Search

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Left Atrium (LA) size has prognostic importance in a variety of cardiac conditions [1] and is known to be enlarged with decreased contractile function in patients with congestive heart failure (CHF) [2]. Nearly 5 million Americans have CHF [3] and a majority of these patients display diastolic dysfunction, which is an abnormality in the left ventricle (LV) myocardial relaxation and/or compliance that alters the ease with which the blood is accepted into the LV from the LA during diastole [4]. Due to abnormal LV filling, the LA experiences intense stress and elevated pressures. In fact, the left atrium is exposed directly to the LV diastolic pressure through the open mitral valve (MV) and because of its thin wall structure it tends to dilate with increasing pressure [5]. This augmented LA size and increased contractility and booster function are some of the mechanisms compensating for decreased early filling in patients with reduced LV compliance [6]. Over time, the LA compensatory contribution decreases, this may lead to intrinsic left atrium dysfunction [7]. This in turn results in a progressive decline in health unless the hearts’ inadequate blood flow is augmented by a left ventricular assist device (LVAD). Although LVAD implantation rest the heart, restores function to the ventricle [8], and improve overall function [9], its effects on the left atrium remain unclear. The purpose of the present study was to use 2D and Doppler echocardiography to define the parameters for assessing LVAD unloading and determine its effect on LA diameter, area, volume, and pressure in patients prior to and following LVAD implantation.Copyright © 2007 by ASME

Echocardiography is a safe, noninvasive, and widely available method that often provides a definitive anatomic and hemodynamic diagnosis and guides medical management. Although long viewed as clinically “mature,” echocardiography has undergone further “revolutionary” advances during the past 10 years, including not only technologic breakthroughs but also new clinical applications for older techniques. The recent explosion of potential “add-on” techniques presents echocardiographers with challenging questions about what constitutes real clinical progress and what techniques should be incorporated into the standard examination protocol. By becoming familiar with their clinical indications, echocardiographers can use these techniques selectively, on an “as-needed” basis, and thus streamline patient care. Because of increased availability and clinical utility, echocardiography’s usage has greatly expanded in recent years. However, echocardiography demands a major commitment in terms of time, personnel, ongoing training, and technology. An understanding of the physics of ultrasound is essential for performing echocardiography examinations and interpreting their results. A comprehensive transthoracic echocardiography examination includes systematic acquisition of a set of twodimensional and M-mode views, along with spectral Doppler and color Doppler evaluation of the intrathoracic cardiovascular structures (e.g., the myocardium, cardiac valves, pericardium, and great vessels). Transthoracic and transesophageal echocardiography are frequently used as complementary imaging techniques. Accordingly, the advantages and disadvantages of these two methods should be understood. Newer imaging modalities that are being introduced into the standard examination include contrast echocardiography, harmonic imaging modalities, parametric imaging modes, and selected three-dimensional techniques. Echocardiography examinations using standardized and novel imaging modes are frequently applied to a wide range of new clinical treatments, including assessment of left ventricular assist devices. In this growing field, important quality assurance measures have evolved along with imaging techniques to improve the quality of delivered care.

Echocardiography is the primary tool for the noninvasive detection, quantitation, and follow-up assessment of valvular heart disease. No single echocardiography method can be considered a robust “gold standard” for quantification of lesion severity in all situations. Valve lesion severity is often diagnosed by a synthesis of several anatomic, qualitative, and quantitative echocardiography severity indicators. For best practice, laboratories should routinely obtain as many severity parameters as possible, so that adequate scanning and interpretation skills are maintained for accurate diagnoses in difficult cases. Transesophageal echocardiography (TEE) may be needed in conjunction with the transthoracic exam (TTE) for a definitive diagnosis.

