Hemodynamic Correlates of Blood Pressure in Older Adults: The Atherosclerosis Risk in Communities (ARIC) Study.

The primary aim of the present study was to identify the hemodynamic correlates of both steady and pulsatile blood pressure (BP) in community-dwelling older adults. In 3762 adults aged 70 to 89 years, significant hemodynamic determinants of both brachial and carotid systolic BP included arterial stiffness as measured by aortic pulse wave velocity, stroke volume (via echocardiography), arterial wave reflection, left ventricular ejection time, and upstroke time. The strongest influence was exerted by arterial stiffness. The steady-state component of blood pressure, mean arterial pressure, was associated with both cardiac index and total peripheral resistance (TPR), but was more strongly associated with TPR. Results were similar when participants taking antihypertensive medications were excluded from analyses. The overall findings suggest that mean arterial pressure is associated strongly with TPR and that significant hemodynamic correlates of systolic BP included arterial stiffness, stroke volume, and arterial wave reflection.

Echocardiography and cardiac MRI in mutation-negative hypertrophic cardiomyopathy in an older patient: a case defining the need for ICD.

We report the case of a 67-year-old man with hypertrophic cardiomyopathy who presented for a second opinion about implantable cardio-defibrillator (ICD) placement after a witnessed syncopal episode. Despite his older age, being mutation-negative, and having a maximal septal thickness of 2.2 cm on echocardiography, he demonstrated rapid progression of myocardial fibrosis on cardiac MRI, correlating to ventricular tachyarrhythmias and syncope. We review the role of echocardiography and cardiac MRI in optimizing medical care for such patients who may not otherwise meet criteria for an ICD placement or further interventions.

Rationale and design of a multicenter echocardiographic study to assess the relationship between cardiac structure and function and heart failure risk in a biracial cohort of community-dwelling elderly persons: the Atherosclerosis Risk in Communities study.

BACKGROUND: Heart failure is an important public health concern, particularly among persons>65 years of age. Women and blacks are critically understudied populations that carry a sizeable portion of the heart failure burden. Limited normative and prognostic data exist on measures of cardiac structure, diastolic function, and novel measures of systolic deformation in older adults living in the community. METHODS AND RESULTS: The Atherosclerosis Risk in Communities (ARIC) study is a large, predominantly biracial, National Heart, Lung, and Blood Institute-sponsored epidemiological cohort study. Between 2011 and 2013, ≈6000 surviving participants, now in their seventh to ninth decade of life, are expected to return for a fifth study visit during which comprehensive 2-dimensional, Doppler, tissue Doppler, and speckle-tracking echocardiography will be performed uniformly in all cohort clinic visit participants. The following objectives will be addressed: (1) to characterize cardiac structural and functional abnormalities among the elderly and to determine how they differ by sex and race/ethnicity, (2) to determine the relationship between ventricular and vascular abnormalities, and (3) to prospectively examine the extent to which these noninvasive measures associate with incident heart failure. CONCLUSIONS: We describe the design, imaging acquisition and analysis methods, and quality assurance metrics for echocardiography in visit 5 of the ARIC cohort. A better understanding of the differences in cardiac structure and function through the spectrum of heart failure stages in elderly persons generally, and between sexes and racial/ethnic groups specifically, will deepen our understanding of the pathophysiology driving heart failure progression in these at-risk populations and may inform novel prevention or therapeutic strategies.

Right ventricular imaging by two-dimensional and three-dimensional echocardiography.

PURPOSE OF REVIEW: The assessment of ventricular systolic performance is one of the most critical roles of echocardiography, often impacting the diagnosis, management, and prognosis of patients with suspected cardiovascular disease. RECENT FINDINGS: Historically, the echocardiographic assessment of diseases affecting the right ventricle has lagged behind that of the left ventricle, despite knowledge demonstrating that diseases affecting the right heart have been shown to have the same clinical consequences as those affecting the left heart. SUMMARY: This up-to-date review of right ventricular imaging by two-dimensional and three-dimensional echocardiography will emphasize the clinical situations for which assessment of right ventricular systolic function is particularly important, and review the systematic assessment of right ventricular regional wall motion in terms of coronary anatomy. Technical and scanning tips designed to optimize the visualization of the right heart with echocardiography with case examples will be presented. Qualitative and quantitative two-dimensional methods for assessing right heart function that are both well established and evolving will be summarized and the case for considering more routine use of ultrasound contrast agents to enhance right ventricular endocardial border definition will be made. The current state of three-dimensional imaging of the right ventricle will be highlighted along with the challenges for making this powerful tool more widespread.

Advanced Cardiovascular Sonographer: a proposal of the American Society of Echocardiography Advanced Practice Sonographer Task Force.

