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Background Atrial arrhythmias following hematopoietic stem cell transplantation (HSCT) have been associated with increased length of stay, need for intensive care, and increased mortality within one-year post-transplant. We sought to identify echocardiographic parameters that may predict the development of new atrial arrhythmias post-HSCT. Methods We performed a retrospective chart review of 753 consecutive patients who underwent HSCT at the University of Chicago from January 2015 through December 2019. Patients with baseline echocardiogram within 6 months prior to transplantation were included. Those with prior transplants, history of atrial arrhythmias, or unavailable echocardiographic images were excluded, resulting in 187 patients included for final analysis. Baseline clinical and demographic variables, as well as echocardiographic parameters, were compared between patients who developed new atrial arrhythmias post-HSCT versus those who did not. Results Of the 187 patients included for analysis, 25 (13%) developed new atrial arrhythmias, with 13 of these occurring within 30 days of transplantation. Despite no significant difference in left atrial (LA) end-systolic volume between those with and without new arrhythmia following HSCT (OR 1.04; 95% CI 0.91–1.09, p = 0.233), univariable analysis demonstrated that patients who developed atrial arrhythmias had reduced LA function, as reflected by lower LA emptying fraction (OR 0.94; 95% CI 0.91–0.98, p = 0.003) and lower LA reservoir strain (OR 0.95; 95% CI 0.92–0.99, p = 0.009). Conclusions Echocardiographic indices of LA function, namely LA emptying fraction and LA reservoir strain, can identify patients at risk for developing new atrial arrhythmias post-HSCT, prior to the development of morphologic changes in the LA.

As clinicians have gained experience in treating patients with the novel SARS-CoV-2 (COVID-19) virus, mortality rates for patients with acute COVID-19 infection have decreased. The Centers for Disease Control (CDC) has identified the African American population as having increased risk of COVID-19 associated mortality, however little is known about echocardiographic markers associated with increased mortality in this patient population. We aimed to compare the clinical and echocardiographic features of a predominantly African American patient cohort hospitalized with acute COVID-19 infection during the first (March–June 2020) and second (September–December 2020) waves of the COVID-19 pandemic, and to investigate which parameters are most strongly associated with composite all-cause mortality. We performed consecutive transthoracic echocardiograms (TTEs) on 105 patients admitted with acute COVID-19 infection during the first wave and 129 patients admitted during the second wave. TTE parameters including left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (LVGLS), right ventricular global longitudinal strain (RVGLS), right ventricular free-wall strain (RVFWS), and right ventricular basal diameter (RVBD) were compared between the two groups. Clinical and demographic characteristics including underlying co-morbidities, biomarkers, in-hospital treatment regimens, and outcomes were collected and analyzed. Univariable and multivariable analyses were performed to determine variables associated with all-cause mortality. There were no significant differences between the two waves in terms of age, gender, BMI, or race. Overall all-cause mortality was 35.2% for the first wave compared to 14.7% for the second wave (p

Cardiac tumors are rare and the majority are from a primary source outside of the heart. Most are found, incidentally, with echocardiography but often additional cardiac imaging is needed to refine the differential diagnosis. For this purpose, cardiac magnetic resonance imaging (MRI) and to a lesser extent cardiac computed tomography (CT) or 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) are useful imaging modalities to better characterize a cardiac tumor and determine the likelihood of a neoplastic versus non-neoplastic origin. Cardiac CT may be useful to evaluate the effect of treatment while using 18F-FDG PET/CT to evaluate cardiac masses is under-studied but may be useful in patients who are already having a scan performed for oncologic reasons. It is through understanding the clinical context of a newly discovered cardiac mass, knowledge of the typical locations of various cardiac tumor types, combined with imaging techniques that avoid ionizing radiation that yield the greatest confidence in the noninvasive diagnosis of a cardiac mass.

