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Effect of transcatheter edge-to-edge repair (TEER) using MitraClip in patients with mitral regurgitation (MR) on left atrial (LA) kinetic energy (LAKE), an index of LA work, and LA strain, a measure of LA performance, have not been well defined.Patients with chronic primary or secondary 3+ or 4+ MR were analyzed pre- and post-TEER using MitraClip. LAKE was determined by echocardiography using LA stroke volume and A-wave velocity. Peak atrial longitudinal strain (PALS), peak atrial strain in early diastole, and peak atrial contraction strain (PACS) were obtained by speckle tracking echocardiography.Thirty-nine patients undergoing TEER with MitraClip were screened, 12 met criteria for analysis (9 primary and 3 secondary MR). Compared to pre-TEER, there was a significant increase post-TEER in LAKE (71.0 ± 64.1 vs. 177.5 ± 167.9 dyne·cm·10sup3/sup, respectively; p = .008) and Doppler transmitral A-wave velocity (87.8 ± 41.4 vs. 138.5 ± 43.7 cm/s, respectively; p lt; .001); LA stroke volume did not change significantly. Mitral valve mean gradient significantly increased post-TEER compared to pre-TEER (5.7 ± 2.1 vs. 3.3 ± 2.1 mmHg, respectively; p = .01). There was a trend toward decrease in PALS post-TEER compared to pre-TEER (16.2 ± 4.8 vs. 20.7 ± 9.9%, respectively; p = .05). Peak atrial strain in early diastole significantly decreased post-TEER compared to pre-TEER (7.2 ± 3.0 vs. 14.1 ± 7.2%; respectively, p lt; .001), while PACS did not significantly change (9.1 ± 3.5 vs. 6.7 ± 5.2%, respectively; p = .07).In patients with chronic MR, LAKE increases after TEER with MitraClip driven by an increase in LA emptying velocities. Changes were also seen in LA strain with MitraClip. These procedurally induced changes due to mild mitral stenosis may have clinical implications.

Secondary (also known as functional) mitral regurgitation (MR) has increased substantially over the last several decades due to an increase in the prevalence of dilated cardiomyopathy (ischemic and non-ischemic). Mortality and morbidity in patients with dilated cardiomyopathy is much greater when associated with MR as compared to without MR. MR will result in further left ventricular (LV) volume overload, LV dilation, and pupillary muscle displacement resulting in deterioration of the severity of MR leading to a vicious cycle. Optimization of heart failure medical therapy, and cardiac resynchronization therapy for those that qualify, can improve severity of MR; however, significant MR will persist in certain patients. Transcatheter mitral valve repair to treat significant MR using the MitraClip (Abbott, Menlo Park, California), which grasps and coapts the posterior and anterior mitral valve leaflets, in appropriately selected patients with dilated cardiomyopathy and secondary MR has been shown to improve quality of life and prolong survival.

We report on the natural history of a cohort of patients presenting with transient ischemic attack or stroke and nonbacterial thrombotic endocarditis treated with warfarin. Patients with valvular vegetations on echocardiography, stroke, or transient ischemic attack presenting to a single neurologist were included. All patients were treated with warfarin until the vegetation resolved or for two years, then were switched to aspirin and had at least one clinical and echocardiographic follow-up. Twenty-nine patients were included and followed for a median of 27 months. Average age was 42 years and 72% were female. Two patients had vegetations on two valves. Five patients (17%) had recurrent strokes, three had systemic lupus erythematosus and antiphospholipid antibodies, one had antiphospholipid antibodies alone and one had neither condition. Three of the five patients did not have resolution of the vegetation at the time of the event. The valvular vegetations resolved in 23 of the 31 affected valves (74%) after a median of 11 months (range 4.5–157.5). Eleven patients had at least one follow-up echocardiogram after resolution of the vegetation and none had recurrent vegetations after warfarin was stopped. This study should serve to provide general recommendations regarding treatment of patients with TIA/stroke with nonbacterial thrombotic endocarditis. Valvular vegetations resolve in most patients and the risk of recurrent stroke is low. Warfarin can safely be switched to aspirin in most patients when the vegetation resolves or after two years if it does not resolve. Prolonged warfarin may be warranted in patients with systemic lupus erythematosus, positive antiphospholipid antibodies, and a persistent vegetation.

