Cardiac remodeling after large ST-elevation myocardial infarction in the current therapeutic era.

BACKGROUND: The evolution and clinical impact of cardiac remodeling after large ST-elevation myocardial infarction (STEMI) is not well delineated in the current therapeutic era. METHODS: The PRESERVATION I trial longitudinally assessed cardiac structure and function in STEMI patients receiving primary percutaneous coronary intervention (PCI). Echocardiograms were performed immediately post-PCI and at 1, 3, 6 and 12 months after STEMI. The extent of cardiac remodeling was assessed in patients with ejection fraction (EF) ≤ 40% after PCI. Patients were stratified by the presence or absence of reverse remodeling, defined as an increase in end-diastolic volume (EDV) of ≤10 mL or decrease in EDV at 1 month, and evaluated for an association with adverse events at 1 year. RESULTS: Of the 303 patients with large STEMI enrolled in PRESERVATION I, 225 (74%) had at least moderately reduced systolic function (mean EF 32 ±â€¯5%) immediately after primary PCI. In the following year, there were significant increases in EF and LV volumes, with the greatest magnitude of change occurring in the first month. At 1 month, 104 patients (46%) demonstrated reverse remodeling, which was associated with a significantly lower rate of death, recurrent myocardial infarction and repeat cardiovascular hospitalization at 1 year (HR 0.44; 95% CI: 0.19-0.99). CONCLUSION: Reduced EF after large STEMI and primary PCI is common in the current therapeutic era. The first month following primary reperfusion is a critical period during which the greatest degree of cardiac remodeling occurs. Patients demonstrating early reverse remodeling have a significantly lower rate of adverse events in the year after STEMI.

Effect of Algorithm-Based Therapy vs Usual Care on Clinical Success and Serious Adverse Events in Patients with Staphylococcal Bacteremia: A Randomized Clinical Trial.

Importance: The appropriate duration of antibiotics for staphylococcal bacteremia is unknown. Objective: To test whether an algorithm that defines treatment duration for staphylococcal bacteremia vs standard of care provides noninferior efficacy without increasing severe adverse events. Design, Setting, and Participants: A randomized trial involving adults with staphylococcal bacteremia was conducted at 16 academic medical centers in the United States (n = 15) and Spain (n = 1) from April 2011 to March 2017. Patients were followed up for 42 days beyond end of therapy for those with Staphylococcus aureus and 28 days for those with coagulase-negative staphylococcal bacteremia. Eligible patients were 18 years or older and had 1 or more blood cultures positive for S aureus or coagulase-negative staphylococci. Patients were excluded if they had known or suspected complicated infection at the time of randomization. Interventions: Patients were randomized to algorithm-based therapy (n = 255) or usual practice (n = 254). Diagnostic evaluation, antibiotic selection, and duration of therapy were predefined for the algorithm group, whereas clinicians caring for patients in the usual practice group had unrestricted choice of antibiotics, duration, and other aspects of clinical care. Main Outcomes and Measures: Coprimary outcomes were (1) clinical success, as determined by a blinded adjudication committee and tested for noninferiority within a 15% margin; and (2) serious adverse event rates in the intention-to-treat population, tested for superiority. The prespecified secondary outcome measure, tested for superiority, was antibiotic days among per-protocol patients with simple or uncomplicated bacteremia. Results: Among the 509 patients randomized (mean age, 56.6 [SD, 16.8] years; 226 [44.4%] women), 480 (94.3%) completed the trial. Clinical success was documented in 209 of 255 patients assigned to algorithm-based therapy and 207 of 254 randomized to usual practice (82.0% vs 81.5%; difference, 0.5% [1-sided 97.5% CI, -6.2% to ∞]). Serious adverse events were reported in 32.5% of algorithm-based therapy patients and 28.3% of usual practice patients (difference, 4.2% [95% CI, -3.8% to 12.2%]). Among per-protocol patients with simple or uncomplicated bacteremia, mean duration of therapy was 4.4 days for algorithm-based therapy vs 6.2 days for usual practice (difference, -1.8 days [95% CI, -3.1 to -0.6]). Conclusions and Relevance: Among patients with staphylococcal bacteremia, the use of an algorithm to guide testing and treatment compared with usual care resulted in a noninferior rate of clinical success. Rates of serious adverse events were not significantly different, but interpretation is limited by wide confidence intervals. Further research is needed to assess the utility of the algorithm. Trial Registration: ClinicalTrials.gov Identifier: NCT01191840.

