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Clinical trials with the Inoue mitral valvotomy balloon have recently begun in the United States. We assessed the effects of 17 demographic, echocardiographic, procedural, and hemodynamic variables on the immediate results, complications, and short-term follow-up of 200 patients in 15 centers undergoing valvotomy with this device. The study population had a mean age +/- SD of 53 +/- 15 years, and the total echocardiographic score was 7.2 +/- 2.4. Valvotomy was technically successful in 96.5% of procedures and increased the mean mitral valve area from 1.0 +/- 0.3 to 1.8 +/- 0.7 cm2 (p less than 0.001); 72% had an increase in valve area greater than or equal to 50%, and 67% had a final area greater than or equal to 1.5 cm2. Major procedural complications included cardiac tamponade during transseptal puncture (1.0%), systemic embolism (1.5%), and severe mitral regurgitation (2.4%); there were no procedural deaths and one hospital death. Multivariate analysis identified the absence of prior surgical commissurotomy and younger age as significant predictors of the gain in mitral valve area, but the correlation coefficients were low. Although the absence of subvalvular disease on echocardiograms was a predictor of a final valve area greater than or equal to 1.5 cm2, the total echocardiographic score did not correlate well with the immediate outcome (r = 0.01, p = NS). No variable was identified as predictive of restenosis, which occurred according to echocardiographic criteria in 14 of 66 (21%) patients evaluated 6 months after valvotomy. Good hemodynamic results with valvotomy were achieved in the majority of patients with low complication rates by many investigators with the use of the Inoue balloon device.(ABSTRACT TRUNCATED AT 250 WORDS)

This study assesses the clinical and electrode complications associated with the use of the epicardial screw-on electrode technique for permanent ventricular pacing. The records of 114 consecutive patients who received screw-on epicardial electrodes were analyzed in-hospital and at one year following implantation We compared two techniques of implanting the screw-on electrode: 72 transmediastinal (TM) and 42 subxiphoid (SX) procedures. Baseline clinical inequalities were not apparent between the SX and TM patients. There was one operative death in the SX series and none among the TM patients. Total hospital mortality was 4% in the SX group and 2% in the TM group. In-hospital morbidity in the SX series (13/72-18%) was less than the TM group [14/42-33%], largely due to pleural entry and necessity for more frequent chest tube placement in TM patients. Electrode complications were low in both groups (3% in-hospital and 3% late; total 6/114, or 5%). Morbidity and mortality of these approaches to direct myocardial pacing remain noticeably higher than reported results of some transvenous series. Excellent electrode stability can be attained using the screw-on electrode, however, and the SX approach offers lower hospital morbidity than the TM method. [ABSTRACT FROM AUTHOR]

In this report, we describe a case of primary pericardial mesothelioma, which is an extremely rare tumor arising from mesothelial cells lining the pericardium and is associated with a dismal prognosis. [ABSTRACT FROM AUTHOR]

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document 1 addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined., (Copyright © 2019. Published by Elsevier Inc.)

Septostomy reduces right ventricular (RV) workload at the expense of hypoxemia in patients with advanced pulmonary hypertension (PH). A patent foramen ovale (PFO) may serve as a "natural" septostomy, but the incidence and impact of a PFO in PH remains uncertain. We prospectively examined echocardiograms in 404 PH patients referred for initial hemodynamic assessment. Patients included had saline bubble injection and if negative repeatinjection after Valsalva maneuver. Echocardiographic and hemodynamic data were examined. Survival was modeled using Kaplan-Meier method. Eisenmenger syndrome or known atrial shunts other than PFO were excluded: 292 patients met entry criteria. A PFO was identified in 16.8% of the entire cohort, 22.9% of pulmonary arterial hypertension (PAH) patients, and 8.6% of Dana Point group 2 PH patients. Right atrial to pulmonary capillary wedge pressure difference was lowest in the latter group (-7.9 ± 7.1 vs -1.7 ± 5.5 mm Hg for all others, p <0.01). Patients with a PFO were younger (53.9 vs 58.6 years, p = 0.02). A PFO was more often present with moderately or severely dilated (p = 0.01) or dysfunctional (p = 0.03) RVs. Six year survival was unchanged by PFO presence for all patients, including those with PAH. Proportional hazards analysis found only age and functional class independently predicted survival (p <0.01). A PFO is identified less often in Dana Point group 2 PH, likely due to inability of Valsalva maneuver to overcome right atrial to pulmonary capillary wedge pressure difference. In conclusion, the incidence of a PFO in the PH population increases with more dilated and dysfunctional RVs, suggesting that the PFO may be stretched open rather than congenital. The presence of a PFO does not impact survival in PH or PAH., (Copyright © 2018. Published by Elsevier Inc.)

