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Preoperative assessment of the cardiac patient before noncardiac surgery is common in the clinical practice of the medical consultant, anesthesiologist, and surgeon. Currently, most noncardiac surgical procedures are performed for patients of advanced age, and the number of such surgeries is likely to increase with the aging of the population. These same patients have an increased prevalence of cardiovascular disease, especially ischemic heart disease, which is the primary cause of perioperative morbidity and mortality associated with noncardiac surgery. Since 1996, 3 American College of Cardiology/American Heart Association guideline documents have been published, each reflecting the available literature, with recommendations for the preoperative cardiovascular evaluation and treatment of the patient undergoing noncardiac surgery. Our review describes the 2007 American College of Cardiology/American Heart Association guidelines, the most recent revision, focusing on a newly recommended 5-step algorithmic approach to managing this clinical problem, particularly for the patient with known or suspected coronary heart disease. Continued emphasis should be given to preoperative clinical risk stratification, with noninvasive testing reserved for those patients in whom a substantial change in medical management would be anticipated based on results of testing. Pharmacologic therapy holds more promise than coronary revascularization for the reduction of major adverse perioperative cardiac events that might complicate noncardiac surgery. [ABSTRACT FROM AUTHOR]

Objective: To characterize the prognostic implications of exercise echocardiography in patients who have reduced exercise capacity at the time of testing. Patients and Methods: We examined the outcomes of 941 patients at the Mayo Clinic in Rochester, Minn, between January 1, 1990, and December 31, 1995, who had reduced exercise capacity on exercise echocardiography (women, <5 metabolic equivalents; men, <7 metabolic equivalents) and evaluated the potential association between clinical, electrocardiographic, and echocardiographic variables and outcomes for patients with normal vs abnormal exercise echocardiograms. We used variables of independent prognostic value to estimate cardiac risk. Results: For patients with normal exercise echocardiograms (n=282), the rate of cardiac death or nonfatal myocardial infarction was 09% per person-year of follow-up, and previous coronary revascularization was the only predictor of the time to cardiac event. For patients with abnormal exercise echocardiograms (n=659), the cardiac event rate was 4.4%. Independent predictors of outcome were exercise left ventricular (LV) ejection fraction (risk ratio, 1.44 per 10% decrement; 95% confidence interval, 1.2-1.7; P<.001) and an increase or no change in LV end-systolic size in response to exercise (risk ratio, 2.22; 95% confidence interval, 1.2-4.1; P=.01). Conclusion: Exercise echocardiographic findings have important prognostic implications for patients who have reduced exercise capacity on testing. Echocardiographic descriptors of LV systolic function and dysfunction obtained immediately after exercise can be used to stratify cardiac risk of patients who do not achieve a level of exercise ordinarily considered to be of "diagnostic" value. [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy. It follows an autosomal dominant inheritance pattern in most cases, with incomplete penetrance and heterogeneity. It is familial in 60% of cases and most of these are caused by pathogenic variants in the core sarcomeric genes ( MYH7 , MYBPC3 , TNNT2 , TNNI3 , MYL2 , MYL3 , TPM1 , ACTC1 ). Genetic testing using targeted disease-specific panels that utilize next-generation sequencing (NGS) and include sarcomeric genes with the strongest evidence of association and syndrome-associated genes is highly recommended for every HCM patient to confirm the diagnosis, identify the molecular etiology, and guide screening and management. The yield of genetic testing for a disease-causing variant is 30% in sporadic cases and up to 60% in familial cases and in younger patients with typical asymmetrical septal hypertrophy. Genetic testing remains challenging in the interpretation of results and classification of variants. Therefore, in 2015 the American College of Medical Genetics and Genomics (ACMG) established guidelines to classify and interpret the variants with an emphasis on the necessity of periodic reassessment of variant classification as genetic knowledge rapidly expands. The current guidelines recommend focused cascade genetic testing regardless of age in phenotype-negative first-degree relatives if a variant with decisive evidence of pathogenicity has been identified in the proband. Genetic test results in family members guide longitudinal clinical surveillance. At present, there is emerging evidence for genetic test application in risk stratification and management but its implementation into clinical practice needs further study. Promising fields such as gene therapy and implementation of artificial intelligence in the diagnosis of HCM are emerging and paving the way for more effective screening and management, but many challenges and obstacles need to be overcome before establishing the practical implications of these new methods.

