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The aim of this study is to explore the value of transthoracic echocardiography in the diagnosis of eosinophilic myocarditis. The echocardiographic characteristics of nine patients with eosinophilic myocarditis in our hospital between January 2004 and January 2012 were retrospectively reviewed. In our study, four of the nine patients were diagnosed to have small pericardial effusion. The obliteration of the apical cavity was observed in five of the nine patients. There were six patients with both mitral and tricuspid regurgitation, one patient with only mitral regurgitation, and one patient with only tricuspid regurgitation. Transthoracic echocardiography showed that the diameters of the left and right atria were both increased in eight of the nine patients. The diameter of the left ventricle was increased in five patients, and the right ventricular diameter was increased in four patients. The left ventricular ejection fraction was decreased in two of the nine patients. Five of the nine patients had pulmonary hypertension, and one patient had severe pulmonary hypertension. Transthoracic echocardiography is the primary method for the diagnosis of eosinophilic myocarditis and is also useful in follow-up of the disease.

Background Anomalous origin of pulmonary artery (AOPA) from the ascending aorta is a rare but serious congenital cardiac malformation, which frequently involves the right pulmonary artery (RPA). Methods We retrospectively analyzed the echocardiographic characteristics of 9 cases with anomalous origin of the right pulmonary artery from the ascending aorta (AORPA) studied from 2007 to 2014 in our institution. The results were compared with the findings at surgery. Results The corrective surgery was performed in all 9 cases with AORPA. The diagnosis by transthoracic echocardiography (TTE) of 8 cases with AORPA was confirmed at surgery. The coincidence rate for TTE and surgical findings was 88.9%. One case was misdiagnosed as anomalous origin of the left pulmonary artery from the ascending aorta. The anomalous RPA in all cases had a proximal origin from the posterior or lateral part of the ascending aorta in our series. The mean distance from the aortic valve to the site of origin of pulmonary artery was 16.1±6.6mm (range: 7.0mm–24.0mm). The mean diameter of the anomalous pulmonary artery was 9.6±4.5mm (range: 4.5mm–17.0mm). In 4 of 9 (44.5%) cases there were associated aortopulmonary septal defect, intact ventricular septum, patent ductus arteriosus and interruption of aortic arch (Type A), also known as the Berry's syndrome. Other associated cardiovascular abnormalities included patent ductus arteriosus, ventricular septal defect and atrial septal defect. Severe pulmonary arterial hypertension was noted in all cases. Conclusions TTE plays an important role in the non-invasive and accurate diagnosis of AORPA. TTE can clearly display its site of origin and course, as well as other associated malformations and hemodynamic changes. TTE also plays an important role in the preoperative diagnosis of AORPA.

Background Coronary artery fistula (CAF) is a rare congenital anomaly, which is conventionally diagnosed by coronary arteriography; however, the relation of the coronary artery fistulas to other structures, their origin and course may not be always apparent. Methods The echocardiograms of 63 patients with coronary artery fistulas, who had undergone coronary arteriography and/or surgery from June 2002 to December 2012 at the Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, were analyzed retrospectively, and the results were compared with findings by coronary arteriography and at surgery. Results Right CAFs were detected in 33 of the 63 patients (52.4%); 11 had drainage to the right atrium, 10 to the right ventricle, 2 to the left ventricle, 9 to the main pulmonary artery, and 1 to the coronary sinus. Left CAFs were detected in 29 patients (46.0%); 6 had drainage to the right atrium, 12 to the right ventricle, 1 to the left atrium, 2 to the left ventricle, 7 to the main pulmonary artery, and 1 to the coronary sinus. One patient (1.6%) had the origin of the fistula in both coronary arteries. The entry point of the fistula was most often a single orifice (96.8%) and rarely multi-orificial (3.2%). 57 patients (90.5%) had isolated coronary fistulas (90.5%); 6 patients (9.5%) had other congenital cardiac malformations. The ultrasonic diagnosis of 60 patients was in line with findings at surgery and/or coronary arteriography. The diagnostic accuracy rate for coronary artery fistula was 95.2%. Preoperative transthoracic echocardiography missed the diagnosis of coronary artery fistula in three patients (4.8%). There is no difference (P>0.05) in diagnostic accuracy between echocardiography and coronary arteriography and/or surgery. Conclusions Transthoracic echocardiography, in comparison with coronary arteriography and/or surgery, is much simpler, easier, less expensive, safer, readily repeatable, and more convenient with equal accuracy, and should be the first-line method for the diagnosis of congenital coronary artery fistula.

Article history: Received 7 August 2013 Accepted 29 August 2013 Available online 7 September 2013 bolysis was more often used in secondary hospitals than in tertiary hospitals (36.8% vs 14.6%, p b 0.01). (II) Percentage usage of medications were: aspirin in 88.0%–98.6%, ACEI/ARB in 60.5%–84.4%, β-blockers in 55.8%–84.4%, LMWH in 54.2%–94.2%, clopidogrel in 14.3%–88.6%, and cholesterol lowering agents (statins) in 51.9%–90.9% (Table 2). (III) Major in-hospital events, death rates and the incidence Acute coronary syndrome (ACS) is comprised of three clinical conditions resulting from an acute imbalance between myocardial oxygen supply and demand: unstable angina, non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI). In the majority of patients, the primary pathology of ACS is either erosion or rupture of an atherosclerotic plaque leading to either subtotal or total occlusion of amajor branch of a coronary artery. A great deal of basic research, clinical investigation and clinical trials has been published in the western literature on various pharmacological and interventional strategies to prevent myocardial cell death during the time of ischemia and subsequent reperfusion [1]. However, no such information is available for China, where one quarter of the world population resides, until very recently [2]. Unfortunately, that report, which was published in Chinese and appeared in a local Chinese medical journal [2], was little known except in China. The purpose of this editorial is to present the highlights of this important report to the international community outside China. For the study, a total of 1307 in-patients with ST-segment elevation ACS from 64 hospitals across China were recruited and a standard questionnaire was used to obtain information about the patients, including demographic data, treatment and in-hospital outcomes. In these patients, the status of application of reperfusion therapy as well as the effect of aspirin, angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB), β-blockers, low molecular weight heparin (LMWH), clopidogrel and cholesterol lowering agents (principally statins) were analyzed. The results were as follows

