67 ± 15years, 60% female, 75% minorities and had hypertension (76%), diabetes (41%), chronic kidney disease (27%) and atrial fibrillation (18%). On TTE, a mass, thrombus, or vegetation was identified in only 4 cases (0.2%), whereas a clinically significant abnormality (ejection fraction < 50%, left ventricle or right ventricle wall motion abnormalities, severe valve disease, pulmonary hypertension, or left ventricular hypertrophy) was identified in 16%. Those with an abnormal TTE had increased risk for death at 10years (hazard ratio [HR] 1.8; 95% confidence interval [CI]: 1.6, 2.0; P < .01), although risk for readmission with stroke was not increased. Abnormal TTE remained associated with increased risk of death at 10years after adjustment for age, sex, race, and cardiovascular risk factors (HR 1.4; 95% CI: 1.2, 1.7; P < .01). CONCLUSIONS: TTE performed as part of an initial workup for stroke had minimal yield for identifying sources of embolism. Clinically important abnormalities found on TTE were independently associated with increased long-term mortality, but not recurrent stroke.

Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial.

BACKGROUND: The role of coronary computed tomography angiography (CCTA) in the management of symptomatic patients suspected of having coronary artery disease is expanding. However, prospective intermediate-term outcomes are lacking. OBJECTIVE: To compare CCTA with conventional noninvasive testing. DESIGN: Randomized, controlled comparative effectiveness trial. (ClinicalTrials.gov: NCT00705458). SETTING: Telemetry-monitored wards of an inner-city medical center. PATIENTS: 400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic and 37% African-American; and low socioeconomic status. INTERVENTION: CCTA or radionuclide stress myocardial perfusion imaging (MPI). MEASUREMENTS: The primary outcome was cardiac catheterization not leading to revascularization within 1 year. Secondary outcomes included length of stay, resource utilization, and patient experience. Safety outcomes included death, major cardiovascular events, and radiation exposure. RESULTS: Thirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, -2.5 percentage points [95% CI, -8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 versus 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003). LIMITATION: This was a single-site study, and the primary outcome depended on clinical management decisions. CONCLUSION: The CCTA and MPI groups did not significantly differ in outcomes or resource utilization over 40 months. Compared with MPI, CCTA was associated with less radiation exposure and with a more positive patient experience. PRIMARY FUNDING SOURCE: American Heart Association.

Rationale and Design of the Echocardiographic Study of Hispanics/Latinos (ECHO-SOL).

BACKGROUND: Information regarding the prevalence and determinants of cardiac structure and function (systolic and diastolic) among the various Hispanic background groups in the United States is limited. METHODS AND RESULTS: The Echocardiographic Study of Latinos (ECHO-SOL) ancillary study recruited 1,824 participants through a stratified-sampling process representative of the population-based Hispanic Communities Health Study - Study of Latinos (HCHS-SOL) across four sites (Bronx, NY; Chicago, Ill; San Diego, Calif; Miami, Fla). The HCHS-SOL baseline cohort did not include an echo exam. ECHO-SOL added the echocardiographic assessment of cardiac structure and function to an array of existing HCHS-SOL baseline clinical, psychosocial, and socioeconomic data and provides sufficient statistical power for comparisons among the Hispanic subgroups. Standard two-dimensional (2D) echocardiography protocol, including M-mode, spectral, color and tissue Doppler study was performed. The main objectives were to: 1) characterize cardiac structure and function and its determinants among Hispanics and Hispanic subgroups; and 2) determine the contributions of specific psychosocial factors (acculturation and familismo) to cardiac structure and function among Hispanics. CONCLUSION: We describe the design, methods and rationale of currently the largest and most comprehensive study of cardiac structure and function exclusively among US Hispanics. ECHO-SOL aims to enhance our understanding of Hispanic cardiovascular health as well as help untangle the relative importance of Hispanic subgroup heterogeneity and sociocultural factors on cardiac structure and function.

Evaluation of the cardiac chambers on axial CT: comparison with echocardiography.

