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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.

Mitral regurgitation (MR) is a common valve disease, frequently encountered in echocardiography laboratories. Correct quantification of the severity of the MR is of paramount importance for accurate prognostication and proper treatment planning. The MR spectral Doppler tracing can provide important information regarding intracardiac pressures and be a clue to the presence of various cardiovascular pathologies. Assessing the MR jet velocity is essentially unrelated to the MR severity. Severity is determined by the quantity of the MR—the volume (or fraction) of blood that spills back into the LA instead of being ejected forward through the aortic valve. MR velocity is determined by the pressure gradient driving this velocity, irrespective of the volume of blood that regurgitates back into the LA. Analyzing MR spectral Doppler can provide a clue to the presence of various cardiac (or extra-cardiac) pathologies, and presence of an unusual MR spectral tracing should prompt a search for its cause.

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.

This chapter provides an overview of the role of three-dimensional echocardiography (3DE) in surgical and percutaneous mitral valve procedures. Throughout the chapter, numerous still images and videos are provided to illustrate the incremental values of 3DE in these procedures. The chapter starts with the description of 3DE imaging of surgical mitral valve replacements and repairs. The 3DE appearance of major types of mechanical and bioprosthetic valves is given including Starr-Edwards, Medtronic Hall, St Jude, and Carpentier Edwards prosthetic valves. Thereafter, an overview of common surgical mitral valve repairs including the Alfieri stitch is discussed. Next, an overview of 3DE in percutaneous alternatives to surgical repairs of native and prosthetic mitral regurgitant lesions is provided including the mitral valve clipping and percutaneous closures of prosthetic paravalvular leaks. The chapter concludes with a description of the role of 3DE in percutaneous mitral balloon valvuloplasty of rheumatic mitral stenosis.

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.

AIMS Transcatheter techniques can theoretically be applied to the treatment of para-annular ring (PAR) leaks. Little is known about their potential application and resultant complications in such cases. We describe the first-in-man percutaneous transapical-transseptal Melody valve-in-ring (ViR) implantation after a complication from percutaneous PAR leak closure. METHODS AND RESULTS A 49-year-old woman, at high operative risk, presented with congestive heart failure secondary to severe para-ring/extravalvular regurgitation two months after bypass surgery and mitral ring annuloplasty. Successful percutaneous closure of the leak was performed using an AMPLATZER Vascular Plug IV. One month later, she developed haemolysis with severe PAR regurgitation, through and around the device. After device retrieval and placement of an AMPLATZER Muscular VSD occluder, the patient developed severe intravalvular regurgitation. Completely percutaneous, transseptal delivery of a Melody ViR was performed over a transapical-transseptal, arteriovenous rail. Echocardiography revealed trivial residual regurgitation through the implanted valve with mild transvalvular gradients. CONCLUSIONS Percutaneous closure of mitral PAR leaks after ring annuloplasty in the high-risk patient is feasible (proof-of-concept), particularly when the leak is para-ring/extravalvular. Potential complications include severe intravalvular mitral regurgitation caused by disruption of the mitral apparatus and/or ring deformation during device deployment, which can be successfully treated via percutaneous transapical-transseptal ViR implantation.

Objectives The aim of this proof-of-principle study is to validate the accuracy of fusion imaging for percutaneous transapical access (TA). Background Structural heart disease interventions, including TA, are commonly obtained under fluoroscopic guidance, which lacks important spatial information. Computed tomographic angiography (CTA)-fluoroscopy fusion imaging can provide the 3-dimensional information necessary for improved accuracy in planning and guidance of these interventions. Methods Twenty consecutive patients scheduled for percutaneous left ventricular puncture and device closure using CTA-fluoroscopy fusion guidance were prospectively recruited. The HeartNavigator software (Philips Healthcare, Best, the Netherlands) was used to landmark the left ventricular epicardium for TA (planned puncture site [PPS]). The PPS landmark was compared with the position of the TA closure device on post-procedure CTA (actual puncture site). The distance between the PPS and actual puncture site was calculated from 2 fixed reference points (left main ostium and mitral prosthesis center) in 3 planes (x, y, and z). The distance from the left anterior descending artery at the same z-plane was also assessed. TA-related complications associated with fusion imaging were recorded. Results The median (interquartile range [IQR]) TA distance difference between the PPS and actual puncture site from the referenced left main ostium and mitral prosthesis center was 5.00 mm (IQR: 1.98 to 12.64 mm) and 3.27 mm (IQR: 1.88 to 11.24 mm) in the x-plane, 4.48 mm (IQR: 1.98 to 13.08 mm) and 4.00 mm (IQR: 1.62 to 11.86 mm) in the y-plane, and 5.57 mm (IQR: 3.89 to 13.62 mm) and 4.96 mm (IQR: 1.92 to 11.76 mm) in the z-plane. The mean TA distance to the left anterior descending artery was 15.5 ± 7.8 mm and 22.7 ± 13.7 mm in the x- and y-planes. No TA-related complications were identified, including evidence of coronary artery laceration. Conclusions With the use of CTA-fluoroscopy fusion imaging to guide TA, the actual puncture site can be approximated near the PPS. Moreover, fusion imaging can help maintain an adequate access distance from the left anterior descending artery, thereby, potentially reducing TA-related complications.