Objective To assess the impact of stroke volume index (SVI) and left ventricular ejection fraction (LVEF) on prognosis in patients with severe aortic stenosis, comparing those undergoing transcatheter aortic valve replacement (TAVR) and those with surgical AVR (SAVR). Patients and Methods A total of 742 patients from the CoreValve US Pivotal High-Risk Trial randomized to TAVR (n=389) or SAVR (n=353) from February 2011 to September 2012 were stratified by an SVI of 35 mL/m2 and LVEF of 50% for comparing all-cause mortality at 1 year. Results The prevalence of an SVI of less than 35 mL/m2 in patients who underwent TAVR and SAVR was 35.8% (125 of 349) and 31.3% (96 of 307), respectively; LVEF of less than 50% was present in 18.1% (63 of 348) and 19.6% (60 of 306), respectively. Among patients with an SVI of less than 35 mL/m2, 1-year mortality was similar between patients with TAVR and SAVR (16.3% vs 22.2%; P=.25). However, in those with an SVI of 35 mL/m2 or greater, 1-year mortality was lower in those with TAVR than SAVR (10.3% vs 17.3%; P=.03). In patients with an LVEF of less than 50%, mortality was not affected by AVR approach (P>.05). In patients with an LVEF of 50% or higher, TAVR was associated with lower mortality than SAVR when SVI was preserved (9.8% vs 18.6%; P=.01). Mortality was not affected by SVI within the same AVR approach when LVEF was 50% or higher. Conclusion In patients with severe aortic stenosis at high risk, there is a significant interaction between AVR approach and the status of SVI and LVEF. When LVEF or SVI was reduced, prognosis was similar regardless of AVR approach. In those with preserved LVEF or SVI, TAVR was associated with a better prognosis than SAVR. Trial Registration clinicaltrials.gov Identifier: NCT01240902

Treatment of patients with heart failure with reduced ejection fraction has evolved. Recently, a fully implantable remote hemodynamic monitoring sensor in the pulmonary artery was approved in the treatment of patients at risk of heart failure readmissions. Several novel devices designed to offload the left atrium by creating a small interatrial shunt are being investigated. Cardiac imaging plays a vital role in the selection process, implantation, and monitoring of individuals with such devices. This article discusses in detail various imaging techniques and key clinical points relating to several cardiac devices used in the treatment of patients with heart failure.

Introduction: Embolic infarct pattern on Neuroimaging as a marker for positive cardioembolism results in the work-up for Embolic Source of Undetermined Etiology (ESUS) in acute ischemic stroke (AIS) is unclear. Methods: Among 1625 acute ischemic stroke (AIS) hospitalized at our academic stroke program from July 2017 to April 2019, 350 (21.5%) had complete ESUS work-up performed (defined as including TEE and cardiac monitoring). Data was abstracted on demographics, medical history, initial National Institutes of Health Stroke Scale (NIHSS), systolic blood pressure (SBP), troponin level, neuroimaging findings, and cardiac test results. Positive ESUS work-up for cardioembolism was defined as results that prompted management change. Embolic infarct pattern was defined as infarct confirmed on neuroimaging to affect 2 or more vessel territories. Results: Among 350 with complete ESUS work-up performed, the mean age was 59.0 (range, 23 to 88) and 170 (48.6%) were female. The mean initial NIHSS was 5.4 (range, 0 to 32). Neuroimaging infarct pattern suggested embolic pattern in 75 (21.4%), single vessel pattern in 274 (78.3%), and not visible in 1 (0.3%). Among 274 with single vessel infarct pattern on neuroimaging, affected territory was MCA in 184, Vertebrobasilar in 46, PCA in 34, and ACA in 10. Cardioembolism source was identified in 96 (27.4%) of patients with completed ESUS work-up (7.1% had positive findings on TEE and 20.3% had new-atrial fibrillation diagnosed on cardiac monitoring). Compared to patients with single territory infarct pattern, patients with embolic pattern were more likely to have a history of diabetes mellitus (44.0% vs 31.3%, p 0.0392), higher SBP (159.0 vs 147.9mm Hg, p 0.002) and higher troponin (0.87 vs 0.07 ng/mL, p 0.0124), but there was no significant difference based upon age, sex, history of hypertension, initial NIHSS, HgbA1c, LDL, or rate of positive ESUS work up for cardioembolism (22.7% vs 28.5%, p 0.0088). Conclusion: Among AIS patients with complete ESUS work-up, the most common neuroimaging pattern was single territory MCA infarct (52.6%) followed by embolic infarct pattern (21.4%). Embolic pattern did not increase the positive yield of ESUS work-up for cardioembolism.

Background and aim Exposure to workplace radiation among cardiac sonographers has been felt to be low, and patient-related sources have been considered negligible. Sonographers may be exposed to radiation from patient emitted sources as well as external sources in interventional laboratories. This study quantified radiation exposure to cardiac sonographers. Methods Cardiac sonographers, vascular imaging technologists, exercise physiologists, noninvasive nursing staff, and CT/MRI technologists were provided body dosimeter badges. Sonographers were provided dosimeter rings for their scanning hands. Radiation exposure was quantified from the dosimeter data, reported in millirems (mrem) for deep, eye, and shallow exposure, as well as shallow exposure data from the rings. Data were prospectively collected for 63 employees over a 12-month period and retrospectively analyzed. Results The mean annual deep body exposure in sonographers was 8.2 mrem/year, shallow exposure 9.8 mrem/year, eye exposure 8.5 mrem/year, and ring exposure 207 mrem/year. There was a significant difference between body and ring exposure (P = .0002). When comparing exposure data between the vascular imaging technologists, CT/MRI technologists, noninvasive nursing staff, and the cardiac sonographers, there were no statistical differences (P > .23). Exercise physiologists had significantly higher exposure compared to sonographers (P Conclusion This single-center experience demonstrates that, while exposure is low, cardiac sonographers are exposed to workplace radiation, most likely from patient emitted radiation. The finding that radiation exposure from rings exceeded body exposure supports this conclusion. Continued education and assessment of work flow practices should be employed to minimize staff radiation exposure.

