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Comparing the right-sided cardiac output and left-sided cardiac output is important in situations where a shunt is suspected; it is done by comparing the flow across the LVOT and the RVOT. It is important to remember the limitations and the pitfalls of this technique, as well as to understand precisely the information obtained from these calculations. PDA is a unique example where the classic comparison of the LVOT and RVOT cardiac output results in “confusing” data. Since PDA is an abnormal communication between the right and the left heart occurring outside the heart, it is important to understand which site (LVOT / RVOT) represents which circulation.

Echocardiography can be utilized to assess pulmonary pressures. Pulmonary pressures are an important part of the hemodynamic assessment and carry significant prognostic and therapeutic implications. Most commonly, peak TR velocity is used to estimate pulmonary artery systolic pressure. While this measurement is commonly available and easily obtained, it provides only an estimate of the pulmonary artery systolic pressure, and not mean PA pressure. Mean PA pressure is the parameter used by the WHO to define presence and severity of pulmonary hypertension and carries important diagnostic and prognostic significance. In addition, evaluating pulmonary vascular resistance is critical for the proper classification of pulmonary hypertension and treatment considerations. Echocardiographic techniques are available to further assess pulmonary pressures including pulmonary artery diastolic pressure, mean pulmonary artery pressure, and pulmonary vascular resistance. Like with any other echo obtained measurement, attention to quality and accuracy of the interrogated flow and the obtained spectral signal is of paramount importance in order to assure the accuracy of the obtained data.

Mitral regurgitation (MR) is one of the most common indications for echocardiography. Accurate quantification of MR severity is extremely important for proper decision-making regarding optimal treatment options. Echocardiography, and frequently trans-esophageal echo, provide thorough quantification information, as well as supporting evidence for the effects of the MR on the heart (e.g., LV/LA enlargement, presence and severity of pulmonary hypertension). It is important to utilize all available tools and measurements when assessing MR severity; reliance on one form of assessment can be deceiving and may result in inaccurate classification of MR severity. Conceptually, the severity of mitral regurgitation is determined by volume—how much blood (in milliliters) spills back from the LV into the LA during systole. A related concept that is also at the crux of determining MR severity is the regurgitant fraction—what percentage of the total stroke volume spills back into the LA. There are multiple echocardiographic quantification techniques for assessing MR severity including anatomic assessment for estimation of regurgitant orifice area, PISA method, color Doppler assessment, and volumetric calculations comparing flow volumes at various locations in the heart. For the most accurate assessment, a comprehensive evaluation should be undertaken and all possible data points should be analyzed.

Intracardiac shunts can occur at various locations and may be the result of a congenital heart defect, other intracardiac pathology (i.e., infectious process), or iatrogenic complications of surgical or structural interventions. When analyzing a ventricular septal defect several parameters must be assessed in order to obtain a comprehensive evaluation. These include type and size of the defect, magnitude and direction of the shunt, cardiac response to the overload (chamber size and function), pulmonary pressures, and pulmonary vascular resistance. Interrogating VSD flow can provide important hemodynamic information and data regarding intracardiac pressures. It is important to make sure that all the flows present are interrogated and measured and obtained parameters should “make sense” when evaluated together; discrepancy in data obtained should prompt a thorough evaluation in order to attain an understanding of the nature of the discordant data.

Echocardiography can be utilized to assess pulmonary pressures. Pulmonary pressures are an important part of the hemodynamic assessment and carry significant prognostic and therapeutic implications. The benefits of using echocardiography for assessing pulmonary pressures include the noninvasive nature of the assessment with no known risks, the ability to perform the study at bedside and repeat as needed, and the availability of complementary information (e.g., right ventricular size and function) that can help understand that pathologic process and its impact on the heart. It is essential to understand which pulmonary pressure (e.g., systolic, diastolic, or mean) is measured by each technique in order to have a comprehensive assessment, as well as compare data across various techniques. The most commonly used measurement to assess pulmonary pressure is the interrogation of tricuspid regurgitation jet velocity. This allows for calculation of the pulmonary artery systolic pressure, which provides a good estimate for the presence and severity of pulmonary hypertension.

