Ratio of transmitral early filling velocity to early diastolic strain rate predicts long-term risk of cardiovascular morbidity and mortality in the general population.

Aims: It has previously been demonstrated that the ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) is a significant predictor of cardiac events in specific patient populations. The utility of this measurement to predict cardiovascular events in a general population has not been evaluated. Methods and results: A total of 1238 participants in a general population study underwent a health examination including echocardiography where global longitudinal strain (GLS) and E/e'sr were determined. The primary endpoint was the composite of incident heart failure (HF), acute myocardial infarction (AMI) or cardiovascular death (CVD). During follow-up (median 11 years), 140 (11.3%) participants reached the composite endpoint. E/e'sr was associated with adverse outcome [HR 1.17 95% CI (1.13-1.21); P < 0.001, per 10 cm increase]. After multivariable adjustment for echocardiographic and clinical parameters, E/e'sr remained an independent predictor of the composite endpoint [HR 1.08, 95% CI (1.02-1.13); P = 0.003] as opposed to E/e' [HR 1.03, 95% CI (0.99-1.06); P = 0.11 per 1 unit increase]. Global longitudinal strain modified the relationship between E/e'sr and outcome (P for interaction = 0.015). E/e'sr was a stronger predictor in participants with good systolic function as determined by GLS (GLS > 18%) after multivariable adjustment, when compared to participants with reduced systolic function (GLS < 18%) [HR 1.28 95% CI (1.06-1.54); P = 0.011, and HR 1.08 95% CI (1.02-1.14); P = 0.012, respectively). E/e'sr provided incremental information [Harrell's C-index: 0.839 (0.81-0.87) vs. 0.844 (0.82-0.87); P = 0.045] beyond the SCORE risk chart. Conclusion: In the general population, E/e'sr provides independent and incremental prognostic information regarding cardiovascular morbidity and mortality. Additionally, E/e'sr is a stronger predictor of cardiac events than E/e'.

Lambl's Excrescences: Association with Cerebrovascular Disease and Pathogenesis.

BACKGROUND: Lambl's excrescences (LEx) are detected by transesophageal echocardiography (TEE) and are characterized as thin, elongated, and hypermobile structures located at the leaflets' coaptation point of the heart valves. The association of LEx with cerebrovascular disease (CVD) is still undefined and yet patients with LEx and suspected CVD receive unproven effective antiplatelet or anticoagulant therapy or even undergo valve surgery. Also, the association of LEx with aging and atherogenic, inflammatory, or thrombogenic parameters has not been reported. METHODS: Seventy-seven patients with systemic lupus erythematosus (SLE) (71 women, age 37 ± 12 years) and 26 age- and sex-matched healthy controls (22 women, age 34 ± 11 years) prospectively underwent routine history and physical exam, transcranial Doppler, brain MRI, TEE, carotid duplex, and clinical and laboratory evaluations of atherogenesis, inflammation, platelet activity, coagulation, and fibrinolysis. Subjects without stroke/TIA on enrollment (with and without LEx) had a median follow-up of 57 months. RESULTS: On enrollment, 33 (43%) of 77 patients had CVD manifested as acute stroke/TIA (23 patients), cerebromicroembolism by transcranial Doppler (17 patients), or cerebral infarcts by MRI (14 patients). Mitral or aortic valve LEx were equally frequent in healthy controls (46%) as in patients with and without any CVD (39 and 43%), stroke/TIA (35 and 43%), cerebromicroembolism (41 and 42%), or cerebral infarcts (36 and 43%) (all p ≥ 0.72). Also, other mechanisms for CVD other than LEx such as Libman-Sacks vegetations, patent foramen ovale or interatrial septal aneurysm, aortic or carotid atherosclerosis, or thrombogenesis were found in ≥94% of patients with CVD. In addition, 36 subjects with and 44 without LEx had similar low incidence of stroke/TIA (1 (1.3%) and 2 (2.5%), respectively, p = 1.0) during follow-up. Finally, LEx were not associated with aging, atherogenic risk factors, atherosclerosis, inflammation, or thrombogenesis. CONCLUSIONS: In this study, LEx are similarly prevalent in healthy controls and SLE patients, are not associated with CVD, and are not associated with pathogenic risk factors. Therefore, the study findings suggest that LEx may not be cardioembolic substrates, may not represent pathologic valve structures, and may not require therapy.