OBJECTIVE: To evaluate qualitative and simple quantitative measures of all 4 cardiac chamber sizes on computed tomography (CT) in comparison with transthoracic echocardiography (TTE). METHODS: We retrospectively identified 104 adults with electrocardiographically gated cardiac CT and TTE within 3 months. Axial early diastolic (75% R-R) CT images were reviewed for qualitative chamber enlargement, and each chamber was measured linearly. Transthoracic echocardiography was reviewed for linear, area, and volume measurements. Interrater agreement was calculated using Cohen κ and Pearson correlation. RESULTS: There were significant correlations between linear left atrium and left ventricle sizes by CT and TTE (r = 0.686 and r = 0.709, respectively). Correlations for right atrium and right ventricle measurements were lower (r = 0.447 and r = 0.492, respectively). Agreement between CT and TTE for qualitative chamber enlargement was poor (highest κ = 0.35). Computed tomography sensitivity was ≤ 62% for enlargement of all chambers. CONCLUSIONS: Linear CT measurements of left-sided chamber sizes correlate well with TTE. Right heart measurements and qualitative assessments agreed poorly with TTE.

Rationale and design of a randomized trial comparing initial stress echocardiography versus coronary CT angiography in low-to-intermediate risk emergency department patients with chest pain.

BACKGROUND: Comparative effectiveness research (CER) has become a major focus of cardiovascular disease investigation to optimize diagnosis and treatment paradigms and decrease healthcare expenditures. Acute chest pain is a highly prevalent reason for evaluation in the Emergency Department (ED) that results in hospital admission for many patients and excess expense. Improvement in noninvasive diagnostic algorithms can potentially reduce unnecessary admissions. OBJECTIVE: To compare the performance of treadmill stress echocardiography (SE) and coronary computed tomography angiography (CTA) in ED chest pain patients with low-to-intermediate risk of significant coronary artery disease. DESIGN: This is a single-center, randomized controlled trial (RCT) comparing SE and CTA head-to-head as the initial noninvasive imaging modality. The primary outcome measured is the incidence of hospitalization. The study is powered to detect a reduction in admissions from 28% to 15% with a sample size of 400. Secondary outcomes include length of stay in the ED/hospital and estimated cost of care. Safety outcomes include subsequent visits to the ED and hospitalizations, as well as major adverse cardiovascular events at 30 days and 1 year. Patients who do not meet study criteria or do not consent for randomization are offered entry into an observational registry. CONCLUSIONS: This RCT will add to our understanding of the roles of different imaging modalities in triaging patients with suspected angina. It will increase the CER evidence base comparing SE and CTA and provide insight into potential benefits and limitations of appropriate use of treadmill SE in the ED.

Echocardiographic left ventricular end-diastolic pressure volume loop estimate predicts survival in congestive heart failure.

BACKGROUND: The left ventricular end-diastolic pressure-volume relationship (LV-EDPVR) is a measure of LV distensibility, conveying the size the LV will assume at a given LV end-diastolic pressure (LV-EDP). Measurement of LV-EDPVR requires invasive testing with specialized equipment. Echocardiography can be used to measure LV end-diastolic volume (EDV) and to grossly estimate LV-EDP noninvasively. We therefore hypothesized that categorization of patients based on these parameters to create an estimate of the end-diastolic pressure-volume loop position (EDPVE) could predict congestive heart failure (CHF) prognosis. METHODS AND RESULTS: Echocardiograms from 968 CHF clinic patients were reviewed. LV-EDP was considered to be elevated if mitral filling pattern was pseudo-normal or restrictive. EDPVE was categorized into 3 groups. EDPVE was considered to have evidence of rightward shift if the LV was severely dilated (>97 mL/m(2)). EDPVE was considered to have evidence of leftward shift if the LV was normal size (<76 mL/m(2)) and there was Doppler evidence of increased LV-EDP. Patients who did not meet criteria for leftward or rightward shift were classified as "intermediate." Using the intermediate group for comparison, those with evidence of leftward shift in EDPVE had increased mortality (hazard ratio [HR] 1.77; 95% confidence interval [CI]: 1.23-2.54). Rightward shift only correlated with increased mortality in those older than age 70 years. Leftward shift remained an independent predictor of mortality even after adjusting for LV ejection fraction, atrial fibrillation, mitral regurgitation, and Doppler indices of diastolic dysfunction. CONCLUSION: EDPVE is a strong predictor of CHF survival which is independent of LV ejection fraction and traditional Doppler indices of LV diastolic function.