Timing of events, as well as the pattern of occurrences, are important details to pay attention to. Occasionally, a discrepancy can be found between electrical and mechanical activity of the heart, and echocardiography can be a tool to identify such inconsistency. Moreover, there can be a discrepancy between the mechanical activation of the heart, and the efficiency of the heart (i.e., the production of cardiac output), and echocardiography can play a central role in diagnosing such a situation. Combining information from ECG tracing, 2D and tissue Doppler assessment of contractility, and spectral tracing across the LVOT can provide evaluation of the electrical activation of the heart, mechanical activation of the heart, and the ultimate “success” of these activation efforts in producing cardiac output.

The unusual timing of an otherwise appearing “insignificant” flow can be a clue to various underlying pathologies and should be thoroughly interrogated and investigated. While these abnormal flows may not be clinically important in and of themselves (e.g., may not cause volume overload or increase in filling pressures), understanding the cause of the abnormal timing is important, as it may clarify the underlying pathology. Diastolic mitral regurgitation is an example of such an abnormally timed event; understanding the mechanism and pressure relationships that result in diastolic MR can help shed light on the pathology causing it.

Aortic stenosis (AS) is frequently encountered in echocardiography laboratories. Accurate evaluation of AS severity is essential for proper decisions regarding optimal treatment and timing of interventions. The severity of aortic stenosis is determined by the aortic valve area (at normal flow state), however, multiple criteria are utilized to grade AS severity: calculated aortic valve area, velocity/gradients across the valve, valvuloarterial impedance, valve calcifications, etc. The importance of accurately assessing AS severity and defining the subtype of AS cannot be overstated. It is essential to use meticulous techniques, including imaging from all views and utilizing the non-imaging transduced in order to measure maximal trans-aortic velocities. When discussing trans-aortic gradients it is necessary to specify exactly which gradient is reported—both for understanding the hemodynamic significance of the finding, as well as accurate communication when different techniques are utilized.

Aortic insufficiency (AI) is frequently encountered in echocardiography; regardless of its cause (e.g., valvular, aortic root pathology, etc.), accurate quantification of AI severity is essential for prognostication and treatment planning. Special attention should be paid to parameters that suggest hemodynamically significant AI with increased LV end-diastolic pressure; these may be signs of impending hemodynamic collapse and may necessitate prompt intervention. While often severity and hemodynamic significance go hand in hand, there can be physiologic reasons or technical reasons for the AI to appear less than severe, yet with signs of significant hemodynamic consequences. The importance of identifying these signs cannot be overemphasized; timely intervention may be lifesaving and echocardiographic findings may precede clinical deterioration.

Background Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial...

Evaluating left ventricular diastolic function and filling pressures is an important consideration in patients presenting with dyspnea or heart failure. Echocardiography has become a key tool for this assessment. This chapter will briefly review the pathophysiology of diastolic dysfunction, the terminology used to describe the stages of diastolic dysfunction and the echocardiographic tools for assessing diastolic function.

Evaluating cardiac hemodynamics is an important part of interpreting echocardiograms. This chapter will review the principles underlying the non-invasive hemodynamic assessment. We will provide a step by step approach for completing an “echocardiographic Swan-Ganz catheterization” which serves as the building blocks for interrogating complex hemodynamic challenges.

This chapter will provide an overview of the evaluation of left ventricular systolic function by echocardiography. Various parameters of systolic function will be discussed and the different methods of obtaining these will be reviewed. In addition, we will review the basic principles of stress echocardiography and the key concepts in performing and interpreting stress echocardiograms.

Left ventricular outflow tract obstruction is a serious complication of mitral valve surgery (repair and replacement) and transcatheter mitral valve replacement. An appreciation of the various mechanisms which cause outflow obstruction in these settings is critical to avoiding this complication and to initiating appropriate treatment. This article discusses the mechanisms, pathophysiology, and imaging of left ventricular outflow tract obstruction which can arise following insertion of a variety of mitral valve prosthetics.