Treatment of patients with heart failure with reduced ejection fraction has evolved. Recently, a fully implantable remote hemodynamic monitoring sensor in the pulmonary artery was approved in the treatment of patients at risk of heart failure readmissions. Several novel devices designed to offload the left atrium by creating a small interatrial shunt are being investigated. Cardiac imaging plays a vital role in the selection process, implantation, and monitoring of individuals with such devices. This article discusses in detail various imaging techniques and key clinical points relating to several cardiac devices used in the treatment of patients with heart failure.

Implantable loop recorders (ILR) are frequently placed after embolic stroke of undetermined source (ESUS) to monitor for occult atrial fibrillation. High false alerts from ILR have been described in routine monitoring practice. We sought to determine the incidence, timing, cause, and frequency of

In patients undergoing transcatheter aortic valve replacement (TAVR), prosthesis gradients are employed for surveillance of valve function and durability. The reliability of these gradients is important as they often drive clinical decision making. Although theoretical limitations of Doppler and

Preview Echocardiography is invaluable in assessing patients with known or suspected cardiac disorders. However, there are often impediments to adequate imaging using the standard transthoracic route (eg, mechanical ventilation, bandages). Transesophageal imaging overcomes many of these technical limitations and, as one researcher notes, provides a "new window to the heart." Drs Peterson and Orsinelli review common clinical applications of the procedure and adjunctive uses.

The prediction of cancer therapeutics-related cardiac dysfunction (CTRCD) is an essential aspect of care for individuals who receive potentially cardiotoxic oncologic treatments. Certain clinical risk factors have been described for incident CTRCD, and measurement of left ventricular (LV) longitudinal strain by speckle tracking 2-dimensional echocardiography (2DE) is the best-validated myocardial mechanical imaging assessment to detect subtle changes in LV function during cancer treatment. However, the direct integration of clinical and imaging risk factors to predict CTRCD has not yet been extensively examined. This was a retrospective study of 183 women with breast cancer aged 50.9 ± 10.8 years who received treatment with anthracyclines (doxorubicin dose of 422 ± 69 mg/m2, with 41.2% of subjects also receiving trastuzumab) and underwent 2DE at clinically determined intervals. CTRCD was diagnosed when LV ejection fraction dropped ≥10% to a subnormal (

Platypnea orthodeoxia syndrome (POS) describes a rare condition of dyspnea and hypoxemia induced by upright posture that resolves when supine. Two conditions must coexist: an interatrial communication and a functional component that redirects shunt flow in the upright position. A 65 year old lady

Background Cardiac resynchronization therapy (CRT) improves echocardiographic measures of ventricular structure and function in the failing heart. To determine whether or not these changes are representative of true biologic reverse ventricular remodeling or simply an artifact of an improved contraction pattern, we evaluated changes in myocardial gene expression typical of reverse remodeling before and after chronic CRT. Methods and Results Optimally medically treated patients with nonischemic heart failure meeting standard clinical criteria for CRT were enrolled. Before implantation of a CRT device, baseline echocardiogram and endomyocardial biopsies were obtained. These studies were repeated after 6 months of CRT. Using quantitative reverse-transcriptase polymerase chain reaction, the amount of messenger RNA for selected genes regulating contractile function (sarcoplasmic reticulum Ca 2+ ATPase, α- and β-myosin heavy chain [MHC] isoforms, phospholamban [PLB]), and pathologic hypertrophy (β-MHC and atrial natriuretic peptide [ANP]) was determined from biopsy samples. Changes in gene expression (baseline to 6 months) were determined and correlated to changes in echocardiographic remodeling parameters. Ten patients were enrolled in the study, with 7 completing both baseline and follow-up biopsies and echocardiograms. On average, a significant increase was observed in α-MHC and PLB gene expression from baseline to 6 months ( P = .016 for both). β-MHC levels tended to decrease with CRT ( P = .078). Increased α-MHC levels correlated best with decreases in left ventricular end-diastolic dimension ( P = .073, r = –0.71) and reductions in mitral regurgitation. No significant correlation between ejection fraction and gene expression was found. Conclusions These changes in myocardial gene expression support the occurrence of reverse remodeling during chronic CRT. The changes are similar to those reported previously with β-blockade, but were seen on top of standard drug therapies for heart failure.

Aneurysms of the coronary arteries are rare and are usually associated with atherosclerosis in adults. Mycotic coronary artery aneurysms are exceedingly uncommon and are typically associated with systemic bacteremia, endocarditis, or septic emboli. Literature and data describing the management of mycotic coronary artery aneurysms are limited. This case describes the successful diagnosis of a large right coronary artery aneurysm by transesophageal echocardiogram as well as the successful management of the aneurysm.