Tumors of the heart are uncommon, and they present in diverse and challenging ways. The heart may be the site of a primary tumor or may be invaded secondarily by malignancies that arise in adjacent or remote organs. Tumors—more frequently carcinomas than sarcomas—that involve the heart, pericardium, or both, originate as primary tumors in some other organ 20 to 40 times more often than they originate as primary tumors of the heart. Although less common than secondary tumors, primary tumors of the heart are far more challenging to both the cardiologist and the surgeon. These tumors usually present as intracavitary lesions. Although more than 75% of them are benign, clinical manifestations are common. Intracardiac myxomas are the most common benign tumors of the heart, constituting nearly 50% of all such tumors. Most patients with cardiac myxomas present with one or more effects of a triad of constitutional, embolic, and obstructive manifestations. Systemic tumor embolization occurs in 40% to 50% of patients with left atrial myxomas. Tumor fragments or surface clots most commonly embolize to arteries in the brain, kidneys, and extremities. Histologic examination of emboli recovered from a peripheral artery at operation can lead to diagnosis of an otherwise unsuspected intracardiac myxoma. Tumor embolization to the central nervous system constitutes about half of all embolic events caused by left atrial myxomas. Rhabdomyomas are the most frequent cardiac tumors in infants and children (usually males). These lesions usually present early in life and cause a variety of manifestations, including arrhythmias and sudden death. Lipomatous hypertrophy of the atrial septum is an unencapsulated hyperplasia of adipose tissue and may not represent a true tumor. Caseous mitral annular calcification is a more recently recognized unusual variant of mitral annular calcification that is generally clinically benign. However, its striking incidental appearance on echocardiography can lead to mistaken diagnosis of a tumor or an abscess. Mesotheliomas (lymphangioepitheliomas) of the atrioventricular node are the smallest tumors capable of producing sudden death by causing complete heart block. Recurrent, nonbloody pericardial effusion is common in children with a teratoma of the pericardium. For metastatic lesions, no particular type of malignant tumor predominates except possibly malignant melanoma, which involves the myocardium in more than 50% of cases.

From April 2000 through September 2001, we studied 11 patients with the Jarvik 2000--a left ventricular assist device with an axial-flow pump that provides continuous blood flow--to determine the echocardiographic characteristics. All patients underwent complete echocardiographic examination, including outflow-graft flow evaluation 24 hours after implantation and each month thereafter for the duration of support. Data were obtained at each pump setting (8000-12000 rpm in 1000-rpm increments) and with the pump off. Left ventricular dimensions and shortening fraction and the duration of aortic valve systolic opening decreased as pump speed increased. Although the aortic valve remained closed at higher pump speeds, pump outflow-graft flow remained pulsatile, because of the systolic thrust of the assisted ventricle. Systolic dominance of phasic flow was more pronounced at lower pump speeds, due to normalization of the diseased heart's Starling response. When the aortic valve was closed continuously, echocardiographic contrast (indicating blood stasis) was noted in the aortic root. Because of the pump outflow graft's proximity to the chest wall, device output could be measured independently of cardiac contributions. Mean peak outflow-graft flow velocities were 0.75 +/- 0.30 m/s (systolic) and 0.41 +/- 0. 13 m/s (diastolic). When the pump was turned off briefly there was minimal regurgitation through the device into the left ventricle. This 1st echocardiographic heart function analysis of the Jarvik 2000 confirms that the device unloads the ventricle and increases cardiac output. Cardiac responses to device-speed changes can be evaluated readily with echocardiography in the early and late postoperative period.

The experimental calf model is used to assess mechanical circulatory support devices and prosthetic heart valves. Baseline indices of cardiac function have been established for the normal awake calf but not for the anesthetized calf. Therefore, we gathered hemodynamic and echocardiographic data from 16 healthy anesthetized calves (mean age, 189.0 +/- 87.0 days; mean body weight, 106.9 +/- 32.3 kg) by cardiac catheterization and noninvasive echocardiography, respectively. Baseline hemodynamic data included heart rate (65 +/- 12 beats per minute), mean aortic pressure (113.5 +/- 17.4 mm Hg), left ventricular end-diastolic pressure (16.3 +/- 38.9 mm Hg), and mean pulmonary artery pressure (21.7 +/- 8.3 mm Hg). Baseline two-dimensional echocardiographic data included left ventricular systolic dimension (3.5 +/- 0.7 cm), left ventricular diastolic dimension (5.6 +/- 0.8 cm), end-systolic intraventricular septal thickness (1.7 +/- 0.2 cm), end-diastolic intraventricular septal thickness (1.2 +/- 0.2 cm), ejection fraction (63 +/- 10%), and fractional shortening (37 +/- 10%). Doppler echocardiography revealed a maximum aortic valve velocity of 0.9 +/- 0.5 m/s and a cardiac index of 3.7 +/- 1.1 L/minute/m2. The collected baseline data will be useful in assessing prosthetic heart valves, cardiac assist pumps, new cannulation techniques, and robotics applications in the anesthetized calf model and in developing calf models of various cardiovascular diseases.