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BackgroundRe-allocation of resources during the COVID-19 pandemic has resulted in delays in care delivery to patients with cardiovascular disease and cancer. The ability of health care providers to provide optimal care in this setting has not been formally evaluated.ObjectivesTo assess the impact of COVID-19 resource re-allocation on scheduling, testing, elective procedures, telemedicine access, use of new COVID-19 therapies, and providers’ opinions on healthcare policies among oncology and cardiology practitioners.MethodsAn electronic survey was conducted by a cardio-oncology collaborative network through regional and state chapters of the American College of Cardiology , American Society of Clinical Oncology, and the International Cardio-Oncology Society. Descriptive statistics were reported by frequency and proportion for analyses, and stratified categorically by geographic region and specialty.Results1,415 providers (43 countries) participated: 986 cardiologists, 306 oncologists, and 118 trainees/internal medicine. 63% (195/306) of oncologists vs 92% (896/976) of cardiologists reported cancellations of treatments/elective procedures (p=0.01). 46% (442/970) of cardiologists and 25% (76/303) of oncologists modified the scope of their practice (p=ConclusionsThese results support initiatives to promote expanded coverage for telemedicine, increased access to PPE, better testing availability and involvement of medical professional societies to help with preparedness for future health care crisis.Appendix: Link to the Survey: https://www.surveymonkey.com/r/C8ZDYNW

Purpose of the Review Point-of-care ultrasound using small ultrasound devices has expanded beyond emergency and critical care medicine to many other subspecialties. Awareness of the strengths and limitations of the technology and knowledge of the appropriate settings and common indications for point-of-care ultrasound is important. Recent Findings Point-of-care ultrasound is widely embraced as an extension of the physical exam and is employed in acute care and medical education settings. Echocardiography laboratories involved in education must individualize training to the intended scope of practice of the user. Advances in artificial intelligence may assist in image acquisition and interpretation by novice users. Summary Point-of-care ultrasound is widely available in a variety of clinical settings. The field has advanced substantially in the past 2 decades and will likely continue to expand with advancement in technology, reduced cost, and improved opportunities to assist new users.

BACKGROUND: Accurate visualization of cardiac valves and lesions by three-dimensional (3D) echocardiography is integral for optimal guidance of structural procedures and appropriate selection of closure devices. A new 3D rendering tool known as transillumination (TI), which integrates a virtual light source into the data set, was recently reported to effectively enhance depth perception and orifice definition. We hypothesized that adding the ability to adjust transparency to this tool would result in improved visualization and delineation of anatomy and pathology and improved localization of regurgitant jets compared with TI without transparency and standard 3D rendering. METHODS: We prospectively studied 30 patients with a spectrum of structural heart disease who underwent 3D transesophageal imaging (EPIQ system, Philips) with standard acquisition and TI with and without the transparency feature. Six experienced cardiologists and sonographers were shown randomized images of all three display types in a blinded fashion. Each image was scored independently by all experts using a Likert scale from 1 to 5, while assessing each of the following aspects: (1) ability to recognize anatomy, (2) ability to identify pathology, including regurgitant jet origin, (3) depth perception, and (4) quality of border delineation. RESULTS: TI images with transparency were successfully obtained in all cases. All experts perceived an incremental value of the transparency mode, compared with TI without transparency and standard 3D rendering, in terms of ability to recognize anatomy (respective scores: 4.5 ± 1.1 vs 4.1 ± 1.1 vs 3.6 ± 1.1, P < .05), ability to identify pathology (4.1 ± 1.1 vs 3.9 ± 1.2 vs 3.3 ± 1, P < .05), depth perception (4.6 ± 0.7 vs 4.1 ± 0.8 vs 3.2 ± 1.0, P < .05), and border delineation (4.6 ± 0.8 vs 4.1 ± 1.0 vs 3.1 ± 1.1, P < .05). CONCLUSIONS: The addition of the transparency mode to TI rendering significantly improves the diagnostic and clinical utility of 3D echocardiography and has the potential to markedly enhance echocardiographic guidance of cardiac structural interventions. (J Am Soc Echocardiogr 2020;33:1316–23.)

In response to the coronavirus disease 2019 (COVID-19) pandemic, the Cardio-Oncology and Imaging Councils of the American College of Cardiology offers recommendations to clinicians regarding the cardiovascular care of cardio-oncology patients in this expert consensus statement. Cardio-oncology patients—individuals with an active or prior cancer history and with or at risk of cardiovascular disease—are a rapidly growing population who are at increased risk of infection, and experiencing severe and/or lethal complications by COVID-19. Recommendations for optimizing screening and monitoring visits to detect cardiac dysfunction are discussed. In addition, judicious use of multimodality imaging and biomarkers are proposed to identify myocardial, valvular, vascular, and pericardial involvement in cancer patients. The difficulties of diagnosing the etiology of cardiovascular complications in patients with cancer and COVID-19 are outlined, along with weighing the advantages against risks of exposure, with the modification of existing cardiovascular treatments and cardiotoxicity surveillance in patients with cancer during the COVID-19 pandemic.