Transcatheter Aortic Valve Replacement (TAVR) effectively treats severe symptomatic aortic stenosis (AS). Left atrial (LA) strain measured by speckle tracking echocardiography quantifies LA function, and has not been evaluated in this population. We measured the baseline reservoir (eR), conduit

Echocardiography plays an important role in the assessment of structural heart disease. The work-up for the assessment for structural interventions often requires a combination of both transthoracic (TTE) and transoesophageal (TEE) imaging. Three-dimensional (3D) echocardiography provides added value to traditional two-dimensional (2D) echocardiography, allowing for definition of anatomical and spatial relationships. Echocardiography is portable and easily accessible, whilst avoiding the need for radiation and contrast making it the preferred mode of imaging in the cardiac catheterisation lab.

An 85-year-old patient presented after an abrupt change in mentation and was found to be hypotensive and hypoxic. Transthoracic echocardiogram (TTE) (see Supplementary data online, Video S1 ) revealed an underfilled, hyperdynamic left ventricle (LV), and a dilated right ventricle (RV) with an akinetic free wall. Pulmonary artery systolic pressure (PASP) was estimated …

Assessing left ventricular function is a common indication for echocardiography. It generally requires expert echocardiographer estimation and is somewhat subjective and prone to reader discordance. Mitral annular plane systolic excursion (MAPSE) has been suggested as a surrogate measurement for left ventricular function. The aim of this study was to examine the accuracy of MAPSE for predicting left ventricular ejection fraction (EF) on the basis of a large cohort of consecutive echocardiograms.The study design was a retrospective analysis of 600 two-dimensional echocardiographic studies performed in a single laboratory. MAPSE measurement was performed by an untrained observer and compared with the EF as determined by an expert echocardiographer. The first 300 studies served as a calibration cohort to establish an algorithm for predicting EF on the basis of MAPSE measurement. The following 300 studies served as a verification cohort to test the accuracy of the established algorithm.Using the first 300 studies, an algorithm was developed to predict EF. Cutoff values for normal EF (≥11 mm for women and ≥13 mm for men) and severely reduced EF (6 mm for men and women) were identified. For the intermediate-range MAPSE values, a gender-specific regression equation was calculated to generate a predicted EF. Using this algorithm, predicted EFs were determined for the 300 patients in the verification cohort. By comparing the predicted EF and the expert-reported EF, positive and negative predictive values, sensitivity (73%-92%), specificity (81%-100%), and accuracy (82%-86%) of MAPSE for predicting EF were calculated.MAPSE measurement by an untrained observer was found to be a highly accurate predictor of EF.

Background There are currently no standardized three-dimensional (3D) transesophageal echocardiographic (TEE) views of the interatrial septum and atrial septal defects (ASDs). Without a standardized approach, it is difficult to ascertain the important anatomic relationships (such as the location of the aortic rim of an ASD), to perform relevant measurements (such as the size of an ASD or the size of its rims), or to guide the deployment of catheters and devices during atrial septal closure. Methods Using a 3D TEE matrix-array transducer, 706 TEE studies were performed over a 14-month period. The purpose of the study was to develop a standardized protocol for anatomically correct orientation of 3D TEE images of the interatrial septum and ASDs. Results Among 706 TEE studies, there were 23 patients with ASDs, representing 3.3% of the study population. Eighteen patients had secundum ASDs, two had primum ASDs, and three had sinus venosus ASDs of the superior vena cava type. A protocol for properly orienting 3D TEE images of the interatrial septum and ASDs was developed. When the images are acquired at an angle of 0°, the septum is properly oriented by the tilt-up-then-left maneuver. The initial 3D TEE image in first tilted up to reveal the right atrial side of the septum. Then the image is tilted 180° around its vertical axis to reveal the left atrial side of the septum; the aortic rim is on the left, the superior vena cava on the top, and the right-sided pulmonary vein ostia on the right side of the screen. For acquisitions at a higher angle, the rotate-left-in-z-axis maneuver is used. The image is first tilted up to reveal the right atrial side of the septum, as in the tilt-up-then-left maneuver. The image is then rotated counterclockwise in the z axis until the superior vena cave is at 12 o'clock. Finally, the image is tilted 180° around its vertical axis to reveal the left atrial side of the septum. Conclusions The use of standardized tilt-up-then-left and rotate-left-in-z-axis maneuvers enhances the diagnosis of ASDs, ascertains the important anatomic relationships of ASDs to surrounding structures, and facilitates communication between echocardiographers obtaining 3D TEE images and interventional cardiologists or cardiac surgeons performing ASD closures.