Objective: To study the usefulness of a novel echocardiographic marker, augmented mean arterial pressure (AugMAP = [(mean aortic valve gradient + systolic blood pressure) + (2 × diastolic blood pressure)] / 3), in identifying high-risk patients with moderate aortic stenosis (AS)., Patients and Methods: Adults with moderate AS (aortic valve area, 1.0-1.5 cm 2 ) at Mayo Clinic sites from January 1, 2010, through December 31, 2020, were identified. Baseline demographic, echocardiographic, and all-cause mortality data were retrieved. Patients were grouped into higher and lower AugMAP groups using a cutoff value of 80 mm Hg for analysis. Kaplan-Meier and Cox regression models were used to assess the performance of AugMAP., Results: A total of 4563 patients with moderate AS were included (mean ± SD age, 73.7±12.5 years; 60.5% men). Median follow-up was 2.5 years; 36.0% of patients died. The mean ± SD left ventricular ejection fraction (LVEF) was 60.1%±11.4%, and the mean ± SD AugMAP was 99.1±13.1 mm Hg. Patients in the lower AugMAP group, with either preserved or reduced LVEF, had significantly worse survival performance (all P<.001). Multivariate Cox regression showed that AugMAP (hazard ratio, 0.962; 95% CI, 0.942 to 0.981 per 5-mm Hg increase; P<.001) and AugMAP less than 80 mm Hg (hazard ratio, 1.477; 95% CI, 1.241 to 1.756; P<.001) were independently associated with all-cause mortality., Conclusion: AugMAP is a simple and effective echocardiographic marker to identify high-risk patients with moderate AS independent of LVEF. It can potentially be used in the candidate selection process if moderate AS becomes indicated for aortic valve intervention in the future., (Copyright © 2023 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Post-transcatheter aortic valve replacement (TAVR) patient outcome is an important research topic. To accurately assess post-TAVR mortality, we examined a family of new echo parameters (augmented systolic blood pressure (AugSBP) and arterial mean pressure (AugMAP)) derived from blood pressure and aortic valve gradients., Methods: Patients in the Mayo Clinic National Cardiovascular Diseases Registry-TAVR database who underwent TAVR between 1 January 2012 and 30 June 2017 were identified to retrieve baseline clinical, echocardiographic and mortality data. AugSBP, AugMAP and valvulo-arterial impedance (Zva) (Zva) were evaluated using Cox regression. Receiver operating characteristic curve analysis and the c-index were used to assess the model performance against the Society of Thoracic Surgeons (STS) risk score., Results: The final cohort contained 974 patients with a mean age of 81.4 ± 8.3 years old, and 56.6% were male. The mean STS risk score was 8.2 ± 5.2. The median follow-up duration was 354 days, and the one-year all-cause mortality rate was 14.2%. Both univariate and multivariate Cox regression showed that AugSBP and AugMAP parameters were independent predictors for intermediate-term post-TAVR mortality (all p < 0.0001). AugMAP1 < 102.5 mmHg was associated with a 3-fold-increased risk of all-cause mortality 1-year post-TAVR (hazard ratio 3.0, 95%confidence interval 2.0-4.5, p < 0.0001). A univariate model of AugMAP1 surpassed the STS score model in predicting intermediate-term post-TAVR mortality (area under the curve: 0.700 vs. 0.587, p = 0.005; c-index: 0.681 vs. 0.585, p = 0.001)., Conclusions: Augmented mean arterial pressure provides clinicians with a simple but effective approach to quickly identify patients at risk and potentially improve post-TAVR prognosis.

Prosthetic valves are increasingly encountered in clinical practice. A grasp of the intricacies of the assessment and management of prosthetic valves is thus a crucial skillset for the practicing cardiologist. Echocardiography is the imaging modality of choice for the anatomic and functional evaluation of prosthetic valve. This document reviews the general features of prosthetic valves, echocardiographic identification of normally functioning and dysfunctional prosthetic valves as well as echocardiographic diagnosis of specific prosthetic valvular abnormalities., Competing Interests: The authors declare no conflict of interest., (Copyright: © 2022 The Author(s). Published by IMR Press.)

