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Endocardial resolution during 2-dimensional echocardiography is technically limited in at least 10% to 15% of patients. Recently, several ultrasound imaging innovations have been introduced that may improve endocardial resolution and decrease the proportion of technically difficult studies. This study compares tissue harmonic imaging, intravenous sonicated albumin, and Doppler myocardial imaging in patients with technically difficult echocardiograms. Twenty-eight patients with known or suspected cardiac disease and poor baseline endocardial resolution were studied. Only harmonic imaging (conventional and optimized for tissue) was superior to baseline fundamental imaging (p <0.001). Harmonic imaging was superior to baseline imaging in all myocardial regions and in the majority of patients, including those with the worst baseline studies. [ABSTRACT FROM AUTHOR]

Patients with transthyretin amyloid cardiomyopathy (ATTR-CM) benefit from disease-modifying agents such as tafamidis. However, the survival benefit of tafamidis in elderly patients (age ≥80 years) is not reported. This study aimed to assess the survival of patients with ATTR-CM aged 80 years and older who were treated with tafamidis compared with patients aged <80 years. We conducted a retrospective analysis of patients with ATTR-CM who underwent tafamidis treatment, aged 45 to 97 years at the time of diagnosis between January 1, 2008, and May 31, 2021. A total of 484 patients were included, with 208 in the ≥80 years group and 276 in the <80 years group. The cohort was followed up for mortality outcomes, and hazard ratios with 95% confidence intervals were calculated. After a median follow-up of 18.5 months, 72 deaths were recorded in the entire cohort. Kaplan-Meier curves showed no differences in survival probability between the 2 groups at 30 months (p for log-rank test = 0.76). The survival rates for patients aged ≥80 years who underwent treatment at 1, 2, 3, 4, and 5 years were 94.7%, 86.0%, 77.0%, 77.0%, and 38.5%, respectively. The corresponding rates for patients aged <80 years who underwent treatment were 93.2, 84.8, 74.4, 68.2, and 64.6%, respectively. In the multivariable analysis, the hazard ratio (95% confidence interval) of the mortality comparing treatment patients aged ≥80 years with those aged <80 years was 0.81 (0.41 to 1.61). In conclusion, tafamidis treatment is associated with similar reductions in mortality in older and younger patients with ATTR-CM., Competing Interests: Declaration of competing interest Dr. Hanna, has served on advisory boards for Pfizer, Alnylam, Eidos, Ionis, and Alexion Pharmaceuticals. Dr. Wolinsky is a consultant to Alynlam, BridgeBio, Pfizer, and Ionis. The remaining authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose of Review: This review presents the etiology, clinical manifestations, diagnostic approach, and treatment of congenital pericardial defects. It also highlights the critical role of echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) in the diagnosis and management approach., Recent Findings: Congenital pericardial defects are rare. Although most cases are found incidentally, some cases could potentially be associated with serious outcomes including sudden cardiac death. The diagnosis is often challenging due to non-specific clinical manifestations and electrocardiogram findings. Echocardiography is the first-line imaging investigation for the evaluation of this condition. Advanced cardiac imaging modalities, including CCT and CMR, play important adjuvant roles in establishing the diagnosis and assists with prognostication., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The diagnosis of infective endocarditis (IE) can pose a significant challenge, particularly in cases of prosthetic valve endocarditis (PVE) or cardiac device-related endocarditis (CDIE) (1). While echocardiography remains a crucial diagnostic tool for identifying IE, including PVE and CDIE, there are certain circumstances where transesophageal echocardiography (TEE) may not be conclusive or practically feasible (2). Recently, intracardiac echocardiography (ICE) has emerged as a promising alternative for diagnosing IE and evaluating intracardiac infections, especially in cases where transthoracic echocardiography (TTE) has not been revealing, and TEE has been contraindicated. Furthermore, ICE has been found to be useful in guiding transvenous lead extractions in infected implantable cardiac devices (3). This systematic review aims to comprehensively explore the various applications of ICE in the diagnosis of IE and assess its efficacy in comparison to traditional diagnostic methods., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Our patient presented with right-sided heart failure symptoms and found to have a large mass protruding into the heart's right ventricle. Cardiac MRI delineated the morphological and tissue characteristics of the tumour. Although 18-fluorodeoxyglucose positron emission tomography (PET) did not reveal an intracardiac mass, the lesion was well demonstrated by Fluciclovine F18 PET/CT., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Transcatheter aortic valve replacement (TAVR) has become the standard of care for most patients with severe aortic stenosis (AS), but the impact of medical therapy prescribing patterns on post-TAVR patients has not been thoroughly investigated., Methods: We analyzed Optum claims data from 9,012 adults who received TAVR for AS (January 2014-December 2018). Pharmacy claims data were used to identify patients who filled ACEI/ARB and/or statin prescriptions during the study's 90-day landmark period post-TAVR. Kaplan-Meier and adjusted Cox Proportional Hazards models were used to evaluate the association of prescribing patterns with mortality during the 3-year follow-up period. Subgroup analyses were performed to examine the impact of 11 potential confounders on the observed associations., Results: A significantly lower adjusted 3-year mortality was observed for patients with post-TAVR prescription for ACEI/ARBs (hazard ratio [HR] = 0.82, 95% confidence interval [CI] 0.74-0.91, P = .0003) and statins (HR = 0.85, 95% CI 0.77-0.94, P = .0018) compared to patients who did not fill prescriptions for these medications post-TAVR. Subgroup analyses revealed that the survival benefit associated with ACEI/ARB prescription was not affected by any of the potential confounding variables, except preoperative ACEI/ARB prescription was associated with significantly lower risk of mortality vs postoperative prescription only. No other subgroup variables had significant interactions associated with survival benefits, including preoperative use of statins., Conclusions: In this large-scale, real-world analysis of patients undergoing TAVR, the prescription of ACEI/ARB and statins was associated with a significantly lower risk of mortality at 3-years, especially in those where the medications were initiated preoperatively., Competing Interests: Conflict of interest Dr. Cubeddu reports receiving payments for occasional lectures from Edwards Lifesciences. Ms. Murphy reports current employment at Edwards Lifesciences; and being a stockholder at Edwards Lifesciences. Dr. Asher reports receiving royalties for educational Books from Wolters Kluwer Publishing Company. Dr. Garcia is supported by The Harold C. Schott Foundation Endowed Chair for Structural and Valvular Heart Disease and is proctor and steering committee member for Edwards Lifesciences. Dr. Granada has no disclosures to report. Dr. Don reports current participation on the data safety monitoring board (DSMB) of Statins for rheumatic heart disease-Nepal. Dr. Patel has no disclosures to report. Dr. Albaghdadi has no disclosures to report. Dr. Cavalcante reports receiving consulting fees from Abbott Structural, Aria CV, Boston Scientific, Edwards Lifesciences, Medtronic, Vdyne, W.L. Gore, and Xylocor. Dr. Coylewright reports receiving fees or honoraria for lectures, presentations, speakers bureau, manuscript writing or educational events from Medtronic, Abbott, Occlutech, CardioSmart, Edwards Lifesciences, and Boston Scientific. Dr. Hahn