Dispelling the Saddle Pulmonary Embolism Myth (from a Comparison of Saddle Versus Non-Saddle Pulmonary Embolism).

In the setting of an acute pulmonary embolism (PE), there is often an assumed association between a saddle PE (SPE) and increased clinical severity. We aimed to determine the magnitude of SPE proximal pulmonary artery (PA) flow obstruction and its impact on right ventricular (RV) function in the setting of acute PE in a single-center series. From 2005 to 2022, patients with acute PE presenting with acute RV dysfunction requiring intervention were classified as SPE and non-SPE based on presenting computed tomography (CT) scans. SPE flow obstruction was determined by the ratio of the orthogonal cross-sectional surface area measurements of clot and native PA at the location of maximum clot burden in the right PA and left PA. Presenting RV function based on clinical and imaging parameters (CT and transthoracic echocardiography) were compared between SPE and non-SPE cohorts. A total of 174 patients were identified (SPE 92 [52.9%] and non-SPE 82 [47.1%]). Demographics and co-morbidities were similar. In patients with SPE, there was a mean 25.9% total flow obstruction (right PA 26.9% and left PA 25.5%). Non-SPE had greater clinical RV dysfunction on presentation as reflected by more high-risk PE (43.9% vs 26.1%, p = 0.01), need for venoarterial extracorporeal membrane oxygenation (21.9% vs 10.9%, p = 0.05), and more preoperative cardiopulmonary resuscitation (16.7% vs 7.8%, p = 0.08). RV:left ventricular ratio (CT and transthoracic echocardiography) and RV fractional area change were statistically similar between groups. In-hospital mortality was statistically similar between cohorts (4.9% non-SPE vs 2.1% SPE, p = 0.32). In conclusion, in a single-center series of patients with acute PE with RV dysfunction, SPE did not cause proximal flow-limiting obstruction. Non-SPE was associated with more clinical RV dysfunction than SPE. Thus, it should not be assumed that a non-SPE is a marker of patient stability.

Administration of perflutren contrast agents during transthoracic echocardiography is not associated with a significant increase in acute mortality risk.

BACKGROUND: Despite the 2008 revision of a previously issued black box warning of the US Food and Drug Administration against the use of perflutren ultrasound contrast agents, the warning still reports fatalities having occurred following their administration. We sought to assess 1-day mortality associated with contrast use across a wide range of clinical settings and co-morbidities. METHODS: We conducted a retrospective study involving 96,705 transthoracic echocardiograms (TTE) in 63,189 adults at our institution between July 2003 and June 2008. A contrast agent was used in 2,518 TTE during this time. The primary outcome was total mortality within 1 day of TTE. RESULTS: Death occurred in 10 patients (0.44%) in the contrast group and in 421 patients (0.69%) in the non-contrast group (p = 0.14). In a multivariate model, use of contrast enhancement was not associated with increased mortality (p = 0.67) after adjustment for age, gender, race, patient location, ejection fraction, and the presence of various co-morbidities. Cause of death analysis did not identify any cases where contrast played a likely role. CONCLUSION: Definity contrast use during TTE was not associated with increased acute mortality risk. Contrast administration during TTE should not be withheld when the additional information obtained could potentially improve patient management.

Long-term echocardiographic changes in left ventricular size and function following surgery for severe mitral regurgitation.

BACKGROUND: Chronic mitral regurgitation (MR) results in a state of chronic left ventricular (LV) volume overload, resulting in compensatory dilatation. Mitral valve (MV) surgery for regurgitation reduces LV preload but increases LV afterload. Few data are available documenting subsequent changes in LV size and function over time following MV surgery for severe regurgitation in unselected populations. MATERIAL/METHODS: Pre- and postoperative echocardiograms (n=454) acquired from 108 consecutive patients with chronic MR who underwent MV surgery were analyzed. RESULTS: LV diastolic diameter was 4 mm smaller on postoperative compared to preoperative exams, whereas LV fractional shortening (FS) was unchanged. Linear regression analysis showed no change in LV diastolic diameter over time postoperatively, whereas LV FS increased over time following surgery. Improvement in LV FS occurred at an average rate of 1.6% per year (95% CI, 0.2-2.9). Subgroups were small, but the same secular trends were generally noted in groups with or without coronary artery bypass graft surgery (CABGS) and in those with or without mitral leaflet disease. CONCLUSIONS: Following MV surgery for MR, LV diastolic diameter reduces by 2 mm at the time of surgery, but then remains stable over time. Improvement in LV function over time postoperatively was only seen in those without concomitant CABGS, possibly related to less baseline myocardial scarring in this group.