Extracorporeal support, in the form of cardiopulmonary bypass, is used frequently in the operating room for physiologic support during cardiac surgery. However, in patients with severe respiratory and/or cardiac failure, such support may be required for prolonged periods of time in the intensive care unit setting. Typically, extracorporeal membrane oxygenation (ECMO) is applied in one of two configurations. Foracute respiratory failure, avenovenous configuration is used in which deoxygenated venous blood is drained from the body, oxygenated,cleared ofcarbondioxide,andpumpedbackintothevenous system near the right atrium, at which time it enters the pulmonary and then systemic circulations. Although much more complex, a venoarterial configuration can be used for refractory cardiac failure, often with associated respiratory failure; this approach also involves drainage of blood from the venous circulation, which is then oxygenated, cleared of carbon dioxide, and pumped back into the arterial system, either through a femoral artery (peripheral) or directly into the ascending aorta (central). Whereas venovenous ECMO requires intact cardiac function, venoarterial ECMO can unload both the left and right heart and allow for rest and recovery—in theory. 1

The conventional treatment strategy for patients with atrial fibrillation who are to undergo electrical cardioversion is to prescribe warfarin for anticoagulation for three weeks before cardioversion. It has been proposed that if transesophageal echocardiography reveals no atrial thrombus, cardioversion may be performed safely after only a short period of anticoagulant therapy.In a multicenter, randomized, prospective clinical trial, we enrolled 1222 patients with atrial fibrillation of more than two days' duration and assigned them to either treatment guided by the findings on transesophageal echocardiography or conventional treatment. The composite primary end point was cerebrovascular accident, transient ischemic attack, and peripheral embolism within eight weeks. Secondary end points were functional status, successful restoration and maintenance of sinus rhythm, hemorrhage, and death.There was no significant difference between the two treatment groups in the rate of embolic events (five embolic events among 619 patients in the transesophageal-echocardiography group [0.8 percent]) vs. three among 603 patients in the conventional-treatment group [0.5 percent], P=0.50). However, the rate of hemorrhagic events was significantly lower in the transesophageal-echocardiography group (18 events [2.9 percent] vs. 33 events [5.5 percent], P=0.03). Patients in the transesophageal-echocardiography group also had a shorter time to cardioversion (mean [+/-SD], 3.0+/-5.6 vs. 30.6+/-10.6 days, P0.001) and a greater rate of successful restoration of sinus rhythm (440 patients [71.1 percent] vs. 393 patients [65.2 percent], P=0.03). At eight weeks, there were no significant differences between the two groups in the rates of death or maintenance of sinus rhythm or in functional status.The use of transesophageal echocardiography to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned.

Choice of the best surgical option for aortic stenosis (AS) must be individualized and requires discussion among patient, cardiologist, and surgeon to weigh the risks and benefits of different options. Mechanical valves have been preferred for young patients, for those with a life expectancy of more than 10 to 15 years, or for those who require anticoagulation. Bioprosthetic valves have been preferred for elderly patients, for patients with limited life expectancy, or for patients who are unable to be anticoagulated. Newer tissue valves (eg, the stentless porcine aortic bioprosthesis and homografts) as well as newer techniques (eg, the Ross procedure) have increased the number of available options and the complexity of the decision-making process.

Pharmacologic stress testing has emerged as an important diagnostic tool in the evaluation and management of patients with known or suspected coronary artery disease (CAD) who are unable to adequately perform physical exercise. In addition, pharmacologic stress testing has become an important adjunct in the assessment of selected patients prior to noncardiac surgery and in the evaluation of myocardial viability, hibernation, and valvular heart disease. Unlike exercise stress testing utilizing treadmill or bicycle stress, in which cardiac imaging is not always a necessary adjunct to the stress ECG, the use of a pharmacologic agent to stress the heart usually requires the use of some form of cardiac imaging to detect evidence of myocardial ischemia. Pharmacologic stress testing with vasodilators (dipyridamole and more recently adenosine) has been used extensively in conjunction with nuclear perfusion imaging. 64 More recently, pharmacologic stress echocardiography has become an accepted alternative to exercise testing and to pharmacologic stress testing with nuclear imaging. Many pharmacologic agents have been used for stress testing. Dipyridamole and adenosine are commonly used in Europe in combination with echocardiographic imaging. In the United States, dobutamine is the pharmacologic agent of choice for use with echocardiography. More recently, arbutamine (a synthetic catecholamine developed specifically as a pharmacologic stress agent) has been evaluated in combination with either nuclear perfusion or echocardiographic imaging and has received Food and Drug Administration approval as a pharmacologic stress agent.