Left ventricular aneurysms mainly occur in patients with transmural myocardial infarction caused by left anterior descending coronary artery occlusion. Left ventricular apical aneurysm is rarely found in patients with normal coronary arteriograms, and even rarer in these patients following cardiac operations. We analyzed 37 patients with postoperative left ventricular apical aneurysm, including 1 case from our hospital and 36 cases from the literature; 23 cases (62%) had left ventricular apical true aneurysms and 14 cases (38%) had left ventricular apical pseudoaneurysms, all confirmed at surgery and/or angiography. All cases, with the exception of one, had previously undergone cardiac surgery under cardiopulmonary bypass with apical venting. Although left ventriculography is generally regarded as the gold standard for diagnosis of ventricular aneurysm, echocardiography is an accurate and sensitive method in the evaluation of left ventricular apical aneurysm. Differential diagnosis of left ventricular apical aneurysm includes takotsubo cardiomyopathy, post transapical approach for transcatheter aortic valve implantation, and left ventricular diverticulum.

The arterial switch operation (ASO) is currently the treatment of choice for infants with transposition of the great arteries (TGA). Little is known, however, about the alteration of anatomic left ventricular (LV) torsional mechanics after the operation. This study sought to evaluate LV torsion in patients of transposition of the great arteries with intact ventricular septum (TGA/IVS) using speckle tracking echocardiography.Echocardiographic images were prospectively acquired in 32 infants (age range, 0.5-60 months) who successfully underwent ASO repair at about 1 month of age and in 48 normal controls. They were divided into early and late categories according to the age at the time of the study. The LV peak systolic torsion and systolic twisting and diastolic untwisting velocities were determined by speckle tracking. Mitral inflow velocity obtained by Pulsed-wave Doppler and mitral annular velocities drawn by septal tissue Doppler were also analyzed.Compared with controls, the early postoperative group (TGA1) had significantly higher septal E/e' (P=0.000). In contrast, septal e' velocity (P=0.000), LV peak apical rotation (P=0.01), twist (P=0.02) and peak untwisting velocity (PUV) (P=0.001) were lower in patients than in controls. For the normal younger group (Control1), PUV correlated positively with e' (r=0.68, P0.001). No significant difference in LV twisting and untwisting was noted between the TGA2 and Control2.Two dimensional speckle tracking echocardiography may sensitively detect impaired LV torsional mechanics in patients with TGA/IVS early after ASO, and the impairment of LV relaxation leads to increased LV filling pressure which is consistent with higher E/e'. However, all patients recovered well thereafter and the overall midterm outcome of ASO is satisfactory.

Objective To explore the value of transthoracic and right heart contrast echocardiography in the diagnosis of coronary sinus septal defect (CSSD), also known as unroofed coronary sinus. Methods The echocardiographic characteristics of 20 patients with CSSD who underwent surgery in our hospital between October 1999 and June 2012 were reviewed retrospectively, including results of 9 cases studied by contrast echocardiography, and compared with surgical results. Results Of the coronary sinuses in these 20 patients, 40% were totally unroofed, 35% partially unroofed in mid-portion, 20% partially unroofed in terminal portion, and 5% mixed type (mid- and terminal portions). Of these 20 patients, 65% were associated with other types of atrial septal defects, and 65% had a persistent left superior vena cava. The diagnostic accuracy of echocardiography for the CSSD was 65%. In patients whose diagnoses were confirmed by echocardiography, the accuracy for the types of CSSD was 84.6%. All of the first 6 cases studied before 2002 were either undiagnosed or misdiagnosed, and 78.6% of the last 14 cases studied were diagnosed accurately. Of 9 patients who underwent contrast echocardiography, 8 were correctly diagnosed, including 5 type II and 3 Raghib syndromes. 1 case of type IIIa was misdiagnosed as Raghib syndrome. Conclusions The combination of transthoracic and contrast echocardiography can diagnose and classify CSSD accurately in most cases and should be the first choice for diagnosing CSSD.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare but potentially fatal complication of infective endocarditis and aortic valve surgery. 149 patients with P-MAIVF, including 7 cases in our hospital and 142 cases from the literatures, were comprehensively analyzed. P-MAIVF is located in the mitral-aortic intervalvular fibrosa area, which communicates with the left ventricular outflow tract. The cavity of P-MAIVF expands during systole and collapses during diastole. Endocarditis and aortic valve surgery are the most frequent causes. Symptoms of endocarditis, chest pain, heart failure, dyspnea, cerebrovascular accidents and systemic embolism are important clinical presentations. The formation of a fistulous tract, coronary artery compression, and rupture into pericardium are important complications. Transesophageal echocardiography is superior to transthoracic echocardiography in identifying P-MAIVF. Surgery is the treatment of choice with P-MAIVF repair and aortic valve replacement.