Background: Although direct oral anticoagulants (DOACs) have been shown to be effective at reducing the risk of stroke in patients with atrial fibrillation/flutter (AF), they are sometimes underdosed off-label to mitigate their associated higher bleeding risk. We sought to evaluate frequency and clinical outcomes of inappropriate underdosing of DOACS in patients with AF., Methods: We conducted a study of subjects with AF who had a clinical indication for stroke prophylaxis (with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 47 years, sex category [CHA 2 DS 2 -VASc] of 2 or greater) and were prescribed 1 of the 4 clinically approved DOACs (apixaban, rivaroxaban, dabigatran, or edoxaban). We compared all-cause mortality, composite of stroke and systemic embolism, composite of myocardial infarction (MI), acute coronary syndromes (ACS), and coronary revascularization, and major bleeding between patients appropriately dosed and inappropriately underdosed., Results: A total of 8125 patients met inclusion criteria, with a mean follow up of 2.2 ± 2 years. Of those, 1724 patients (21.2%) were inappropriately dosed. After adjusting for baseline variables, there was no difference in all-cause mortality, risk of stroke or systemic embolism, International Society on Thrombosis and Haemostasis (ISTH) major bleeding, or composite of myocardial infarction, acute coronary syndromes, or coronary revascularization between patients appropriately dosed and inappropriately underdosed. In subgroup analysis, only apixaban demonstrated an increased incidence all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.03-1.49) with inappropriate underdosing. There was no difference in the remaining clinical outcomes noted on subgroup analysis., Conclusion: Underdosing of DOACs did not minimize risk of bleeding, systemic embolization or all-cause mortality in patients with AF. Inappropriate underdosing with apixaban in particular was associated with increased all-cause mortality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Left bundle branch block (LBBB), which is associated with underlying cardiac disease, is believed to play a role in the pathogenesis of cardiomyopathy through delays in interventricular conduction, leading to dyssynchrony. However, this has not been established in previous studies. It is unclear whether LBBB indicates clinically advanced cardiac disease or is an independent factor responsible for increased mortality and the development of heart failure. We investigated the natural history of isolated LBBB without any associated structural heart disease in order to determine its clinical significance., Methods: We performed a retrospective chart review on consecutive patients who fulfilled the 12-lead electrocardiographic (ECG) criteria for complete LBBB and had a normal echocardiogram with no evidence of structural heart disease and left or right ventricular systolic dysfunction within three months of the initial ECG between January 1, 2000 and December 31, 2009. We excluded patients with documented coronary artery disease (CAD) at any time, any structural heart disease, or cardiac devices. We evaluated the primary endpoints of mortality and incidence of cardiomyopathy, as well as any heart failure hospitalizations over a 1- and 10-year period., Results: We identified 2522 eligible patients. The mean follow-up duration was 8.4±3.2 years. The one-year mortality rate was 7.8%, with a 10-year mortality rate of 22.0%. The incidence of cardiomyopathy over one year was 3.2% and over 10 years was 9.1%. There was no significant difference in QRS duration between patients who were alive and those that were deceased at 10 years (141+/-18 vs. 141+/-17 ms; p=0.951) and patients with and without cardiomyopathy at 10 years (142±17 vs. 141±17 ms; p=0.532)., Conclusion: Isolated LBBB occurring without structural heart disease, ventricular dysfunction, or CAD is associated with a low mortality rate and incidence of cardiomyopathy.