Backround : Transesophageal echocardiography (TEE) is a useful procedure to evaluate selected stroke patients for cardiac sources of embolism. To date, noninfective valvular vegetations have not been described in large studies using transesophageal echocardiography to detect cardiac sources of embolism. We sought to investigate the frequency of noninfective valvular vegetations in patients with unexplained stroke referred for TEE and to determine the relationship of these vegetations to unrecognized thrombophilic disorders. Methods : We evaluated 641 consecutive patients referred for TEE as a result of unexplained stroke or transient ischemic attack for the presence of valvular vegetations. Of those with vegetations identified, serial blood cultures were obtained to evaluate for an infectious etiology. Patients also had serum testing for thrombophilic disorders and selected patients underwent cerebral angiography. Results : Thirteen patients (2%) who underwent TEE evaluation for unexplained stroke or transient ischemic attack were found to have noninfective valvular vegetations, all involving the mitral valve; none were identified by transthoracic echocardiography. Antiphospholipid antibodies were identified in 8 of these 13 patients (62%) and a protein C deficiency in 1 patient (8%). Conclusions : Noninfective valvular vegetations are a potential cardiac source of embolism in patients with unexplained stroke that can be better identified using transesophageal echocardiography. A large percentage of these individuals have a previously unrecognized thrombophilic disorder.

Fistulas between the aorta and left atrium, invariably a complication of aortic valvular endocarditis, are rare and infrequently diagnosed premortem. We describe a patient who presented with this entity and review the reports of five other patients for whom a diagnosis was made premortem. A number of causative organisms have been identified. The clinical course is characteristically one of rapidly progressive heart failure. Notably, only half of these fistulas were detected by transthoracic echocardiography, whereas all were identified by transesophageal echocardiography when utilized. Once the diagnosis is made, prompt surgical repair is required to avert the high mortality from rapidly developing refractory congestive heart failure.

The effects of hypertension on the arterial vasculature were examined in a study group of 20 patients with newly diagnosed essential hypertension, 18 patients with chronic essential hypertension, and 32 control subjects with normal blood pressure. Left ventricular mass was determined echocardiographically. Carotid artery intimal-medial thickness was measured by means of B-mode ultrasound imaging, and carotid arterial waveforms were obtained by applanation tonometry. Compared with that in control subjects, carotid intimal-medial thickness was increased in patients with chronic hypertension (0.74 +/- 0.17 mm vs 0.61 +/- 0.15 mm in control subjects; p < 0.01) and in patients with newly diagnosed hypertension (0.66 +/- 0.12 mm vs 0.61 +/- 0.15 mm in control subjects; p < 0.05). Left ventricular mass was also higher in patients with chronic hypertension than in control subjects but was very similar between control subjects and those with newly diagnosed hypertension. Both the group with early hypertension and the group with chronic hypertension had an increased incidence of early waveform reflection evident on carotid arterial waveform examination. By multiple regression analysis, independent predictors of increased carotid intimal-medial thickness were age, systolic arterial pressure, and Murgo class of arterial waveform. Conduit arterial wall thickening precedes left ventricular remodeling in essential hypertension and is significantly related to the degree of pressure elevation and the arterial waveform contour.

Background and Purpose Filamentous strands attached to the mitral valve are a recently described finding in occasional patients undergoing transesophageal echocardiography (TEE), but the frequency and clinical significance of these strands remain poorly defined. The purpose of the present study was to review the prevalence of mitral valve strands in patients undergoing TEE examination and to explore the relation of these strands to cardioembolic cerebral ischemia. Methods All patients with native mitral valves referred for clinically indicated TEE over a 2-year period at our institution were evaluated for the presence of mitral valve strands (defined as highly mobile filamentous masses Results Of 968 study patients, mitral valve strands were identified in 22 individuals (2.3%). Mitral valve strands were significantly more common in patients referred for TEE as a result of a recent ischemic cerebrovascular event compared with patients referred for other study indications (6.3% versus 0.3%, respectively; P Conclusions Filamentous strands attached to the mitral valve appear to represent another risk factor for embolic cerebral ischemia, particularly in patients ≤50 years of age.

Atrial fibrillation (AF) is the most commonly encountered cardiac rhythm disorder and is strongly associated with stroke. The risk of stroke and the benefit of anticoagulant therapy in patients with AF associated with mitral stenosis has been well accepted. Until recently the risk of stroke and the role of anticoagulant therapy in patients with nonrheumatic AF was unclear. Over the past decade studies have shown an approximate fivefold increase in the risk of stroke in patients with nonrheumatic AF. The results of large clinical trials have shown a benefit of treatment with anticoagulants and, to a lesser extent, aspirin for both the primary and secondary prevention of thromboembolic complications. Other than patients with a low risk of thromboembolic complications (primarily young patients without clinical risk factors), current guidelines recommend anticoagulation of most patients with AF. The studies that form the basis for these recommendations and the currently published guidelines are reviewed.

Echocardiography is invaluable in assessing patients with known or suspected cardiac disorders. However, there are often impediments to adequate imaging using the standard transthoracic route (eg, mechanical ventilation, bandages). Transesophageal imaging overcomes many of these technical limitations and, as one researcher notes, provides a "new window to the heart." Drs Peterson and Orsinelli review common clinical applications of the procedure and adjunctive uses.