reports speaker fees from Abbott Structural, Baylis Medical, Edwards Lifesciences, and Philips Healthcare; she has institutional consulting contracts for which she receives no direct compensation with Abbott Structural, Edwards Lifesciences, Medtronic and Novartis; she is Chief Scientific Officer for the Echocardiography Core Laboratory at the Cardiovascular Research Foundation for multiple industry-sponsored tricuspid valve trials, for which she receives no direct industry compensation. Dr. Genereux reports receiving consultation fees and institution research grant from Edwards Lifesciences; and receiving payment or honoraria for lectures from Edwards Lifesciences. Dr. Yadav reports receiving consulting fees from Edwards Lifesciences and Abbott Vascular; receiving payment or honoraria for lectures, presentations, speakers bureau, manuscript writing or educational events from Edwards Lifesciences, Abbott Vascular, and Shockwave medical; and current participation on the DSMB or advisory board of Dasi simulations. Dr Thourani reports receiving grants from Edwards Lifesciences; and receiving payment or honoraria for lectures, presentations, speakers bureau, manuscript writing or educational events from Edwards Lifesciences. Dr. Leon reports receiving grants or contracts from Abbott Vascular, Medtronic, Boston Scientific, and Edwards Lifesciences; and receiving consulting fees from Bain Capital., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to compare 5-year cardiovascular, renal, and bioprosthetic valve durability outcomes in patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR)., Background: Patients with severe AS and CKD undergoing TAVR or SAVR are a challenging, understudied clinical subset., Methods: Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate <60 mL/min/m 2 ) from the PARTNER (Placement of Aortic Transcatheter Valve) 2A trial (patients randomly assigned to SAPIEN XT TAVR or SAVR) and SAPIEN 3 Intermediate Risk Registry were pooled. The composite primary outcome of death, stroke, rehospitalization, and new hemodialysis was evaluated using Cox regression analysis. Patients with and without perioperative acute kidney injury (AKI) were followed through 5 years. A core laboratory-adjudicated analysis of structural valve deterioration and bioprosthetic valve failure was also performed., Results: The study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs 68.0%; P = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs 58.7%; P = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs 10.3%; P < 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (P < 0.05) but not for SAPIEN 3 TAVR., Conclusions: In intermediate-risk patients with AS and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses., Competing Interests: Funding Support and Author Disclosures Edwards Lifesciences funded the PARTNER 2A trial and the SAPIEN 3 Intermediate Risk Registry. Dr Garcia has received institutional research grants from Edwards Lifesciences, Abbott Vascular, BSCI, and Biotronik; is a consultant for NeoChord, Medtronic, BSCI, and Abbott Vascular; and is a proctor for Edwards Lifesciences. Dr Cubeddu is an educational speaker and has conducted proctor-related activities for Edwards Lifesciences and Abbott Vascular. Dr Hahn has received speaker fees from Edwards Lifesciences and Philips Healthcare; has received consulting fees from Abbott Structural, Boston Scientific, Edwards Lifesciences, Gore & Associates, and Medtronic; holds equity with Navigate; and is chief scientific officer for the echocardiography core laboratory at the Cardiovascular Research Foundation for multiple industry-sponsored trials, for which she receives no direct industry compensation. Dr Kapadia has received institutional research grants from Edwards Lifesciences (no direct physician compensation). Dr Kodali is a consultant (honoraria) for Admedus and Dura Biotech; is a scientific advisory board member (equity) for Dura Biotech, MicroInterventional Devices, Thubrikar Aortic Valve, Supira, Admedus, TriFlo, and Adona; and has received institutional research funding from Edwards Lifesciences, Medtronic, Abbott Vascular, Boston Scientific, JenaValve, and Keystone Medical. Dr Thourani is a consultant for Abbott Vascular, Boston Scientific, Cryolife, Edwards Lifesciences, JenaValve, Shockwave, and W.L. Gore. Dr Jaber receives monetary institutional support for echocardiography core laboratory in TAVR, with no direct or indirect personal compensation. Dr Elmariah has received institutional research grants from Edwards Lifesciences, Medtronic, and Abbott Vascular; and is a consultant for Edwards Lifesciences. Dr Makkar has received grants from Edwards Lifesciences and Abbott; and has served as a consultant for Cordis and Medtronic. Dr Webb has served as a proctor and consultant for Edwards Lifesciences. Dr Herrmann has received institutional research grants from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Medtronic; and has received consulting and speaker honoraria from Edwards Lifesciences and Medtronic. Dr Lu is an employee of Edwards Lifesciences. Dr Devireddy has received consulting fees from Edwards Lifesciences, Medtronic, ReCor Medical, and Shockwave Medical. Dr Malaisrie has received consulting fees Edwards Lifesciences, Medtronic, and Cryolife. Dr Smith has been reimbursed for travel and other customary expenses related to trial management as a principal investigator of the PARTNER trials. Dr Mack has received consulting fees from Gore; has served as a trial coprimary investigator for Edwards Lifesciences and Abbott; and has served as a study chair for Medtronic. Dr Sorajja has received institutional research grants from Edwards Lifesciences, Abbott Vascular, Boston Scientific, and Medtronic; and is a consultant for Abbott Vascular, Boston Scientific, Medtronic, NeoVasc, TeleFlex, TriFlo, VDyne, and W.L. Gore. Dr Cavalcante has received research grants from and is a consultant for Abbott Vascular, Circle Cardiovascular Imaging, Boston Scientific, Medtronic, Siemens Healthineers, and Edwards Lifesciences; is a consultant for VDyne and Triflo; and is a member of the Speakers Bureau for Circle Cardiovascular Imaging, Medtronic, Siemens Healthineers. Dr Goessl is a consultant for Abbott Vascular. Dr Leon has received institutional research support from Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott. Dr Pibarot has received research grants from Edwards Lifesciences and Medtronic for echocardiography core laboratory or in vitro analyses in TAVR, with no personal compensation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to examine the cumulative experience of peri-device leak (PDL) closure following left atrial appendage (LAA) closure., Background: The management of PDL following LAA closure remains controversial. While PDL closure has been proposed, procedural features and clinical outcomes have not been well established., Methods: A systematic review of all published cases of PDL closure with available anatomical, procedural, and clinical outcomes was performed., Results: We identified 18 indexed publications and 110 cases between April 2013 and March 2020. 71 patients (mean age 72 ± 8 yrs), met study criteria and were included. PDL closure was most common in males, bilobar LAA morphology, and after Watchman procedures. The mean PDL size was 7.6 ± 5.8 mm (range 2-26 mm). Leaks were classified according to size: small (<5 mm; 45%), moderate (≥5-9 mm; 25%), and large (≥10 mm; 30%). Endovascular coils and endovascular plugs were used to close both small and moderate sized leaks, and second LAA closure devices were exclusively used for large PDLs. Successful PDL closure occurred in 90%, and was similar between PDL sizes and types of occluder used. Procedural complication rates were uncommon (2.8%). No strokes were reported following PDL closure at 6 months., Conclusions: In patients with PDL for whom discontinuation of OAC may be considered unsafe, percutaneous closure using a tailored approach with either endovascular coils, plugs, or second occluder represents a safe, and feasible alternative associated with favorable clinical outcomes., (© 2021 Wiley Periodicals LLC.)