The Role for Cardiovascular Remodeling in Cardiovascular Outcomes.

PURPOSE OF REVIEW: Ischemic and non-ischemic injury to the heart causes deleterious changes in ventricular size, shape, and function. This adverse remodeling is mediated by neurohormonal and hemodynamic alterations and is reflected in non-invasive measures of left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), and left ventricular end-diastolic volume (LVEDV). These measures are closely linked to cardiovascular outcomes and have become key surrogate endpoints for evaluating the therapeutic efficacy of contemporary treatments for heart failure with reduced ejection fraction (HFrEF). In this review, we critically evaluate recent published data (2015-2016) from randomized clinical trials (RCTs) and observational studies of HFrEF therapies to assess the role of ventricular remodeling on outcomes. RECENT FINDINGS: These data highlight the benefits of certain guideline-directed medical therapies (GDMT) such as cardiac resynchronization therapy, surgical revascularization, and mechanical circulatory support on remodeling, while revealing the limitations of other therapies-routine mitral valve repair for patients with moderate ischemic mitral regurgitation and adjuncts to percutaneous coronary intervention in patients with ST elevation myocardial infarction (cyclosporine A and bioabsorbable cardiac matrix). The new angiotensin receptor blocker/neprilysn inhibitor, sacubitril/valsartan, demonstrates convincing improvements in clinical outcomes with a study of remodeling parameters to follow; the new cardiac myosin activator, omecamtiv mecarbil, demonstrates improvement in remodeling parameters without a clear early clinical benefit. The concepts and contemporary trials reviewed in this paper reinforce the value of non-invasive measures of ventricular remodeling (LVEF, LVESV, and LVEDV) as important metrics across a range of cardiovascular therapies. Global non-invasive measures of cardiovascular remodeling have roughly paralleled or preceded hard clinical outcomes. Additionally, the capacity for reverse remodeling in HFrEF with GDMT motivates continued research in the fields of implementation science, diagnostic imaging, and gene-based therapeutics.

Relationship of T2-Weighted MRI Myocardial Hyperintensity and the Ischemic Area-At-Risk.

RATIONALE: After acute myocardial infarction (MI), delineating the area-at-risk (AAR) is crucial for measuring how much, if any, ischemic myocardium has been salvaged. T2-weighted MRI is promoted as an excellent method to delineate the AAR. However, the evidence supporting the validity of this method to measure the AAR is indirect, and it has never been validated with direct anatomic measurements. OBJECTIVE: To determine whether T2-weighted MRI delineates the AAR. METHODS AND RESULTS: Twenty-one canines and 24 patients with acute MI were studied. We compared bright-blood and black-blood T2-weighted MRI with images of the AAR and MI by histopathology in canines and with MI by in vivo delayed-enhancement MRI in canines and patients. Abnormal regions on MRI and pathology were compared by (a) quantitative measurement of the transmural-extent of the abnormality and (b) picture matching of contours. We found no relationship between the transmural-extent of T2-hyperintense regions and that of the AAR (bright-blood-T2: r=0.06, P=0.69; black-blood-T2: r=0.01, P=0.97). Instead, there was a strong correlation with that of infarction (bright-blood-T2: r=0.94, P<0.0001; black-blood-T2: r=0.95, P<0.0001). Additionally, contour analysis demonstrated a fingerprint match of T2-hyperintense regions with the intricate contour of infarcted regions by delayed-enhancement MRI. Similarly, in patients there was a close correspondence between contours of T2-hyperintense and infarcted regions, and the transmural-extent of these regions were highly correlated (bright-blood-T2: r=0.82, P<0.0001; black-blood-T2: r=0.83, P<0.0001). CONCLUSION: T2-weighted MRI does not depict the AAR. Accordingly, T2-weighted MRI should not be used to measure myocardial salvage, either to inform patient management decisions or to evaluate novel therapies for acute MI.