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.

Catheter-based mitral valve clip repair (CBMCR) is feasible for selected patients with mitral regurgitation (MR). Two-dimensional (2D) transesophageal echocardiography (TEE) is the standard modality for evaluating MR and procedural guidance. Recently, real-time three-dimensional TEE became available. The aim of this study was to evaluate the value of combined 2D and three-dimensional TEE for CBMCR. In evaluating MR for CBMCR, the confidence of interpretation of 2D TEE was compared with that of combined imaging for the localization of major valve pathology. In patients who underwent CBMCR, the outcomes and the duration of CBMCR were compared.In this retrospective study, MR evaluation was performed by 2D TEE alone and by combined imaging in 80 and 57 patients, respectively. CBMCR was guided by 2D TEE alone in 20 patients and by combined imaging in 39 patients.Examination by combined imaging allowed en face visualization of mitral valve anatomy and MR jet origin. The confidence of interpretation by combined imaging was higher than for 2D TEE (1.1 ± 0.3 vs 1.8 ± 0.7, P.001).The guidance of CBMCR by combined imaging facilitated alignment of the catheter trajectory, clip positioning, and orientation of clip arms. The procedural success and final MR grade were not different between the two study groups. However, the procedural time of CBMCR using combined imaging compared with that using 2D TEE guidance alone was shorter (241 ± 58 vs 201 ± 68 min, P = .035).The use of combined imaging compared with 2D TEE alone appears to enhance the confidence of interpretation concerning mitral pathology and catheter-clip system location and may also reduce CBMCR time.

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.

Cardiac valve replacement, albeit a well-established and safe procedure, is associated with a significant risk of complications. Symptomatic paravalvular leak (PVL) is a significant post-operative complication of cardiac valve replacement. The prevalence of this complication along with the long-term significance of asymptomatic leaks remains unknown. When these patients develop worsening heart failure or severe haemolysis that requires multiple transfusions from paravalvular regurgitation, the current recommendation is for closure of the leak. The recommended approach has been surgical closure until transcatheter techniques were introduced by Hourihan et al .1 There have been significant innovations in occlusive devices over the past 20 years; however, there are no specifically designed device(s) for the treatment of PVLs. Percutaneous device closure of PVLs has become an attractive alternative to surgical closure. This has further been enhanced by the ability to integrate multi-imaging modalities that have helped to define the pre-operative anatomy as well as to plan and guide the percutaneous closure procedure, resulting in improved outcomes. Since no single imaging modality has the capability to provide all the crucial information that is required for percutaneous closure of PVLs, in our centre we utilize an integrated multiple imaging modalities within a bi-plane cardiac catheterization laboratory. The following modalities assist in the assessment and guidance of percutaneous closure of PVLs. ### Echocardiography Echocardiography is a multifaceted tool used for the diagnosis, quantification, and guidance of treatment of paravalvular prosthetic valve leaks. ### Diagnosis Two-dimensional (2D) echocardiography with spectral and colour Doppler flow images are frequently used for the non-invasive diagnosis of PVLs. Transthoracic echocardiography (TTE) in various imaging planes obtained from the parasternal, apical, subxyphoid, and suprasternal windows helps to define the site of the leak ( Figure 1A ). However, the jet of prosthetic valvular and/or PVL may be overshadowed by the prosthetic valve, thus underestimating the degree of leak …

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.