Background: The effect of transcatheter aortic valve replacement (TAVR) on kidney function stage in patients with aortic stenosis remains poorly understood. We hypothesized that in some patients, TAVR results in improved kidney function by alleviating cardiorenal syndrome., Objectives: The purpose of this study was to assess change in chronic kidney disease (CKD) stage following TAVR, identify variables associated with pre- and post-TAVR estimated glomerular filtration rate (eGFR), and assess association of post-TAVR eGFR with mortality., Methods: Patients (n = 5,190) receiving TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) 1, 2, and PARTNER 2 S3 trials between April 2007 and October 2014 were included. Pre-TAVR and procedural variables associated with post-TAVR eGFR, change in CKD stage at ≤7 days post-TAVR, and association of post-TAVR eGFR on intermediate-term mortality were assessed., Results: At baseline, CKD stage ≥2 was present in 91% of patients. CKD stage either improved or was unchanged following TAVR in the majority of patients (77% stage 1, 90% stage 2, 89% stage 3A, 94% stage 3B, and 99% stage 4). Progression to CKD stage 5 occurred in 1 (0.035%) of 2,892 patients within 7 days post-TAVR. Of 3,546 patients in whom data were available, 70 (2.0%) underwent post-TAVR dialysis. Higher pre-TAVR eGFR and transfemoral approach were strongly associated with higher post-TAVR eGFR. Lower baseline and longitudinal post-TAVR eGFR were associated with lower intermediate-term survival., Conclusions: In patients with severe aortic stenosis undergoing TAVR, even with baseline impaired eGFR, CKD stage is more likely to stay the same or improve than worsen. Aortic stenosis may contribute to cardiorenal syndrome that improves with TAVR., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Nonsteroidal anti-inflammatory drugs and colchicine remain the standard of care as the initial treatment of acute pericarditis. Corticosteroids and traditional immunosuppressive medications are often added if patients develop recurrent symptoms and remain medically refractory. There has been growing interest in the use of interleukin-1 receptor antagonists (IL-1RAs) in managing pericarditis, especially, in medically refractory cases. Anakinra-Treatment for Recurrent Idiopathic Pericarditis is a recent pilot trial showing a benefit of using the IL-1RA, anakinra, in recurrent pericarditis. Publications remain limited and more outcomes trials are needed. This review focuses on the mechanism of action, clinical utility, current, and future studies that investigate the role of IL-1RAs in the management of recurrent pericarditis., (Copyright © 2020 Elsevier Inc. All rights reserved.)

A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardial syndromes, calling for a better understanding of its pathophysiology, diagnoses, and management. Uremic pericarditis, the most common manifestation of uremic pericardial disease, is a contemporary problem that calls for intensive hemodialysis, anti-inflammatories, and often, drainage of large inflammatory pericardial effusions. Likewise, asymptomatic pericardial effusions can become large and impact the hemodynamics of patients on chronic hemodialysis. Constrictive pericarditis is also well documented in this population, ultimately resulting in pericardiectomy for definitive treatment. The management of pericardial diseases in ESRD patients involves internists, cardiologists, and nephrologists. Current guidelines lack clarity with respect to the management of pericardial processes in the ESRD population. Our review aims to describe the etiology, classification, clinical manifestations, diagnostic imaging tools, and treatment options of pericardial diseases in this population., (© 2017 Wiley Periodicals, Inc.)

Coronary artery calcification (CAC) is a known risk factor for adverse outcomes in the general population and in patients with coronary artery disease. We performed a survey of United States radiologists to evaluate the trends in reporting the presence or absence of CAC on NCCT examinations. An 11 multiple-choice questionnaire was distributed to members of the American College of Radiology, and 530 members participated in the study. Eighty-seven percent of the analyzed group report the presence of CAC on standard CT scans of the chest, and approximately half them (52 %) use a qualitative modifier. Only 32 % of cardiac imagers were aware of the published data correlating qualitative and quantitative calcium scores on non-gated chest CT examinations compared to 17 % of non-cardiac imagers. We believe that subjective or objective grading of coronary calcified plaque burden on standard chest CT exams is warranted as it may not only help risk-stratify patients, but also may eliminate the need for dedicated CACS in many patients and may be useful in treatment guidance.