This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined., (Copyright © 2017. Published by Elsevier Inc.)

Objectives: Pulmonary hypertension portends a poorer prognosis for blacks versus white populations, but the underlying reasons are poorly understood. We investigated associations of disease characteristics, insurance status, and race with clinical outcomes., Study Design: Retrospective cohort study of patients presenting for initial pulmonary hypertension evaluation at 2 academic referral centers., Methods: We recorded insurance status (Medicare, Medicaid, private, self-pay), echocardiographic, and hemodynamics data from 261 patients (79% whites, 17% blacks) with a new diagnosis of pulmonary hypertension. Subjects were followed for 2.3 years for survival. Adjustment for covariates was performed with Cox proportional hazards modeling., Results: Compared with white patients, blacks were younger (50 ± 15 vs 53 ± 12 years; P = .04), with females representing a majority of patients in both groups (80% vs 66%; P = .08) and similar functional class distribution (class 2/3/4: 30%/52%/16% blacks vs 33%/48%/14% whites; P = .69). Blacks diagnosed with incident pulmonary hypertension were more frequently covered by Medicaid (12.5% vs 0.7%) and had less private insurance (50% vs 61%; P = .007) than whites. At presentation, blacks had more right ventricular dysfunction (P = .04), but similar mean pulmonary arterial pressure (46 vs 45 mm Hg, respectively; P = .66). After adjusting for age and functional class, blacks had greater mortality risk (hazard ratio [HR], 2.06; 95% confidence interval [CI], 1.18-3.44), which did not differ by race after additional adjustment for insurance status (HR, 1.74; 95% CI, 0.84-3.32; P =.13)., Conclusions: In a large cohort of patients with incident pulmonary hypertension, black patients had poorer right-side heart function and survival rates than white patients. However, adjustment for insurance status in our cohort removed differences in survival by race.

Diabetes complicates management in a number of disease states and adversely impacts survival; how diabetes affects patients with pulmonary hypertension (PH) has not been well characterized. With insulin resistance having recently been demonstrated in PH, we sought to examine the impact of diabetes in these patients. Demographic characteristics, echo data, and invasive hemodynamic data were prospectively collected for 261 patients with PH referred for initial hemodynamic assessment. Diabetes was defined as documented insulin resistance or treatment with antidiabetic medications. Fifty-five patients (21%) had diabetes, and compared with nondiabetic patients, they were older (mean years ± SD, 61 ± 13 vs. 56 ± 16; [Formula: see text]), more likely to be black (29% vs. 14%; [Formula: see text]) and hypertensive (71% vs. 30%; [Formula: see text]), and had higher mean (±SD) serum creatinine levels (1.1 ± 0.5 vs. 1.0 ± 0.4; [Formula: see text]). Diabetic patients had similar World Health Organization functional class at presentation but were more likely to have pulmonary venous etiology of PH (24% vs. 10%; [Formula: see text]). Echo findings, including biventricular function, tricuspid regurgitation, and pressure estimates were similar. Invasive pulmonary pressures and cardiac output were similar, but right atrial pressure was appreciably higher (14 ± 8 mmHg vs. 10 ± 5 mmHg; [Formula: see text]). Despite similar management, survival was markedly worse and remained so after statistical adjustment. In summary, diabetic patients referred for assessment of PH were more likely to have pulmonary venous disease than nondiabetic patients with PH, with hemodynamics suggesting greater right-sided diastolic dysfunction. The markedly worse survival in these patients merits further study.