Left atrial size and function are related to pulmonary hypertension in coronary artery disease.

BACKGROUND: Left atrial (LA) size reflects diastolic burden and is a prognostic parameter of common cardiovascular death. However, the association between LA size and function and pulmonary hypertension (PH) in coronary artery disease (CAD) has not been well investigated. We hypothesized that LA size and function are associated with PH in CAD. METHODS: One hundred seven patients with CAD were studied. LA size was determined in three different methods; namely, LA volume index (LAV), LA area index, and LA dimension. LAV total emptying fraction was also determined. Pulsed Doppler E, A, E/A, DT, tissue Doppler E', A', and E/E' were measured. Pulmonary artery systolic pressure (PASP) was estimated. RESULTS: All LA size parameters are significantly associated with PH. LAV emptying fraction, age, E, E/A, E/E', and A' were also associated with PH significantly. CAD patients with PH showed larger LA size, higher E, E/A, and E/E' and lower LAV emptying fraction, A and A' than CAD patients without PH. Multivariate regression analysis revealed that maximum LAV, E, E/A ratio, and age were independent predictors of PH. Maximum LAV > 35.6 mL/m(2) predicted PASP > 40 mmHg with a sensitivity of 83.9% and specificity of 62.2%. CONCLUSION: LAV is associated with PH in CAD patients.

Very Low Prevalence and Incidence of Atrial Fibrillation among Bolivian Forager-Farmers.

Background: Atrial fibrillation is the most common arrhythmia in post-industrialized populations. Older age, hypertension, obesity, chronic inflammation, and diabetes are significant atrial fibrillation risk factors, suggesting that modern urban environments may promote atrial fibrillation. Objective: Here we assess atrial fibrillation prevalence and incidence among tropical horticulturalists of the Bolivian Amazon with high levels of physical activity, a lean diet, and minimal coronary atherosclerosis, but also high infectious disease burden and associated inflammation. Methods: Between 2005-2019, 1314 Tsimane aged 40-94 years (52% female) and 534 Moseten Amerindians aged 40-89 years (50% female) underwent resting 12-lead electrocardiograms to assess atrial fibrillation prevalence. For atrial fibrillation incidence assessment, 1059 (81% of original sample) Tsimane and 310 Moseten (58%) underwent additional ECGs (mean time to follow up 7.0, 1.8 years, respectively). Findings: Only one (male) of 1314 Tsimane (0.076%) and one (male) of 534 Moseten (0.187%) demonstrated atrial fibrillation at baseline. There was one new (female) Tsimane case in 7395 risk years for the 1059 participants with >1 ECG (incidence rate = 0.14 per 1,000 risk years). No new cases were detected among Moseten, based on 542 risk years. Conclusion: Tsimane and Moseten show the lowest levels of atrial fibrillation ever reported, 1/20 to ~1/6 of rates in high-income countries. These findings provide additional evidence that a subsistence lifestyle with high levels of physical activity, and a diet low in processed carbohydrates and fat is cardioprotective, despite frequent infection-induced inflammation. Findings suggest that atrial fibrillation is a modifiable lifestyle disease rather than an inevitable feature of cardiovascular aging.

Diastolic dysfunction: improved understanding using emerging imaging techniques.