Comparison of Surgical Embolectomy and Veno-arterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism.

Massive pulmonary embolism (MPE) is associated with a 20-50% mortality rate with guideline directed therapy. MPE treatment with surgical embolectomy (SE) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) have shown promising results. In the context of a surgical management strategy for MPE, a comparison of outcomes associated with VA-ECMO or SE was performed. A retrospective review of a single institution cardiac surgery database was performed, identifying MPE treated with SE or VA-ECMO between 2005-2020. Primary outcome was in-hospital survival. 59 MPE [27 (46.8%) VA-ECMO vs 32 (54.2%) SE] were identified. All presented with elevated cardiac biomarkers, tachycardia (mean heart rate 113 ± 20 beats/minute), hypotension (mean systolic blood pressure 85 ± 22 mm Hg) and vasopressors requirement, without significant differences between cohorts. Preoperative CPR was performed in 37.3% (22/59), without a significant difference between cohorts. More VA-ECMO presented with questionable neurologic status (GCS ≤ 4) [9/27 (33.3%) vs 2/32 (6.2%), P = 0.008] and more VA-ECMO failed thrombolysis [8/27 (29.6) vs 2/32 (6.3), P = 0.014]. All presented with severe RV dysfunction, by discharge all had normalization of echocardiographic RV function. Overall mortality was 10.2%, with a trend toward higher mortality among VA-ECMO [14.9% (4/27) vs 6.3% (2/32) P = 0.14]. CPR was independently associated with death (OR 10.8, P = 0.02) whereas treatment modality was not (OR 0.24). In an extremely unstable MPE population VA-ECMO and SE were safely performed with low mortality while achieving RV recovery. Adverse outcomes were more closely associated with preoperative CPR than with treatment modality.

Variations in Mitral Valve Leaflet and Scallop Anatomy on Three-Dimensional Transesophageal Echocardiography.

BACKGROUND: Textbook depictions of the mitral valve (MV) often illustrate it as composed of a single nonscalloped anterior leaflet, with the posterior leaflet having three symmetric and evenly spaced scallops. However, common variations in this anatomy have been noted in autopsy series for decades. Improved cardiac imaging with three-dimensional transesophageal echocardiography (TEE) now affords the ability to detect variations in scallop anatomy in vivo. The aims of this study were to catalog variations in mitral anatomy and to examine for association with mitral regurgitation in patients referred for clinical three-dimensional TEE. METHODS: Three-dimensional transesophageal echocardiographic images of the MV from 107 subjects were reviewed for MV variations. Three-dimensional analysis software was used to characterize mitral leaflet anatomy and assess the relative sizes of posterior leaflet scallops. RESULTS: Variations from the classic MV configuration were seen in 58.9%. Symmetric variations in the posterior leaflet (dominant P2 scallop, accessory P2 scallop, absent P2 scallop, and dichotomous P2 scallop) were seen in 33.6% of the study group. Asymmetric variants in the posterior leaflet (fused P1 and P2, fused P2 and P3, commissural scallop, accessory scallops, dichotomous P1 or P3, and dominant P2 or P3) were seen in 24.3%. Indentations or folds in the anterior leaflet were noted in 5.6%. Leaflet variations were not associated with patient demographics, indication for TEE, mitral regurgitation, mitral annular dimensions, or Carpentier class. CONCLUSIONS: Mitral leaflet morphologic variants were well characterized using three-dimensional TEE. Variants are common and were present with a frequency consistent with autopsy series. Mitral scallop variations were not associated with mitral regurgitation.

Predictors of cardiac hepatopathy in patients with right heart failure.