Echocardiographic examinations require a well-trained and competent sonographer to obtain proper anatomic and physiologic data to establish an accurate diagnosis for clinical decision-making and patient management. Although the formal education and training of cardiovascular sonographers are evolving, many entry-level and staff sonographers may not have sufficient practical or clinical knowledge of the necessary components of the echocardiographic study for the individual patient's clinical presentation. In many clinical settings, echocardiograms are read after the patient has left the laboratory. Thus, there is a role for a sonographer who can practice at an advanced level in a cardiovascular ultrasound laboratory to ensure a proper echocardiographic examination is performed on every patient. In this setting, an Advanced Cardiovascular Sonographer (ACS) would be able to review the indication for and quality of the examination. If additional images were needed, the ACS would assist the sonographer in obtaining these images, which would lead to the performance of a complete and fully diagnostic examination before the patient had left the echocardiography laboratory. In clinical practice, the quality of the examinations performed would improve, advancements in echocardiographic methods could be taught and incorporated into daily practice, and patients would be better served. The present report is a proposal from the American Society of Echocardiography Advanced Practice Task Force that identifies the potential of cardiac sonographers to achieve the ACS level.

Cardiac manifestations of Alström syndrome: echocardiographic findings.

BACKGROUND: Alström syndrome is an extremely rare autosomal recessive genetic disorder characterized by infantile-onset cardiomyopathy (CMP), blindness, hearing impairment/loss, and obesity. Prior reports have demonstrated that the dilated CMP of Alström syndrome occurs in about 62% of patients with this syndrome. To date, there have been no reports examining the echocardiographic features of Alström-related heart disease. METHODS: Eleven patients diagnosed with Alström syndrome who underwent one or more transthoracic echocardiograms from 1994 to 2003 were retrospectively evaluated. A total of 16 transthoracic echocardiograms were comprehensively reviewed with an emphasis on chamber sizes, wall thickness, left ventricular (LV) and right ventricular (RV) systolic function, and valve function. RESULTS: Four of 11 patients (36%) had evidence of global LV systolic dysfunction (quantitative ejection fraction [EF] range 9%-29%). Three of these 4 patients also had severe generalized RV systolic dysfunction, whereas one had normal RV systolic function. LV and RV dilation was present in 3 of 4. All patients with low EF had an apically tethered mitral valve closure pattern although only one of 4 had more than mild mitral regurgitation. Although 3 of 4 patients with low EF had an apically tethered tricuspid valve closure pattern, none had more than mild tricuspid regurgitation. Reduced EF was not associated with regional wall-motion abnormalities. Three of 11 patients (27%) overall and two of 4 of the patients with low EF (50%) had pericardial effusions. CONCLUSIONS: The Alström CMP in this cohort of patients was typically dilated and nonsegmental with predominantly biventricular involvement. It was infrequently associated with myocardial hypertrophy. Apically tethered mitral and tricuspid valve closure patterns were visualized, although severe functional valvular insufficiency was not present. LV and left atrial dilation was observed in a number of patients without reduced EF, and may be an early stage in the development of the CMP.

Contrast echocardiography improves the diagnostic yield of transthoracic studies performed in the intensive care setting by novice sonographers.

BACKGROUND: Bedside portable echocardiography in the intensive care department (ICU) is technically difficult, but crucial for directing patient care. Prior studies have shown contrast echocardiography (CE) in the ICU clarifies left ventricular wall motion when performed by experienced sonographers (ESO). However, in most hospitals, ESO are unavailable around the clock, and less experienced cardiovascular fellows or trainees may be asked to perform these examinations. METHODS: Transthoracic echocardiograms were retrospectively evaluated by level III trained echocardiographers for 213 patients in the ICU. Most were performed to assess left ventricular function (65% or 139 of 213) and were scanned by cardiology fellows (70% or 149 of 213) with less than 3 months echocardiography experience. Contrast agent was used in 29% (62 of 213) of all patients. RESULTS: The conversion of suboptimal or diagnostically inadequate apical 4- and 2-chamber views to diagnostically adequate with contrast was statistically significant when performed by both cardiology fellows and ESO (Fischer exact test, P < .0002). CONCLUSIONS: CE is effective in improving the diagnostic yield of transthoracic echocardiographic ICU studies performed by both novice sonographers and ESO. Using cardiology fellows to perform CE in this setting can be appropriate, particularly in after-hour situations, when ESO are not always available and the clinical question is left ventricular function. Results also suggest cardiology fellows can easily learn CE.

Successful surgical repair of a giant left main coronary artery aneurysm with arteriovenous fistula draining into a persistent left superior vena cava and coronary sinus: role of intraoperative transesophageal echocardiography.