Apical hypertrophic cardiomyopathy (HC) has been considered a "benign" form of HC, with limited data on long-term outcome. We compared apical HC patients with a non-HC, age- and gender-matched Minnesota white population to identify outcomes and prognostic factors. Between 1976 and 2006, 193 patients (62% men) with apical HC were seen at our clinic. Their most recent echocardiographic examinations were reviewed. Mean ± SD age at first presentation was 58 ± 17 years. A family history of HC or sudden cardiac death (SCD) was reported by 43 patients (22%); coronary artery disease was known in 22 (11%). An apical pouch was present in 29 patients, including an apical aneurysm in 6 and apical dilatation with hypokinesis in 23. Median follow-up (187 patients [97%]) was 78 months (range, 1-350). Death from all causes occurred in 55 patients (29%; 33 women) at a mean age of 72 years (range, 20-92). During follow-up, more women had heart failure (p = 0.001), atrial fibrillation (p = 0.009), or died (p <0.001) than men. Survival was worse than expected (p = 0.001); the observed versus expected 20-year survival was 47% versus 60%. SCD, resuscitated cardiac arrest, and/or defibrillator discharge was observed in 11 patients (6%) during follow-up. Multivariate predictors of decreased survival were higher age at baseline (p <0.001), female gender (p <0.001), and atrial fibrillation at baseline (p = 0.06). In conclusion, apical HC in this population was associated with increased mortality, especially in women. Because apical HC is less benign than previously suspected, careful longitudinal care is warranted., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Minority children and children from lower income families are more likely to experience the burden of oral disease. Since oral disease reduces quality of life, it is a priority to utilize preventive dental services. The research questions ask if affiliated practice increases utilization of preventive dental services by underserved children from birth to 18 years of age, and what the barriers to receiving preventive dental services are and their level of importance., Methods: A survey was administered to parents/guardians of patients from birth to 18 years of age who received preventive dental services from Catholic Healthcare West East Valley Children's Dental Clinic, an affiliated practice dental clinic in Chandler, Arizona. Thirty-four surveys were completed: 21 completed in English and 13 completed in Spanish. The data was analyzed to provide descriptive statistics and non-parametrically analyzed using the Friedman's, Kendall's W and Wilcoxon Signed Ranks Tests., Results: The cost of preventive dental services is more important to this population than both convenience of appointment time and distance traveled. As the cost increases for preventive dental services, this population will utilize preventive dental services less frequently., Conclusion: The study indicated that the increase of self-reported utilization of preventive dental services by underserved children, ranging in age from birth to 18 years old, in Arizona affiliated practice dental clinics, was primarily impacted by perceived reduced costs of receiving care. Funding efforts, reimbursement mechanisms and legislative policies should support this dental care delivery model to provide care to underserved children, adults and seniors throughout the U.S.

Intraoperative (IO) transesophageal echocardiography (TEE) is widely used for assessing the results of valvular heart disease (VHD) surgery. Epiaortic ultrasonography (EAU) has been recommended for prevention of perioperative strokes. To what extent does high-quality evidence justify the widespread use of these imaging modalities? In March 2009, we searched MEDLINE (PubMed and OVID interfaces) and EMBASE for studies published in English using database-specific controlled vocabulary describing the concepts of IOTEE, cardiac surgery, VHD, and EAU. We found no randomized trials or studies with control groups assessing the impact of IOTEE in VHD surgery. Pooled analysis of 8 observational studies including 15,540 patients showed an average incidence of 11% for prebypass surgical changes and 4% for second pump runs, suggesting that patients undergoing VHD surgery may benefit significantly from IOTEE, particularly from postcardiopulmonary bypass IOTEE in aortic repair and mitral repair and replacement, but less so in isolated aortic replacement. Further available indirect evidence was satisfactory in the test accuracy and surgical quality control aspects, with low complication rates for IOTEE. The data supporting EAU included 12,687 patients in 2 prospective randomized studies and 4 nonrandomized, controlled studies, producing inconsistent outcome-related results. Despite low-quality scientific evidence supporting IOTEE in VHD surgery, we conclude that indirect evidence supporting its use is satisfactory and suggests that IOTEE may offer considerable benefit in valvular repairs and mitral replacements. The value of IOTEE in isolated aortic valve replacement remains less clear. Evidence supporting EAU is scientifically more robust but conflicting. These findings have important clinical policy and research implications.

Background: The aims of this study were to evaluate the feasibility of real-time 3-dimensional (3D) transesophageal echocardiography in the intraoperative assessment of mitral valve (MV) pathology and to compare this novel technique with 2-dimensional (2D) transesophageal echocardiography., Methods: Forty-two consecutive patients undergoing MV repair for mitral regurgitation (MR) were studied prospectively. Intraoperative 2D and 3D transesophageal echocardiographic (TEE) examinations were performed using a recently introduced TEE probe that provides real-time 3D imaging. Expert echocardiographers blinded to 2D TEE findings assessed the etiology of MR on 3D transesophageal echocardiography. Similarly, experts blinded to 3D TEE findings assessed 2D TEE findings. Both were compared with the anatomic findings reported by the surgeon., Results: At the time of surgical inspection, ischemic MR was identified in 12% of patients, complex bileaflet myxomatous disease in 31%, and specific scallop disease in 55%. Three-dimensional TEE image acquisition was performed in a short period of time (60 +/- 18 seconds) and was feasible in all patients, with optimal (36%) or good (33%) imaging quality in the majority of cases. Three-dimensional TEE imaging was superior to 2D TEE imaging in the diagnosis of P1, A2, A3, and bileaflet disease (P < .05)., Conclusions: Real-time 3D transesophageal echocardiography is a feasible method for identifying specific MV pathology in the setting of complex disease and can be expeditiously used in the intraoperative evaluation of patients undergoing MV repair.