In May 2011 Professor Xin-fang Wang (王新房) from Wuhan, China was named the “Father of Modern Echocardiography” by the International Society of Cardiovascular Ultrasound (Fig. 1). In an auspicious ceremony, the certificate was presented to Professor Wang in Wuhan by Dr. Nanda, President of the Society of Cardiovascular Ultrasound (Fig. 2). Although this exciting news was widely and appropriately publicized in China (Fig. 3), it was not well known in the rest of the world. Therefore, I would like to introduce Professor Wang in this editorial as well as the history and evolution of echocardiography in China under Professor Wang's influence.

IntroductIon Studies conducted so far have shown that patients with left ventricular hypertrophy have increased adiponectin levels; however, these studies were performed only in resting condition. objEctIvEs The aim of the study was to compare adiponectin, resistin, and leptin levels (at rest and after exercise) between patients with hypertrophic cardiomyopathy (HCM) and healthy controls. Additionally, we examined potential relationships between the levels of the 3 adipokines and the left ventricular outflow tract (LVOT) gradient both at rest and at peak exercise. PAtIEnts And mEthods We studied 29 patients with HCM (mean age 42.7 ±11.9 years, 16 men and 13 women). The control group included 19 healthy subjects matched for age-, sex-, and the body mass index. After echocardiographic examination in a supine position, all patients were placed in an upright position and treadmill exercise test was performed with simultaneous continuous echocardiographic monitoring of the LVOT gradient. Adiponectin, resistin, and leptin levels were measured immediately prior to exercise in a supine position and at peak exercise in an upright position. rEsuL ts At baseline (at rest), adiponectin levels tended to be increased in patients with HCM (P = 0.09), while resistin and leptin levels were significantly higher in patients with HCM than in healthy controls. In HCM patients, exercise induced an increase in adiponectin (20.74 ±7.95 vs. 22.52 ±8.10 μg/ml, P

Objectives To observe the motion of pericardium and myocardium in patients with constrictive pericarditis (CP) and normal subjects using two-dimensional (2D) echocardiography and quantitative tissue Doppler imaging (QTDI), and to investigate the value of this echocardiographic approach in the diagnosis of pericardial adhesion in CP. Background The relationship of the motion of pericardium and myocardium in CP has not been investigated by QTDI. Methods The motions of pericardium and myocardium and the difference between them were investigated using 2D echocardiography combined with QTDI technique in 20 patients with CP and 20 age- and sex-matched normal subjects. Systolic peak displacements of pericardium ( D 1 ), outer-layer myocardium ( D 2 ) and inner-layer myocardium ( D 3 ) were measured from quantitative tissue displacement curves. The ratios of ( D 3 – D 2 )/( D 2 – D 1 ) were then calculated. Results In normal subjects, the motion of myocardium was found to be stronger than that of pericardium, but the motions of outer-layer and inner-layer myocardium were virtually identical. However, in patients with CP, the motion of outer-layer myocardium was significantly reduced approaching that of pericardium, while the motion of inner-layer myocardium was stronger than that of outer-layer myocardium. The ratios of ( D 3 – D 2 )/( D 2 – D 1 ) were significantly higher in patients with CP than those in normal subjects (5.0±4.7 vs 0.6±0.7, P Conclusions Obvious differences exist in the motion of pericardium and myocardium between normal subjects and patients with CP; observations of these differences using 2D echocardiography and QTDI provide a new and sensitive method in the diagnosis of pericardial adhesion in CP.

Hypertrophic cardiomyopathy (HCM) is the commonest cause of sudden cardiac death in the young, especially the young athletes, accounting for one third [1]. The fact that young athletes, especially elite athletes, often have enlarged hearts has been known before HCM was described. Tung [2] in China noticed in 1930 a markedly enlarged heart in an otherwise healthy ricksha puller, employed in one of the departments of his hospital, during a routine physical examination. This finding led to the study of 46 healthy ricksha pullers nearly half of whom showed definite cardiac enlargement, which he reported in 1934 [3]. White in his textbook, entitled “Heart Disease” that was published in 1952 [4], described similar findings, which he called the ‘athletic heart’. “It is of considerable interest to note that the hearts of very active animals are much larger than are those of relatively inactive animals of the same size; for example, the heart of the hare is three times as heavy, relative to body weight, as that of the rabbit, while the heart of the racing greyhound is, in proportion to size, the largest mammalian heart of all (Herrmann, 1926). Finally, when animals, such as dogs or rats, are made to exercise strenuously for long periods of time, it is found that eventually their hearts are considerably larger and heavier than those of control animals of the same age and size, and even from the same litter. This is especially true when the strenuous exercise is imposed during the period of rapid growth. There is no indication that such hypertrophy, when it does occur, is harmful. Recent studies indicate that athletes do not suffer early disability or death because of their exercise in youth; in fact the reverse seems to be the case, at least as regards oarsmen (Cooper et al., 1937; Hartley and Llewellyn, 1939). An interesting volume was published by