Relationships between cardiac magnetic resonance imaging abnormalities in the inter-ventricular septum and Selvester QRS scoring criteria for anterior-septal myocardial infarction in patients with right ventricular volume overload.

BACKGROUND: Patients with ostium secundum atrial septal defects (ASDs) were studied to determine the prevalence of Selvester anteroseptal myocardial infarction QRS points, and to test the hypothesis that there is a relationship between these criteria and thinning and/or scarring of the inter-ventricular septum (IVS). METHODS: Demographic, electrocardiographic (ECG), and cardiac magnetic resonance imaging (CMR) data were acquired on 46 patients with a secundum ASD closed percutaneously. Selvester QRS scoring on patient ECGs was performed for areas representing the anteroseptal region of the left ventricle (LV). The IVS to LV free wall thickness ratio was used to assess thinning of the IVS while late gadolinium enhancement (LGE) of the IVS was used for scarring; both using CMR. RESULTS: Twenty-four (52%) patients scored Selvester QRS points in the anteroseptal region with a mean score of 2.6±1.8. The mean IVS/LV free wall thickness ratio at the basal level and mid-ventricular level was 1.1±0.3 and 1.3±0.3, respectively. There was no association of Selvester QRS points with IVS/LV free wall ratio at the basal (p=0.59) or mid-ventricular (p=0.13) levels. The one patient with LGE in the IVS had 4 Selvester anteroseptal QRS points. CONCLUSION: The results of our study demonstrate that in our patient population there is a 52% prevalence of Selvester anteroseptal QRS points which are due to thinning and/or scarring of the IVS in only one patient.

Clinical characteristics and outcome of infective endocarditis involving implantable cardiac devices.

CONTEXT: Infection of implantable cardiac devices is an emerging disease with significant morbidity, mortality, and health care costs. OBJECTIVES: To describe the clinical characteristics and outcome of cardiac device infective endocarditis (CDIE) with attention to its health care association and to evaluate the association between device removal during index hospitalization and outcome. DESIGN, SETTING, AND PATIENTS: Prospective cohort study using data from the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS), conducted June 2000 through August 2006 in 61 centers in 28 countries. Patients were hospitalized adults with definite endocarditis as defined by modified Duke endocarditis criteria. MAIN OUTCOME MEASURES: In-hospital and 1-year mortality. RESULTS: CDIE was diagnosed in 177 (6.4% [95% CI, 5.5%-7.4%]) of a total cohort of 2760 patients with definite infective endocarditis. The clinical profile of CDIE included advanced patient age (median, 71.2 years [interquartile range, 59.8-77.6]); causation by staphylococci (62 [35.0% {95% CI, 28.0%-42.5%}] Staphylococcus aureus and 56 [31.6% {95% CI, 24.9%-39.0%}] coagulase-negative staphylococci); and a high prevalence of health care-associated infection (81 [45.8% {95% CI, 38.3%-53.4%}]). There was coexisting valve involvement in 66 (37.3% [95% CI, 30.2%-44.9%]) patients, predominantly tricuspid valve infection (43/177 [24.3%]), with associated higher mortality. In-hospital and 1-year mortality rates were 14.7% (26/177 [95% CI, 9.8%-20.8%]) and 23.2% (41/177 [95% CI, 17.2%-30.1%]), respectively. Proportional hazards regression analysis showed a survival benefit at 1 year for device removal during the initial hospitalization (28/141 patients [19.9%] who underwent device removal during the index hospitalization had died at 1 year, vs 13/34 [38.2%] who did not undergo device removal; hazard ratio, 0.42 [95% CI, 0.22-0.82]). CONCLUSIONS: Among patients with CDIE, the rate of concomitant valve infection is high, as is mortality, particularly if there is valve involvement. Early device removal is associated with improved survival at 1 year.

Cardiovascular complications of breast cancer therapy in older adults.

Older adults frequently have pre-existing and cancer-related risk factors for cardiovascular toxicity from cancer treatment. In this review, we discuss the risk factors and strategies for prevention and management of cardiovascular complications in older women with breast cancer.

Resolution and Speckle Reduction in Cardiac Imaging.