Diastolic heart failure is increasing in prevalence. Although the pathophysiology is incompletely understood and current therapeutic strategies are limited, identification of diastolic dysfunction is important. We review the role of contemporary techniques with echocardiography and cardiac magnetic resonance imaging (CMRI) in the assessment of diastolic dysfunction. Cardiac catheterization is the criterion standard for demonstrating impaired relaxation and filling by making direct measurements; however, echocardiography has replaced it as the most clinically used tool. By evaluating mitral inflow pulsed-wave Doppler with and without the Valsalva maneuver, isovolumetric relaxation time, pulmonary venous flow Doppler, color M-mode velocity propagation, tissue Doppler imaging, and speckle tracking, echocardiography is considered an accurate method for diagnosis and grading diastolic dysfunction. Evaluation of diastolic function can also be performed by CMRI. Mitral valve inflow velocities, early deceleration time, and pulmonary vein flow velocities are diastolic parameters that can be measured by phase-contrast CMRI. Cardiac magnetic resonance imaging steady-state gradient echo can evaluate functional dimensions for time-volume curves; and myocardial tagging can assess ventricular diastolic "untwisting," which may be important for improved pathophysiologic understanding. Studies have compared echocardiography and CMRI for diagnosing diastolic dysfunction in small patient groups with similar results. Cardiac magnetic resonance imaging can now provide clinically relevant data regarding the underlying cause of diastolic dysfunction and offers promise to gain mechanistic insights for therapeutic strategy development and clinical trial planning.

Morphologic features of carcinoid heart disease as assessed by three-dimensional transesophageal echocardiography.

BACKGROUND: Carcinoid heart disease (CHD) is a rare cause of valvular heart disease and carries a poor prognosis. CHD has a unique morphology and echocardiographic features that predominantly involve right-sided valvular structures. The diagnosis of CHD is usually made by two-dimensional transthoracic echocardiography (TTE). With the superior spatial resolution of real time three-dimensional transesophageal echocardiography (3DTEE), structural changes that occur in patients with CHD-associated valvular heart disease can be examined in greater detail. We undertook this study to examine the incremental value of 3DTEE in the diagnosis of CHD. METHODS: A total of four patients with CHD underwent TTE, transesophageal echocardiography (TEE), and 3DTEE as part of their routine clinical evaluation. RESULTS: TTE and TEE for all four patients revealed thickened, fibrosed, retracted, and malcoapted tricuspid leaflets with wide-open tricuspid valve regurgitation. 3DTEE en face imaging of the tricuspid valve demonstrated the characteristic morphologic features of CHD more clearly in all four patients. CONCLUSIONS: 3DTEE provides substantial incremental value over TTE in the assessment of characteristic CHD pathology and thus enhances the echocardiographic diagnosis of CHD.

A Complex Tricuspid Clip: Bridging the Decision.

We present this case of a 22-year-old woman with congenital heart disease as the youngest reported patient, to the best of our knowledge, to successfully undergo treatment of medically refractory torrential tricuspid regurgitation with the MitraClip system as an adjunct to guideline directed therapy. (Level of Difficulty: Advanced.).

A Rare Case of Carcinoid Constrictive Pericarditis.

We describe a case of atypical carcinoid heart disease. A 62-year-old woman with well-differentiated neuroendocrine tumor metastatic to the liver and lymph nodes presented with recurrent unilateral pleural effusions and lower extremity edema. Multimodality imaging and workup resulted in the diagnosis of carcinoid-related constrictive pericarditis, a rare form of carcinoid heart disease. (Level of Difficulty: Intermediate.).

The clinical application of the ratio of transmitral early filling velocity to early diastolic strain rate: a systematic review and meta-analysis.