The ductus arteriosus (DA) is one of the most important vessels of the fetal circulation. A variety of fetal congenital heart disease (CHD) may greatly influence the structure and flow patterns of the DA. This study was to investigate the structural characteristics of the DA and its value in the diagnosis of fetal CHD using fetal echocardiography combined with cardiovascular casting technology.Twenty-six cases of a normal fetus and 20 cases of a fetus with CHD (10 cases of right-sided obstructive CHD and 10 cases of left-sided obstructive CHD) were enrolled in this study. The three-vessel view and the long axis view of the DA arch were chosen to observe the fetal DA. The diameters of the ascending aorta (AO) and the pulmonary artery trunk (PA) were measured on the left ventricular outflow tract view and the three-vessel view separately, and AO/DA and PA/DA values were calculated separately. The flow direction of the DA was recorded, and the blood flow peak velocity was measured using color and spectral Doppler technology. Cardiovascular cast specimens were made for fetuses secured from induced labor to facilitate further observations of the true form and connections of the DA. At the same time, heart and great vessel deformities were also recorded through careful observation of the cardiovascular cast.The following DA anomalies were observed: ① abnormal diameter (6 cases of stenosis and 9 cases of dilatation); ② abnormal blood flow direction (reverse flow in 5 cases); ③ abnormal blood flow speed (12 cases); ④ abnormal connection site (right-sided DA in 2 cases and a DA connection between the left pulmonary artery and the left subclavian artery in one case); and ⑤ absence of the DA in 2 cases. Compared with the control group, the DA diameter in the right-sided obstructive group was obviously narrowed; by contrast, the diameter of the DA in the left-sided obstructive group was obviously dilated. These differences were statistically significant (p0.05). Compared with the control group, the AO/DA values in the right- and left-sided obstructive groups were significantly increased and decreased, respectively. Finally, relative to the control group, the PA/DA values of the right- and left-sided obstructive groups were significantly reduced.DA enlargement was often associated with left-sided obstructive CHD, whereas a small DA and reverse blood flow often indicated the presence of right-sided obstructive CHD. DA connections can manifest with multiple anatomical variations. During fetal echocardiography, evaluation of the DA is very important; such analyses may help search for associated cardiac defects whenever a diagnosis of CHD is made.

The purpose of this study was to explore whether dysglycemia, and/or an increased body mass index, and/or an increased waist/hip ratio increased the risk of hypertension in a lean population of South China. The association among dysglycemia, obesity, and hypertension has been well documented in Western populations. A stratified cluster sampling method was used according to the National Diabetes Mellitus Epidemiology Survey Program in 1998. Blood pressure, fasting plasma glucose, and plasma glucose were measured 2 hours after 75-g oral glucose consumption using the enzymatic method in the morning. Body height, weight, and waist and hip measurements were also collected for the survey. The criteria for the diagnosis of hypertension and diabetes mellitus, including impaired glucose tolerance (IGT), were those published by the World Health Organization in 1999. A total of 11,402 participants were included in the investigation (5,195 men and 6,207 women; age 20 to 74 years). A total of 1,775 cases of hypertension were confirmed in the survey. The prevalence of hypertension was significantly higher in those with diabetes mellitus than in those with a normal blood glucose level, in those with IGT than in those with normal glucose tolerance test findings, and in obese participants than in those with a normal weight (45.5% vs 14.4%, 32.2% vs 14.5%, and 20.6% vs 12.1%, respectively). Multiple logistic regression analysis indicated that age and gender-adjusted odds ratio of hypertension was 2.24 (95% confidence interval 1.88 to 2.68) with IGT compared with those without IGT. The odds ratio for hypertension associated with an increased body mass index and waist/hip ratio was 1.19 (95% confidence interval 1.17 to 1.21) and 1.08 (95% confidence interval 1.07 to 1.09), respectively. In conclusion, the data from an epidemiologic study in South China demonstrated that dysglycemia and increased body mass index and/or waist/hip ratio increase the risk of hypertension even in a lean Chinese population.

Mitral valve area (MVA) in 30 patients with mitral stenosis (MS) and 34 normal controls was calculated by real-time, 3-dimensional echocardiography (RT3DE); MVA in patients with MS correlated well with the mitral area determined by 2-dimensional echocardiography (r = 0.98) and by pressure half-time (r = 0.90). MVA in normal controls on RT3DE correlated well with MVA on 2-dimensional echocardiography (r = 0.94) and pressure half-time (r = 0.91). There were significant differences between the orifice areas in patients with MS and normal controls. RT3DE can provide not only the anatomic structure of mitral valve apparatus, but also the optimal plane of the smallest mitral valve orifice, and can thus accurately measure the MVA.

Since the founding of the People’s Republic of China in 1949, many changes have taken place in China over the past half century. Whereas China has made phenomenal strides both economically and geopolitically, it has also undergone dramatic changes in the prevalence of coronary heart disease (CHD). People in China used to be known for their lean body build, low plasma cholesterol levels and low incidence of CHD [1]. Now all has changed; CHD in China has climbed from the fifth most common form of heart disease in 1949–1957 (6%) to the second most common in 1958–1968 (16%) and rising again in 1969–1979 (26%) to become the most common in 1980–1989 (27%) where it remains until today [1]. What are the risk factors responsible for this drastic change in modern China?

Switzerland is a small country in the heart of Europe and well known worldwide for its Alps, foreign bank accounts, cheese, chocolate and watches. However, it also has made a significant contribution to cardiology, especially interventional cardiology. It was where balloon angioplasty and stenting of obstructed coronary arteries, two of the most stunning advances in cardiology in the last 30 years and the two most frequently performed interventional procedures in cardiology, originated. The author, who recently served as a visiting professor in the University of Geneva, University of Bern and University of Zurich, summarized his personal observations and impressions in this report.