A 75-year old woman with a history of coronary disease status post 3-vessel coronary artery bypass grafting (CABG) 8 years ago and a repeat one-vessel CABG 2 years ago in the setting of aortic valve replacement with a #19 mm St. Jude bileaflet mechanical valve for severe aortic stenosis presented with two to three weeks of progressive dyspnea and increasing substernal chest discomfort. Echocardiography revealed a gradient to 31 mmHg across her aortic valve, increased from a baseline of 13 mmHg five months previously. Fluoroscopy revealed thrombosis of her mechanical aortic valve. She was not a candidate for surgery given her multiple comorbidities, and fibrinolysis was contraindicated given a recent subdural hematoma 1 year prior to presentation. She was treated with heparin and eptifibatide and subsequently demonstrated resolution of her aortic valve thrombosis. We report the first described successful use of eptifibatide in addition to unfractionated heparin for the management of subacute valve thrombosis in a patient at high risk for repeat surgery or fibrinolysis.

Therapeutic ionizing radiation, such as that used in the treatment of Hodgkin's lymphoma, can cause cardiac valvular damage that may take several years to manifest as radiation-associated valvular heart disease. Treatment can be complicated by comorbid radiation injury to other cardiac and mediastinal structures that lead to traditional surgical valve replacement or repair becoming high-risk. A representative case is presented that demonstrates the complexity of radiation-associated valvular heart disease and its successful treatment with percutaneous transcatheter valve replacement. The prevalence and pathophysiologic mechanism of radiation-associated valvular injury are reviewed. Anthracycline adjuvant therapy appears to increase the risk of valvular fibrosis. Left-sided heart valves are more commonly affected than right-sided heart valves. A particular pattern of calcification has been noted in some patients, and experimental data suggest that radiation induction of an osteogenic phenotype may be responsible. A renewed appreciation of the cardiac valvular effects of therapeutic ionizing radiation for mediastinal malignancies is important, and the treatment of such patients may be assisted by the development of novel, less-invasive approaches.

Infective endocarditis (IE) is an infection of a heart valve or other cardiac structure at a site of endothelial damage. The definition has been also expanded to include infected cardiac devices. A variety of organ systems may be adversely affected in patients with IE. Although advances have improved the diagnostic accuracy for IE, morbidity and mortality remain remarkably high. This article reviews the pathophysiology, complications, diagnosis, and management of IE with recent updates to the literature and the major cardiovascular society guidelines. The increasingly prevalent clinical problem of intracardiac device-related IE is addressed, along with the recent changes to the IE prophylaxis guidelines.

Opinion Statement: Our approach to the management of the patient with a bicuspid aortic valve (BAV) takes several factors into consideration. First, is the dysfunction of the valve due to aortic stenosis (AS), aortic regurgitation (AR), or a combination of stenosis and regurgitation, and what is the severity? Next, is there aortic dilation in any of the regions (sinuses of Valsalva, sinotubular junction, tubular ascending aorta, or transverse arch) discussed in this article. In general, we follow patients with a BAV and moderate valve dysfunction (AS or AR) with yearly surveillance transthoracic echocardiography for left ventricular function, jet velocity, gradient, and valve area with AS, whereas left ventricular (LV) function and LV dimensions are monitored for patients with AR. In addition, yearly clinical evaluation for change in symptom status or functional capacity is critical. More recently, we have utilized NT-pro BNP levels to help assess patients, particularly those in whom the anatomic severity does not match the clinical symptoms (ie, the valve severity appears mild but the patient is complaining of symptoms or the valve severity seems significant but no symptoms are noted). All patients with a bicuspid valve should have evaluation of the aorta with a MRI or CT angiography at some point, as 50% of BAV patients have aortic root involvement. At our institution, cardiac MRI is preferred unless there is a contraindication, particularly in younger patients, given the cumulative radiation exposure from surveillance CT scans. Cardiac MRI also provides the added benefit of information regarding LV function, LV dimensions, and assessment of valve stenosis/regurgitation severity, thus obviating the need for echocardiographic data in those being followed with serial cardiac MRI. For those with no aortic dilatation, we tend to use only echocardiography for follow-up. For patients with mild aortic dilation, surveillance aortic imaging is usually performed every 3-5 years. However, for those with greater degrees of aortic dilation (aortic diameters >4.0 cm) or notable interval change in dimensions, then aortic imaging every year is conducted. For young adult patients with isolated aortic stenosis, balloon aortic valvuloplasty is often an effective and temporizing treatment option. In older patients with aortic stenosis or those with AR, aortic valve replacement, with or without a surgery on the aorta depending on whether concomitant dilation (aortic diameter >4.5 cm) of the aorta is present, is the preferred management strategy. In a few patients, surgery on the aortic alone may be indicated if the maximal diameter exceeds 5.0 cm.