We review the use of real-time three-dimensional transesophageal echocardiography (RT3D-TEE) in guiding percutaneous catheter-based procedures to repair structural heart defects. The utility of this novel imaging technique in percutaneous mitral valve repair and valvuloplasty, aortic valve insertion, device closure of atrial and ventricular septal defects, obliteration of the left atrial appendage, and pulmonary vein ablation is described. The main advantages of RT3D-TEE lie in its ability to visualize the entire length of intracardiac devices, including their tips, and to demonstrate their relationship to cardiac structures, to provide en face views of cardiac structures (such as the interatrial septum and the mitral valve) that are unobtainable in real time by any other imaging technique, and to allow for continuous monitoring during the procedure. It is likely that RT3D-TEE will become the standard of care for guidance of percutaneous, catheter-based procedures.

Objectives: To examine the association between heart rate and mortality risk in the elderly. Design: Longitudinal cohort. Setting: Outpatient. Participants: Four hundred twenty-two people, aged 70 upon entry, were surveyed and followed for 6 years. Measurements: Pulse rate was measured manually, while sitting and standing, and heart rate was measured from electrocardiogram recordings. The population was divided into quartiles of heart rate, with the top quartile comprising those with heart rate greater than 77 beats per minute (bpm) and the bottom quartile those with heart rate less than 60 bpm. Results: After controlling for possible confounders, there was a clear correlation (r) between heart rate and all-cause mortality in elderly women (r=0.25, P=.0003). The correlation in women was observed using the three different methods for measuring heart rate. Heart rate was associated with all-cause and cardiovascular mortality. There was no relationship between heart rate and level of exercise or smoking status. In multiple regression analysis, the increased risk of death in the women was independent of previous cardiovascular or cerebrovascular disease, hypertension, anemia, congestive heart failure, smoking, and level of exercise or activities of daily living (relative odds ratio (ROR)=3.37, 95% confidence interval (CI)=0.96–11.8). When women using beta-blockers were excluded, this relationship became even stronger (ROR=8.5, 95% CI=1.19–60.1). Conclusion: Elevated heart rate is related to increased mortality in elderly women, thus representing a simple index of general health status in this population. Elevated heart rate did not predict mortality in elderly men.

OBJECTIVES Characterization of sleep-induced pulse and mean arterial pressure (MAP) dip. DESIGN Prospective study of consecutive referred patients. SETTING Hypertension unit of community university hospital. PARTICIPANTS A total of 500 consecutive subjects referred to our unit for ambulatory blood pressure (BP) monitoring. There were 200 men and 300 women, the majority of which were treated hypertensives. Mean age was 59.7 +/- 16.6 years. MAIN OUTCOME MEASURES Effect of sleep on MAP and pulse pressure (PP). RESULTS Twenty-four hour MAP was 98 +/- 10 mmHg. Awake and asleep MAPs were 101 +/- 11 and 87 +/- 11 mmHg, respectively. Twenty-four hour, awake and asleep pulse pressures were 60 +/- 13, 61 +/- 13 and 58 +/- 13 mmHg, respectively. MAP dip was 14%, 95% confidence interval (CI) 13.4-14.6, whereas PP dip was 5%, 95% CI 4.1-5.8. Thus, the MAP dip was almost three times the PP dip (P < 0.0001). This held true for normotensives, hypertensives (treated and untreated), men, women and diabetic subjects. CONCLUSIONS Although pulse pressure is derived from BP, it is more stable during a 24-h period, with a lesser effect of sleep compared with MAP. This more rigid nature of the PP could explain its better prognostic value, compared to that of MAP.