Cardiology in China has shown significant changes in the last decade or so. Interventional cardiology, in particular, has shown remarkable advances, especially in the management of coronary artery disease, which, unfortunately, has shown a disconcerting increase in incidence in a country traditionally known for very low incidence of coronary artery disease. Important contributing factors include increasing affluence, westernization of dietary habit and lifestyle, and rampant cigarette smoking. At present, the Chinese population has an annual coronary mortality of one sixth of that reported in the West, an incidence of acute myocardial infarction of one tenth to one eighth, and a mortality of acute myocardial infarction of one eighth. The prevalence of coronary artery disease among the general Chinese population (3–7%) is roughly one quarter of that among the Caucasians in the West, but this will get worse for sure. China still has a lot of catching up to do to reach full modernization. There is a price that every developing country must pay for modernization. However, let the price the Chinese pay not exceed the benefits derived from modernization. Can we achieve a utopian stage in the 21st century in which the modern Chinese retain their ancestral low rates of coronary artery disease while adapting the positive aspects of a modern western lifestyle?

Background : Percutaneous transluminal septal myocardial ablation (PTSMA) has been introduced as an alternative treatment for hypertrophic obstructive cardiomyopathy (HOCM). We report on the acute, short- and long-term results of our experiences in 119 patients from a single center in China. Methods and results : PTSMA was performed in 119 patients with symptomatic HOCM (mean age 35.4±14.8 years, male 80, female 39). All patients had echocardiography performed prior to the procedure, 2-week post-PTSMA, and 6-month post-PTSMA, and 65 patients had echocardiography repeated at 2-year follow-up. The average left ventricular outflow tract (LVOT) gradient was 67.3±7.8 mm Hg before the procedure, and 15.9±6.8 mm Hg after the procedure ( p p p Conclusions : PTSMA is a promising non-surgical procedure for symptomatic patients with HOCM because of its low risk and its significant hemodynamic, echocardiographic and clinical improvement. The significant therapeutic remodeling period was up to 6 months rather than 2 years following the procedure.

To evaluate the possibility and accuracy of Doppler tissue image (DTI) on assessment of normal and abnormal ventricular activation and contraction sequence, 9 open chest canine hearts were analyzed by acceleration mode, M-mode, and spectrum mode DTI. Our results showed that: (1) Acceleration mode DTI could show the origin of activation and conduction sequence on line; (2) M-mode DTI revealed that the activation in mid-interventricular septum was earlier than that in mid-left ventricular posterior wall at sinus activation; (3) Spectrum DTI showed the ventricular endocardium was activated earlier than the ventricular epicardium in all segments at sinus rhythm. The earliest site of activation of the normal ventricular wall was at middle interventricular septum; the latest site was at basal-posterior wall; the contraction sequence was different at the different walls; (4) During abnormal ventricular activation, mid-left ventricular posterior wall was activated earliest in accordance with the pacing sites. Abnormal ventricular activation was slower than sinus activation, and the contraction sequence varied at different sites of ventricular wall. It is concluded that DTI can be used to localize the origin of normal or abnormal myocardial activation and to assess the contraction sequence conveniently, accurately and non-invasively.

Background Published correlations between histological abnormalities and right ventricular (RV) function, as evaluated by speckle tracking echocardiography (STE), are scarce in patients with tetralogy of Fallot (TOF). The purpose of the study is to assess age-associated differences in the effect of RV myocardial remodeling on ventricular function in patients with TOF. Methods Operatively resected crista supraventricularis muscle from 30 patients (median age 12months) undergoing intracardiac repair of TOF were studied by light microscopy. The patients were divided into younger (age at surgery ≤12months) and older (age at surgery >12months) subgroups. The RV global longitudinal peak systolic strain (GLS), strain rate (GLSRs) and early diastolic strain rate (GLSRe) were measured by two-dimensional STE before and 6months after repair. Results The histopathological data revealed hypertrophy of the cardiomyocytes, a thickened endocardium, and increased interstitial and perivascular collagen in RV, which were associated with older age at the time of repair. The RV global systolic and diastolic functions in patients with repaired TOF were increased compared with the preoperative values. The RV cardiomyocyte diameter and collagen volume fraction (CVF) correlated with the preoperative GLS, GLSRs and GLSRe, respectively, in the younger patients (r 1 =−0.566, P 1 =0.018; r 2 =−0.493, P 2 =0.004; r 3 =−0.504, P 3 =0.039). The RV cardiomyocyte diameter and CVF correlated with preoperative GLS, GLSRs and GLSRe, respectively, in the older patients (r 1 =−737, P 1 =0.004; r 2 =−0.588, P 2 =0.035; r 3 =−0.812, P 3 =0.001). The correlation of the RV cardiomyocyte diameter with the postoperative GLS and GLSRe (r 1 =−665, P 1 =0.036; r 2 =−0.787, P 2 =0.007) and the CVF with the postoperative GLSRs and GLSRe (r 1 =−762, P 1 =0.002; r 2 =−0.713, P 2 =0.004) were identified only in the older patients. Multivariate analysis indicated that the age at repair was an independent predictor of postoperative GLSRs and GLSRe in all of the patients (β=−0.449, P=0.041; β=−0.607, P=0.004). Conclusions The effect of RV myocardial remodeling on preoperative RV function was more pronounced in the older patients with TOF than in the younger ones. Preoperative myocardial remodeling affected the postoperative RV function in the older but not in the younger patients. The age at the time of surgical repair was the independent determinant of the postoperative RV myocardial function.