Congenital absence of the pericardium (CAP) is one of the rarest cardiac congenital anomalies. It can occur as a complete absence of the entire pericardium, absence of the right or left portion of the pericardium or a partial, foramen-like defect of the right or left pericardium. While the majority of cases are clinically silent, multiple reports associate CAP with symptomatic presentation. The most feared complication of CAP is sudden death due to cardiac strangulation across a partial defect of the left pericardium. Given its rare occurrence, most clinicians and imaging specialists will have little experience with this condition and may fail to recognize it on thoracic or cardiac studies. Thus, the purpose of this review is to highlight the common clinical and multimodality imaging features associated with this anomaly and suggest a management algorithm., (Copyright © 2016. Published by Elsevier Inc.)

Background: National prosthesis use in active aortic valve infective endocarditis (IE) is unreported. Prosthesis usage and outcomes in patients undergoing an aortic valve operation with active IE was evaluated., Methods: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to identify patients with active IE who underwent an aortic valve operation from January 1, 2005, to June 30, 2011. All patients with active IE were included. Demographics, procedures, outcomes, and trends were analyzed., Results: Of 11,560 patients who were identified as having active IE, 8,421 (73%) had no prior operations (primary) and 3,139 (27%) had a history of any prior cardiac operation (reoperative). Operations for primary vs reoperative patients included isolated replacement in 88.5% vs 58.7% and root replacement in 7.2% vs 29.9%. Major morbidity was 60.8% vs 68%, and the unadjusted mortality rate was 9.8% vs 21.1%. Over time, for primary operations, biologic valve use increased (57% to 67%), and mechanical and homograft valve use decreased (30% to 24% and 9% to 6%; p < 0.001). For reoperations, biologic valve use increased (38% to 52%), and mechanical and homograft use decreased (20% to 17% and 38% to 28%; p < 0.001). Homografts were used more often in reoperations (32% vs 7%)., Conclusions: Morbidity and mortality rates death are high for operations for active IE. Biologic valves were increasingly used vs mechanical and homograft valves. Homograft valves were used more often in reoperative patients after any prior cardiac operation. The mortality rate varied among prosthesis groups but may be related to the severity of infection and type of procedure performed., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Heart failure (HF) is the leading cause of hospitalizations and readmissions in the United States. Approximately one-third of patients admitted for HF are readmitted within 3 months; however, there are few markers that can identify those at highest risk for readmission. The purpose of this study was to identify clinical and laboratory markers associated with hospital readmission in decompensated HF., Hypothesis: Clinical and laboratory markers are associated with readmission rates in decompensated HF., Methods: Clinical and laboratory data from 412 patients admitted with HF were analyzed using a multivariable logistic regression analysis to find predictors of HF readmission by 30 days., Results: HF readmission rates at 30 days were lowest in those with at least 2 of the following discharge criteria: net fluid reduction >1.3 L (odds ratio [OR]: 0.27, P = 0.019), serum sodium level >135 (OR: 0.46, P = 0.034), and N-terminal brain natriuretic peptide level reduction >23% (OR: 0.11, P = 0.048). In multivariate analysis, those patients meeting ≥2 criteria had a very low risk of 30-day readmission (OR: 0.10, 95% confidence interval: 0.01-0.68, P = 0.019) compared to patients who failed to meet 2 criteria., Conclusions: A negative fluid balance, normal serum sodium, and net reduction in N-terminal brain natriuretic peptide level during hospitalization may be important indices to target to help reduce the likelihood of HF readmission within 30 days., (© 2013 Wiley Periodicals, Inc.)

The risk factors for aortic and mitral valve diseases that require surgical repair such as congenital bicuspid aortic valve (BAV) and mitral valve prolapse include acquired clinical factors and genetic influences. Whether race affects the prevalence of certain valvular diseases has not been sufficiently investigated. Through the Cleveland Clinic's Cardiovascular Information Registry, we evaluated the data from 40,419 patients who had undergone aortic valve surgery, mitral valve surgery, and/or coronary artery bypass grafting from 1993 to 2007. Of these patients, 38,366 were white and 2,053 were black. The prospective evaluation of valvular disease was coded, identifying the etiology and morphology by echocardiographic, surgical, and pathologic inspection. At baseline, compared to white patients, the black patients were younger, more often women, had a greater body mass index, and a greater prevalence of hypertension, diabetes, tobacco use, and renal disease. The prevalence of congenital BAV and mitral valve prolapse was considerably lower in blacks than in whites (9% vs 25%, p <0.001, and 27% vs 52%, p <0.001, respectively), as was the presence of calcific aortic stenosis (14% vs 28%; p <0.001), pathologically determined aortic valve calcium (50% vs 67%; p <0.001), and mitral valve chordal rupture (13% vs 31%; p <0.001). In conclusion, in the present large surgical series, the valve etiologies and morphology differed among blacks and whites. Despite an adverse cardiovascular risk profile, blacks had a significantly lower prevalence of valvular calcium and degeneration than did the whites and a lower prevalence of congenital BAV and mitral valve prolapse. Our findings offer insight into the influence of race on the development of mitral valve disease and congenital BAV., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The correlation between formal coronary artery calcium scoring (CACS) determined by multi-detector CT (MDCT) and the presence of coronary calcium on standard non-gated CT chest examinations was evaluated. In 163 consecutive healthy participants, we performed screening same-day standard non-gated, non-enhanced CT chest exams followed by high-resolution, ECG-synchronized MDCT exams for CACS. For the standard CT examinations, a scoring system (Weston score, range 0-12) was developed assigning a score (0-3) for each coronary vessel including the left main trunk. Overall, 30% and 39% of patients had CAC on standard CT and MDCT exams, respectively (P = 0.13). CAC on standard CT was highly correlated to the Agatston CACS on the MDCT (Spearman correlation coefficient 0.83, P < 0.001). Absence of calcium on the standard CT exam was associated with a very low CACS (mean Agatston 0.5, range 0-19). A Weston score >2 identified a CACS > 100 with an area under the curve of 0.976, sensitivity of 100%, and specificity of 85%. A Weston score >7 identified a CACS > 400 with an area under the curve of 0.991, sensitivity of 100%, specificity of 98%. The intra-observer variability was low as was the inter-observer variability between a cardiac specialized radiologist and a non-specialized reader. A visual coronary artery scoring system on standard, non-gated CT correlates well with traditional methods for CACS. Further, a non-expert cardiac radiologist performed equally well to a cardiac expert. This information suggests that a visual scoring system, at least in a descriptive manner can be utilized for a general statement about coronary artery calcification seen on standard CT imaging to guide clinicians in risk stratification.

