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As of July 5, 2020, approximately 2.8 million coronavirus disease 2019 (COVID-19) cases and 130,000 COVID-19-associated deaths had been reported in the United States (1). Populations historically affected by health disparities, including certain racial and ethnic minority populations, have been disproportionally affected by and hospitalized with COVID-19 (2-4). Data also suggest a higher prevalence of infection with SARS-CoV-2, the virus that causes COVID-19, among persons experiencing homelessness (5). Safety-net hospitals,† such as Boston Medical Center (BMC), which provide health care to persons regardless of their insurance status or ability to pay, treat higher proportions of these populations and might experience challenges during the COVID-19 pandemic. This report describes the characteristics and clinical outcomes of adult patients with laboratory-confirmed COVID-19 treated at BMC during March 1-May 18, 2020. During this time, 2,729 patients with SARS-CoV-2 infection were treated at BMC and categorized into one of the following mutually exclusive clinical severity designations: exclusive outpatient management (1,543; 56.5%), non-intensive care unit (ICU) hospitalization (900; 33.0%), ICU hospitalization without invasive mechanical ventilation (69; 2.5%), ICU hospitalization with mechanical ventilation (119; 4.4%), and death (98; 3.6%). The cohort comprised 44.6% non-Hispanic black (black) patients and 30.1% Hispanic or Latino (Hispanic) patients. Persons experiencing homelessness accounted for 16.4% of patients. Most patients who died were aged ≥60 years (81.6%). Clinical severity differed by age, race/ethnicity, underlying medical conditions, and homelessness. A higher proportion of Hispanic patients were hospitalized (46.5%) than were black (39.5%) or non-Hispanic white (white) (34.4%) patients, a finding most pronounced among those aged

Background Coronavirus disease 2019 (COVID-19) vaccine trials and post-implementation data suggest that vaccination decreases infections. We examine vaccination’s impact on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case rates and viral diversity among health care workers (HCWs) during a high community prevalence period. Methods In this prospective cohort study, HCW received 2 doses of BNT162b2 or mRNA-1273. We included confirmed cases among HCWs from 9 December 2020 to 23 February 2021. Weekly SARS-CoV-2 rates per 100,000 person-days and by time from first injection (1–14 and ≥15 days) were compared with surrounding community rates. Viral genomes were sequenced. Results SARS-CoV-2 cases occurred in 1.4% (96/7109) of HCWs given at least a first dose and 0.3% (17/5913) of HCWs given both vaccine doses. Adjusted rate ratios (95% confidence intervals) were 0.73 (.53–1.00) 1–14 days and 0.18 (.10–.32) ≥15 days from first dose. HCW ≥15 days from initial dose compared to 1-14 days were more often older (46 vs 38 years, P = .007), Latinx (10% vs 8%, P = .03), and asymptomatic (48% vs 11%, P = .0002). SARS-CoV-2 rates among HCWs fell below the surrounding community, an 18% vs 11% weekly decrease, respectively (P = .14). Comparison of 50 genomes from post–first dose cases did not indicate selection pressure toward known spike antibody escape mutations. Conclusions Our results indicate an early positive impact of vaccines on SARS-CoV-2 case rates. Post-vaccination isolates did not show unusual genetic diversity or selection for mutations of concern.

The March 2018 issue of Circulation: Cardiovascular Imaging marks the completion of the near 10-year term of the outgoing editorial team of the Journal. At the start of our tenure in July 2008, we committed to foster a new forum for timely dissemination of advances in imaging so as to keep investigators and clinicians at the cutting edge of imaging science and its application to clinical practice. We sought to create a unique venue that would publish high-quality articles featuring innovative approaches, often including multiple imaging modalities, that would validate and advance the science of imaging and accelerate its adoption into clinical practice. We strove to complement original research articles with editorials, state-of-the-art reviews, points of view, and controversies, that in aggregate, would provide critical, scientifically grounded viewpoints and discussion on …

Over the past 2 decades, we have witnessed an explosive expansion in the armamentarium of noninvasive and invasive imaging technologies capable of providing detailed information about the structure and function of the heart and vasculature. Many of these technologies are integrative (eg, positron emission tomography and computed tomography, positron emission tomography and MRI), thereby compounding the unique strengths of the component technologies to achieve unprecedented improvements to our ability to diagnose disease, improve patient care, and advance biomedical research. In addition, the miniaturization of imaging devices with dramatic increases in sensitivity and spatial resolution, coupled with the development of quantitative molecular imaging approaches for evaluating physiology and pathobiology at the cellular and molecular levels, provides a unique platform for a new era in diagnostic imaging. The crucial role of imaging in early phenotyping of disease, risk assessment, and management guidance is expanding rapidly in ways previously thought unrealistic. Along with clinical, molecular, and genomewide association studies, structural and functional quantitative imaging already plays a critical role in phenotyping cardiovascular disease. Unique strengths of imaging phenotyping include its ability to provide precise, organ-specific anatomic localization and quantification of disease traits, to demonstrate and quantify involvement of other organs in cardiac disease, to provide an opportunity to investigate the time course of disease-specific molecular events in vivo, and to track their response to therapy. In so doing, quantitative structural and functional imaging can provide a nuanced description of disease burden (eg, atherosclerosis, myocarditis), disease subtypes (eg, amyloidosis), and, importantly, the relationship between the specific phenotype and outcomes, thereby informing treatment strategies and allowing more personalized approaches to patient management. Our objectives for this article are to (1) provide a viewpoint regarding the evolving role of cardiovascular imaging in biomedical research and clinical practice, (2) discuss the challenges associated with clinical translation of …