BACKGROUND: The ratio of transmitral early filling velocity to early diastolic strain rate (E/e'sr) has recently emerged as a novel and accurate non-invasive measure of left ventricular (LV) filling pressure. This systematic review and meta-analysis aimed to give an overview of the possible clinical implications of E/e'sr. METHODS: We conducted a systematic review and meta-analysis of all studies involving E/e'sr. Of 598 identified studies, 16 met our inclusion criteria. Studies involving E/e'sr either investigated its prognostic value (n = 9) or its correlation with invasively measured LV filling pressure (n = 7). RESULTS: The pooled meta-analysis showed a significant correlation between E/e'sr and pulmonary capillary wedge pressure (PCWP) measured invasively across the studies assessing this relationship (Cohen's d = 3.90 95% CI [2.38-6.39], p < 0.001) and between E/e'sr and left ventricle end-diastolic pressure (LVEDP) measured invasively across the studies assessing this relationship (Cohen's d = 5.30 95% CI [2.83-9.96], p < 0.001). The pooled analysis of the prognostic studies showed that E/e'sr was a significant predictor of adverse outcomes after multivariable adjustment across the different study populations in a random effects model (overall estimated HR: 1.58 95% CI [1.28-1.96], p < 0.001, per 1 m increase). CONCLUSION: E/e'sr correlates well with invasive measures of LV filling pressure. In addition, E/e'sr provides significant prognostic information across various patient populations. Further studies are needed to test if E/e'sr has an advantage to E/e'.

Visual assessment of left ventricular dyssynchrony using tissue synchronization imaging.

BACKGROUND: Tissue synchronizing imaging (TSI) allows visual detection of asynchronous myocardial contraction. Although it is a screening tool for the detection of left ventricular (LV) dyssynchrony, its use as a qualitative method to assess dyssynchrony has not been studied. We evaluated the correlation of the visual assessment of dyssynchrony using TSI with quantitative assessment, the value of visual assessment to predict reverse remodeling to cardiac resynchronization therapy (CRT). METHODS: Echocardiograms from 100 consecutive patients were retrospectively evaluated. We compared visual TSI assessment with the qualitative assessment of dyssynchrony obtained by tissue Doppler imaging (TDI). The utility of visual assessment as a predictor of response to CRT was evaluated in 43 patients. RESULTS: In 86% of the cases, visual assessment was possible, and reproducibility was unrelated to observer experience. Each grade of visual dyssynchrony corresponded to a range of values of time to peak velocity (TPV) gradient (p < 0.001). Grade >or=1 dyssynchrony by visual assessment had 90% sensitivity and 95% specificity to identify >or=65 ms TPV gradient of LV opposing walls, and 93% sensitivity and 70% specificity to predict reverse LV remodeling. CONCLUSION: LV dyssynchrony may be visually assessed by TSI, which can also predict reverse LV remodeling.

Chlamydia pneumoniae antibody titers and cardiac calcifications: a cross-sectional serological-echocardiographic correlative study.

BACKGROUND: Chlamydia pneumoniae has previously been associated with higher prevalence of valvular and cardiac calcifications. OBJECTIVES: To investigate a possible association of seropositivity for C. pneumoniae and the presence of cardiac calcifications (mitral annular or aortic root calcification, and aortic valve sclerosis). METHODS: We retrospectively analyzed serological data (immunoglobulin G TWAR antibodies) from the AZACS trial (Azithromycin in Acute Coronary Syndromes), and correlated the serological findings according to titer levels with the presence of cardiac calcifications as detected by transthoracic echocardiography. RESULTS: In 271 patients, age 69 +/- 13 years, who underwent both serological and echocardiographic evaluation, we found no significant association between the "calcification sum score" (on a scale of 0-3) in seropositive compared to seronegative patients (1.56 +/- 1.15 vs.1.35 +/- 1.15, respectively, P = 0.26). The median calcification sum score was 1 (interquartile range 0-3) for the seronegative group, and 2 (interquartile range 0-3) for the seropositive group (P = 0.2757). In addition, we did not find a significant correlation of any of the individual sites of cardiac calcification and C. pneumoniae seropositivity. CONCLUSION: Our findings suggest that past C. pneumoniae infection may not be associated with the pathogenesis of valvular and cardiac calcifications.

Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism.

Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination.

This study compared the accuracy of cardiovascular diagnoses by medical students operating a small hand-carried ultrasound (HCU) device with that of board-certified cardiologists using standard physical examinations. Sixty-one patients (38% women; mean age 70 +/- 19 years) with clinically significant cardiac disease had HCU studies performed by 1 of 2 medical students with 18 hours of training in cardiac ultrasound and physical examinations by 1 of 5 cardiologists. Diagnostic accuracy was determined by standard echocardiography. Two-hundred thirty-nine abnormal findings were detected by standard echocardiography. The students correctly identified 75% (180 of 239) of the pathologies, whereas cardiologists found 49% (116 of 239) (p <0.001). The students' diagnostic specificity of 87% was also greater than cardiologists' specificity of 76% (p <0.001). For nonvalvular pathologies (115 findings), students' sensitivity was 61%, compared with 47% for cardiologists (p = 0.040). There were 124 clinically significant valvular lesions (111 regurgitations, 13 stenoses). Students' and cardiologists' sensitivities for recognizing lesions that cause a systolic murmur were 93% and 62% (p <0.001), respectively. Students' sensitivity for diagnosing lesions that produce a diastolic murmur was 75%; cardiologists recognized 16% of these lesions (p <0.001). The diagnostic accuracy of medical students using an HCU device after brief echocardiographic training to detect valvular disease, left ventricular dysfunction, enlargement, and hypertrophy was superior to that of experienced cardiologists performing cardiac physical examinations.

Libman-Sacks Endocarditis: Detection, Characterization, and Clinical Correlates by Three-Dimensional Transesophageal Echocardiography.

BACKGROUND: Libman-Sacks endocarditis, characterized by Libman-Sacks vegetations, is common in patients with systemic lupus erythematosus and is commonly complicated with embolic cerebrovascular disease. Thus, accurate detection of Libman-Sacks vegetations may lead to early therapy and prevention of their associated complications. Although two-dimensional (2D) transesophageal echocardiography (TEE) has high diagnostic value for detection of Libman-Sacks vegetations, three-dimensional (3D) TEE may allow improved detection, characterization, and clinical correlations of Libman-Sacks vegetations. METHODS: Twenty-nine patients with systemic lupus erythematosus (27 women; mean age, 34 ± 12 years) prospectively underwent 40 paired 3D and 2D transesophageal echocardiographic studies and assessment of cerebrovascular disease manifested as acute clinical neurologic syndromes, neurocognitive dysfunction, or focal brain injury on magnetic resonance imaging. Initial and repeat studies in patients were intermixed in a blinded manner with paired studies from healthy controls, deidentified, coded, and independently interpreted by experienced observers unaware of patients' clinical and imaging data. RESULTS: The results of 3D TEE compared with 2D TEE were more often positive for mitral or aortic valve vegetations, and 3D TEE detected more vegetations per study and determined larger sizes of vegetations (P ≤ .03 for all). Also, 3D TEE detected more vegetations on the anterior mitral leaflet, anterolateral and posteromedial scallops, and ventricular side or both atrial and ventricular sides of the leaflets (P < .05 for all). In addition, 3D TEE detected more vegetations on the aortic valve left and noncoronary cusps, coronary cusps' tips and margins, and aortic side or both aortic and ventricular sides of the cusps (P ≤ .01 for all). Furthermore, 3D TEE more often detected associated mitral or aortic valve commissural fusion (P = .002). Finally, 3D TEE detected more vegetations in patients with cerebrovascular disease (P = .01). CONCLUSIONS: Three-dimensional TEE provides clinically relevant additive information that complements 2D TEE for the detection, characterization, and association with cerebrovascular disease of Libman-Sacks endocarditis.

Aortic valve sclerosis, mitral annular calcium, and aortic root sclerosis as markers of atherosclerosis in men.