A 78-year-old woman with a history of coronary artery bypass grafting underwent transapical transcatheter aortic valve replacement with a Sapien XT (Edwards, Irvine, California) prosthesis that was complicated by an apical left ventricular pseudoaneurysm (LVPA). Unsuccessful attempts at closure

Left ventricular pseudoaneurysm and ventricular septal defect are rare but devastating complications of myocardial infarction. With medical treatment alone, the majority of patients will die from these complications. Until recently, the recommended treatment was surgical closure. These surgeries carried extreme risk due to abnormal hemodynamics, necrotic substrates and the comorbidities of these patients. Recently, trans-catheter closure was shown to be an acceptable alternative to open surgical intervention. 3D echocardiography identifies the location, size, and shape of the defect and can assess, guide, and follow up the closure procedure.

Nondipping, ie, failure to reduce blood pressure by ≥10% during the night, is considered an important prognostic variable of 24-hour ambulatory blood pressure monitoring. However, some people wake up at night to urinate. Usually, 24-hour ambulatory blood pressure monitoring–derived blood pressure includes these rises in the nighttime blood pressure mean. We identified 97 subjects undergoing 24-hour ambulatory blood pressure monitoring who reported waking up at night to urinate. We assessed the 24-hour ambulatory blood pressure monitoring first using total daytime and total nighttime means and then using actual daytime awake and nighttime asleep (as reported by the patient) means. Nocturnal decline in blood pressure was 14.4±8.5/11.8±6.1 mm Hg with the first method and 17.1±8.3/13.8±5.9 mm Hg with the second one ( P P ≤0.00001), and that of diastolic blood pressure was 14.2% and 16.7%, respectively ( P ≤0.00001). The prevalence of systolic blood pressure nondipping decreased from 42.2% by the first method to 31.9% by the second method ( P ≤0.0056), and that of diastolic blood pressure nondipping decreased from 22.6% to 11.3% ( P ≤0.00001). Inclusion of awake blood pressure measurements during the night obscured the normal dipping pattern in people who woke up to urinate. Thus, taking into account people’s actual behavior increases the accuracy of the results.

Posterior mitral valve (MV) leaflet aneurysms are extremely rare complications of infective endocarditis (IE). When MV aneurysms occur, they usually involve the anterior leaflet. Real time three-dimensional transesophageal echocardiography (RT3D TEE) has been recently developed and provides views of unparalleled quality by optimizing visualization of spatial relationships. We present a rare case of a posterior MV leaflet aneurysm due to IE in a 64-year-old woman, best visualized by RT3D TEE.

Percutaneous occlusion of left atrial appendage (LAA) with specifically designed devices has been proposed for those patients with AF who are ineligible for or non-compliant with anticoagulation therapy.The left atrial appendage has a complex and extremely variable structure with a multi-lobulated configuration.Because the size of occlusion device is strictly dependent on the size and shape of LAA, understanding this complex anatomy has become of paramount relevance for interventionalists involved in percutaneous occlusion of the LAA.Three-dimensional TEE provides a 3D data set of LAA which can be cut and analyzed from a countless number of planes. Additionally, each plane can be observed from multiple perspectives, allowing a more precise assessment of the anatomy of the LAA. Furthermore, a long segment of catheter can be visualized in a single image and the tip of the catheter can be tracked during the procedure. In this chapter we describe the 3D TEE anatomy of the LAA and its role in percutaneous closure of LAA.

Ventricular septal defect (VSD) is a rare but deadly mechanical complication of acute myocardial infarction (AMI). Although significantly lower than with conservative management, in-hospital mortality after surgery remains as high as 47%, and dehiscence of the patch requiring a second operation is not infrequent because the sutures may teat out of the friable support around the defect. In today's era of percutaneous interventions, percutaneous closure is considered a valid alternative to surgical repair in patients with small to medium VSDs, since the occlusion device may provide a definitive treatment. Two-dimensional TTE/TEE color Doppler provides the most rapid diagnosis by demonstration of a discontinuity in the ventricular septum with left-to-right shunt. 3D TEE appears to be a very valuable tool in showing the defect as it anatomically is: a hole through the septum. In this chapter we describe 3D TEE anatomy of ventricular septum, 3D TEE imaging of post-AMI VSDs, and the current use of 3D TEE during percutaneous closure with catheter-based devices.