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflict of interest that might arise as a result of an industry relationship or personal interest of the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, were asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing committee at each meeting, and updated and reviewed by the writing committee as changes occur. Please see Appendix 1 for author relationships with industry and Appendix 2 for peer reviewer relationships with industry. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. These guideline recommendations reflect a consensus of expert opinion after a thorough review of the available, current scientific evidence and are intended to improve patient care. If these guidelines are used as the basis for regulatory/payer decisions, the ultimate goal is quality of care and serving the patient's best interests. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient.

Obese patients frequently complain of dyspnea. Deconditioning and altered left ventricular (LV) systolic or diastolic function with elevated filling pressures may contribute to dyspnea. This study analyzed 4,281 patients who underwent diagnostic coronary angiography from January 1, 1995, to December 31, 2000. No patients had coronary artery stenoses >50% of the luminal diameter, and all underwent echocardiography within the same 6-year period. The association between body mass index (BMI) and LV structure and systolic and diastolic function was examined. All analyses controlled for age and gender, with the effect size for BMI expressed using a standardized coefficient (SC). A higher BMI was associated with greater LV mass (SC 0.18, p <0.001), wall thickness (SC 0.17, p <0.001), and end-diastolic diameter (SC 0.07, p <0.001). Stroke volume increased with a higher BMI (SC 0.12, p = 0.001), but there was no association between BMI and the ejection fraction (SC 0.003, p = 0.81). Hemodynamic data from invasive studies showed an association between a higher BMI and increased LV end-diastolic pressure (mean 17 mm Hg for BMI <25 kg/m(2) vs 24 mm Hg for BMI >or=40 kg/m(2); SC 0.18, p <0.001), which persisted after controlling for end-diastolic volume (SC 0.22, p <0.001). Obesity was associated with ventricular remodeling, which may normalize wall stress while increasing stroke volume to match metabolic demand. Obesity was not associated with decreased systolic function. However, obesity was associated with increased LV end-diastolic pressure, which suggests an association between obesity and diastolic dysfunction. In conclusion, ventricular remodeling, LV diastolic dysfunction, and elevated filling pressures may contribute to the prevalence of heart failure in obese patients.

Objectives: To evaluate consecutive therapeutic echocardiographically (echo)-guided pericardiocenteses performed at Mayo Clinic, Rochester, Minn, from 1979 to 2000 and to determine whether patient profiles, practice patterns, and outcomes have changed over time., Patients and Methods: Consecutive echo-guided pericardiocenteses performed between February 1, 1979, and January 31, 2000, for treatment of clinically significant pericardial effusions were identified in the Mayo Clinic Echocardiographic-guided Pericardiocentesis Registry. The medical records of these patients were examined, and a follow-up survey was conducted. Clinical profiles, echocardiographic findings, procedural details, and outcomes were determined for 3 periods: February 1, 1979, through January 31, 1986; February 1, 1986, through January 31, 1993; and February 1, 1993, through January 31, 2000., Results: During the 21-year study period, 1127 therapeutic echo-guided pericardiocenteses were performed in 977 patients. The mean +/- SD age at pericardiocentesis increased from 49+/-14 years in period 1 to 57+/-14 years in period 3. In recent years, cardiothoracic surgery replaced malignancy as the leading cause of an effusion requiring pericardiocentesis and together with malignancy and perforation from catheter-based procedures accounted for nearly 70% of all pericardiocenteses performed. The procedural success rate was 97% overall, with a total complication rate of 4.7% (major, 1.2%; minor, 3.5%). These rates did not change significantly over time. The use of a pericardial catheter for extended drainage increased from 23% in period 1 to 75% in period 3 (P<.001), whereas rates of effusion recurrence and pericardial surgery decreased significantly (P<.001)., Conclusions: The profile of patients presenting with clinically significant pericardial effusion has changed over time. Increasing numbers of older patients and those who have undergone cardiothoracic surgery or catheter-based procedures develop effusions that can be rapidly, safely, and effectively managed with echo-guided pericardiocentesis. Extended drainage with use of a pericardial catheter has become standard practice, and concomitantly, recurrence rates and need for surgical management have decreased considerably.