BACKGROUND: Some patients with right heart failure develop cardiac hepatopathy (CH). The pathophysiology of CH is thought to be secondary to hepatic venous congestion and arterial ischemia. We sought to define the clinical and hemodynamic characteristics associated with CH. MATERIAL/METHODS: A retrospective cross sectional analysis was performed in which subjects were identified from our institutional cardiology database if echocardiography showed either right ventricular (RV) hypokinesis or dilatation, and was performed within 30 days of right heart catheterization. A chart review was then performed to identify patient clinical characteristics and to determine if the patients had underlying liver disease. Subjects with non-cardiac causes for hepatopathy were excluded. RESULTS: In 188 included subjects, etiology for right heart dysfunction included left heart failure (LHF), shunt, pulmonary hypertension, mitral- tricuspid- and pulmonic valvular disease. On multivariate analysis, higher RV diastolic pressure and etiology for RV dysfunction other than LHF were both associated with CH. Low cardiac output was associated with CH only amongst those without LHF. CONCLUSIONS: CH is most often seen in subjects with elevated RV diastolic pressure suggesting a congestive cause in most cases. CH associated with low cardiac output in patients without LHF suggests that low flow may be contributing to the patophysiology in some cases.

Pulmonary Artery Denervation as an Innovative Treatment for Pulmonary Hypertension With and Without Heart Failure.

Pulmonary hypertension (PH) is categorized into 5 groups based on etiology. The 2 most prevalent forms are pulmonary arterial hypertension (PAH) and PH due to left heart disease (PH-LHD). Therapeutic options do exist for PAH to decrease symptoms and improve functional capacity; however, the mortality rate remains high and clinical improvements are limited. PH-LHD is the most common cause of PH; however, no treatment exists and the use of PAH-therapies is discouraged. Pulmonary artery denervation (PADN) is an innovative catheter-based ablation technique targeting the afferent and efferent fibers of a baroreceptor reflex in the main pulmonary artery (PA) trunk and its bifurcation. This reflex is involved in the elevation of the PA pressure seen in PH. Since 2013, both animal trials and human trials have shown the efficacy of PADN in improving PAH, including improved hemodynamic parameters, increased functional capacity, decreased PA remodeling, and much more. PADN has been shown to decrease the rate of rehospitalization, PH-related complications, and death, and is an overall safe procedure. PADN has also been shown to be effective for PH-LHD. Additional therapeutic mechanisms and benefits of PADN are discussed along with new PADN techniques. PADN has shown efficacy and safety as a potential treatment option for PH.

Treatment of Peripheral Pulmonary Artery Stenosis.

Peripheral pulmonary artery stenosis (PAS) is an abnormal narrowing of the pulmonary vasculature and can form anywhere within the pulmonary artery tree. PAS is a congenital or an acquired disease, and its severity depends on the etiology, location, and number of stenoses. Most often seen in infants and young children, some symptoms include shortness of breath, fatigue, and tachycardia. Symptoms can progressively worsen over time as right ventricular pressure increases, leading to further complications including pulmonary artery hypertension and systolic and diastolic dysfunctions. The current treatment options for PAS include simple balloon angioplasty, cutting balloon angioplasty, and stent placement. Simple balloon angioplasty is the most basic therapeutic option for proximally located PAS. Cutting balloon angioplasty is utilized for more dilation-resistant PAS vessels and for more distally located PAS. Stent placement is the most effective option seen to treat the majority of PAS; however, it requires multiple re-interventions for serial dilations and is generally reserved for PAS vessels that are resistant to angioplasty.

Disparities in emptying velocity within the left atrial appendage.