During transesophageal echocardiographic studies in patients with prosthetic cardiac valves, we have noticed the presence of bright, highly mobile echoes (termed microbubbles because of their similarity to saline contrast bubbles) that move rapidly away from the valve. These echoes are distinct from spontaneous echo contrast. The purpose of this study was to determine the frequency with which microbubbles are detected in association with prosthetic valves. No microbubbles were detected in association with bioprosthetic valves. Thus analysis was limited to 198 studies performed in 138 patients with left-sided mechanical valves. Microbubbles were detected in 69 (35%) studies. No differences were found between studies with and without microbubbles with regard to patient characteristics or the indication for the study. Among the 173 individual valves studied, microbubbles were more frequently detected in association with mitral valves (34 of 82, 41%) versus aortic valves (14 of 91, 15%; p 0.0001). Microbubbles were more frequently detected with disc-type mitral valves (30 of 42, 17%) in comparison to Starr-Edwards mitral valves (4 of 39, 10%; p 0.0001). Microbubbles were more often detected with abnormal valves (28 of 76, 37%) than normal valves (20 of 97, 21%), p 0.02. We conclude that bright, highly mobile echoes (microbubbles) distinct from spontaneous echo contrast are frequently detected during transesophageal echocardiography in association with mechanical prosthetic valves. Although the cause and clinical significance of these microbubbles are unknown, it is important to distinguish these echoes from valvular masses such as thrombus or vegetations.

Background Cardioversion (CV) and radiofrequency catheter ablation (RFA) are often used to restore sinus rhythm in patients with atrial fibrillation (AF). These procedures are associated with a risk for stroke. The use of transesophageal echocardiography (TEE) to guide the management of AF is a validated strategy for patients in whom CV is planned, as well patients before RFA. For patients in whom the initial procedure fails, repeat TEE is often performed before repeat CV or RFA. The aim of this study was to test the hypothesis that patients with initial negative results on TEE would be unlikely to have thrombi detected on subsequent TEE and thus may avoid repeat procedures. Methods A total of 2,999 patients with AF were identified via retrospective review who had undergone TEE before CV or RFA, and 418 of these individuals underwent repeat TEE. After excluding patients who underwent repeat TEE >365 days from the initial study ( n = 135) and those with thrombi on initial TEE ( n = 20), 263 patients who had underwent two or more examinations were identified and analyzed. Results Of 263 eligible patients, two (0.8%; 95% confidence interval, 0.21–2.7%) had thrombi on subsequent TEE. Conclusions Fewer than 1% of patients with AF with negative results on baseline TEE had thrombi detected on repeat TEE before subsequent CV or RFA. Thus, it may be possible to selectively screen patients to identify those at low risk for developing thrombi subsequent to negative results on initial TEE, especially if patients are in sinus rhythm. These results suggest the need for a prospective trial to definitively answer the question regarding repeat TEE in low-risk patients.

Within a 3-month period, a 71-year-old man went from an asymptomatic, active existence to intractable heart failure and death. Widespread amyloid deposition was noted on the histologic examination of endomyocardial biopsy samples. The historical and laboratory features of this patient's rapidly devastating clinical course form the basis of this report.

Transesophageal echocardiography (TEE) has become an important imaging modality for evaluating patients with prosthetic valves, as well as patients who have suffered a suspected cardioembolic event. Many findings of uncertain clinical significance have been noted in both patient populations. Valve strands, seen on both prosthetic and native valves, are one of these entities. Previous investigators have described strand like structures detected by TEE on both native and prosthetic valves as early as 1991. Strands appear as highly mobile, thin filamentous structures attached to native valve leaflets as well as prosthetic valves. On prosthetic valves, they appear different from sutures, microbubbles, vegetations, or thrombi. They are typically seen attached to the left atrial side of mitral prostheses and the left ventricular side of aortic valves. The exact nature and etiology of the strands as well as their clinical significance and potential for cardiac embolization is not certain, though multiple reports in the literature do support an association between valve strands and embolic events. The appropriate management of such patients remains uncertain.

A 43-year-old man was evaluated by his primary care physician for atypical chest pain and worsening dyspnea on exertion. A transthoracic echocardiogram was performed at our institution to evaluate for an underlying cardiomyopathy. Much to the surprise of the sonographer and the interpreting physician, the only abnormality discovered was a quadricusp aortic valve (QAV). The valve had 4 leaflets or cusps instead of the normal 3-leaflet configuration and had associated mild to moderate aortic regurgitation (Figures 1 to 3; and Cine 1 and 2). QAV is a rare congenital valve disease first described in 1862 with an incidence of 0.013%. QAV can occur in isolation but it is also associated with other cardiac defects including coronary artery anomalies, ventricular septal defect, patent ductus arteriosus, ruptured sinus of Valsalva, or complete heart block. The most common manifestation is valvular insufficiency that may progress throughout life. It can be speculated that abnormal valve motion and stress distribution may lead to early fibrotic changes and, therefore, to later valve dysfunction. Although the findings on the echocardiogram were not believed to account for his symptoms of atypical chest pain and dyspnea, the patient in this case was, in a way, lucky. The incidental QAV will need to be periodically