We present the case of a 43-year-old male who was initially evaluated for angina pectoris and dyspnea. His CK, CK-MB, and cTnI were all elevated following a blood transfusion and he underwent coronary arteriography, which demonstrated no luminal obstructions. After several months, he was transferred to Mayo Clinic where diagnoses of fulminant cardiac amyloidosis and systemic multiple myeloma were established. The cTnI remained elevated despite normalization of the CK and CK-MB. Despite aggressive treatment, the patient died. Postmortem analysis demonstrated amyloid cardiac deposition including involvement of the coronary microvasculature. Electron microscopy revealed myocyte compression injury from amyloid infiltration. We believe this is the first report of elevated troponin I in a patient with cardiac amyloidosis. The electron microscopy in our case confirms cardiac damage as the mechanism for cTnI elevation. This observation strengthens our knowledge about the specificity of cTnI for the detection of cardiac injury.

The natural history, prognostic significance, and optimal therapy of asymptomatic thoracic aorta mural thrombi detected incidentally is not well defined in the literature. We report a case of asymptomatic thoracic aorta mural thrombi in a 42-year-old woman with a history of smoking and steroid use that was conservatively managed with anticoagulation and had a favorable outcome.

In this study, we sought to define the impact of intraoperative transesophageal echocardiography (IOTEE) among patients undergoing aortic valve replacement for severe aortic stenosis. We reviewed the clinical data and preoperative, intraoperative, and postoperative echocardiograms of all adults who underwent aortic valve replacement for aortic stenosis and had IOTEE between January 1993 and December 1996. There were 383 patients (223 men, 160 women; mean age, 69 years). Fifty-four (14%) of the 383 patients had mitral valve surgery at the time of aortic valve replacement. In 6 patients, mitral valve surgery was not planned but was added because of findings on IOTEE. In 25 patients, mitral valve surgery was canceled on the basis of the IOTEE. Additional information was found by IOTEE in 25 patients before and after bypass, altering the surgical plan in 18 of these 25 patients. Overall, IOTEE altered the planned operation in 49 (13%) of the 383 patients. These data support the routine use of IOTEE among patients undergoing aortic valve replacement for aortic stenosis.

In 2 patients with severe proximal coronary artery stenosis and normal wall motion in this territory, we observed marked wall motion abnormalities with low and intermediate doses of dobutamine, followed by marked improvement with continued dobutamine infusion. This unusual response suggests ischemic preconditioning and recruitment of coronary collaterals and would be recognized only by monitoring of images obtained at all stages of dobutamine infusion.

Objectives: This study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography., Background: In patients with mitral regurgitation (MR), valve repair is a major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown., Methods: In 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined., Results: Compared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease., Conclusions: Transesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR.

Study Objectives: This study assessed the clinical features, timing of presentation, and echocardiographic characteristics associated with clinically significant pericardial effusions after cardiothoracic surgery. The outcomes of echocardiographically (echo-) guided pericardiocentesis for the management of these effusions were evaluated., Design: From the prospective Mayo Clinic Registry of Echo-guided Pericardiocentesis (February 1979 to June 1998), 245 procedures performed for clinically significant postoperative effusions were identified. Clinical features, effusion causes, echocardiographic findings, and management outcomes were studied and analyzed. Cross-referencing the registry with the Mayo Clinic surgical database provided an estimate of the incidence of significant postoperative effusions and the number of cases in which primary surgical management was chosen instead of pericardiocentesis., Results: Use of anticoagulant therapy was considered a significant contributing factor in 86% and 65% of early effusions (< or =7 days after surgery) and late effusions (>7 days after surgery), respectively. Postpericardiotomy syndrome was an important factor in the development of late effusions (34%). Common presenting symptoms included malaise (90%), dyspnea (65%), and chest pain (33%). Tachycardia, fever, elevated jugular venous pressure, hypotension, and pulsus paradoxus were found in 53%, 40%, 39%, 27%, and 17% of cases, respectively. Transthoracic echocardiography permitted rapid diagnosis and hemodynamic assessment of all effusions except for three cases that required transesophageal echocardiography for confirmation. Echo-guided pericardiocentesis was successful in 97% of all cases and in 96% of all loculated effusions. Major complications (2%), including chamber lacerations (n = 2) and pneumothoraces (n = 3), were successfully treated by surgical repair and chest tube reexpansion, respectively. Median follow-up duration for the study population was 3.8 years (range, 190 days to 16.4 years). The use of extended catheter drainage was associated with reduction in recurrence for early and late postoperative effusions by 46% and 50%, respectively., Conclusions: The symptoms and physical findings of clinically significant postoperative pericardial effusions are frequently nonspecific and may be inadequate for a decision regarding intervention. Echocardiography can quickly confirm the presence of an effusion, and pericardiocentesis under echocardiographic guidance is safe and effective. The use of a pericardial catheter for extended drainage is associated with lower recurrence rates, and the majority of patients so treated do not require further intervention.