Background: Anemia is a marker of worsened clinical outcome in patients with heart failure from left ventricular dysfunction. Pulmonary hypertension often results in right ventricular dysfunction. Accordingly we sought to examine the association of hemoglobin levels and long-term all-cause mortality in a cohort of patients with pulmonary hypertension., Methods: Baseline demographic information, clinical characteristics and fasting blood work were obtained in a cohort of 145 patients with pulmonary hypertension referred for pulmonary vasodilator testing. Data was retrospectively analyzed with Cox-proportional hazards analysis., Results: Baseline characteristics of the cohort included age (mean±SD) 55.8±14.6 years, 75% women, 50% with idiopathic pulmonary hypertension, mean pulmonary artery pressure 46.1±14.2 mm Hg and arterial O(2) saturation 91±6 %. The most commonly utilized pulmonary hypertension specific therapeutic agents in descending order of frequency were epoprostenol (27%), sildenafil (21%), bosentan (17%), and treprostinil (6%). Over a median follow-up of 2.1 years, there were 39 deaths (26.9%). Patients who died had significantly lower hemoglobin levels than those survived (12.2±2.3 vs. 13.7±2.0, p<0.001). After adjustment for known predictors of death and pulmonary hypertension etiology, anemic patients were 3.3 times more likely to die than non-anemic patients (95% CI [1.43-7.51], p=0.005)., Conclusions: Hemoglobin levels closely parallel survival in pulmonary hypertension. Modification of anemia in this disorder could alter the clinical course and calls for further research in this area., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine the ability of vasodilator response to predict survival in a diverse cohort of patients with pulmonary hypertension (PH)., Patients & Methods: A total of 214 consecutive treatment-naive patients referred for invasive PH evaluation were enrolled between November 1998 and December 2008. Vasoreactivity was assessed during inhalation of 40 parts per million nitric oxide (iNO) and vasodilator responders were defined as those participants who achieved a mean pulmonary artery pressure (PAP) of ≤ 40 mm Hg and a drop in mean PAP ≥ the median for the cohort (13%). Kaplan-Meier analysis and Cox proportional hazards modeling were used to identify predictors of survival., Results: There were 51 deaths (25.9%) over a mean follow-up period of 2.3 years. Kaplan-Meier analysis demonstrated that vasodilator responders had significantly improved survival (P < .01). Vasodilator responders had improved survival regardless of whether or not they had idiopathic or nonidiopathic PH (P = .02, P < .01) or whether or not they had Dana Point class 1 or non-Dana Point class 1 PH (P < .01, P = .01). In multivariate modeling, advanced age, elevated right atrial pressure, elevated serum creatinine, and worsened functional class significantly predicted shorter survival (P = .01, P = .01, P = .01, P < .01), whereas vasodilator response predicted improved survival (P = .01)., Conclusions: Vasodilator responsiveness to iNO is an important method of risk stratifying PH patients, with results that apply regardless of clinical etiology., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Pulmonary hypertension (PH) is the end result of a variety of diverse pathologic processes. The chronic elevation in pulmonary artery pressure often leads to right ventricular pressure overload and subsequent right ventricular failure. In patients with left-sided cardiac disease, PH is quite common and associated with increased morbidity and mortality. This article will review the literature as it pertains to the epidemiology, pathogenesis, and diagnosis of PH related to aortic valve disease, mitral valve disease, left ventricular systolic and diastolic dysfunction, and pulmonary veno-occlusive disease. Moreover, therapeutic strategies, which focus on treating the underlying cardiac pathology will be discussed.