Good-quality chest compressions improve outcomes in cardiac arrest. While manual chest compressions are suboptimal in this regard, the LUCAS device has been shown to improve the effectiveness of chest compressions during cardiopulmonary resuscitation (CPR). The complication rate associated with mechanical CPR, however, has not been adequately studied. Limited evidence suggests no difference in internal injury between manual and mechanical CPR. We report the case of a patient on anticoagulation who developed a mediastinal hematoma post mechanical CPR and on whom subtle findings on initial echocardiography could have alerted the clinician to this complication early during the clinical course. This case further suggests that there may be special populations of patients in whom we may need to be more vigilant in the use of mechanical CPR.

Objectives and importance: Patients with multiple myeloma (MM) have an increased risk of cardiovascular comorbidities due to disease burden and treatment-related risk factors. Proteasome inhibitors, including bortezomib and carfilzomib, are effective and generally well tolerated anti-MM agents. However, cardiovascular-related toxicities have been reported with this class of agents, the mechanisms of which are not fully understood. We discuss the practical management of cardiovascular events during carfilzomib therapy for relapsed MM.We present two adapted cases of treatment-emergent cardiovascular events in patients receiving an approved regimen of carfilzomib for the treatment of relapsed MM. These cases are reflective of clinical practice at the University of Chicago Medicine.Using the two adapted cases, we discuss and illustrate practical approaches for management of cardiovascular events during carfilzomib therapy, including baseline cardiac risk assessment, hydration, cardiovascular monitoring, and interventions for patients with suspected cardiovascular signs or symptoms, and patient education.Carfilzomib has a favorable benefit-risk profile in MM; adopting proactive practices can assist in the prevention, early detection, and management of carfilzomib-associated cardiovascular events, which may allow for continuation of therapy with this effective agent.

The purpose of this review is to outline the role of echocardiography in identifying patients at increased cardiovascular risk for cancer treatment-associated cardiotoxicity. With a wide array of cancer therapeutics, a variety echocardiographic cardiotoxicity phenotypes have been identified. Recent consensus statements from several professional societies have provided a framework for risk assessment prior to cancer therapy that involves assessment and optimization of cardiac risk factors but also involves echocardiographic evaluation of left ventricular (LV) function at baseline, during, and after treatment. While newer echocardiographic techniques such as global longitudinal strain are key to detecting subclinical cardiotoxicity, it is as yet unclear if strain-directed initiation of cardioprotective medications will result in better outcomes. This is the subject of an ongoing clinical trial, the results of which are eagerly awaited. Given the serial nature of echocardiographic assessments in the cancer population, the application of automated techniques for ejection fraction and strain may have the potential to further reduce measurement variability and are also subjects of ongoing research. Echocardiography is the preferred imaging modality for the detection of cardiotoxicity related to cancer therapy. Our expanded understanding of the cardiac side effects of cancer therapy and optimal surveillance strategies for those at risk is predicated on the ascertainment of cardiac outcomes in future clinical trials, for which echocardiography will undoubtedly play a pivotal role.

Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.

Purpose of review The purpose of this review is to discuss the clinical and treatment-related factors that increase the risk of cardiotoxicity with anthracyclines and human epidermal growth factor 2 receptor inhibitors. Recent findings Age and preexisting left ventricular dysfunction have been identified most consistently as being associated with the development of clinical heart failure or a worsening of left ventricular function with chemotherapy. Other cardiovascular conditions, including hypertension, diabetes, and coronary artery disease, are also associated with the risk of cardiotoxicity. There is growing evidence that Blacks are at a higher risk of developing cardiotoxicity than Whites, even after adjusting for known confounders. Pharmacogenomics is also emerging as a potential tool to help identify patients who are at higher risk for cardiotoxicity. Treatment-related risk factors include the dose of anthracycline or its formulation, whether the patient is receiving additional chemotherapeutic agents or radiation. Summary Several clinical and treatment-related risk factors are associated with cardiotoxicity. Further study is needed to determine whether optimization of modifiable risk factors prior to treatment can reduce the risk of cardiotoxicity.