A mass lesion occupying the left ventricle was noted on a screening CT scan in a 42-year-old man with a history of malignant melanoma. Subsequent echocardiography and cardiac MR imaging provided further hemodynamic and anatomic characterization of the lesion. These studies were also essential in guiding the proper surgical approach to allow extensive resection of the large mass without disrupting cardiac structures and function. The unique clinical aspects of this case are the unusual location for a lone cardiac metastasis of melanoma and the asymptomatic presentation despite the large size of the tumor and its apparent obstruction of ventricular outflow. The clinical and imaging features of this patient’s threatening cardiac lesion are presented.

Background Electrical cardioversion in patients with atrial fibrillation (AF) is associated with an increased risk of stroke. We compared a transesophageal echocardiography (TEE)–guided strategy with a conventional strategy in patients with AF >2 days' duration undergoing electrical cardioversion over a 6-month follow-up. Methods The ACUTE study was a multicenter, randomized, clinical trial, with 1222 patients. Six-month follow-up was available in 1034 patients (85%), 525 in the TEE group and 509 in the conventional group. The primary composite end points were cerebrovascular accident, transient ischemic attack, and peripheral embolism at 6 months, which was a prespecified time point. Secondary end points were hemorrhage, mortality, and sinus rhythm. Results At 6 months, there was no difference in composite embolic events between the TEE group and the conventional group (10 [2%] vs 4 [0.8%]; risk ratio (RR) 2.47, 95% CI 0.78-7.88; P = .11). However, the hemorrhagic rate was significantly lower in the TEE group (23 [4.4%] vs 38 [7.5%]; RR 0.58, 96% CI 0.35-0.97; P = .04). There was no difference between the 2 treatment groups in all-cause mortality (21 [4%] vs 14 [2.8%]; RR 1.48, 95% CI 0.76-2.92; P = .25) and in the occurrence of normal sinus rhythm between the 2 groups (305 [62.2%] vs 280 [58.1%]; P = .51). Sinus rhythm at 6 months was more common in the TEE-guided group, in those patients who had direct current cardioversion (238 [62.5%] vs 151 [53.9%]; P = .03). Conclusion The TEE-guided strategy may be considered a clinically effective alternative to a conventional anticoagulation strategy for patients with AF of >2 days' duration undergoing electrical cardioversion over a 6-month period.

Unstable heart failure represents the clinical state of progressively worsening or decompensated heart failure, which, if not improved within a reasonable time (usually minutes to hours), often evolves into markedly symptomatic heart failure, cardiovascular collapse, and shock or death. The clinical settings include, among others, the patient who arrives in the emergency room in acute pulmonary edema, the patient with postinfarction cardiogenic shock, the patient who cannot be weaned from cardiopulmonary bypass after cardiac surgery, or the chronic heart failure patient who is experiencing a rather abrupt worsening of symptoms. Most patients with unstable heart failure must be approached with a certain sense of urgency.

We report the case of a 30-year-old man with acute pericarditis in whom effusive-constrictive physiology developed rapidly in less than 2 weeks. Serial echocardiography demonstrated a dramatic change in the appearance of the pericardial effusion and the pericardial space. The patient underwent pericardiectomy with symptom relief. The findings at operation included a markedly thickened and inflamed pericardium. The case highlights the role of echocardiography in the evaluation of patients with pericardial disease and the echocardiographic features that prompted early surgical intervention.

Elective cardioversion of atrial fibrillation may be complicated by systemic thromboembolic events, presumably caused by embolization of preexisting left atrial (LA) thrombi. 1–4 Transesophageal echocardiography (TEE) has proven to be a very sensitive means of detecting LA thrombi 5 and may therefore provide a means of screening patients before cardioversion. We report our initial experience with TEE as a screening test before elective cardioversion in patients who were referred for the purpose of excluding the presence of LA thrombus before cardioversion.