Background and Aim of the Study: Pulmonary hypertension frequently complicates mitral stenosis, with a subset of these patients exhibiting pressures well in excess of their mitral valve hemodynamics. The prevalence of this condition and its impact on clinical outcome following percutaneous balloon mitral commissurotomy (PBMC) is unknown., Methods: The transpulmonary gradient (TPG) was measured in 317 patients undergoing PBMC; patients were subsequently defined as having either an appropriate or excessive TPG (< or =15 mmHg or >15 mmHg, respectively). Twenty-two patients were excluded due to valvuloplasty-related significant mitral regurgitation. The remaining 295 patients (250 females, 45 males; mean age 52 +/- 13 years) were prospectively followed up, with each patient underwent serial echocardiography., Results: Among the patients, 214 (73%) had pulmonary hypertension (pulmonary artery pressure >25 mmHg) and 55 (19%) also had an elevated TPG. Females were almost fivefold more likely than males to have an elevated TPG (p = 0.003). Patients with an elevated TPG had a worse mean NYHA functional class than those with a normal TPG (3.0 +/- 0.5 versus 2.7 +/- 0.6, p = 0.01), while the mitral valve area (MVA) was slightly smaller in patients with an elevated TPG (1.0 +/- 0.2 versus 1.1 +/- 0.2 cm2, p = 0.003). All patients demonstrated a significant increase in MVA after commissurotomy (final MVA 1.7 +/- 0.6 cm2, p < 0.001 for elevated TPG; 1.8 +/- 0.4 cm2, p < 0.001 for normal TPG), and the NYHA class at six months was improved for all patients (2.8 +/- 0.6 versus 1.6 +/- 0.7, p < 0.001). The improvements in NYHA class, TPG and MVA were sustained at 36 months., Conclusion: Pulmonary hypertension with elevated TPG occurs in patients with mitral stenosis, and is significantly more common in females. Despite worse symptoms and higher right-sided pressures, PBMC is equally successful in patients with a normal TPG, and provides sustained benefit for up to 36 months after the procedure.

Background: Ranolazine is increasingly being prescribed for the treatment of chronic stable angina. This report describes an adverse effect that may be related to ranolazine., Case Summary: A 77-year-old white man with chronic renal insufficiency was evaluated for moderate dyspnea on exertion (DOE). Cardiac and pulmonary workup revealed nonobstructive coronary artery disease and mild obstructive lung disease. The patient had been taking ranolazine 500 mg daily for possible angina for the past 2 months. Given the temporal association of his symptoms with drug initiation, ranolazine was discontinued during the hospitalization. One month after discontinuing ranolazine, the patient's DOE had completely resolved; the only intervention had been discontinuation of ranolazine. The patient's Naranjo algorithm score was 3, indicating a possible adverse drug reaction., Conclusions: No previous cases of ranolazine-related DOE requiring drug cessation have been published. Ranolazine may be associated with DOE in this elderly man., (Copyright 2010 Excerpta Medica Inc. All rights reserved. Published by EM Inc USA.. All rights reserved.)

Background and Aim of the Study: Pure annular dilation (PAD) is a recognized etiology of mitral regurgitation, yet few data exist to define the prognostic profile of this disorder relative to other etiologies, such as ischemia or myxomatous prolapse., Methods: A total of 535 patients undergoing mitral repair at two institutions between 1993 and 2002 was retrospectively reviewed. PAD was defined as requiring only ring annuloplasty +/- cleft repair, without evidence of prolapse, regional wall motion abnormality, or infarction., Results: PAD was identified in 74 patients, while alternative etiologies were myxomatous prolapse (n = 290), ischemia (n = 141), and 'other' (n = 30). PAD patients were more often female (78%) than male (38%) (p < 0.001), more often hypertensive (37% versus 26%; p = 0.003), and had a left ventricular ejection fraction (LVEF) that was lower (0.41 +/- 0.12) than those in patients with prolapse (0.51 +/- 0.11; p < 0.01) but similar to values in ischemic patients (0.38 +/- 0.10). The valve size was smaller for PAD versus prolapse (ring size 24-26 mm in 71% versus 12%; p < 0.001). The unadjusted PAD prognosis was intermediate, with five-year survival being 70 +/- 8%, compared to 87 +/- 3% for prolapse and 56 +/- 5% for ischemia (p < 0.01). Survival adjusted for differences in baseline characteristics was not different among the three groups (p > 0.10)., Conclusion: PAD is a clinically distinct etiology of mitral regurgitation associated with female gender, small valve size, a lower LVEF, and hypertension. Early, more aggressive hypertension control might improve or minimize the consequences of this predominantly female cardiac disorder.