Cardiac imaging depends on clear visualization of several different structural and functional components to determine left ventricular and overall cardiac health. Ultrasound imaging is confounded by the characteristic speckle texture resulting from subwavelength scatterers in tissues, which is similar to a multiplicative noise on underlying tissue structure. Reduction of this texture can be achieved through physical means, such as spatial or frequency compounding, or through adaptive image processing. Techniques in both categories require a tradeoff of resolution for speckle texture reduction, which together contribute to overall image quality and diagnostic value. We evaluate this tradeoff for cardiac imaging tasks using spatial compounding as an exemplary speckle reduction method. Spatial compounding averages the decorrelated speckle patterns formed by views of a target from multiple subaperture positions to reduce the texture at the expense of active aperture size (and, in turn, lateral resolution). We demonstrate the use of a novel synthetic aperture focusing technique to decompose harmonic backscattered data from focused beams to their aperture-domain spatial frequency components to enable combined transmit and receive compounding. This tool allows the evaluation of matched data sets from a single acquisition over a wide range of spatial compounding conditions. We quantified the tradeoff between resolution and texture reduction in an imaging phantom and demonstrated improved lesion detectability with increasing levels of spatial compounding. We performed a cardiac ultrasound on 25 subjects to evaluate the degree of compounding useful for diagnostic imaging. Of these, 18 subjects were included in both qualitative and quantitative analysis. We found that compounding improved detectability of the endocardial border according to the generalized contrast-to-noise ratio in all cases, and more aggressive compounding made further improvements in ten out of 18 cases. Three expert reviewers evaluated the images for their usefulness in several diagnostic tasks and ranked four compounding conditions ("none," "low," "medium," and "high"). Contrary to the quantitative metrics that suggested the use of high levels of compounding, the reviewers determined that "low" was usually preferred (77.9%), while "none" or "medium" was selected in 21.2% of cases. We conclude with a brief discussion of the generalization of these results to other speckle reduction methods using the imaging phantom data.

Evaluation of Women and Underrepresented Racial and Ethnic Group Representation in a General Cardiology Fellowship After a Systematic Recruitment Initiative.

Importance: The proportion of women and underrepresented racial and ethnic groups (UREGs) matriculating into general cardiology fellowships remains low. Objective: To assess a systematic recruitment initiative aimed at ensuring adequate matriculation of women and UREGs in a general cardiology fellowship. Design, Setting, and Participants: This quality improvement study took place at a large, tertiary academic medical center and associated Accreditation Council for Graduate Medical Education Cardiovascular Disease fellowship. Participants included cardiology fellowship and divisional leadership and general cardiology fellow applicants to the Duke Cardiovascular Disease Fellowship Program from 2017 to 2019. Data analysis was performed from December 2019 to May 2020. Exposure: Multipronged initiative that created an environment committed to ensuring equity of opportunity. This included the creation of a fellowship diversity and inclusivity task force that drafted recommendations, which included reorganization of the fellowship recruitment committee, and changes to the applicant screening process, the interview day, applicant ranking process, and postmatch interventions. Main Outcomes and Measures: The percentage of matriculating and overall women and UREGs before and after the interventions were recorded. Results: The fellowship received a mean (SD) of 462 (55) applications annually before the interventions (2006-2016) and 611 (27) applications annually after the interventions (2017-2019). Between the 10-year period before the interventions and the 3-year period during the interventions, there was a significant increase in the annual mean (SD) percentage of women (22.4% [2.9%] vs 26.4% [0.07%]; P < .001) and UREG applicants (10.5% [1.1%] vs 12.5% [1.9%]; P = .01) to the program. Among applicants interviewed, the percentage of women increased from 20.0% to 33.5% (P = .01) and that of and UREGs increased from 14.0% to 20.0% (P = .01). Before the interventions, a mean (SD) of 23.2% (16.2%) women and 9.7% (7.8%) UREGs matriculated as first-year fellows, whereas after the interventions, a mean (SD) of 54.2% (7.2%) women and 33.3% (19.0%) UREGs matriculated as first-year fellows. The proportion of the entire fellowship who were women increased from a 5-year mean (SD) of 27.0% (8.8%) to 54.2% (7.2%) after 3 years of interventions, and that of UREGs increased from 5.6% (4.6%) to 33.3% (19.0%). Overall, the proportion of applicants in the entire population who were either women or from UREGs increased from 27.8% to 66.7%. Conclusions and Relevance: After implementing interventions to promote equity of opportunity in the cardiovascular disease fellowship, the percentage of women and UREGs significantly increased in the fellowship over a 3-year time period. These interventions may be applicable to other cardiovascular disease fellowships seeking to diversify training programs.