(Semi) supine exercise testing has an established role in the evaluation of patients with valvular heart disease and can help clinical decision making. Stress echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. However, exercise-induced changes in valve hemodynamics, left ventricular outflow obstruction and pulmonary artery pressure depended on load variation. Changing position from supine to upright rapidly decreases load conditions for the ventricles. Therefore several cardiac centers have proposed exercise stress echocardiography in the upright position with gradient monitoring sometimes also in post-exercise recovery. Doppler measurement of subaortic gradient has been a very helpful and informative examination in several heart diseases (especially in hypertrophic cardiomyopathy, valve heart diseases, prosthesis dysfunction).

Background Although Hippocrates has been traditionally recognized worldwide as the father of medicine, the fact that he was seminal in the development of cardiology is much less well appreciated. Therefore his role in forming the foundation of scientific practice of cardiology needs to be defined. Methods This article was based on a personal 3-day visit in 1999 to the island of Kos, the birthplace of Hippocrates, and further research on the subject on return to the United States. Results Considering the fact that all the references to the heart and diseases of the heart were recorded almost 2500 years ago at a time when knowledge of anatomy was fragmentary and pathophysiology practically nonexistent, Hippocrates had truly accomplished a remarkable task in describing the various disorders of the heart and blood vessels, defining the methods of diagnosis and treatment, and outlining the prognostic factors and preventive measures. Conclusions Hippocrates was the pioneer in carefully documenting and thoughtfully interpreting case studies, an essential prerequisite to the coupling of clinical, physiologic, and pathologic features of diseases in the practice of cardiology that characterized the beginning of modern scientific medicine in the Renaissance. (Am Heart J 2001;141:173-83.)

The birth of therapeutic balloon dilation in the management of cardiovascular disease can be traced to Rashkind who in 1966 developed balloon atrial septostomy for palliation of patients with complete transposition of the great vessels. Actually, Dotter and Judkins anteceded Rashkind by coaxial sequential dilation of iliofemoral atherosclerotic obstruction in 1964. However, it was not until the development by Gruntzig in 1978 of a miniaturized flexible balloon catheter for percutaneous transluminal coronary angioplasty that therapeutic balloon dilation began to be applied to stenotic heart valves. The development of percutaneous balloon valvuloplasty was the natural consequence of the early success of surgical mechanical dilation of stenotic heart valves; first the pulmonic valve, then the mitral valve, and finally the aortic valve. The successful relief of valvular stenosis by percutaneous balloon valvuloplasty is a remarkable example of how the pioneering cardiac surgeons paved the way for interventional cardiologists to take over the treatment of heretofore, surgically managed diseases.

To the Editor: I enjoyed reading the beautifully illustrated case report of submitral aneurysm by Kontozis et al.1 However, I questioned the appropriateness of the term “false aneurysm” used by the authors to describe the submitral left ventricular aneurysm. False aneurysm is a healed myocardial free-wall rupture of a myocardial infarct.2 Because the authors stated clearly that submitral left ventricular aneurysms are caused by a congenital defect in the posterior portion of …

We studied the first 202 patients with rheumatic mitral stenosis (MS) who underwent percutaneous balloon mitral valvuloplasty (PBMV) with the Inoue balloon catheter for a follow-up (FU) period of 5–11 years. Pre- and post-PBMV and at FU, the mean left atrial pressure was 21.3 ± 7.4, 10.2 ± 5.6, and 11.2 ± 4.1 mm Hg; mean diastolic mitral gradient was 18.4 ± 7.3, 2.9 ± 3.2, and 5.1 ± 4.3 mm Hg; and mitral valve area was 1.0 ± 0.3, 2.1 ± 0.6, and 1.7 ± 0.5 cm2. Functional status improved from New York Heart Association (NYHA) class IV in 3, class III in 119, and class II in 80 pre-PBMV to class I in 163, class II in 37, and class III in 2 post-PBMV, and was class I in 146, class II in 39, and class III in 17 patients at FU. In the 17 patients with NYHA class III at FU, mitral restenosis was the culprit; 4 underwent repeat PBMV, 12 had mitral valve replacement for severe mitral calcification and subvalvular fusion, and 1 refused further intervention. Thus PBMV using the Inoue balloon catheter is an effective method of relieving MS with excellent long-term results in patients without severe mitral calcification and subvalvular fusion. Cathet. Cardiovasc. Diagn. 43:132–139, 1998. © 1998 Wiley-Liss, Inc.