AIMS: Pulsed Doppler measurement of left atrial appendage (LAA) emptying velocity, a marker of left atrium contractile function, has been shown to predict success of cardioversion, thrombo-embolic risk, and maintenance of sinus rhythm after cardioversion and pulmonary vein isolation. However, in the published literature, emptying velocity measurement location is not uniform, and no standard currently exists. We assessed the hypothesis that emptying velocity when acquired near the LAA orifice differs from that at the LAA apex. METHODS AND RESULTS: The study group comprised 44 patients (32 in sinus rhythm and 12 in atrial fibrillation) who were able to complete a non-emergent transoesophageal echocardiography. Pulsed Doppler recordings were obtained with the sample volume first positioned 1 cm from the LAA orifice, and then positioned within 1 cm of the LAA apex. At each location, we calculated the average of the peak end-diastolic LAA emptying velocity from five consecutive cardiac cycles. LAA orifice emptying velocity was higher than the apex emptying velocity in all patients. The median velocity at the orifice was 72 cm/s, which was 45% higher than the median velocity at the apex (43 cm/s, P < 0.001). Lower LAA emptying velocity at the orifice was associated with a larger discrepancy between orifice and apex velocities. The ratio of orifice to apex velocity did not vary with orifice velocity. Multivariate analysis demonstrated that clinical patient characteristics were not significant predictors of the discrepancy between orifice and apex velocities. CONCLUSION: LAA emptying velocity is greater at the LAA orifice compared with the LAA apex. Higher, more easily measured velocity and greater variability observed with orifice measurements make it the location of choice for research and clinical applications.

Occult double RV physiology complicating VSD repair.

Double-chamber right ventricle (DCRV) is an uncommon congenital abnormality usually described in children. It occurs due to partitioning of the right ventricle by prominent muscle bundles. In this case report, we describe an adult in cardiogenic shock postoperatively from repair of a ventricular septal defect in whom a previously undiagnosed DCRV was found to be clinically significant.

Pacing at accelerated heart rate during echocardiography-guided atrioventricular optimisation following cardiac resynchronisation therapy.

INTRODUCTION: Although echo-guided atrioventricular optimisation (AVO) is standardly performed at rest, this approach may not provide optimal AV synchrony during daily activities. MATERIAL AND METHODS: The AVO protocol at one of two hospital campuses had been modified to be performed while pacing at an accelerated heart rate. We tested if this approach would improve the yield from AVO compared to the other campus, where AVO was performed at the intrinsic sinus rate. RESULTS: Between campuses, no significant differences were seen in demographics, chamber sizes, left ventricular ejection fraction, and diastolic function grade. Those having AVO at C2 were more likely to demonstrate "fusion prone" physiology (36% vs. 9%; p = 0.006) and were more likely to display either "truncation- or fusion-prone" physiology (58% vs. 27%; p = 0.007). CONCLUSIONS: When AVO was performed at an accelerated heart rate, patients with "truncation-prone" or "fusion-prone" physiology were identified more readily.

Heightened risk of cardiac events following percutaneous coronary intervention for cocaine-associated myocardial infarction.

INTRODUCTION: Several works have suggested heightened risk for cardiac events in cocaine users following percutaneous coronary intervention (PCI). Such studies have generally been performed in small, poorly defined samples and have not utilised optimal control groups. We aimed to define the short-term risk for death or recurrent myocardial infarction (MI) when PCI was performed for myocardial infarction in subjects presenting with urine toxicology positive for cocaine in relation to subjects testing negative for cocaine use. MATERIAL AND METHODS: Our institutional electronic health record (EHR) was queried for all subjects with urine toxicology performed for cocaine exposure within 5 days before or after having elevated troponin-T assay between 1/1/08 and 12/31/13. Query results were cross-referenced with our institutional cardiology database to identify the sample who had PCI on the same admission as the cocaine test. Subsequent readmission for MI was assessed from the EHR, and deaths were identified from the National Death Index. RESULTS: PCI had been performed in 380 subjects who tested negative for cocaine and 44 subjects who tested positive. In the cocaine-positive group, incidences of death or MI at 30 days and 1 year were 18% and 23%, respectively. Those who tested positive for cocaine had increased odds (odds ratio (OR) = 2.3, 95% confidence interval (CI): 1.0-5.1, p = 0.04) for death or MI at 30 days post PCI, after adjustment for age, sex, prior MI, and comorbidity index. Although the odds for events 1-year post PCI were not increased (OR = 2.0, 95% CI: 0.9-4.3), the p-value approached significance in this small sample (p = 0.09). CONCLUSIONS: This retrospective study suggests that PCI performed in cocaine-associated myocardial infarction comes with a high 30-day and one-year risk. Further prospective studies are needed to better define this risk and to lend insight into better management strategies.