Prevalence and clinical characteristics associated with left atrial appendage thrombus in fully anticoagulated patients undergoing catheter-directed atrial fibrillation ablation.

INTRODUCTION: Catheter-directed atrial fibrillation (AF) ablation is contraindicated among patients with left atrial appendage (LAA) thrombus. The prevalence of LAA thrombus among fully anticoagulated patients undergoing AF ablation is unknown. METHODS AND RESULTS: We retrospectively evaluated the prevalence of LAA thrombus among 192 consecutive patients undergoing AF ablation between July 2006 and January 2009. Seven of 192 patients (3.6%) had evidence of thrombus on transesophageal echocardiogram (TEE) despite being fully anticoagulated on warfarin (international normalized ratio [INR] 2-3) for 4 consecutive weeks prior to echocardiogram. Univariate analysis demonstrated that structural heart disease, large left atrial dimension, and number of AF ablations were associated with thrombus. Three patients with thrombus had paroxysmal AF with normal LV function. CONCLUSION: Despite full anticoagulation, 3.6% of patients undergoing AF ablation had LAA thrombus. We recommend that all patients, regardless of LV function or left atrial size, should undergo preprocedural TEE to exclude the presence of LAA thrombus.

The utility of modified Butler-Leggett criteria for right ventricular hypertrophy in detection of clinically significant shunt ratio in ostium secundum-type atrial septal defect in adults.

BACKGROUND: This study was performed to test the hypothesis that there exists a correlation between the Butler-Leggett (BL) criterion for right ventricular hypertrophy on the electrocardiogram and the Qp/Qs shunt ratio in adults with ostium secundum atrial septal defects (ASDs). METHODS: Demographic, cardiac catheterization, ASD closure, and electrocardiographic data were acquired on 70 patients with secundum ASDs closed percutaneously. Simple linear regression and logistic regression models were created to test the hypothesis. RESULTS: The mean Qp/Qs ratio and BL criterion value were 1.61 +/- 0.46 and 0.11 +/- 0.41, respectively. The BL criterion values correlated with shunt ratios (r(2) = 0.11 and P = .004). A BL criterion value greater than 0 mV predicted a significant shunt ratio (Qp/Qs > or = 1.5) (odds ratio, 4.8; 95% confidence interval, 1.3, 18.1; P = or <.0001) with a sensitivity of 0.68 and specificity of 0.65. CONCLUSION: Our results indicate that there is limited utility of the BL criterion at detecting right ventricular volume overload, although a BL criterion value greater than 0 mV being used to identify patients with significant intracardiac shunts yielded a sensitivity of 0.68 and specificity of 0.65.

Perceptions on Diversity in Cardiology: A Survey of Cardiology Fellowship Training Program Directors.

Background The lack of diversity in the cardiovascular physician workforce is thought to be an important driver of racial and sex disparities in cardiac care. Cardiology fellowship program directors play a critical role in shaping the cardiology workforce. Methods and Results To assess program directors' perceptions about diversity and barriers to enhancing diversity, the authors conducted a survey of 513 fellowship program directors or associate directors from 193 unique adult cardiology fellowship training programs. The response rate was 21% of all individuals (110/513) representing 57% of US general adult cardiology training programs (110/193). While 69% of respondents endorsed the belief that diversity is a driver of excellence in health care, only 26% could quote 1 to 2 references to support this statement. Sixty-three percent of respondents agreed that "our program is diverse already so diversity does not need to be increased." Only 6% of respondents listed diversity as a top 3 priority when creating the cardiovascular fellowship rank list. Conclusions These findings suggest that while program directors generally believe that diversity enhances quality, they are less familiar with the literature that supports that contention and they may not share a unified definition of "diversity." This may result in diversity enhancement having a low priority. The authors propose several strategies to engage fellowship training program directors in efforts to diversify cardiology fellowship training programs.