Structural deterioration and paravalvular leak (PVL) are complications associated with surgically–implanted prosthetic valves. Until recently, the only available treatment has been surgery. Percutaneous PVL closure has demonstrated reasonable technical success and clinical outcomes. In addition

A 72-year-old male presented with an ST-elevation myocardial infarction complicated by cardiogenic shock warranting placement of a left ventricular assist device (LVAD, Tandem Heart, Cardiac Assist, Inc., Pittsburgh, PA, USA) and an intra-aortic balloon pump. Eight hours after the LVAD placement, transthoracic echocardiogram revealed an echodense immobile structure filling the whole left ventricular cavity, diagnosed as a thrombus ( Figure …

A 45-year-old woman with a history of congenital heart disease that was not previously well defined presented with progressive dyspnoea on exertion for 1 year. Three-dimensional (3D) transthoracic (TTE) and transoesophageal (TEE) echocardiography with agitated saline injection (bubble study) were performed. A severely dilated coronary sinus (CS) was visualized measuring 3.5 cm in its largest diameter with a present …

Atrial fibrillation is a common, clinically significant arrhythmic disorder that results in increased risk of morbidity and mortality in affected patients. Atrial fibrillation is more prevalent among men compared with women and the risk for developing atrial fibrillation increases with advancing age. Ischaemic stroke is the most common clinical manifestation of embolic events from atrial fibrillation. While anticoagulation treatment is the preferred treatment, unfortunately, many patients have contraindications for anticoagulation treatment making this option unavailable to them. Previous data have shown that most thrombi that form in association with non-valvular atrial fibrillation occur in the left atrial appendage (LAA). It has been suggested that isolating the LAA from the body of the left atrium might reduce the risk of embolic events and that LAA obliteration may be a treatment option for patients with atrial fibrillation who are not candidates for anticoagulation treatment. Several procedures have been developed for isolation of the LAA, including surgical procedures as well as catheter-based ones. In this paper, we will review the currently available techniques, emphasizing the catheter-based ones. We will examine the increasing role of real-time three-dimensional transoesophageal echocardiography for appropriate screening and patient selection for these procedures, intra-procedural guidance, and follow-up care.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 78-year-old man with bioprosthetic aortic valve replacement presented with leg edema. Two-dimensional transthoracic echocardiography revealed a high-velocity systolic jet entering the right atrium (RA)

Over the recent years, strain echocardiography has emerged as a quantitative technique for the evaluation of global and segmental cardiac function. Strain is a measure of deformation, expressed as a percent change in a segment's length compared to its predeformation length. Strain rate (SR) is the local rate of deformation or strain per unit time. Recently non-Doppler two dimensional strain imaging has been developed. This technique is based on tracking ultrasonic speckles from the two dimensional echocardiographic images. These speckles are followed over a number of successive frames, and myocardial velocity is calculated by measuring frame-to-frame changes. This technique is independent of the Doppler angle of incidence and allows measurement of several vectors of strain within myocardial tissue. Non-Doppler strain is a powerful tool, enabling detection of subtle abnormalities in myocardial function. Current evidence shows that non-Doppler strain imaging may allow identification of the early changes that occur with ischemic insult to the myocardium. It may also provide a tool for identification of scarred, non-viable myocardium, with similar accuracy to that of cardiac MRI. Non-Doppler strain imaging is likely to become a standard tool in the evaluation of patients with ischemic heart disease.

We present an adult patient who had an acute myocardial infarction complicated by a ventricular septal defect and had it repaired percutaneously. Real-time three-dimensional echocardiography (RT3D) before and during the closure procedure were performed. RT3D provided anatomical and functional information of the defect as well as real-time guidance during the procedure. This case highlights the utility of three-dimensional echocardiography in guiding transcatheter procedures.