Aim: To study the interobserver variability between a cardiologist and vascular medicine specialist in the screening of the abdominal aorta during transthoracic echocardiography (TTE)., Methods: Consecutive patients, > 55 years of age, underwent abdominal aortic imaging following standard TTE. Two cardiologists and one vascular medicine specialist performed a blinded review of the images. Interobserver agreement of abdominal aortic size was determined by the correlation coefficient and paired t test. Interobserver reliability for each cardiologist was assessed using Bland-Altman plots., Results: Ninety patients were studied. The mean age of patients was 72 ± 10 years and 48% were male. The mean aortic diameter was 2.31 ± 0.50 cm and 5 patients (5.5%) had an abdominal aortic aneurysm (AAA). The additional time required for the abdominal aortic images was 4.4 ± 0.9 min per patient. Interobserver agreement between the 2 cardiologist interpreters and the vascular medicine specialist was excellent (P > 0.05 for all comparisons). On Bland-Altman analysis of interobserver reliability, the 95% lower and upper limits for measurement by the cardiologists were 84% and 124% of that of the vascular specialist., Conclusion: The assessment of the abdominal aorta during a routine TTE performed by a cardiologist is accurate in comparison to that of a vascular medicine specialist. In selected patients undergoing TTE, the detection rate of AAA is significant. Additional time and effort required to perform imaging of the abdominal aorta after TTE is less than 5 min.

Background. It has been observed that African American race is associated with a lower prevalence of atrial fibrillation (AF) compared to Caucasian race. To better quantify the association between African American race and AF, we performed a meta-analysis of published studies among different patient populations which reported the presence of AF by race. Methods. A literature search was conducted using electronic databases between January 1999 and January 2011. The search was limited to published studies in English conducted in the United States, which clearly defined the presence of AF in African American and Caucasian subjects. A meta-analysis was performed with prevalence of AF as the primary endpoint. Results. In total, 10 studies involving 1,031,351 subjects were included. According to a random effects analysis, African American race was associated with a protective effect with regard to AF as compared to Caucasian race (odds ratio 0.51, 95% CI 0.44 to 0.59, P < 0.001). In subgroup analyses, African American race was significantly associated with a lower prevalence of AF in the general population, those hospitalized or greater than 60 years old, postcoronary artery bypass surgery patients, and subjects with heart failure. Conclusions. In a broad sweep of subjects in the general population and hospitalized patients, the prevalence of AF in African Americans is consistently lower than in Caucasians.

Chylopericardium after cardiac surgery is rare, and there are few reports of its occurrence after aortic valve surgery. Chylous pericardial effusion 4 months after aortic valve replacement for endocarditis is highly unusual.Herein, we report the case of a 54-year-old man who had undergone bioprosthetic aortic valve replacement because of endocarditis and valvular dysfunction. Two months later, he underwent pericardiocentesis twice because of large pericardial effusions consisting of pinkish white fluid with predominant lymphocytes. Four months after valve replacement, he presented with recurrent effusion consistent with early tamponade, and a pericardial window was created. At surgery, 1,500 cc of milky white fluid was recovered, and the diagnosis of chylopericardium was made. Postoperative high-volume drainage prompted thoracic duct ligation, which was curative.

Prior epidemiologic studies have shown that increasing body mass index (BMI) is associated with higher total cholesterol and low-density lipoprotein cholesterol (LDL). However, these studies were limited by underrepresentation of obese subjects. The aim of this study was to determine whether there is an association between BMI and lipid profiles in a population of patients with a broad spectrum of BMI values. A case-control study was performed involving patients seen at the Cleveland Clinic Florida. Cases (BMI >30 kg/m(2)) were obtained from the obesity surgery database between August 31, 2000, and April 4, 2002. Controls (BMI ≤ 30 kg/m(2)) were obtained from a database of primary care physicians between May 1, 2004, and November 18, 2004. Pearson correlation coefficients were used to assess the relationship between BMI and lipid fractions. Multiple linear regression was performed to assess the independent effect of BMI on lipid levels while adjusting for potential confounders and propensity scores. Six hundred thirty-seven patients were analyzed (females, n = 362, 57%). There was no association between higher BMI and LDL (r = 0.19 p = 0.07), a negative association with high-density lipoprotein cholesterol (HDL; r = 0.45, p < 0.001), and a positive association with the log transformation of triglycerides (r = 0.32, p = 0.005).Higher BMI was inversely associated with HDL and directly associated with TG. BMI showed no significant association with LDL. Although the association between BMI and both HDL and TG may be explained by insulin resistance, the lack of a significant association between BMI and LDL remains an unexpected finding that requires further investigation.

Background: There has been a substantial increase in the number of imaging studies performed to assess thoracic aortic pathology. We sought to determine the accuracy of transthoracic echocardiography (TTE) compared to transesophageal echocardiography (TEE) for measuring ascending aortic size., Hypothesis: Transthoracic echocardiography is reasonably accurate for assessing ascending aortic dimension., Methods: Fifty-two patients with or without aortic disease underwent both TTE with nonstandard views and TEE. The ascending aorta was measured at 4 levels by 2 blinded observers for each modality. Pearson's correlation coefficients were determined and Bland-Altman plots and analyses were constructed. Inter- and intraobserver variability was determined in a random subgroup of patients., Results: The mean age of the group was 65.5 years old and 15% had aortic dilation >4.0 cm. A strong positive correlation between the 2 imaging modalities was seen at all levels with the highest correlation for the maximum diameter of the ascending aorta (r = 0.936, P < 0.0001). Interobserver and intraobserver variability showed a good intraclass correlation among readers and among the same reader at all levels., Conclusions: Transthoracic echocardiography using nonstandard imaging windows is accurate in comparison to TEE for measurement of the ascending aorta at multiple levels in patients with or without aortic pathology. The findings of this study provide support for selected serial follow-up of patients with aortic disease by TTE only.