Serial assessments of left ventricular ejection fraction (LVEF) are customary in patients with breast cancer receiving trastuzumab. Radionuclide angiography (RNA) is often used; however, a typical monitoring schedule could include 5 scans in a year. We evaluated the proportion of imaging-related ionizing radiation attributable to RNA in 115 patients with breast cancer, from 3 medical centers in the United States, Ireland, and Japan, who completed 12 months of trastuzumab treatment. Estimated radiation dose (ERD) was used to calculate exposure associated with imaging procedures spanning the 18 months before and after trastuzumab therapy. In addition, 20 cardiologists and oncologists from participating centers were surveyed for their opinions regarding the contribution of RNA to overall radiation exposure during trastuzumab treatment. When RNA was used to monitor LVEF, the mean ERD from imaging was substantial (34 ± 24.3 mSv), with the majority attributable solely to RNA (24.7 ± 14.8 mSv, 72.6%). Actual ERD associated with RNA in this population differed significantly from the perception in surveyed cardiologists and oncologists; 70% of respondents believed that RNA typically accounted for 0% to 20% of overall radiation exposure from imaging; RNA actually accounted for more than 70% of ERD. In conclusion, RNA was used to monitor LVEF in most patients in this cohort during and after trastuzumab therapy. This significantly increased ERD and accounted for a greater proportion of radiation than that perceived by surveyed physicians. ERD should be taken into account when choosing a method of LVEF surveillance. Alternative techniques that do not use radiation should be strongly considered.

Atrial fibrillation (AF) is associated with worsening tricuspid regurgitation (TR) in part due to adverse chamber remodeling. We sought to determine the impact of successful cardioversion (CV) for AF on chamber remodeling and TR. We prospectively evaluated 55 patients with AF (median duration of AF

The impact of the parental origin of associated alleles in GWAS has been largely ignored. Yet sequence variants could affect traits differently depending on whether they are inherited from the mother or the father, as in imprinted regions, where identical inherited DNA sequences can have different effects based on the parental origin. To explore parent-of-origin effects (POEs), we studied 21 quantitative phenotypes in a large Hutterite pedigree to identify variants with single parent (maternal-only or paternal-only) effects, and then variants with opposite parental effects. Here we show that POEs, which can be opposite in direction, are relatively common in humans, have potentially important clinical effects, and will be missed in traditional GWAS. We identified POEs with 11 phenotypes, most of which are risk factors for cardiovascular disease. Many of the loci identified are characteristic of imprinted regions and are associated with the expression of nearby genes., Sahar Mozaffari et al. conduct a parent of origin genome-wide association study in a large Hutterite pedigree to determine parent-of-origin effects on 21 phenotypes. They identify effects on 11 phenotypes (including single parent and opposite parental effects), most of which are associated with cardiovascular disease.

Genome-wide association studies (GWASs) have become a standard tool for dissecting genetic contributions to disease risk. However, these studies typically require extraordinarily large sample sizes to be adequately powered. Strategies that incorporate functional information alongside genetic associations have proved successful in increasing GWAS power. Following this paradigm, we present the results of 20 different genetic association studies for quantitative traits related to complex diseases, conducted in the Hutterites of South Dakota. To boost the power of these association studies, we collected RNA-sequencing data from lymphoblastoid cell lines for 431 Hutterite individuals. We then used Sherlock, a tool that integrates GWAS and expression quantitative trait locus (eQTL) data, to identify weak GWAS signals that are also supported by eQTL data. Using this approach, we found novel associations with quantitative phenotypes related to cardiovascular disease, including carotid intima-media thickness, left atrial volume index, monocyte count and serum YKL-40 levels.

The impact of the parental origin of associated alleles in GWAS has been largely ignored. Yet sequence variants could affect traits differently depending on whether they are inherited from the mother or the father. To explore this possibility, we studied 21 quantitative phenotypes in a large Hutterite pedigree. We first identified variants with significant single parent (maternal-only or paternal-only) effects, and then used a novel statistical model to identify variants with opposite parental effects. Overall, we identified parent of origin effects (POEs) on 11 phenotypes, most of which are risk factors for cardiovascular disease. Many of the loci with POEs have features of imprinted regions and many of the variants with POE are associated with the expression of nearby genes. Overall, our results indicate that POEs, which are often opposite in direction, are relatively common in humans, have potentially important clinical effects, and will be missed in traditional GWAS.