Background Real-time three-dimensional (RT3D) echocardiography is a recently developed technique that is being increasingly used in echocardiography laboratories. Over the past several years, improvements in transducer technologies have allowed development of a full matrix-array transducer that allows acquisition of pyramidal-shaped data sets. These data sets can be processed online and offline to allow accurate evaluation of cardiac structures, volumes, and mass. More recently, a transesophageal transducer with RT3D capabilities has been developed. This allows acquisition of high-quality RT3D images on transesophageal echocardiography (TEE). Percutaneous catheter-based procedures have gained growing acceptance in the cardiac procedural armamentarium. Advances in technology and technical skills allow increasingly complex procedures to be performed using a catheter-based approach, thus obviating the need for open-heart surgery. Methods The authors used RT3D TEE to guide 72 catheter-based cardiac interventions. The procedures included the occlusion of atrial septal defects or patent foramen ovales (n = 25), percutaneous mitral valve repair (e-valve clipping; n=3), mitral balloon valvuloplasty for mitral stenosis (n = 10), left atrial appendage obliteration (n = 11), left atrial or pulmonary vein ablation for atrial fibrillation (n = 5), percutaneous closures of prosthetic valve dehiscence (n = 10), percutaneous aortic valve replacement (n = 6), and percutaneous closures of ventricular septal defects (n = 2). In this review, the authors describe their experience with this technique, the added value over multiplanar two-dimensional TEE, and the pitfalls that were encountered. Results The main advantages found for the use RT3D TEE during catheter-based interventions were (1) the ability to visualize the entire lengths of intracardiac catheters, including the tips of all catheters and the balloons or devices they carry, along with a clear depiction of their positions in relation to other cardiac structures, and (2) the ability to ability to demonstrate certain structures in an "en face" view, which is not offered by any other currently available real-time imaging technique, enabling appreciation of the exact nature of the lesion that is undergoing intervention. Conclusion RT3D TEE is a powerful new imaging tool that may become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based procedures.

Transcatheter therapies in structural heart disease have evolved tremendously over the past 15 years. Since the introduction of the first balloon-expandable valves for stenotic lesions with implantation in the pulmonic position in 2000, treatment for valvular heart disease in the outflow position has become more refined, with newer-generation devices, alternative techniques, and novel access approaches. Recent efforts into the inflow position and regurgitant lesions, with transcatheter repair and replacement technologies, have expanded our potential to treat a broader, more heterogeneous patient population. The evolution of multimodality imaging has paralleled these developments. Three- and 4-dimensional visualization and concomitant use of novel technologies, such as fusion imaging, have supported technical growth, from pre-procedural planning and intraprocedural guidance, to assessment of acute results and follow-up. A multimodality approach has allowed operators to overcome many limitations of each modality and facilitated integration of a multidisciplinary team for treatment of this complex patient population.

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.

Transcatheter aortic valve implantation has been introduced into the clinical arena as an alternative to traditional surgical aortic valve replacement for these high-risk patients. The anatomic suitability is decided by a number of imaging techniques including 2-dimensional transthoracic (2D TTE) and transesophageal (2D TEE) echocardiography, coronary and peripheral angiography, and computed tomography scanning from the aortic root to the common femoral artery. New insights into the anatomy of the aortic valve complex in the beating heart became possible with the rapidly increasing availability of 3-dimensional imaging techniques that have extended our concepts of the “in vivo” 3D morphology of the valve. A comprehensive understanding of the 3D anatomy of aortic root is of paramount importance for both interventionalists and experts in cardiac imaging. The purposes of this chapter are: to describe 3D TEE anatomy of normal aortic root ; to describe RT 3D TEE imaging of calcific aortic stenosis and, finally, to outline the debated role of 2D TEE and 3D TEE during the procedure.

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.

Complex ablations procedure might greatly benefit of an imaging technique capable of showing the anatomical details of the ‘terrain’ where the ablation takes place, guiding in real time catheter movements and continuously monitoring the catheter-tissue contact points during the energy delivery. Because 3D TEE provides high-resolution 3D images of the anatomy of the posterior structures of the heart (i.e. left and right atrium), at least in theory, this technique may have the potential to become a new, anatomy-driven navigational guide for ablation procedures. In this chapter we illustrate, normal 3D TEE anatomy of right and left atrial structures involved in ablation procedures and their anatomical variants, and then discuss the strengths and limitations of the technique during catheter ablation for typical atrial flutter and atrial fibrillation.