A man with endocarditis was found to have prosthetic tricuspid valve (TV) stenosis without regurgitation. The large vegetation moved into the TV prosthesis orifice in diastole. A seldom-recognized echocardiographic finding was observed in which the interatrial septum bulged toward the left atrium in diastole.

We present an adult patient with cor triatriatum (CTT) due to a left atrial (LA) membrane. Two-dimensional and real-time three-dimensional transthoracic echocardiography (3DE) were performed as well as echocardiographic examination after exercise. These non-invasive modalities provided a comprehensive anatomic and hemodynamic evaluation of the anomaly.

Pulsus alternans is usually a systolic phenomenon. We present a case of a patient with severe heart failure, and systolic and diastolic pulsus alternans. This case may help clarify the mechanism of pulsus alternans.

Pulse pressure is a derivative of arterial stiffness. We have previously demonstrated ambulatory pulse pressure to be relatively independent from the blood pressure (BP) lowering during sleep, and thus of a neurogenic effect. On the other hand, white coat BP effects are thought to involve neurogenic activation. The aim of this work was to analyze white coat induced variability in pulse pressure.Percent clinic-awake differences in systolic BP (SBP) and pulse pressure (white coat effects) were calculated for 688 consecutive subjects (mean age 60 +/- 16 years, 58% female). Of the subjects, 23% had controlled hypertension, 45% uncontrolled hypertension, 8% normotension, and 4% isolated office hypertension; all were referred to our unit for 24 h ambulatory BP monitoring.Pulse pressure highly correlated with SBP (r = 0.82, P.00001). We found a larger white coat effect on pulse pressure than on SBP (8.3% and 5.2%, respectively, Por =.0001). This was true in all subgroups except in normotensive subjects. Specifically, the magnitude of the white coat effect on pulse pressure was greater than on SBP in subjects with treated hypertension, untreated hypertension, and isolated office hypertension, and in young hypertensive subjects, older subjects, and those with diabetes.Although pulse pressure is related to the mechanical properties of large arteries, it is also influenced by the white coat effect, a neurogenic process. Furthermore, in hypertensive but not in normotensive subjects, the white coat effect on pulse pressure is significantly more pronounced than on SBP.

Non-dipping, ie failure to lower blood pressure during sleep, has been found to be more prevalent in diabetic than in non-diabetic subjects. However, the reasons remain to be clarified. Diabetic patients may wake up more frequently during the night (for instance, due to nocturia). This may result in inclusion of awake blood pressure measurements in the night-time average and thus erroneously raise this average, causing misclassification of patients as non-dippers. However, non-dipping in diabetes may be due to blunted effect of sleep itself on blood pressure secondary to autonomic neuropathy. We undertook this study in order to further clarify this question. We studied 23 diabetic patients, and 23 matched controls who underwent 24-h ambulatory blood pressure monitoring, and reported taking an afternoon nap. Afternoon nap, by virtue of its short duration, is devoid of interruptions, and thus can be used as a model for tiled, non-interrupted sleep. We found that, both in diabetic patients and controls, blood pressure declined during the afternoon nap in a similar magnitude to the night-time decline. However, this decline was significantly blunted in the diabetic patients (13.9 +/- 2.2% decline in diastolic blood pressure during naptime in the diabetic patients, as compared with 24 +/- 2.3% decline in diastolic blood pressure during the siesta in the control group, P0.02). The blunted decline of blood pressure during the nap in diabetic patients demonstrates that non-dipping is due to the blunted effect of sleep itself. This can be another facet of autonomic dysfunction seen in diabetes mellitus.