Malignant pericardial mesothelioma accounts for 2-3% of all pericardial tumors, and its prevalence in the general population is

A variety of interventional management approaches exist for the treatment of acute pulmonary embolism (PE). However, when PE is accompanied by residual right heart thrombus, the best therapeutic options are less clear. We describe a novel combined technique of percutaneous aspiration of unstable right atrial thrombus followed by ultrasound-directed thrombolysis of massive PE.

Human epidermal growth factor receptor 2-positive (HER2+) breast cancer is associated with aggressive disease and a poor prognosis. There are a number of anti-HER2 therapies currently available and more in development. Cardiac concerns raised by early experience with HER2 inhibitor trastuzumab had led to subsequent trial designs focused on a more selective patient population with a lower cardiac risk, generally with a median age of 50–55 years old, with a normal left ventricular ejection fraction (LVEF) at study entry, and with no clinical cardiovascular disease or uncontrolled cardiac risk factors. Within this context, the cardiac safety profile of the agents outlined in this review appears to be quite acceptable and thus the risk to benefit ratio is favorable. Given the theoretical cardiac concerns of this class of cancer therapeutics that prompted the stringent patient selection and eligibility criteria in clinical trials, clinicians should exercise reasonable caution and monitor patients carefully for cardiac sequelae when using these agents outside of the controlled conditions applied in the clinical trials.

Modern advances in cancer treatment have resulted in improved survival. As a result, effects of cancer therapy on other organ systems such as the heart are more likely to become clinically relevant. One such possibility is chemotherapy-related left ventricular dysfunction. Although in clinical practice cardiotoxicity is evaluated by symptoms and left ventricular ejection fraction, these occur relatively late in the disease process after the heart's compensatory mechanisms have been expended. Ideally, left ventricular dysfunction would be identified early so that cancer patients and their physicians can make informed decisions about their therapeutic options and institute careful surveillance and early initiation of cardioprotective medication where appropriate. This review discusses the role of echocardiography to detect subclinical left ventricular dysfunction in cancer patients exposed to chemotherapy with potential cardiotoxicity, particularly anthracyclines and trastuzumab.

Despite advances in the diagnosis and treatment of cardiovascular disease in the United States, its burden remains significant. Carotid intima-media thickness (CIMT), measured noninvasively with B-mode ultrasound, is an indicator of subclinical vascular disease that has been associated with established cardiovascular risk factors as well as incident and prevalent cardiovascular disease in large epidemiologic studies. As a clinical tool, CIMT has the potential to refine risk stratification in individual patients who may otherwise be at intermediate cardiovascular risk based on conventional risk assessment algorithms. Future clinical trials are needed to determine whether CIMT-guided risk reduction can lead to improved cardiovascular outcomes.

Pamela S. Douglas, MD, FASE, Chair, Jeanne M. DeCara, MD, Richard B. Devereux, MD, Shelly Duckworth, RDCS, Julius M. Gardin, MD, FASE, Wael A. Jaber, MD, Annitta J. Morehead, RDCS, FASE, Jae K. Oh, MD, FASE, Michael H. Picard, MD, FASE, Scott D. Solomon, MD, Kevin Wei, MD, and Neil J. Weissman, MD, FASE, Durham, North Carolina; Chicago, Illinois; New York, New York; Hackensack, New Jersey; Cleveland, Ohio; Rochester, Minnesota; Boston, Massachusetts; Portland, Oregon; Washington, DC

The purpose of this study was to determine whether a non-sonographer clinician (NSC) could obtain ultrasound images of the carotid artery, measure carotid intima-media thickness (CIMT), and identify findings indicating increased cardiovascular risk in an office setting.Eight NSCs from five sites were trained to use a handheld ultrasound device to screen the carotid arteries for plaques and to measure CIMT.NSCs scanned 150 subjects who provided 900 images, of which 873 (97%) were interpretable. Differences between NSCs and the core laboratory were small (0.002 +/- 0.004 mm) and bioequivalent (P(TOST)0.05) with a low coefficient of variation (3.9% +/- 0.5%). There wasor = 90% agreement on the presence of CIMTor = 75th percentile andor = 80% agreement on plaque presence.This is the first multicenter study to show that NSCs can obtain images of the carotid arteries using a handheld ultrasound device, accurately measure CIMT, and identify findings indicating increased cardiovascular risk.