Background The bileaflet valve is currently the mechanical replacement valve of choice. Though durable, it does not closely mimic native valve hemodynamics and remains potentially thrombogenic. Methods Prototype trileaflet valves (T1 and T2) were implanted in the mitral position in calves. Group I calves received either a T1 valve (n = 12) or a control bileaflet valve (n = 5); Group II, either a T2 valve (n = 7) or a control bileaflet valve (n = 5). Valve function, perivalvular leakage, and transvalvular pressure gradients were evaluated. Also, long-term prototype leaflet wear was evaluated in vivo in one Group I calf (502 days) and two Group II calves (385 and 366 days). Calves were euthanized and necropsied at study termination, and major organs weighed and examined. Results Valve function was excellent and hematologic parameters remained normal in all calves that survived to study termination. Mean peak transvalvular pressure gradients were 10 ± 7 mm Hg for T1 valves, 6 ± 3 mm Hg for T2 valves, and 12 ± 4 mm Hg for bileaflet control valves. Clinically insignificant valvular regurgitation was observed in both prototypes. Explanted valves showed no thrombus-impaired leaflet motion, except in two T1-fitted calves and one T2-fitted calf. Major organs showed no evidence of clinically significant thromboembolic events. There were no other significant differences between the results of experimental and control groups. Conclusions Prototype trileaflet valves performed safely and effectively in the mitral position in calves, even without long-term anticoagulation. This warrants their evaluation as an equivalent alternative to bileaflet valves.

A 21-year-old man presented with syncope and a heart murmur. Screening echocardiography revealed severe asymmetric septal hypertrophic cardiomyopathy (thickness, 3.7 cm). No resting or provocable left ventricular outflow obstruction was present. Because the patient was not an athlete and performed no regular …

ObjectivesThe goal of this study was to evaluate whether quantitation of thrombus burden with transesophageal echocardiography (TEE) can help risk-stratify patients undergoing thrombolysis of prosthetic valve thrombosis (PVT).BackgroundThrombolytic therapy of PVT has an unpredictable risk of embolization and complications.MethodsAn international registry of patients with suspected PVT undergoing two-dimensional/Doppler and TEE before thrombolysis was established. All TEE studies were reviewed and quantitated by a single observer blinded to all data.ResultsFrom 1985 to 2001, 107 patients (71 females; age 24 to 86 years) from 14 centers (6 in the U.S.) were identified. The majority of cases involved the mitral valve (79 mitral, 13 aortic, and 15 tricuspid). Hemodynamic success rate was achieved in 85% and was similar across valves. Overall complications were observed in 17.8%, and death in 5.6%. Predictors of complications were: New York Heart Association (NYHA) functional class, presence of shock, sinus tachycardia, hypotension, previous history of stroke, thrombus extension beyond the valve ring, and thrombus area. Multivariate analysis demonstrated that two variables were independent predictors of complications: thrombus area by TEE (odds ratio [OR] 2.41 per 1 cm2increment, 95% confidence interval [CI] 1.12 to 5.19) and prior history of stroke (OR 4.55, 95% CI 1.35 to 15.38). A thrombus area

Cardiovascular imaging and procedures have experienced exponential growth over the past 20 years in terms of new modalities, procedure volume, technological sophistication, and cost. As a result, related quality improvement tools have become multifaceted works in progress. This article briefly summarizes the evolution of the time-honored American College of Cardiology Foundation/American Heart Association clinical practice guidelines versus the newer American College of Cardiology Foundation appropriate-use-criteria guidelines and how these may interact with emerging performance measures, clinical data registries, and cardiovascular laboratory accreditation initiatives.

The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac computed tomography (CCT) is frequently considered. The present document is an update to the original CCT/cardiac magnetic resonance (CMR) appropriateness criteria published in 2006, written to reflect changes in test utilization, to incorporate new clinical data, and to clarify CCT use where omissions or lack of clarity existed in the original criteria ( 1 ). The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Ninety-three clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of CCT angiography for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease (CAD) was viewed favorably, whereas testing in high-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Use of noncontrast computed tomography (CT) for calcium scoring was rated as appropriate within intermediate- and selected low-risk patients. Appropriate applications of CCT are also within the category of cardiac structural and functional evaluation. It is anticipated that these results will have an impact on physician decision making, performance, and reimbursement policy, and that they will help guide future research.

A 44-year-old Hispanic man underwent a routine cardiac evaluation for kidney transplantation. He had a history of polycystic kidney disease and had been receiving hemodialysis for 2 years. A 2-dimensional echocardiogram revealed large trabeculations and deep recesses in the endocardial wall of both ventricles (Movie I; see Data Supplement). Cardiac …