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In recent years cardioversion of atrial fibrillation has become a routine procedure, enabling symptomatic functional improvement in most cases. However, some patients develop complications after cardioversion. Identifying these individuals is an important step toward improving patient outcome.To characterize those patients who may not benefit from cardioversion or who may develop complications following cardioversion.We retrospectively analyzed 186 episodes of cardioversion in 163 patients with atrial fibrillation who were admitted to our cardiology department between 2008 and 2013 based on their clinical and echocardiographic data. Patients were divided into two groups: those with uncomplicated cardioversion, and those who developed complications after cardioversion.Of the 186 episodes, cardioversion was done in 112 men (60%) and 74 women (40%), P0.00001. Complications after cardioversion occurred in 25 patients (13%). These patients were generally older (72 vs. 65 years, P0.01), were more often diabetic (52% vs. 27%, P = 0.005), had undergone emergency cardioversion (64% vs. 40%, P = 0.01), had left ventricular hypertrophy (left ventricular mass 260 vs. 218 g, P = 0.01), had larger left atrium (left atrial volume 128 vs. 102 ml, P0.009), and more often died from complications of cardioversion (48% vs. 16%). They had significant mitral regurgitation (20% vs. 4%, P = 0.03) and higher pulmonary artery pressure (50 vs. 42 mm Hg, P0.02).People with complications after cardioversion tend to be older, are more often diabetic and more often have severe mitral regurgitation. In these patients, the decision to perform cardioversion should consider the possibility of complications.

The search for the presence of vegetations in patients with suspected infective endocarditis is a major indication for trans-esophageal echocardiographic (TEE) examinations. Advances in harmonic imaging and ongoing improvement in modern echocardiographic systems allow adequate quality of diagnostic images in most patients.To investigate whether TEE examinations are always necessary for the assessment of patients with suspected infective endocarditis.During 2012-2014 230 trans-thoracic echo (TTE) exams in patients with suspected infective endocarditis were performed at our center. Demographic, epidemiological, clinical and echocardiographic data were collected and analyzed, and the final clinical diagnosis and outcome were determined.Of 230 patients, 24 had definite infective endocarditis by clinical assessment. TEE examination was undertaken in 76 of the 230 patients based on the clinical decision of the attending physician. All TTE exams were classified as: (i) positive, i.e., vegetations present; (ii) clearly negative; or (iii) non-conclusive. Of the 92 with clearly negative TTE exams, 20 underwent TEE and all were negative. All clearly negative patients had native valves, adequate quality images, and in all 92 the final diagnosis was not infective endocarditis. Thus, the negative predictive value of a clearly negative TTE examination was 100%.In patients with native cardiac valves referred for evaluation for infective endocarditis, an adequate quality TTE with clearly negative examination may be sufficient for the diagnosis.

Aims Lambl's excrescences (valvular strands) have been associated with an increased embolic risk. In previous studies, valvular strands have mostly been detected by transoesophageal echo (TEE). The current high-resolution echo systems allow better detection of valvular strands often even by transthoracic echocardiography (TTE). We attempted to determine the incidence of valvular strands during routine echo exams, TTE and/or TEE, and their relation to the cardiovascular risk factor, co-morbidities, and outcome. Methods and results Over 21 000 echo exams were performed at our hospital during 2008–12 and were searched for reporting of valvular strands. One hundred and fifty such studies were identified and the presence of valvular strands was confirmed. These patients were then evaluated for clinical characteristics, co-morbidities, and outcome, and compared with 150 age- and gender-matched patients without valvular strands. Incidence of valvular strands was maximal at age 61–70 (0.94%), and they were found more commonly in men than in women, 92 vs. 58, P < 0.00001. Valvular strands occurred more often on the aortic than on the mitral valve, 125 vs. 36, respectively, P < 0.00001, were more often associated with thickened or calcified aortic or mitral valve, and occupied the ventricular side of the aortic valve and the atrial side of the mitral valve, P < 0.00001. Embolic events occurred in 40 of the 150 patients with strands (27%). Valvular strands were not associated with increased mortality. Conclusion Valvular strands (Lambl's excrescences) appear not to affect life expectancy, but are often associated with embolic/cerebrovascular events, are more common in older patients, in men than in women, and are more commonly located on the aortic than on the mitral valve.