There is an increasing awareness and clinical interest in cardiac safety during cancer therapy as well as in optimally addressing cardiac issues in cancer survivors. Although there is an emerging expertise in this area, known as cardio-oncology, there is a lack of organization in the essential components of contemporary training. This proposal, an international consensus statement organized by the International Cardioncology Society and the Canadian Cardiac Oncology Network, attempts to marshal the important ongoing efforts for training the next generation of cardio-oncologists. The necessary elements are outlined, including the expectations for exposure necessary to develop adequate training. There should also be a commitment to local, regional, and international education and research in cardio-oncology as a requirement for advancement in the field.

10.2217/FCA.15.43 © 2015 Future Medicine Ltd “The aim of cardio-oncology is not to prevent cancer patients with ca rdiovascular disease and risk factors from receiving n ecessary life-saving cancer therapy, but to prevent and/or treat cardiac disease as best as possible alongside their ca ncer therapy/care; incorporating a most co mprehensive approach with their oncology and other care team.’ Tochi M Okwuosa

We report a case of congenital bicuspid aortic valve infective endocarditis in an 18-year-old male with no significant past medical history. He presented to the emergency department from an ophthalmology clinic with new right-eye vision changes. Initial EKG revealed sinus tachycardia and he was hemodynamically stable. Expedited diagnostic transesophageal echocardiography revealed vegetations on both aortic leaflets, an aortic root abscess, and a fistulous tract extending from the left ventricular outflow tract into the right ventricular outflow tract. Although he was evaluated by the cardiothoracic surgery team and scheduled for operative repair, he acutely became bradycardic, developed pulseless electrical activity, and was resuscitated on multiple occasions, but died suddenly from PEA arrest within 24 hours of presenting to the emergency department. This case demonstrates complications of acute bacterial endocarditis. We discuss the current debate surrounding the role of antibiotic prophylaxis for infective endocarditis. Additionally, we suggest that patients with a bicuspid aortic valve, a common congenital defect with a known increased risk for bacterial endocarditis, might represent a unique cohort to prospectively study whether antibiotic prophylaxis reduces the incidence, morbidity, and mortality of bacterial endocarditis in patients at increased risk.

Background Transesophageal echocardiography (TEE) is an essential diagnostic tool that has gained widespread use in clinical cardiology. It is considered reasonably noninvasive and safe; however, insertion and operation of the TEE probe may cause hypopharyngeal, esophageal, or gastric trauma. The current study reports a single-center experience of esophagogastric trauma in 10,000 consecutive TEE examinations. Methods TEE examinations were performed by 9 attending physicians who were trained in endoscopic procedures and had been performing TEE studies for at least 1 year. Results One case of hypopharyngeal perforation (0.01%), 2 cases of cervical esophageal perforation (0.02%), and no cases of gastric perforation (0%) occurred after TEE examination. No fatalities (0%) occurred. We describe the clinical characteristics of individuals who experienced esophageal perforation during this 10-year period. Conclusions This single-center study demonstrates that TEE examinations are associated with a very low risk of esophagogastric trauma when performed in a safe setting by experienced operators.

Background No technique exists for objective evaluation of left ventricular wall motion in contrast-enhanced images. We tested a new technique for quantification of regional fractional area change using contrast-enhanced power modulation imaging with color kinesis. Methods The feasibility of this technique for detecting acute ischemia was first tested in 11 pigs. Next, the accuracy for detecting resting wall-motion abnormalities was determined in 52 patients requiring contrast and compared with conventional interpretation of 2-dimensional images by inexperienced readers. Expert interpretation of 2-dimensional images served as the gold standard. Results In pigs, coronary occlusion resulted in reversible hypokinesis and reduced regional fractional area change. In patients with poor acoustic windows, this technique's accuracy for quantitative detection of resting wall-motion abnormalities was 86% compared with 81% for conventional interpretation by inexperienced readers ( P Conclusions Regional wall motion can be accurately assessed using color-encoded power modulation imaging for patients requiring contrast. This technique may prove a useful diagnostic aid to echocardiographers of varying levels of experience.