Objective: The purpose of our study was to evaluate the feasibility of detecting mitral valve prolapse with ECG-gated 64-MDCT angiography in comparison with the reference standard, transthoracic echocardiography., Materials and Methods: The charts of patients consecutively referred for clinically indicated 64-MDCT angiography were reviewed. The study cohort consisted of patients who had undergone transthoracic echocardiography. Two experienced radiologists performed blinded consensus review of the MDCT angiograms of 20 patients, and the findings were compared with those of transthoracic echocardiography, which was the reference standard., Results: With the findings on each anterior and posterior leaflet as separate data points, sensitivity was calculated to be 69.2-84.6% and specificity, 100%. The positive and negative predictive values were estimated to be 100% and 87.0-93.1%., Conclusion: ECG-gated cardiac 64-MDCT angiography can be used reliably to detect mitral valve prolapse.

More than 10 million people, many elderly and likely to harbor cardiovascular (CV) disease, embark on cruise ship travel worldwide every year. The clinical presentation and outcome of CV emergencies presenting during cruise ship travel remain largely unknown. Our department provides contracted cardiology consultations to several large cruise lines. We prospectively maintained a registry of all such consultations during a 2-year period. One hundred consecutive patients were identified (age 66 +/- 14 years, range 18 to 90, 76% men). The most common symptom was chest pain (50%). The most common diagnosis was acute coronary syndrome (58%; ST elevation in 21% and non-ST elevation in 37%). On-board mortality was 3%. Overall, 73% of patients required hospital triage. Of the 25 patients triaged to our institution, 17 underwent a revascularization procedure. One patient died. Ten percent of patients had cardiac symptoms in the days or weeks before boarding; all required hospital triage. Access to a baseline electrocardiogram would have been clinically useful in 23% of cases. In conclusion, CV emergencies, such as acute coronary syndrome and heart failure, are not uncommon on cruise ships. They are often serious, requiring hospital triage and coronary revascularization. A pretravel medical evaluation is recommended for passengers with a cardiac history or a high-risk profile. Passengers should be encouraged to bring a copy of their electrocardiogram on board if abnormal. Cruise lines should establish mechanisms for prompt consultation and triage., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to determine whether high-sensitivity C-reactive protein (hsCRP) levels differ among patients with acute aortic syndromes (AAS) and if hsCRP could predict their long-term outcomes., Design: Retrospective observational study., Setting: Cleveland Clinic Hospital, Cleveland, Ohio., Patients: 115 consecutive patients with AAS admitted to the cardiac intensive care unit., Interventions: HsCRP and other laboratory data were measured within 24 h of admission. Demographic, imaging and laboratory data were obtained at the time of presentation. For the long-term survival analysis, the social security death index was used to determine all-cause mortality., Main Outcome Measures: HsCRP levels among AAS patients., Results: Hospital mortality was 4.3% for AAS patients. HsCRP levels differed significantly among AAS; the median hsCRP was higher in the aortic dissection group (49 mg/l) than in those with penetrating aortic ulcer (28 mg/l), symptomatic aortic aneurysm (14 mg/l), and intramural haematoma (10 mg/l); (p=0.02). In multivariable analysis, aortic dissection patients had higher hsCRP levels than intramural haematoma (p=0.03) and symptomatic aortic aneurysm (p=0.04) patients, after adjusting for age and gender. Multivariable Cox regression analyses showed that elevated hsCRP levels at presentation were associated with a higher long-term mortality (p=0.007)., Conclusions: Among patients with AAS, those with aortic dissection have the highest hsCRP levels at presentation. Elevated hsCRP independently predicted a higher long-term mortality in AAS patients.

Background: Obesity surgery reduces the incidence of long-term cardiovascular events by modifying the associated risk factors. The derived benefits of weight loss surgery might be counterbalanced by the increased cardiovascular risks in some patients. The primary objective of the present study was to determine the rate of cardiovascular events after obesity surgery in patients considered to have an increased cardiac risk profile at a tertiary referral hospital., Methods: A retrospective analysis of the data from consecutive patients who underwent obesity surgery at the Cleveland Clinic Florida was performed. The use of beta-blockers, noninvasive stress testing, and perioperative events were assessed., Results: The data from 154 patients who had undergone a preoperative cardiac consultation at the Cleveland Clinic Florida before obesity surgery from 2003 to 2006 were analyzed. Most patients were women (n = 108, 69%), and 25 (16%) were >65 years old. The number of patients who received perioperative beta-blockers was 72 (47%). Noninvasive stress testing was performed in 78 patients (50%). Of the 78 patients who underwent noninvasive stress testing, 25 (32%) had a positive finding. Only 1 patient with positive stress test results had an obstructive coronary artery lesion found on cardiac catheterization. A total of 5 nonfatal cardiac-related events (3.2%) occurred. The in-hospital mortality rate was 0%., Conclusion: Obesity surgery in patients with established coronary heart disease or risk factors is a safe and well-tolerated procedure, with an overall low rate of cardiac events. Noninvasive stress testing in this population resulted in a high rate of false-positive results and uncommonly led to intervention.

Background: The aim of this study was to determine the ability to identify thrombus within the left atrial appendage (LAA) in the setting of atrial fibrillation (AF) using transthoracic echocardiography (TTE). In AF, the structure and function of the LAA has historically been evaluated using transesophageal echocardiography (TEE). The role of TTE remains undefined., Methods: The Comprehensive Left Atrial Appendage Optimization of Thrombus (CLOTS) multicenter study enrolled 118 patients (85 men; mean age, 67 +/- 13 years) with AF of >2 days in duration undergoing clinically indicated TEE. On TEE, the LAA was evaluated for mild spontaneous echo contrast (SEC), severe SEC, sludge, or thrombus. Doppler Tissue imaging (DTI) peak S-wave and E-wave velocities of the LAA walls (anterior, posterior, and apical) were acquired on TTE. Transthoracic echocardiographic harmonic imaging (with and without intravenous contrast) was examined to determine its ability to identify LAA SEC, sludge, or thrombus., Results: Among the 118 patients, TEE identified 6 (5%) with LAA sludge and 2 (2%) with LAA thrombi. Both LAA thrombi were identified on TTE using harmonic imaging with contrast. Anterior, posterior, and apical LAA wall DTI velocities on TTE varied significantly among the 3 groups examined (no SEC, mild SEC, severe SEC, sludge or thrombus). An apical E velocity < or = 9.7 cm/s on TTE best identified the group of patients with severe SEC, sludge, or thrombus. An anterior S velocity < or = 5.2 cm/s on TTE best identified the group of patients with sludge or thrombus., Conclusions: The CLOTS multicenter pilot trial determined that TTE is useful in the detection of thrombus using harmonic imaging combined with intravenous contrast (Optison; GE Healthcare, Milwaukee, WI). Additionally, LAA wall DTI velocities on TTE are useful in determining the severity of LAA SEC and detecting sludge or thrombus.