Unrecognized non-Q-wave myocardial infarction: prevalence and prognostic significance in patients with suspected coronary disease.

BACKGROUND: Unrecognized myocardial infarction (UMI) is known to constitute a substantial portion of potentially lethal coronary heart disease. However, the diagnosis of UMI is based on the appearance of incidental Q-waves on 12-lead electrocardiography. Thus, the syndrome of non-Q-wave UMI has not been investigated. Delayed-enhancement cardiovascular magnetic resonance (DE-CMR) can identify MI, even when small, subendocardial, or without associated Q-waves. The aim of this study was to investigate the prevalence and prognosis associated with non-Q-wave UMI identified by DE-CMR. METHODS AND FINDINGS: We conducted a prospective study of 185 patients with suspected coronary disease and without history of clinical myocardial infarction who were scheduled for invasive coronary angiography. Q-wave UMI was determined by electrocardiography (Minnesota Code). Non-Q-wave UMI was identified by DE-CMR in the absence of electrocardiographic Q-waves. Patients were followed to determine the prognostic significance of non-Q-wave UMI. The primary endpoint was all-cause mortality. The prevalence of non-Q-wave UMI was 27% (50/185), compared with 8% (15/185) for Q-wave UMI. Patients with non-Q-wave UMI were older, were more likely to have diabetes, and had higher Framingham risk than those without MI, but were similar to those with Q-wave UMI. Infarct size in non-Q-wave UMI was modest (8%+/-7% of left ventricular mass), and left ventricular ejection fraction (LVEF) by cine-CMR was usually preserved (52%+/-18%). The prevalence of non-Q-wave UMI increased with the extent and severity of coronary disease on angiography (p<0.0001 for both). Over 2.2 y (interquartile range 1.8-2.7), 16 deaths occurred: 13 in non-Q-wave UMI patients (26%), one in Q-wave UMI (7%), and two in patients without MI (2%). Multivariable analysis including New York Heart Association class and LVEF demonstrated that non-Q-wave UMI was an independent predictor of all-cause mortality (hazard ratio [HR] 11.4, 95% confidence interval [CI] 2.5-51.1) and cardiac mortality (HR 17.4, 95% CI 2.2-137.4). CONCLUSIONS: In patients with suspected coronary disease, the prevalence of non-Q-wave UMI is more than 3-fold higher than Q-wave UMI. The presence of non-Q-wave UMI predicts subsequent mortality, and is incremental to LVEF. TRIAL REGISTRATION: Clinicaltrials.gov NCT00493168.

Improved Visualization in Difficult-to-Image Stress Echocardiography Patients Using Real-Time Harmonic Spatial Coherence Imaging.

Stress echocardiography is used to detect myocardial ischemia by evaluating cardiovascular function both at rest and at elevated heart rates. Stress echocardiography requires excellent visualization of the left ventricle (LV) throughout the cardiac cycle. However, LV endocardial border visualization is often negatively impacted by high levels of clutter associated with patient obesity, which has risen dramatically worldwide in recent decades. Short-lag spatial coherence (SLSC) imaging has demonstrated reduced clutter in several applications. In this work, a computationally efficient formulation of SLSC was implemented into an object-oriented graphics processing unit-based software beamformer, enabling real-time (>30 frames per second) SLSC echocardiography on a research ultrasound scanner. The system was then used to image 15 difficult-to-image stress echocardiography patients in a comparison study of tissue harmonic imaging (THI) and harmonic spatial coherence imaging (HSCI). Video clips of four standard stress echocardiography views acquired with either THI or HSCI were provided in random shuffled order to three experienced readers. Each reader rated the visibility of 17 LV segments as "invisible," "suboptimally visualized," or "well visualized," with the first two categories indicating a need for contrast agent. In a symmetry test unadjusted for patientwise clustering, HSCI demonstrated a clear superiority over THI ( ). When measured on a per-patient basis, the median total score significantly favored HSCI with . When collapsing the ratings to a two-level scale ("needs contrast" versus "well visualized"), HSCI once again showed an overall superiority over THI, with by McNemar test adjusted for clustering.

Venous thrombosis in patients with short- and long-term central venous catheter-associated Staphylococcus aureus bacteremia.