Pulmonary autograft aortic valve replacement (Ross procedure) is increasing in popularity, particularly in children and young adults. We performed a controlled study of pediatric and adult Ross procedure patients to evaluate postoperative exercise valvular hemodynamics and cardiac rhythm. Thirty-one patients and 24 controls underwent stress echocardiography. Doppler and 2-dimensional echocardiography assessed valvular hemodynamics and right and left ventricular size at baseline and after exercise. Electrocardiography monitored cardiac rhythm. Patients and controls had neoaortic and neopulmonic valve insufficiency ranging from none to moderate that improved or did not change with exercise. Baseline and exercise mean peak transaortic gradients were not significantly different between patients (baseline 6.3 +/- 3.8 mm Hg, exercise 12.8 +/- 7.3 mm Hg) and controls (baseline 6.7 +/- 2.5 mm Hg, exercise 14.3 +/- 5.2 mm Hg). However, baseline and exercise mean peak transpulmonic gradients were significantly different between patients (baseline 20.7 +/- 9.6 mm Hg, exercise 45.2 +/- 23.5 mm Hg) and controls (baseline 3.7 +/- 1.3 mm Hg, exercise 10.6 +/- 3.7 mm Hg). Significant exercise-induced arrhythmias occurred in 8 patients (26%) and no controls. Occurrence of arrhythmias correlated with an older age at surgery and age at study. After the Ross procedure, patients have valve competence and transaortic gradients similar to controls at baseline and with exercise. However, patients have significantly increased baseline and exercise transpulmonic gradients compared with controls. Furthermore, exercise-induced arrhythmias occurred frequently in our patient group and were associated with an older age at surgery and age at study.

Hemangioma of the heart is a rare lesion, representing 5% to 10% of benign cardiac tumors. Hemangioma of the mitral valve has been reported previously in one autopsy case report. We describe the excision and repair of a hemangioma of the mitral valve in a 33-year-old African-American woman.

The use of assist devices for ventricular support after myocardial infarction with cardiogenic shock has become common practice. Thrombosis, bleeding, and infection are common complications. However, native valve thrombosis is a rare complication. We present a case of aortic valve thrombosis after implantation of a left ventricular assist device (LVAD) treated with thrombus removal at time of device exchange.

Dobutamine stress echocardiography is a safe method for the evaluation of coronary artery disease, myocardial function, and viability. The potential for cardiac rupture exists. Although clinical and electrocardiographic criteria may be helpful in identifying those patients at risk for cardiac rupture, the criteria are neither sensitive nor specific enough to exclude patients or make recommendations regarding which patients should undergo dobutamine stress echocardiography in the post-infarction period. Physicians must be aware of the possibility and be prepared to treat cardiac rupture when performing dobutamine stress echocardiography.

Although it is well recognized that dobutamine is a powerful positive inotropic agent mediating increased myocardial contractility through direct β-adrenergic stimulation, the mechanism of its overall circulatory effects appears more complex than that which may be ascribed solely to this direct action on the myocardium. Previous investigations have implied that reflex alterations in autonomic balance may contribute significantly to the response to this agent, but direct evidence describing such a response has not been reported. The objective of this investigation was to assess changes in autonomic tone induced by dobutamine in the presence and absence of ischemia through the measurement of heart rate variability in patients undergoing dobutamine stress echocardiography. Of 25 consecutive patients undergoing dobutamine stress echocardiography, 16 were found to have unequivocal evidence for or against the presence of ischemia during dobutamine infusion. Heart rate data from these 16 patients were submitted for spectral analysis of heart rate variability and quantification of parasympathetically governed high-frequency heart rate variability and sympathetically influenced low-frequency heart rate variability. Of the 16 patients nine were not found to have evidence for ischemia (group 1), and seven were found to have echocardiographic findings consistent with dobutamine-induced ischemia (group 2). The two groups significantly differed (p = 0.04) in the change in parasympathetic tone associated with dobutamine with a significant (p = 0.04) increase in parasympathetic tone in group 1 and a numeric decrease in group 2. A significant (p = 0.04) decrease in sympathetic tone was noted in group 1 as reflected by low-frequency heart rate variability with a numeric increase in this measure in group 2. Patients in group 1 had significantly (p = 0.0007) increased ejection fraction and were found to have a significantly (p < 0.05) lower peak heart rate with dobutamine administration as compared with patients in group 2, who were not found to have any change in ejection fraction and who had a greater increase in peak heart rate over baseline. These results indicate that in the absence of myocardial ischemia dobutamine administration is associated with a significant increase in parasympathetic tone and reduction of sympathetic drive, which is not seen in patients in whom ischemia develops with dobutamine stimulation. The autonomic changes in the absence of ischemia may represent a reflex response to myocardial mechanoreceptor or arterial baroreceptor stimulation, which does not occur in the presence of ischemia. Therefore these data provide evidence that alterations in autonomic balance contribute significantly to the circulatory response to dobutamine and suggest that such reflex mechanisms contribute to the response to positive inotropic agents in general.

Two patients with a malignancy involving the lungs and spontaneous systemic embolization in whom transesophageal echocardiography detected masses consistent with tumor invading the pulmonary veins are reported. In the first patient, tumor embolization resulted in acute aortic obstruction. Transesophageal echocardiography revealed tumor present in the pulmonary veins that extended into the left atrium. This was confirmed by magnetic resonance imaging. The second patient had a stroke. Transesophageal echocardiography demonstrated a mass in the right pulmonary vein in this patient as well. In patients with pulmonary malignancy who have a systemic embolic event, tumor emboli from the pulmonary vein should be included in the differential diagnosis of possible causes of the event. Transesophageal echocardiography is a valuable tool for diagnosis of tumor involvement of the pulmonary veins in such patients.