Degenerative aortic valve stenosis (AS) has an incidence of 2-7% in the Western European and North American populations over 65 years of age. The aim of this study was to perform a meta-analysis of the published literature evaluating the accuracy of CT planimetry to measure the aortic valve area. The PUBMED and OVID databases were searched up to May 2008. Major criteria for article inclusion was the use of (a) multi-detector computed tomography as a diagnostic test for the assessment of AVA in patients with AS, and (b) TTE as the reference standard. Nine studies were included in the analysis with 175 women and 262 men. The mean AVA as measured by CT was 1.0 +/- 0.1. The mean AVA measured by TTE was 0.9 +/- 0.1. The correlation between CT and TTE AVA measurements was r = 1.45. The mean difference was 0.03 +/- 0.05. The results of our meta-analysis suggest that multi-detector CT is an accurate method for obtaining AVA measurements in patients with AS.

Background: National Cholesterol Education Program (NCEP) guidelines have been used to define treatment goals in patients with hypercholesterolemia. However, epidemiology-based guidelines are unable to identify all subjects with coronary artery disease for aggressive lipid intervention., Objective: We sought to evaluate the additive value of multislice computed tomography (MSCT) angiography to the NCEP guideline classification for lipid treatment., Methods: Multislice computed tomography was performed in 114 consecutive patients (mean age 57+/-14 y; 59% male) without known coronary artery disease. Subjects were classified into 3 categories (low-, intermediate-, and high-risk) according to their Framingham risk scores (FRS)., Results: Traditional cardiac risk factors were common: hypertension 59%, diabetes 13%, and smoking 22%. On the basis of the FRS, 11% (n=12/114) of the patients met high-risk criteria requiring aggressive cholesterol reduction. Of those in the low- and intermediate-risk groups, MSCT found coronary plaque in 76% (n=77/102), with moderate or severe plaque in 38% (n=39/102), thus reclassifying them in the high-risk category. Use of statin drugs increased from 32% at baseline to 53% (p=0.002) based on MSCT results; statin dose was increased in 31% of the patients who were already on a statin. The mean low-density lipoprotein cholesterol (LDL-c) decreased from 114 mg/dL to 91 mg/dL after MSCT (p<0.001)., Conclusion: Multislice computed tomography reclassifies a high percentage of patients considered to be low- to intermediate-risk into the high-risk category based on their coronary artery lesions. Thus, the rise in MSCT use at present may have a large impact on clinician practice patterns in lipid-lowering therapy., (Copyright (c) 2008 Wiley Periodicals, Inc.)

Background: Left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve occurs as a result of a dynamic interplay between the anatomy and mechanics of the heart. While systolic anterior motion and left ventricular outflow tract obstruction are well-recognized hallmarks of hypertrophic obstructive cardiomyopathy, several other specific etiologies have been described with similar pathophysiology., Case Report: We present a unique case of a middle-aged woman who developed acute dynamic left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve resulting from a large left-sided pleural effusion., Conclusions: Dynamic outflow tract obstruction should be considered among the potential causes of a new systolic murmur in patients with large pleural effusions in the absence of valvular heart disease.

The development of atrial fibrillation (AF) in cardiac patients is multifactorial, including not well defined genetic factors. To determine if Asian ethnicity is associated with the development of AF in patients with coronary disease, a meta-analysis was conducted of patient-level data from 7 prospective randomized clinical trials that prospectively collected information on the development of AF: 3 trials in patients with ST-elevation myocardial infarction (Global Use of Strategies to Open Occluded Coronary Arteries [GUSTO] I, GUSTO III, and GUSTO V), 3 trials in patients with non-ST-elevation acute coronary syndromes (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy [PURSUIT], Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis-II [IMPACT II], and Platelet IIb/IIIa Antagonist for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network [PARAGON A]), and 1 trial in patients with both conditions (GUSTO IIb). A total of 94,785 patients were identified (93,050 white, 1,735 Asian). At baseline, Asian patients were younger; had lower body mass indexes; had a lower prevalence of female gender, previous angioplasty, and previous coronary artery bypass grafting; and had a greater prevalence of diabetes compared with white patients. The development of AF was lower in Asian than in white patients (4.7% vs 7.6%, p <0.001), while rates of ventricular tachycardia and fibrillation were similar in the 2 groups. In multivariate logistic regression analysis, Asian ethnicity was associated with significantly lower rates of AF (odds ratio 0.65, 95% confidence interval 0.50 to 0.84, p = 0.001) compared with white ethnicity. In conclusion, similar to previous studies showing a lower incidence of AF in non-Caucasian populations, Asians experiencing acute ischemic syndromes have a significantly lower frequency of AF compared with whites. Further study is needed to investigate the mechanisms and potential genetic underpinnings behind this association.

Objectives: We aimed to evaluate left atrial appendage (LAA) exclusion in patients undergoing mitral valve surgery with respect to thromboembolic events., Background: LAA is the predominant source of emboli in patients with atrial fibrillation. Prophylactic LAA exclusion at the time of heart surgery has been recommended to reduce the risk of future thromboembolism., Methods: An observational cohort of 136 patients undergoing LAA exclusion during mitral valve surgery was identified between May 1993 and November 1998 at our institution., Results: During a mean follow-up of 3.6 +/- 1.3 years, there were 14 (12.3%) thromboembolic events. Compared with patients who received warfarin upon hospital discharge, there were more thromboembolic events in patients not prescribed warfarin upon hospital discharge (n = 7/67, 10% vs n = 6/40, 15%, respectively). The warfarin status was not known for one patient. The majority of thromboembolic events (n = 10/14, 71%) occurred in those who underwent mitral valve repair., Conclusion: In this observational study, patients who undergo LAA exclusion during mitral valve surgery to reduce the risk of thromboembolism have a significant incidence of thromboembolic events, especially when warfarin therapy is not prescribed upon hospital discharge.