OBJECTIVE: Infection and thrombosis are important complications of intravascular catheters. The purpose of this study was to determine the incidence of thrombosis in patients with central venous catheter-associated Staphylococcus aureus bacteremia and the utility of physical examination for diagnosing upper extremity or neck venous thrombosis. DESIGN: Prospective observational cohort. SETTING: Tertiary care facility. PATIENTS: In all, 65 consecutive patients with catheter-associated S. aureus bacteremia with central venous catheters of the internal jugular, brachial, or subclavian veins were eligible for participation. INTERVENTION: From July 1999 through August 2004, enrolled patients underwent physical examination and ultrasonography independently to identify the presence of catheter-associated thrombosis. Study ultrasonograms were interpreted blindly using defined criteria. Outcomes were defined at 12-wk follow-up. MEASUREMENTS AND MAIN RESULTS: A total of 48 patients were enrolled. By ultrasonography, definite or possible thrombosis was present in 34 of 48 patients (71%) in this cohort. Death or recurrent bacteremia occurred in 11/34 (32%) infected patients with thrombosis and two of 14 (14%) infected patients without thrombosis (p = .29). Sensitivity of all physical examination findings, either alone or in combination, was low (< or = 24%). Only engorged veins upon hand elevation and the presence of multiple physical examination abnormalities were specific (100% each). CONCLUSIONS: Thrombosis is a common complication of central venous catheter-associated S. aureus bacteremia. Patients with central venous catheter-associated S. aureus bacteremia should undergo ultrasonography to detect thromboses even if the physical examination is normal.

Crowdsourcing consensus: proposal of a novel method for assessing accuracy in echocardiography interpretation.

Quality in stress echocardiography interpretation is often gauged against coronary angiography (CA) data but anatomic obstructive coronary disease on CA is an imperfect gold standard for a stress induced wall motion abnormality. We examined the utility of crowd-sourcing a "majority-vote" consensus as an alternative 'gold standard' against which to evaluate the accuracy of an individual echocardiographer's interpretation of stress echocardiography studies. Participants independently interpreted baseline and post-exercise stress echocardiographic images of cases that had undergone follow up CA within 3 months of the stress echo in two surveys, 2 years apart. We examined the agreement of consensus on survey (survey participant response (> 60%) for one decision) with the stress echocardiography clinical read and with CA results. In the first survey, 29 participants reviewed and independently interpreted 14 stress echo cases. Consensus was reached in all 14 cases. There was good agreement between clinical and consensus (kappa = 0.57), survey participant response and consensus (kappa = 0.68) and consensus and CA results (kappa = 0.40). In the validation survey, the agreement between clinical reads and consensus (kappa = 0.75) and survey participant response and consensus (kappa = 0.81) remained excellent. Independent consensus is achievable and offers a fair comparison for stress echocardiographic interpretation. Future validation work, in other laboratories, and against hard outcomes, is necessary to test the feasibility and effectiveness of this approach.

Two-dimensional global longitudinal strain is superior to left ventricular ejection fraction in prediction of outcome in patients with left-sided infective endocarditis.

BACKGROUND: Impaired cardiac function is the main predictor of poor outcome in infective endocarditis (IE). Global longitudinal strain (GLS) derived from two-dimensional strain echocardiography has proven superior in prediction of long-term outcome as compared to left ventricular ejection fraction (LVEF) in valvular disease and heart failure in general. Whether measurements of cardiac deformation can predict survival in patients with IE has not previously been investigated. METHODS: The study included consecutive patients with Duke definite IE who underwent transthoracic and transesophageal echocardiography within 7 days. Clinical and echocardiographic markers associated with 1-year survival were identified using a Cox-proportional hazards model that included propensity adjustment for surgery. Reclassification statistics including receiver operating characteristic curves and net reclassification improvement were applied to LVEF and GLS, respectively. RESULTS: A cohort of 190 patients met eligibility criteria. LVEF and GLS were both prognostic markers of mortality. Independent markers of 1-year mortality were S. aureus IE (HR:2.02; 95%CI 1.11-5.72, p = .022), diabetes (HR:2.05; 95%CI 1.12-3.75, p = .020), embolic stroke (HR:3.95; 95%CI 1.93-8.10, p < .001) and LVEF<45% (HR: 3.02; 95% CI 1.70-5.38, p < .001), GLS> -15.4% (HR:2.95; 95%CI 1.52-5.72, p < .001). Adding LVEF<45% to a model with known risk factors of IE did not significantly improve risk classification, whereas addition of GLS to the model resulted in significant increase (AUC = 0.763, p < .001). CONCLUSIONS: When treatment was taken into account, LVEF<45% and GLS > -15.4% were both associated with adverse long-term outcome in left-sided IE. GLS >-15.4 % was significantly associated with 1-year mortality in the multivariate analysis. Further, GLS was superior to LVEF in risk prediction and risk discrimination of long-term outcome in patients with left-sided IE.