Every year, millions of Moslems throughout the world fast from sunrise till sunset daily during the month of Ramadan, that is, experience repeated cycles of fasting-refeeding. Studies in animal models have shown that repeated cycles of fasting-refeeding may cause or exacerbate hypertension. Changes in sleeping patterns as well as changes in medication timing may also influence ambulatory blood pressure. We undertook this study in order to examine the effect of the Ramadan fast on treated hypertensive subjects. Seventeen hypertensive subjects were examined, and 24-h blood pressure monitoring was carried out twice, before and during the last week of the Ramadan. All continued their medications, which were all once-daily preparations. Twenty-four hour mean blood pressure as well as average awake and average asleep blood pressure were compared. There was no difference between mean blood pressure before and during the Ramadan (138.5 +/- 18.5/77.2 +/- 8.1 mm Hg vs 136.4 +/- 20.4/75.7 +/- 5.9 mm Hg, P-nonsignificant). Blood pressure load also did not differ before and during Ramadan (systolic load 49% vs. 44%, diastolic load 21% vs. 18%, P-nonsignificant). Weight was reduced by 1.4 +/- 1.6 kg (P < 0.002). We conclude, that according to our findings, treated, hypertensive patients may be assured that, with continuation of previous medications, traditional fasting during the month of Ramadan can be safely undertaken.

We present a 19-year-old patient who was admitted for evaluation of prolonged watery diarrhea. Previous study showed one stool culture positive for Campylobacter jejuni, which was treated with appropriate antibiotics with no response. She underwent colonoscopy with multiple biopsies, which led to a diagnosis of lymphocytic colitis. We believe that the patient's disease was due to the infectious process, which triggered an autoimmune response and caused the lymphocytic colitis.

A 78-year-old man with coronary artery disease, prior myocardial infarction, and heart failure was referred for coronary artery bypass surgery. Left ventricular (LV) angiography showed the presence of a large apical aneurysm and, therefore, surgery included exclusion of the aneurysm using an aneurysmorphaphy patch. Myocardial viability study was not performed at this stage. An echocardiogram was performed 2 months after the surgery. The study showed that the aneurysm cavity was not clotted as had been expected (Figure Because of partial patch dehiscence there was a communication between the aneurysm cavity and the body of the LV. Color Doppler showed that in systole there was flow from the aneurysm into the ventricle and in diastole the flow reversed–from the LV into the aneurysm (Figure 2). Continuous wave Doppler confirm this to-and-fro flow.

ObjectiveThe inflammatory process of aortic stenosis involves the differentiation of aortic valve myofibroblasts into osteoblasts. Osteopontin, a proinflammatory glycoprotein, both stimulates differentiation of myofibroblasts and regulates the deposition of calcium by osteoblasts. Osteopontin levels are increased in patients with such conditions as end-stage renal disease, ectopic calcification, and autoimmune disease. We hypothesized that increased plasma osteopontin levels might be associated with the presence of aortic valve calcification and stenosis.MethodsVenous blood from volunteers older than 65 years undergoing routine echocardiographic analysis or aortic valve surgery for aortic stenosis was collected. Plasma osteopontin levels were measured by means of enzyme-linked immunosorbent assay. The presence of aortic stenosis was defined as an aortic valve area of less than 2.0 cm2. Aortic valve calcification was assessed by using a validated echocardiographic grading system (1, none; 2, mild; 3, moderate; 4, severe). Comparisons were performed with nonpaired t tests.ResultsAortic stenosis was present in 23 patients (mean age, 78 years) and was absent in 7 patients (mean age, 72 years). Aortic valve calcification scores were 3.5 ± 0.6 and 1.3 ± 0.5 in patients with and without aortic stenosis, respectively (P < .001). Patients with no or mild aortic valve calcification had lower osteopontin levels compared with patients with moderate or severe aortic valve calcification (406.1 ± 165.8 vs 629.5 ± 227.5 ng/mL, P = .01). Similarly, patients with aortic stenosis had higher osteopontin levels compared with patients without aortic stenosis (652.2 ± 218.7 vs 379.7 ± 159.9 ng/mL, P < .01).ConclusionIncreased levels of plasma osteopontin are associated with the presence of aortic valve calcification and stenosis. These findings suggest that osteopontin might play a functional role in the pathogenesis of calcific aortic stenosis.