The ACUTE trial randomly assigned patients who had atrial fibrillation (AF) of >2 days' duration to a transesophageal echocardiographically guided or a conventional strategy before cardioversion. In the 571 patients who underwent transesophageal echocardiography (TEE) in the ACUTE trial, we assessed the relative predictive value of baseline data derived by history, transthoracic echocardiography, and TEE for prediction of thrombus and adjudicated embolism (thromboembolism) as a composite end point. TEE was performed at 70 centers in 571 patients, 549 in the transesophageal echocardiographically guided group and 22 crossovers in the conventional group. Six patients (1.1%) who had embolism and 79 (13.8%) who had thrombi were identified in this group. Thrombus was completely resolved in 76.5% of patients who had repeat transesophageal echocardiographic procedures after 31.7 +/- 7.5 days of anticoagulation. For patients who had embolic events, none had a transesophageal echocardiographically identified thrombus; 5 of 6 (83.3%) had >/=1 transesophageal echocardiographic risk factors (including spontaneous echocardiographic contrast, aortic atheroma, patent foramen ovale, atrial septal aneurysm, mitral valve strands), and 4 of 6 (66.66%) had subtherapeutic anticoagulation or no anticoagulation. Clinical, transthoracic echocardiographic, and transesophageal echocardiographic risk factors contributed significantly to the prediction of composite thrombus/embolism. However, transesophageal echocardiographic thromboembolic risk factors were the strongest predictors of thromboembolism and provided statistically significant incremental value (chi-square 38.0, p <0.001) for identification of risk. Thus, in addition to thrombus identification, TEE has significant incremental value in the identification of patients who had high thromboembolic risk. In conclusion, this study supports the role of TEE and anticoagulation monitoring in patients who have atrial fibrillation and is useful for identifying thromboembolic risk factors.

Right atrial (RA) masses are rare entities often detected incidentally during imaging studies. Leading etiologies of right atrial masses are tumor, thrombi, and vegetations. We present two cases of right atrial masses, a cardiac lipoma and an artifact. Clinical and echocardiographic characteristics of benign cardiac tumors are reviewed. We then highlight the importance of considering artifact in the differential diagnosis of atrial masses. Finally, we discuss echocardiographic characteristics of right atrial masses that may provide clues for diagnosis. Right atrial masses, often detected incidentally during imaging studies, are uncommon and can be due to many etiologies including tumors, thrombus, vegetations, normal variants, and artifacts. We describe 2 patients with RA masses detected on routine transthoracic echocardiogram.

Background: Heart transplant recipients require frequent myocardial biopsies to screen for acute rejection. The purpose of this study was to identify demographic and echocardiographic factors associated with transplant rejection and develop a predictive model, which may reduce the number of cardiac biopsies., Methods: From January 1998 to December 2001, we performed 406 echocardiographic studies on 264 heart transplant patients who had biopsies performed on the same day. Two-dimensional, pulsed and tissue Doppler echocardiographic variables were compared between patients with and without rejection, and their predictive ability for detecting rejection was determined by uni- and multivariate analyses., Results: In 268 biopsies there was no significant rejection (ISHLT Grade <==II), whereas 138 showed rejection (ISHLT Grade > or =IIIa). By multivariate analysis, pericardial effusion, isovolumic relaxation time (IVRT) <90 milliseconds and mitral inflow E/A ratio >1.7, diameter of inferior vena cava and duration of pulmonary vein atrial reversal were independently associated with rejection. Because the odds ratios were similar for all 5 predictors, a simplified model was developed based on the sum of the number of abnormal predictors present (0 to 5). The probability of rejection increased from 15.9%, in the absence of any predictor, to 39.7%, 52.0% and 71.1%, if 1, 2 or 3 predictors were present, respectively., Conclusions: Recipient age, pericardial effusion, IVRT and ratio of pulsed Doppler E/A are significant predictors of acute cardiac allograft rejection. However, no single predictor or combination of predictors were powerful enough to eliminate surveillance endomyocardial biopsies.

Although the evidence that right ventricular (RV) function has significant impact on cardiac hemodynamics and outcome is indisputable, its evaluation has been hampered by problems with image quality, geometric variability, and the absence of a standard of reference. A resurgence of research activity has sought to discern the pathophysiology of RV dysfunction and to explore new methods for measuring performance. Noninvasive techniques such as tissue Doppler echocardiography, three-dimensional echocardiography, and magnetic resonance imaging provide new quantitative information and may improve prediction of outcomes. These advances in technology, and the recognition that RV systolic function is essential in many conditions, provide the impetus for future studies. This review highlights the past and present efforts to incorporate RV systolic function into the mainstream of cardiology practice.

Real-time 3-dimensional echocardiography was performed in 10 patients with obstructive hypertrophic cardiomyopathy (HC) before and after myectomy and in 6 controls. The exact location of systolic anterior motion of the mitral leaflet was shown in all patients with HC with a predominant involvement of the medial portion in 4 patients and the middle portion in 6 patients. The smallest area of the left ventricular outflow tract was significantly smaller in patients with HC than in controls (1.4 +/- 0.7 vs 5.1 +/- 1.2 cm(2), p <0.01), significantly increased after myectomy (4.8 +/- 1.8 cm2, p <0.01) and was associated with a reduction of the pressure gradient at rest from 63 +/- 41 to 15 +/- 5 mm Hg (p <0.01).

The baseline characteristics, complications, and survival of 489 black and 6,890 non-black patients with acute coronary syndromes were studied. Important racial differences were observed in demographic features, atherosclerosis risk factors, and treatment strategies; however, despite these differences, no independent difference was observed in clinical outcomes according to race. The 1-year mortality rate was 2.9% for black patients and 2.5% for non-black patients (p = 0.93).