The purpose of this study was to evaluate the safety and efficacy of echocardiographically (echo) guided pericardiocentesis in pediatric patients. Echo-guided pericardiocenteses performed in pediatric patients (age >/=16 years) at the Mayo Clinic between 1980 and 1997 were identified. Presentation, cause and characteristics of the effusion, details of the pericardiocentesis procedure, and outcome were determined by comprehensive chart review supplemented by telephone interviews when necessary. Seventy-three pediatric patients, median age 6.7 years (range 1 day to 16 years), underwent 94 consecutive echo-guided pericardiocenteses for effusions of various causes. Twenty-one (22%) procedures were performed in children younger than 2 years. All but 1 procedure were successful (99%). A mean fluid volume of 237 mL (range 4 to 970 mL) was withdrawn. Only a single attempt was needed for entry into the pericardial space in 87 (93%) procedures. No deaths were associated with the pericardiocentesis procedure. Only 1 major complication occurred (1%), a pneumothorax requiring chest tube reexpansion. Three (3%) minor complications-2 instances of right ventricular puncture and a small pneumothorax-did not require treatment. Extended catheter drainage for a mean of 5.2 +/- 4.5 days (range 1 to 19 days) was used with 30 (32%) of the 94 procedures. For the 52 patients who underwent pericardiocentesis without catheter drainage as the initial management strategy, 18 required 21 repeat pericardiocenteses for recurrence of effusion. In contrast, for the 21 patients who had pericardial catheterization as the initial management strategy, none had recurrences necessitating a repeat procedure (P <.001). Increased utilization of a pericardial catheter was associated with a concomitant decrease in the number of surgical pericardial procedures over the study period. Echo-guided pericardiocentesis was the only therapeutic modality for the management of effusion in 73% of all patients. Echo-guided pericardiocentesis is safe and effective in pediatric patients, including children younger than 2 years. The increasing use of pericardial catheterization in conjunction with this technique was associated with significant reduction of recurrence and decreased frequency of surgical interventions for treatment of pericardial effusion. Echo-guided pericardiocentesis with extended catheter drainage should be considered as primary management strategy for clinically significant pericardial effusions in pediatric patients.

Objectives: The purpose of this study was to determine the safety and efficacy of rescue echocardiographically guided pericardiocentesis as a primary strategy for the management of acute cardiac perforation and tamponade complicating catheter-based procedures., Background: In this era of interventional catheterization, acute tamponade from cardiac perforation as a complication is encountered more frequently. The safety and efficacy of echocardiographically guided pericardiocentesis in this life-threatening situation and outcomes of patients managed by this technique are unknown., Methods: Of the 960 consecutive echocardiographically guided pericardiocenteses performed at the Mayo Clinic (1979 to 1997), 92 (9.6%) were undertaken in 88 patients with acute tamponade that developed in association with a diagnostic or interventional catheter-based procedure. Most of the patients were hemodynamically unstable at the time of pericardiocentesis, with clinically overt tamponade in 40% and frank hemodynamic collapse (systolic blood pressure <60 mm Hg) in 57%. Clinical end points of interest were the success and complication rates of rescue pericardiocentesis and patient outcomes, including the need for other interventions, clinical and echocardiographic follow-up findings and survival., Results: Rescue pericardiocentesis was successful in relieving tamponade in 91 cases (99%) and was the only and definitive therapy in 82% of the cases. Major complications (3%) included pneumothorax (n=1), right ventricular laceration (n=1) and intercostal vessel injury with right ventricular laceration (n=1); all were treated successfully. Minor complications (2%) included a small pneumothorax and an instance of transient nonsustained ventricular tachycardia; all were resolved spontaneously. Further surgical intervention was performed in 16 patients (18%). No deaths resulted from the rescue pericardiocentesis procedure itself. Early death (<30 days) in this series was due to injuries from cardiac catheter-based procedures (n=3), perioperative complications (n=2) and underlying cardiac diseases (n=2). Clinical or echocardiographic follow-up for a minimum of 3 months or until death (if <3 months) for recurrent effusion or development of pericardial constriction was achieved in 87 (99%) of the patients., Conclusions: Echocardiographically guided pericardiocentesis was safe and effective for rescuing patients from tamponade and reversing hemodynamic instability complicating invasive cardiac catheter-based procedures. For most patients, this was the definitive and only therapy necessary.