We report the case of a 74-year-old woman with a history of hypertension, hypercholesterolemia, and pacemaker who presented to the hospital with new onset New York Heart Association class IV congestive heart failure. Transthoracic echocardiography revealed a markedly dilated right ventricle with normal right ventricular systolic function. There was moderate pulmonary hypertension with an estimated pulmonary artery systolic pressure of 60 mm Hg. Her echocardiogram 1 year earlier had demonstrated normal right ventricular size and systolic function, and no pulmonary hypertension. Additional transthoracic imaging with saline contrast study through a left peripheral vein demonstrated the presence of a dilated coronary sinus with a persistent left superior vena cava. Color Doppler demonstrated turbulent flow within the coronary sinus with evidence of significant left-to-right shunting. Cardiac catheterization revealed a massively dilated left main coronary artery aneurysm with an arteriovenous fistula into the left superior vena cava and coronary sinus. The calculated Qp/Qs was 2:1. The patient underwent 2 unsuccessful attempts at percutaneous intervention to occlude the arteriovenous fistula. She then underwent successful surgical closure of the coronary arteriovenous fistula. The important role of intraoperative transesophageal echocardiography in guiding this technically challenging surgical case is discussed.

Successful repair of aortic and mitral incompetence induced by methylsergide maleate: confirmation by intraoperative transesophageal echocardiography.

Methylsergide maleate, an effective anti-migraine medication, has a well-documented association with left-sided cardiac valve dysfunction. Prior reports have described cardiac valve dysfunction in patients using methylsergide chronically for a minimum of 6 years, with surgical intervention consisting of valve replacement for patients with intractable congestive heart failure. We report a 51-year-old woman who developed severe mitral and aortic valvular dysfunction after taking methylsergide maleate for migraine headaches for a period of 19 months, and who subsequently underwent aortic and mitral valve repair with excellent short-term results.

Anomalous right coronary artery from the main pulmonary artery in a patient with double-chambered right ventricle.

We describe a rare case of double-chambered right ventricle (DCRV) in a 32-year-old female presenting to the echocardiography lab for evaluation of congenital heart disease. We identified a unique constellation of findings, including the DCRV, a perimembranous ventricular septal defect, aortic valve prolapse, patent foramen ovale, and an anomalous right coronary artery coming off the main pulmonary artery. To the best of our knowledge, this is the first reported case describing the association of an anomalous right coronary artery coming off the main pulmonary artery in a patient with DCRV.

Echocardiographic diagnosis of apical hypertrophic cardiomyopathy with optison contrast.

We describe a case of obstructive apical hypertrophic cardiomyopathy in a 61-year-old Caucasian female with a history of chest pain syndrome. The patient was referred to the echo lab by her nuclear cardiologist, who was impressed by her abnormal stress nuclear perfusion scan that showed marked increased uptake of radioisotope at the left ventricular (LV) apex. The patient had deep negative T waves on her electrocardiogram similar to those originally described in the Japanese population. Transthoracic echocardiography with native harmonic imaging was suboptimal for visualizing LV segments. Therefore, 0.5 cc of Optison contrast was given intravenously, with repeat transthoracic imaging confirming the diagnosis. The patient and her family were referred for additional genetic testing and cardiovascular workup.

Transesophageal Echocardiography with Pathological Correlation in Severe Valvular Disease Associated with Fenfluramine-Phentermine.

We describe the case of severe diffuse multivalvular disease associated with fenfluramine-phentermine (Fen-Phen) in a 52-year-old patient who presented to the echocardiography laboratory for evaluation of a new heart murmur and ultimately required isolated aortic valve replacement. The patient was known to have a transthoracic echocardiogram 1 year before starting the diet pill combination that showed no significant valvular disease. Pathological evaluation of the excised aortic valve was consistent with that described with Fen-Phen use. Transesophageal echocardiography played an important role in defining unique features associated with the valvular disease and in intraoperative management of the patient.

Severe Aortic Coarctation in an Adult Without Left Ventricular Hypertrophy Nor Overt Collateral Channels.

We describe an unusual case of periductal carctation of the aorta in a 40-year-old patient presenting to the echocardiography laboratory for evaluation of a heart murmur. Subsequent clinical history revealed easy fatigability, dyspnea on exertion, and hypertension. Despite a lack of left ventricular hypertrophy, aortic coarctation was suggested by echocardiography. It was later confirmed to be severe by multiple additional imaging modalities, despite an absence of overt collateral arterial channels. The importance of echocardiography in the diagnosis of coarctation of the aorta and the management of this complicated patient is discussed.

Aortic valvular disease in adults.

Preview How common is sudden death in patients with aortic valvular disease? Is medical therapy ever helpful? When is valve replacement indicated, and what type of prosthesis should be used? In this article, Drs Mangion and Tighe review current recommendations on these problems and discuss overall management of both aortic stenosis and aortic regurgitation.