Although harmonic imaging (HI) improves endocardial visualization and is necessary for myocardial perfusion imaging, it has yet to be implemented in transesophageal echocardiography. Our goal was to determine whether HI implemented in a prototype transesophageal echocardiography probe improved endocardial visualization and allowed perfusion imaging.In 23 patients, fundamental and harmonic images were obtained in the transgastric short-axis (TSAX) and midesophageal 4-chamber views, and reviewed for endocardial visualization by 3 readers blinded to imaging mode. In 14 additional patients, perfusion imaging was performed in the TSAX view during contrast infusion.HI improved overall endocardial visualization, most noticeably in the anterior and lateral segments (P.004) in the TSAX view, and in the lateral segments (P.01) in the midesophageal 4-chamber view. The salvage rate was 8.3% in the TSAX view and 12.6% in the midesophageal 4-chamber view. Myocardial perfusion was consistently confirmed in the inferior (86%), posterior (100%), and lateral (79%) segments, but rarely in the septal (21%), anteroseptal (0%), and anterior (14%) segments.Use of HI with transesophageal echocardiography improves endorcardial visualization and allows partial assessment of myocardial perfusion.

Objective The feasibility and accuracy of direct transthoracic 3-dimensional (3D) mitral valve area (MVA) measurements obtained using freehand scanning was investigated in patients with mitral stenosis. Methods A total of 30 patients (26 women, 4 men; aged 55 ± 13 years) underwent a 2-dimensional (2D) and Doppler study 1 hour before percutaneous balloon mitral valvuloplasty. Transthoracic freehand data were acquired using a magnetic receiver attached to a broadband transducer, gated to electrocardiography and respiration. Volumetric MVA measurements from the left ventricle and left atrium were obtained and compared with MVA measurements derived from 2D planimetry, pressure half-time, and proximal isovelocity surface area. Invasive Gorlin MVA measurements were the gold standard for comparison. Results In all, 29 patients (97%) had 3D data allowing MVA measurements. Direct 3D measurements from the left ventricle had the least bias (0.06 ± 0.19 cm 2 ) and tightest limits of agreement (−0.44 to 0.32) compared with left atrium measurements (0.17 ± 0.25 cm 2 and −0.67 to 0.33, respectively). The proximal isovelocity surface area method (bias: 0.09 ± 0.34 cm 2 ) was the most accurate of all 2D methods followed by pressure half-time (0.17 ± 0.36 cm 2 ) and planimetry (0.21 ± 0.29 cm 2 ). Conclusion Direct 3D MVA measurements from the left ventricle using transthoracic freehand scanning are more accurate than traditional 2D methods.

We hypothesized that color-encoded, contrast-enhanced, power modulation imaging could allow simultaneous quantification of myocardial perfusion and regional left ventricular function. We studied 12 anesthetized, closed-chest pigs at baseline, during acute ischemia, and during reperfusion, and 8 patients after acute myocardial infarction. Color kinesis was used to color encode endocardial motion during real-time contrast perfusion imaging with high-energy ultrasound pulses. Wall motion was assessed by calculating regional fractional area changes. Translation-free perfusion analysis was performed in automatically identified myocardial regions of interest. Steady-state intensity and postimpulse rate of contrast replenishment were calculated. In all animals, ischemia caused reversible changes in the images and the perfusion- and function-calculated indices. A significant decrease in pixel intensity (14%) and contrast replenishment rate (66%) in left anterior descending coronary artery segments, in agreement with fluorescent microspheres measurements, coincided with a decrease in fractional area change (34%). For patients, respective perfusion and function indices were 61%, 51%, and 58% lower in segments where perfusion defects, regional wall-motion abnormalities, or both were noted in gray scale images. Color-encoded, contrast-enhanced power modulation allows simultaneous real-time imaging and quantitative analysis of myocardial perfusion and regional left ventricular function.

This article describes the obstacles to stress echocardiographic interpretation, and reviews the techniques currently available that offer a more objective approach to stress wall motion analysis than the conventional visual methodology. These techniques include Doppler-based methods, such as myocardial Doppler velocity and strain rate imaging, as well as automated border detection techniques, such as acoustic quantification and color kinesis. (ECHOCARDIOGRAPHY, Volume 20, October 2003)