Objectives: We sought to determine, using serial echocardiography, the hydrodynamic mechanisms involved in the occurrence of hemolysis after mitral valve repair., Background: Recently, fluid dynamic simulation models have identified distinct patterns of mitral regurgitant flow disturbances in patients with mitral prosthetic hemolysis that were associated with high shear stress and may therefore produce clinical hemolysis. Rapid acceleration, fragmentation, and collision jets were associated with high shear stress and hemolysis whereas slow deceleration and free jets were not., Methods: We reviewed serial echocardiographic studies of 13 consecutive patients with hemolytic anemia after mitral valve repair who were referred for mitral reoperation between January 1985 and December 1996 (group 1). Thirteen patients undergoing reoperation for mitral regurgitation after mitral valve repair but without hemolysis served as controls (group 2)., Results: The mitral regurgitant jet was central in origin in 12 group 1 patients and 9 group 2 patients (Fisher exact test, p= 0.3). The other patients had para-ring regurgitation. Group 1 patients had collision (n=11), rapid acceleration (n=2) or fragmentation (n=1) jets whereas group 2 patients had slow deceleration (n=11) or free jets (n=2) (Fisher exact test, p < 0.0001). One patient with hemolysis had both collision and rapid acceleration jets. The "culprit" jet could be identified on the postbypass transesophageal echocardiography (TEE) study in only 1 patient at the time of initial mitral repair. Twelve group 1 patients underwent reoperation, with subsequent resolution of hemolysis in all patients. At reoperation, the initial repair was found to be intact in 8 (67%) patients., Conclusion: Distinct patterns of flow disturbance associated with high shear stress were identified by color Doppler imaging in patients with hemolysis after mitral valve repair. The majority (92%) of these color flow disturbances were not present during intraoperative postbypass TEE study after initial mitral repair and subsequently developed in the early postoperative period.

Percutaneous pericardiocentesis was introduced during the 19th century and became a preferred technique for the management of pericardial effusion by the early 20th century. Until the era of two-dimensional echocardiographically guided pericardiocentesis, however, the procedure was essentially "blind," and serious complications were comparatively common, an outcome that resulted in an increased preference for surgical solutions. Because two-dimensional echocardiography facilitates direct visualization of cardiac structures and adjacent vital organs, percutaneous pericardiocentesis can be performed with minimal risk. Since its inception in 1979 (19 years ago), the echocardiographically guided pericardiocentesis technique has continued to evolve. Important procedural adaptations and modifications that optimize safety, simplicity, and patient comfort and minimize the recurrence of effusion have been defined and incorporated. This technique has been proved to be safe and effective. A detailed step-by-step description of the procedure and the necessary precautions to optimize success and safety is presented herein.

Cardiac herniation through an acquired pericardial defect is potentially fatal. Typically, symptoms manifest within days of a surgical procedure. We describe a patient with late ventricular herniation after surgical formation of an apical pericardial window.

Embolic events have become a major indication for transesophageal echocardiography. We report three patients with cerebrovascular accident who were discovered to have retained left atrial catheter as a cardiac source of embolism. These radiolucent catheters, placed during previous cardiac surgery, were used for perioperative left atrial monitoring. Fracture of the catheter occurred during percutaneous removal after surgery. Subsequent identification was established by transesophageal echocardiography, which demonstrated a characteristic appearance of the catheter remnant within the left atrium. All patients underwent reoperation to remove the retained catheter and have had no recurrent embolic events. Although uncommon, retained catheter in the left atrium is an important potential source of systemic embolism. The diagnosis can be easily made with transesophageal echocardiography and should prompt surgical extraction of the catheter.

We conclude that echocardiographically detected cardiac rhabdomyomata are common in patients with tuberous sclerosis complex, and are more prevalent and prominent in the younger patient. Tumors regress in size or number, or both, in most patients aged < 4 years, and less so in older patients. Cardiac rhabdomyomata are associated with a higher incidence of preexcitation and may increase the risk for arrhythmia.