Background: Women and minorities traditionally have shown less use of diagnostic cardiac catheterization. We sought to determine whether mobile cardiac catheterization laboratories may increase the use of catheterization among women and minorities by bringing the technology to remote communities., Methods: We collected data on consecutive patients undergoing cardiac catheterization at mobile laboratories located at 15 community hospitals in North Carolina and Virginia from 1994 to 2005. These data were compared with those from similar consecutive outpatients at the Duke University Medical Center (Durham, NC) cardiac catheterization laboratory over the same period. Logistic regression modeling techniques were used to determine which patient factors were associated with the decision to use a particular facility., Results: Women comprised 48% of the patients undergoing cardiac catheterization via mobile laboratory versus 42% of those patients receiving outpatient catheterization at the medical center laboratory (P < .001). All racial minorities combined (African American, Hispanic, Native American, Asian, and other) made up 27% of the mobile laboratory population undergoing catheterization versus 21% of the medical center outpatients who underwent the procedure (P < .001). Most minorities were African American. The most important predictor of patients receiving catheterization via a mobile laboratory rather than at the medical center catheterization laboratory was distance to the nearest mobile facility. Within a home-to-mobile laboratory range of approximately 35 miles, the odds of being treated at a mobile laboratory increased greatly the closer the patient lived to the facility., Conclusions: The strongest predictor of mobile laboratory use was the patient's proximity to the mobile facility. When compared with a traditional tertiary referral outpatient hospital setting, a greater percentage of women and African Americans received cardiac catheterization at mobile laboratories. The availability of mobile laboratories may increase the use of cardiac procedures among women and African Americans.

With improved imaging techniques, such as cardiac magnetic resonance imaging and computed tomography, 2 unusual cardiomyopathies have been added to the differential diagnosis of nonischemic dilated cardiomyopathies. Ventricular noncompaction (VNC) classically affects the left ventricle, although right ventricular involvement can also be seen. Symptoms can be absent or can be consistent with varying degrees of heart failure and arrhythmias. VNC can initially present in all age groups, from neonates to the elderly. In takotsubo cardiomyopathy, the characteristic appearance of the left ventricle involves transient regional dysfunction of the apex and mid-ventricle, with hyperkinesis of the basal segments. Classically, it occurs after an emotionally stressful event, and it predominantly affects postmenopausal women. This article reviews characteristics of these unique cardiomyopathies.

Background and Aim of the Study: Inflammation may play a central role in the progression of stenotic valvular heart disease. Serum levels of matrix metalloproteinases (MMPs), markers of extracellular matrix (ECM) turnover and potential markers of active inflammation, have been recently demonstrated in several inflammatory processes. The present study was designed to examine whether systemic evidence of ECM turnover was present in advanced stenotic mitral valve disease., Methods: Serum levels of MMP-1, -3 and -9 were measured in 114 patients with mitral stenosis referred for percutaneous balloon mitral valve commissurotomy, and compared to those in 48 healthy, age- and gender-matched controls., Results: Serum levels of MMP-1, -3 and -9 did not vary according to hemodynamic profile or heart failure class at the time of blood sampling. Levels of MMP-1 and -3 were not significantly different between those patients with mitral stenosis and controls. The level of MMP-9 was significantly higher in patients with mitral stenosis than in controls, and did not appear to be altered by commissurotomy., Conclusion: Serum levels of MMP-9 were elevated in patients with mitral stenosis, providing further evidence that inflammation and ECM remodeling plays an important role in the pathophysiology of valvular heart disease.

With infective endocarditis afflicting 15,000 patients each year and with a mortality rate that still hovers at almost 40%, the disease remains a very serious health problem. Surprisingly, the incidence has not declined over the last 30 years, and now with more health care interventions, such as pacer/defibrillators, and an increasingly elderly population with degenerative valvular heart disease, the number susceptible to endocarditis is actually increasing. Given the weak evidence for endocarditis prophylaxis, there remains a large population at risk. Much has been learned recently about the pathogenesis of endocarditis, including the role of endothelial damage, platelet adhesion, and microbial adherence to the vegetation or intact valvular tissue. Three-fourths of patients have preexisting structural heart disease. Once infection is manifest, major cardiac complications include congestive heart failure, embolization, mycotic aneurysms, renal dysfunction, and abscess formation. The diagnosis of endocarditis has been enhanced recently by modifications in the Duke criteria to include the use of transesophageal echocardiography and microbial antibody titers. Surgery continues to play an important role, with criteria for emergency, urgent, and early surgery now defined. The major organisms involved in infective endocarditis include streptococci and staphylococcus (representing 75% or so of all cases). Enterococcal infections account for many of the remaining cases, although small series and case reports suggest almost all organisms that infect humans can be implicated at times. A sizeable number of "culture-negative" cases still occur despite all the improvements in diagnostic methodology. Recent guidelines for the diagnosis, treatment, and management of infective endocarditis from the American Heart Association are reviewed and the issues surrounding prophylaxis are summarized. International cooperative databases are now being developed that hold promise for a continual reexamination of the epidemiology of this highly aggressive disease and may help provide sorely needed prospective trial data that will enhance our understanding and treatment.