Catheter-based percutaneous edge-to-edge repair using the MitraClip device (Abbott Vascular; Abbott Park, IL, USA) is a well-established, effective, and safe procedure that can be utilized in selected patients with mitral regurgitation (MR). The procedure mimics Alfieri’s surgical technique, bringing the anterior and posterior leaflets together from beneath the valve with a metallic stitch. Echocardiographic evaluation before the procedure is of paramount importance in defining the complex morphology of the valve and in detecting target leaflet lesion. Intra-procedural monitoring (i.e. delivery and placement of the clip) is usually performed under fluoroscopic and two-dimensional transoesophageal echocardiography. With the introduction of real-time three-dimensional transesophageal echocardiography (3D TEE), it appeared evident that the new technique would provide unique additional anatomical information both in selecting patients and guiding the procedure. In the selection of patients, the complex spatial structure of the valve is displayed as it actually is, allowing a precise assessment of the culprit as well as of secondary lesions. During the procedure, it has the unique ability to depict the “whole” scenario in which the procedure takes place in a single three-dimensional, real-time, easily understandable perspective. In this chapter we describe the normal mitral valve anatomy as displayed by 3D TEE, the 3D TEE pre-procedural characterization of valve morphology and the growing role of RT TEE in any individual steps of this complex procedure.

Percutaneous mitral commissurotomy (PMC) was one of the first catheter-based therapies for structural heart disease and has now become the treatment of choice for selected patients with rheumatic mitral stenosis. Inoue’s single-balloon technique has become the most popular method for performing PMC in most institutions today. The traditional tools of invasive cardiologist (i.e. fluoroscopy and hemodynamic pressure measurement) are inadequate for this procedure, and transoesophageal echocardiography (TEE) has become an essential component. Real time three-dimensional transesophageal echocardiography (RT 3D TEE) has greatly expanded the visualization of mitral stenosis. It provides detailed morphology of leaflets and commissures, and permits accurate planimetry of the valve. It is likely that RT 3D TEE will be used as a primary modality for guiding PMBV in the future. In this chapter we will describe the RT 3D TEE morphology of mitral stenosis, and how RT 3D TEE may add useful information in each stage of the procedure.

The presence of clinically significant paravalvular leak (PVL) that warrant repair ranges from 1 to 5% of patients with prosthetic valves and it is usually related to tissue friability, annular calcification, valve infection or technical factors. Surgical repair is the standard treatment for symptomatic PVL. Because of the increased risk of reoperation, there is tremendous interest in percutaneous closure of PVL. The accurate determination of the anatomical characteristics of the PVL (i.e. site, size and shape) is of paramount importance for proper selection of patients suitable for percutaneous closure, and the key for success of the procedure. 3D TEE appears to be the ideal technique for this purpose. In this chapter we will describe the normal 3D TEE appearance of mitral valve prostheses (both mechanical and biological), the 3D TEE imaging of mitral and aortic PVL, and, finally, the current role of 3D TEE during percutaneous PVL closure.

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

Over the past decade, catheter based treatments of an increasing variety of cardiac diseases have expanded dramatically. These advancements became available through new developments and improvements in available devices, as well as increasing expertise of operators. However, arguably it is the innovation and progress in imaging techniques, and in particular in echocardiography, that allowed for such a surge in available percutaneous procedures. In this paper, current echocardiographic techniques, imaging protocols and recommendations will be reviewed and clinical examples will be shown to illustrate the use and importance of echocardiographic imaging in catheter based procedures for structural heart disease.

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 …

Real-time 3D transesophageal imaging has advanced significantly over the past several years. In our laboratory, we currently use real-time 3D transesophageal imaging in addition to multiplane 2D imaging in all of our transesophageal imaging. As the equipment and software continue to advance, new imaging modes and views become available. Recently we started using a new view, which we named the 4V (4-valve) view. We found that it can be acquired in all patients undergoing a transesophageal imaging and provides a new perspective on cardiac anatomy (Figure 1 and online-only Supplemental Video). Figure 1. The 4-valve (4V) view. AV indicates aortic valve; MV, mitral valve; PV, pulmonic valve; and TV, tricuspid valve. The 4V view is most easily acquired from the midesophageal position, at a transducer angle of 0°. A 4-chamber view is the starting 2D view (Figure 2A). Once an adequate image is attained, the …