Background Hypertrophic cardiomyopathy (HCM) and left ventricular noncompaction (LVNC) are both genetically determined and familial diseases that possess variable but overlapping genetic defects. Previous literature has mostly reported their occurrences as either separate disorders in different members of a family or coexisting entities in sporadic cases rather than familial cases. This study explored the echocardiographic diagnostic values and familial features in a family with coexistence of HCM and LVNC. Methods A four-generation family comprised of 30 members was studied; 28 members underwent familial screening by routine transthoracic echocardiography (TTE), contrast echocardiography (CE), and/or cardiac magnetic resonance imaging (cMRI). Echocardiographic and cMRI findings were then compared. Results Four members (13.3%) died of sudden death or heart failure. Eleven members (39%) suffered from HCM, LVNC or both. There were 13 left ventricular hypertrophic segments among the echocardiographic images of 9 locally archived patients, including septal, inferior and anterior wall segments (8, 3, 2 respectively) as well as 20 noncompaction segments, including lateral, apical, anterior, antero-septal and inferior wall segments (8, 5, 4, 2, 1 respectively). Left atrial dilatation and diastolic dysfunction were significant in these subjects. Findings from TTE and CE were in accordance with those from cMRI in lesion locations. CE provided more information about noncompaction segments located in the antero-septum and near field than TTE. Conclusions HCM and LVNC coexist in one Chinese family, with overlapping phenotypes and different ages, clinical manifestations and multimodality imaging findings. TTE is an excellent tool to diagnose HCM and LVNC with supplementation by CE.

It has been proposed to use exercise stress echocardiography in the upright position with left ventricular outflow tract gradient monitoring both during and after exercise as a marker of genotype-positive/phenotype negative hypertrophic cardiomyopathy (HCM). Doppler measurement of gradient has been a very helpful and diagnostic examination in several subgroups of subjects (especially in young persons, athletes). Recently, many noninvasive (bio)markers have been found to be very helpful in screening patients suspected of HCM before full expression of phenotype.

To observe the stereoscopic structure and the motion of the prolapsing mitral valve and its regurgitant jet in comparison with the normal mitral valve, four-dimensional (or dynamic three-dimensional) echocardiography of mitral valve apparatus was obtained in 20 patients with mitral valve prolapse and 10 unaffected subjects by use of transthoracic and transesophageal methods. The normal mitral valve apparatus has a consistent saddle-shaped configuration, with its anterior and posterior high points located near the aortic root and posterior left ventricular wall, respectively, and its low points located medially and laterally. In mitral valve prolapse, the spatial relation of mitral leaflets and anulus can be observed in four dimensions either from the left ventricle toward the left atrium or from the left atrium toward the left ventricle; the position, size, shape, motion, and extent of functional abnormality of the prolapsing mitral valve were clearly displayed. On the long-axis view of the left ventricle and the apical four-chamber view of four-dimensional echocardiography, the part of prolapsing mitral valve that protruded into the left atrium appeared as a spoon-like depression. We also obtained four-dimensional images of regurgitant blood flow to observe the stereoscopic view of blood flow column and its cross-sectional area, spatial position, and dynamic changes. This technique is of great value in evaluating patients with mitral valve prolapse, increasing the diagnostic sensitivity and specificity, and giving assistance to the surgeons in making preoperative therapeutic decisions and assessing the intraoperative and postoperative results.

Acupuncture combines the Latin acus (needle) and punctum (a prick) [1]. From the historical record of Huangdi Neijin (the Yellow Emperor’s Classic), acupuncture has been used in China as a therapeutic tool for at least 2000 years [2]. In ancient China, soldiers noted, after being wounded by arrows, that their pain often eased for quite a while [3]. Therefore, a cause-andeffect relationship was assumed between the arrow wound and the unexpected diminution of pain. However, acupuncture has been little known in the Western world until 1970s after U.S. President Nixon’s historic visit to China in 1972 [4]. Following the initial excitement engen‐ dered by the press reports [5], acupuncture becomes one of the most popular treatments in alternative medicine (Figure 1), and accounts for more than 10 million treatments given annually in the United States [6]. Much interest was further engendered by tales by subsequent visitors to China who witnessed surgical operations being successfully performed on con‐ scious patients under acupunctural anesthesia [7-15]. Scientific studies using modern technol‐ ogy on acupuncture actually began in China in the late 1950s with further progress being made since the discovery of endogenous opioids in 1975 [2,16]. Much more advances have been made in more recent years in further understanding of the basic mechanisms underlying this millennium old medical treatment and its various clinical applications in the 21st century. This chapter reviews the current role of acupuncture in cardiology.