Aortic valve sclerosis (AVS) and mitral annular calcium (MAC) as detected by transthoracic echocardiography have been associated with atherosclerosis. Aortic root sclerosis (ARS) may have a similar association, but has not been studied. This study evaluates, by transesophageal echocardiography, the association of AVS, MAC, and ARS with aortic atheromatous disease and cardiovascular disease. Multiplane transesophageal echocardiography with evaluation of AVS, MAC, ARS, and aortic atheromatous disease by 2 experienced observers unaware of clinical data was performed in 157 male patients > or =50 years old. The presence of cardiovascular disease, defined as coronary, carotid, or peripheral artery disease, was determined by specific criteria. The prevalence of AVS, MAC, ARS, and aortic atheromatous disease was 42%, 30%, 48%, and 71%, respectively. The presence of AVS, MAC, or ARS was highly associated with aortic atheromatous disease (odds ratio 4.9 to 12.0, confidence interval 1.4 to 35.8, p <0.001). ARS was also associated with cardiovascular disease (odds ratio 2.2, confidence interval 1.0 to 4.5, p = 0.038). The presence of AVS, MAC, or ARS had a sensitivity of 77%, specificity of 72%, a positive predictive value of 88%, and a negative predictive value of 55% for aortic atheromatous disease. We concluded that the prevalence of AVS, MAC, or ARS by transesophageal echocardiography in men is common, and their presence is highly associated with aortic atheromatous disease and coronary, carotid, or peripheral artery disease.

Comparison of frequency of left ventricular wall motion abnormalities in patients with a first acute myocardial infarction with versus without left ventricular hypertrophy.

One hundred fifty patients with their first acute myocardial infarctions (AMIs) were studied. AMIs were confirmed by troponin levels, ST-segment elevation, or angiographic coronary occlusion. In 36% of patients (16 of 45) with left ventricular (LV) hypertrophy, the wall motion score index was normal, whereas in patients with no LV hypertrophy, only 18% (19 of 105) had no segmental wall motion abnormalities (p = 0.03). When adjusting for troponin level, the odds ratio for normal wall motion of patients with LV hypertrophy was 2.86 (95% confidence interval 1.26 to 6.50) compared with those with normal wall thickness. Consequently, normal LV wall motion by echocardiography in the setting of LV hypertrophy does not exclude AMI.

Usefulness of a hand-carried cardiac ultrasound device to detect clinically significant valvular regurgitation in hospitalized patients.

The accuracy of a hand-carried cardiac ultrasound (HCCU) device for the diagnosis of valvular regurgitations using color-flow Doppler was assessed. One hundred twenty hospitalized patients with at least mild valvular regurgitation by standard echocardiography were evaluated by 2 cardiologists using HCCU. The HCCU operator identified 99% of clinically significant valvular regurgitations and assessed the severity correctly in 83% of cases. For mild regurgitation, the HCCU sensitivity and specificity were 82% and 93%, respectively, resulting in correct assessments of severity in 71% of cases. HCCU used by trained cardiologists has high sensitivity for the detection and accurate assessment of the severity of clinically relevant valvular regurgitation.

Usefulness of a hand-carried cardiac ultrasound device for bedside examination of pericardial effusion in patients after cardiac surgery.

To identify the incidence of pericardial effusion in patients after cardiac surgery using a hand-carried cardiac ultrasound device, 200 patients were assessed on postoperative day 3. If a pericardial effusion was found, patients were monitored for 3 consecutive days with a hand-carried cardiac ultrasound device. Within 72 hours after surgery, 43 patients (21.5%) had developed an effusion, of whom 2 patients had cardiac tamponade and 41 patients (21%) had a small pericardial effusion. No difference was found in the incidence of effusion based on the type of cardiac surgery. Of patients with a small pericardial effusion on day 3 after surgery, an additional 2 of 41 (5%) developed cardiac tamponade.