Adults with congenital heart disease (CHD) constitute a patient population that has grown rapidly, due to advances in diagnosis and treatment of children with CHD. Though ideally served by cardiologists with advanced training in congenital conditions, adults with CHD often receive the majority of their care from primary care physicians and general cardiologists. These patients often have unique clinical presentations. An understanding of available therapeutic modalities can assist clinicians in the timing of subspecialty referral. This review focuses on the unique challenges of cardiac catheterization and the role of percutaneous interventions in adults with CHD.

The mechanism by which hypoxia [low partial pressure of O(2) (pO(2))] elicits signaling to regulate pulmonary arterial pressure is incompletely understood. We considered the possibility that, in addition to its effects on smooth muscle, hypoxia may influence pulmonary vascular tone through an effect on RBCs. We report that exposure of native RBCs to sustained hypoxia is accompanied by a buildup of heme iron-nitrosyl (FeNO) species that are deficient in pO(2-)governed intramolecular transfer of NO to cysteine thiol, yielding a deficiency in the vasodilator S-nitrosohemoglobin (SNO-Hb). S-nitrosothiol (SNO)-deficient RBCs produce impaired vasodilator responses in vitro and exaggerated pulmonary vasoconstrictor responses in vivo and are defective in oxygenating the blood. RBCs from hypoxemic patients with elevated pulmonary arterial pressure (PAP) exhibit a similar FeNO/SNO imbalance and are thus deficient in pO(2)-coupled vasoregulation. Chemical restoration of SNO-Hb levels in both animals and patients restores the vasodilator activity of RBCs, and this activity is associated with improved oxygenation and lower PAPs.

Background: Assessment of pulmonary vasodilator responsiveness is important in determining the prognosis and management of patients with pulmonary hypertension. Many patients, however, are already on vasodilators at the time of testing. It is unclear if these agents should be temporarily discontinued to improve the sensitivity of testing., Methods: We examined the hemodynamic effects of nitric oxide (NO) inhalation in 60 patients with pulmonary arterial hypertension. Thirty-one of these patients were receiving medications with vasodilating properties. Vasodilator testing was performed with invasive measurement of pressure of the right side of the heart at baseline and during inhalation of 40 ppm NO., Results: No significant demographic differences were seen between patients receiving and not receiving vasodilators. Similar reductions in mean pulmonary artery pressure (19 +/- 12% vs 20 +/- 12%, P = .734) and pulmonary vascular resistance (31 +/- 18 vs 32 +/- 16, P = .967) were seen in patients receiving and not receiving vasodilators. Using the definition of positive vasodilator response (> or = 20% drop in mean pulmonary artery pressure), 55% (17/31) of patients in the baseline vasodilator group had a positive response compared with 62% (18/29) of the patients not on vasodilators (P = .570)., Conclusions: Concurrent use of oral vasodilators does not appear to mask a significant response to inhaled NO on the pulmonary vasculature. Therefore, routine discontinuation of pulmonary vasodilators is likely unnecessary before vasodilator testing in patients with pulmonary arterial hypertension.

A prospective cohort of patients with mitral stenosis and no history of atrial arrhythmias showed no decrease in the incidence of atrial fibrillation (AF) after successful versus unsuccessful Inoue balloon percutaneous balloon mitral valve commissurotomy. Advanced age and left atrial dimension best predicted which patients developed AF during follow-up, whereas percutaneous balloon mitral valve commissurotomy procedural success and left atrial pressure reduction did not have an impact on incidence of AF.