More than half a century ago, the renowned American physiolo-gist Walter B. Cannon [1] published a paper entitled ""Voodoo"Death”, based on anecdotal experiences, largely from the anthropolo-gy literature, of death from fright. He postulated that such a deathwas caused “by a lasting and intense action of sympathico-adrenalsystem” [1,2]. Today's phrases “scared to death” [3] and “a brokenheart” [4] are deeply rooted in folk wisdom and reflect potentially le-thal consequences of emotional, depressogenic or mental stress. In1971, Engel [5] collected 170 accounts from the lay press of suddendeath that were attributed to disruptive life events. He found thatsuch events could be divided into 8 categories: (1) on the impactof the collapse or death of a close person; (2) during acute grief;(3) on threat of loss of a close person; (4) during mourning or onan anniversary; (5) on loss of status or self-esteem; (6) personalangeror threat of injury; (7)after danger is over;and (8) reunion,tri-umph, or happy ending. Engel proposed that any of these eventscould provoke neurovegetative responses, involving both the flight–fight and conservation–withdrawal systems, conducive to lethal car-diac events, particularly in individuals with preexisting cardiovascu-lar disease [5].Stress-induced cardiovascular reactivity has been shown to be as-sociated with carotid intima-media thickness and early atherogensis[6]. Daily stress is associated with a >2.1-fold increase in risk for de-veloping coronary artery disease and acute myocardial infarction [7],whichis similarto therelativerisksof diabetes,hypercholesterolemiaand hypertension [8]. Psychosocial stress accounts for 30% of the pop-ulation attributable risk of acute myocardial infarction [9]. Onlysmoking and hyperlipidemia account for greater population attribut-able risk, while hypertension, diabetes and abdominal obesity ac-count for lower population attributable risk [6,8,9].Takotsubo cardiomyopathy, alsoreferred to as transientleftventric-ular apical ballooning, stress-induced cardiomyopathy, takotsubo syn-drome, apical ballooning syndrome, atypical apical ballooning, ampullacardiomyopathy, broken heart syndrome, or transient left ventriculardysfunction syndrome [10], was named after a round-bottomed andnarrow-necked fishing pot – takotsubo 蛸壺 in Japanese – for trappingoctopus, because of its resemblance to the left ventriculogram in thesepatients.Itwas firstdescribedin1991byDoteetal. [11]andpopularized10 yearslaterbyTsuchihashietal. [12].Itisaclinicalconditionaffectingindividuals (mainly postmenopausal women), following emotional dis-tress,resemblingacutemyocardialinfarction,withusuallynormalcoro-nary arteries on coronary arteriography and transient left ventriculardysfunction. However, there are many questions regarding etiology,pathophysiology and treatment which still remain unanswered.In the very interesting article of Yoshida et al. [13] published inthis journal about a 78-year-old woman with takotsubo cardiomyop-athy, the patient developed cardiac rupture, massive hemorrhagicpericardial effusion and left ventricular mural thrombus. Fortunately,the patient survived after surgical performance of a pericardial win-dow and intravenous heparin therapy. Yoshida et al. [13] postulatedventricular rupture associated with coagulation abnormalities andcontraction band necrosis. Indeed, on light microscopy, increased eo-sinophilic staining with preservation of cross-striations and totaltransformation of the myocardial cytoplasm into dense eosinophilictransverse bands with intervening irregularity have been recognizedas the main findings of catecholamine-induced cardiomyopathysince long time ago [14]. Contraction-band necrosis has been de-scribed in clinical states of catecholamine excess such as pheochro-mocytoma [15] and subarachnoid hemorrhage [16]. It has also beenobserved post mortem in people who died under terrifying circum-stances such as fatal asthma [17] and violent assault [18], suggestingthat catecholamines may be an important link between emotionalstress and cardiac injury. In fact, takotsubo cardiomyopathy hasbeen reported following intravenous administration of epinephrineduring an anaphylactic reaction [19] and in association with pheo-chromocytoma [20].The precise incidence of patients with takotsubo cardiomyopathy isdifficult to ascertain, because its diagnosis has largely been a process ofexclusion [21]. The best estimate is 2.1% of female patients and 0.5% ofall patients with ST-elevation myocardial infarction, as reported in the

recent studies of ancient egyptian mummies by whole-body multislice computed tomographic scans documented the presence of atherosclerosis in their aorta, as evidenced by calcification, as well as in the femoral, iliac, carotid, and coronary arteries.1, 2 therefore, arteriosclerosis and cardiovascular calcification are not unique to contemporary humans. indeed, coronary atherosclerotic disease is not a modern ailment: it existed in China as far back as 2nd-century B.C.3-8 extensive occlusive coronary atherosclerotic disease was found in a 50-year-old Chinese noblewoman — lady dai — who died in 163 B.C.9 she had a severely occluded left anterior descending coronary artery (Figure 1), which was responsible for her sudden death from an anterior myocardial infarction an hour or so after a meal.3-8 lady dai had several risk factors. First, she had a type a personality; 1381⁄2 musk melon seeds were found in her stomach (Figure 2), and researchers believed she must have gulped down

Three-dimensional transesophageal echocardiography is a new and evolving cardiac imaging technique. We reported our experiences of its clinical applications in 59 patients. A series of special temporal longitudinal views were selected by the frame grabber. Then the computer connected each digitized endocardial surface of the longitudinal views according to their spatial position and reconstructed the three-dimensional, cardiac shaded picture with gray scale. The three-dimensional transesophageal echocardiographic images were divided into three areas. The right area was right anterior to the esophagus and included such structures as the superior vena cava, right atrium, interatrial septum, and left atrium; the size, shape, and location of an atrial septal defect could be clearly shown. In the middle area the origin and the course of the two great arteries could be visualized, thus facilitating the diagnosis of transposition of the great arteries; in patients with obstruction of the right ventricular outflow tract, the circular ridgelike narrowing in the right ventricle was clearly visualized. In the left area the contour and size of the left ventricle and left atrium and the shape and point of coaptation of the mitral valve could be demonstrated; in patients with mitral valve prolapse, part of either leaflet protruded into the left atrium and appeared as a spoonlike depression in the mitral valve. Other entities subjected to three-dimensional transesophageal echocardiographic reconstruction included cor triatriatum, left atrial myxoma, aneurysm of sinus of Valsalva, dissecting aortic aneurysm, mitral stenosis, mitral regurgitation, and mitral valve prolapse.(ABSTRACT TRUNCATED AT 250 WORDS)

To the Editor: In the review1 on exercise testing in nonatherosclerotic heart disease, the important role of upright position during exercise stress test in hypertrophic cardiomyopathy to provoke left ventricular (LV) outflow tract gradient (LVOTG) was not mentioned. Changing position from supine to standing may provoke LVOTG by reduction of LV preload and may induce the symptom of presyncope. Standing position during exercise, especially in a stress test using the more natural treadmill instead of the less natural supine bicycle, reflects the physiological condition during …