A 45-year-old man was admitted due to fever and chills, and blood cultures were positive for Streptococcus mitis. Echocardiography revealed a mobile vegetation of 6 mm on the ventricular aspect of the anterior mitral leaflet, a three-leaflet aortic valve with a lack of co-optation, and a moderate aortic regurgitant jet directed towards the anterior mitral leaflet ( Panel A , and …

43-year—old man was admitted to the coronary care unit because of recurrent syncope. His medical history included pulmonic valve angioplasty at age 9 years, mechani-cal mitral valve replacement because of severe mitral regur-gitation caused by congenital atrioventricular canal, and pacemaker implantation because of complete atrioventricular block. On admission he was orthopneic, his blood pressure was 78/45 mmHg, and his pulse was 72 beats per minute, irregu -lar. On auscultation, lungs were clear and there were irregular cardiac sounds of mechanical mitral prosthesis. There were no signs of peripheral edema. ECG showed slow atrial fibrillation with intermittent ventricular pacing. International normalized ratio was in high therapeutic range, at 4.5. Echo examination showed intermittent opening of the mitral valve 1:2. This was confirmed by continuous wave Doppler, M-mode echo, and color M-mode echo (Figure) with mildly elevated gradient 20/8 mmHg. Cine fluoroscopy showed intermittent open -ing of the mitral prosthesis (online-only Data Supplement Movie I; Bjork -Shiley mono-leaflet tilting disk).The patient underwent surgery. Massive calcified pan-nus covered the valve and interfered with the opening of the prosthesis.Intermittent opening of prosthetic mitral valve is rare

Background Until recently acute inflammatory peri-myocardial syndromes have been associated with global rather regional left ventricular (LV) dysfunction. Recent advances in cardiac imaging with echocardiographic techniques and magnetic resonance imaging (MRI) permit comprehensive evaluation of global and regional LV function. Our study was aimed to assess regional LV function in 100 patients with acute perimyocarditis, and correlate these findings with the clinical presentation. Methods We report on 100 patients with acute perimyocarditis admitted during 2008–2011, in whom LV function was assessed by semi-quantitative wall motion score analysis on conventional echo. Long-term mortality and recurrent hospitalization were also assessed. Results Wall motion score in 100 patients with acute perimyocarditis demonstrated a significant predominance of regional wall motion abnormalities in the infero-postero-lateral LV wall. These data correspond well with speckle tracking results of a subgroup of these patients published earlier. Recent MRI data show frequent late enhancement of contrast in the infero-lateral region of the LV in patients with perimyocarditis. These observations were useful in re-classification of our patients into one of the following groups: pure or predominant pericarditis, and pure or predominant myocarditis. Over a mean period of 37 months, there was no mortality. Though recurrent hospitalizations were rather frequent, no significant differences were observed among groups. Conclusions Regional wall motion abnormalities in the infero-postero-lateral segments of the LV are frequent in patients with acute perimyocarditis. Detailed echocardiographic examination early in the course of the disease should become a major factor in the clinical differentiation among the various clinical presentations of acute inflammatory peri-myocardial syndromes. The long-term outcome of these patients appears to be benign, though recurrent hospitalizations are not infrequent.

Objectives: To compare non-invasive determination of cardiac index (CI) by whole body electrical bioimpedance using the NICaS apparatus and Doppler echocardiography, and the role of cardiac power index (Cpi) and total peripheral resistance index (TPRi) calculation during dobutamine stress echocardiography (DSE). Subjects and methods: We enrolled 60 consecutive patients undergoing DSE. Patients were prospectively divided into 3 groups: Group 1 (n=20): normal DSE (control). Group 2 (n=20): EF

Cardiac rupture is a rare but ominous complication of myocardial infarction.To study the clinical presentation, medical course, outcome and echocardiographic predictors of patients with myocardial rupture.We evaluated 15 consecutive patients with cardiac rupture during a 4 year period in our department. The current report explores the presence of potential risk factors, timing, relation to the thrombolysis, coronary interventions and outcome.The index event in all patients was first ST elevation myocardial infarction. In seven patients rupture occurred in the first 24 hours. Pericardial effusion on admission with a clot was present in three patients. Five patients received thrombolytic therapy. Only three patients underwent coronary angioplasty, but in one case it was performed late and in two patients the culprit artery could not be opened. Six patients reached the operating room, of whom three survived.The lack of early mechanical reperfusion in acute myocardial infarction and thrombolytic therapy are risk factors for cardiac rupture. Pericardial effusion on admission and evidence of a clot are echocardiographic indicators of cardiac rupture and should alert the medical team to further assess the possibility of cardiac rupture.