Dark-Blood Delayed Enhancement Cardiac Magnetic Resonance of Myocardial Infarction.

OBJECTIVES: This study introduced and validated a novel flow-independent delayed enhancement technique that shows hyperenhanced myocardium while simultaneously suppressing blood-pool signal. BACKGROUND: The diagnosis and assessment of myocardial infarction (MI) is crucial in determining clinical management and prognosis. Although delayed enhancement cardiac magnetic resonance (DE-CMR) is an in vivo reference standard for imaging MI, an important limitation is poor delineation between hyperenhanced myocardium and bright LV cavity blood-pool, which may cause many infarcts to become invisible. METHODS: A canine model with pathology as the reference standard was used for validation (n = 22). Patients with MI and normal controls were studied to ascertain clinical performance (n = 31). RESULTS: In canines, the flow-independent dark-blood delayed enhancement (FIDDLE) technique was superior to conventional DE-CMR for the detection of MI, with higher sensitivity (96% vs. 85%, respectively; p = 0.002) and accuracy (95% vs. 87%, respectively; p = 0.01) and with similar specificity (92% vs, 92%, respectively; p = 1.0). In infarcts that were identified by both techniques, the entire length of the endocardial border between infarcted myocardium and adjacent blood-pool was visualized in 33% for DE-CMR compared with 100% for FIDDLE. There was better agreement for FIDDLE-measured infarct size than for DE-CMR infarct size (95% limits-of-agreement, 2.1% vs. 5.5%, respectively; p < 0.0001). In patients, findings were similar. FIDDLE demonstrated higher accuracy for diagnosis of MI than DE-CMR (100% [95% confidence interval [CI]: 89% to 100%] vs. 84% [95% CI: 66% to 95%], respectively; p = 0.03). CONCLUSIONS: The study introduced and validated a novel CMR technique that improves the discrimination of the border between infarcted myocardium and adjacent blood-pool. This dark-blood technique provides diagnostic performance that is superior to that of the current in vivo reference standard for the imaging diagnosis of MI.

Training cardiovascular specialists in imaging: a curriculum based on fundamental concepts required for multimodal imaging.

BACKGROUND: Training cardiovascular (CV) imaging specialists is becoming increasingly complex owing to rapidly emerging technological advances and the growing recognition that single modality training is inefficient and results in suboptimal education and practice. The purpose of this document was to propose a multimodality CV imaging curriculum to improve training of future CV imaging specialists. METHODS: Relevant national standards relating to aiming training, competence, and quality were reviewed, including current training recommendations from the American College of Cardiology and requirements from the Accreditation Council for Graduate Medical Education. Experts from all imaging modalities identified areas of commonality that could create efficiencies in training. Finally, the proposed curriculum was placed within the context of a standard 3-year fellowship training program with optional advanced imaging training. RESULTS: Multimodality imaging training can be accomplished efficiently and effectively for most trainees by introducing a curriculum of imaging didactic content broadly based on understanding basic cardiovascular anatomy and physiology, principles of performing quality CV imaging, and imaging in the broader health care environment. A curriculum and training program are proposed that satisfy level 2 training in 2 to 3 modalities and level 3 training in 1 modality in a traditional 3-year fellowship. CONCLUSIONS: Training cardiovascular specialists to be competent in multimodality imaging is possible based on the proposed curriculum and training program within a traditional 3-year cardiovascular fellowship. Imaging specialists may require additional training.