Each year hundreds of reviewers volunteer their time and expertise to peer review, a process that contributes critically to the quality of Circulation: Cardiovascular Imaging . The editors are grateful for the help of all our reviewers. Here, we acknowledge those who reviewed 2 or more papers during 2015. Many thanks on behalf of the Circulation: Cardiovascular Imaging editorial team. Abbasi, Siddique Abidov, Aiden Abraham, Theodore Adhyapak, Srilakshmi M. Aggarwal, Niti R. Agostini, Denis Ahmad, Rizwan Ajijola, Olujimi A. Albisu, Juan Pablo Aletras, Anthony H. Allman, Kevin C. An, Hyonggin Andersen, Mads J. Arai, Andrew E. Arbab-Zadeh, Armin Asch, Federico M. Aurigemma, Gerard P. Avelar, Erick Badano, Luigi P. Baggish, Aaron L. Baldassarre, Lauren Barac, Ana Barasch, Eddy Bax, Jeroen J. Beller, George A. Bengel, Frank M. Berman, Daniel S. Berry, Colin Bertini, Matteo Biering-Sorensen, Tor Bijnens, Bart Bismuth, Jean Bittencourt, Marcio Sommer Blaha, Michael J. Blankstein, Ron Boccara, Franck Bolger, …

BACKGROUND Glucose-insulin-potassium (GIK) infusion improves clinical outcome after coronary artery bypass surgery (CABG). The mechanism of benefit is unclear, but GIK limits ischemia and reperfusion injury. This study was designed to assess whether the clinical benefit of perioperative GIK infusion is mediated through reduction in the severity of diastolic dysfunction that occurs after CABG. METHODS AND RESULTS Thirty-one patients undergoing CABG were randomized to GIK infusion (n = 14) or no-GIK (n = 17). Left ventricular compliance, using pressure-area relationships, was assessed by simultaneous transesophageal echocardiographic measurement of LV end-diastolic area (LVEDA) and pulmonary capillary wedge pressure (PCWP) at baseline prior to CABG, early post cardiopulmonary bypass (CPB), after sternal closure, and 3 hours postoperatively. Measures of LVEDA were made at a constant PCWP and a decrease in LVEDA reflects a leftward shift in the pressure-area relationship consistent with decreased compliance. Both study groups demonstrated progressive and consistent worsening of LV compliance, as evidenced by a reduction of LVEDA from 17.0 +/- 3.9 cm(2) at baseline to 15.3 +/- 3.6 cm(2) after CPB, 14.6 +/- 2.9 cm(2) after sternal closure, and 14.1 +/- 3.2 cm(2) (p < 0.0001) at three hours postoperatively. LVEDA decreased from a baseline of 16.3 +/- 2.8 to 13.8 +/- 2.9 cm(2) in the GIK group, while the non-GIK group demonstrated a reduction of LVEDA from 17.5 +/- 4.6 to 14.3 +/- 3.5 cm(2). Doppler transmitral E wave deceleration time shortened as well, which is consistent with more restrictive LV filling due to rapid equilibration of LA and LV pressures. GIK infusion did not alter either measure of diastolic function significantly. CONCLUSION Diastolic dysfunction occurs nearly universally after CABG, worsens with chest closure, persists for up to 3 hours postoperatively, and is unaffected by GIK. Despite theoretical reasons why GIK might limit ischemia and reperfusion injury, the clinical benefits do not appear to be related to amelioration of diastolic dysfunction. SUPPORT The study was partially supported by Agilent Technologies/Philips Imaging.

Objective To determine the characteristics and prognostic importance of right ventricular (RV) dilatation and dysfunction in patients with cardiogenic shock secondary to left ventricular (LV) dysfunction enrolled in the Should we emergently revascularize occluded coronaries for cardiogenic shock (SHOCK) trial. Methods LV and RV size and function were quantified by echocardiography in 99 patients with cardiogenic shock secondary to predominant LV dysfunction. Results For all patients, RV dysfunction was not associated with a poor 1-year survival. When the 59 patients with RV dysfunction were stratified into two morphologic groups based upon LV-to-RV end-diastolic area ratio (LV/RV) < or ≥ 2, the presence of disproportionate RV enlargement (LV/ RV

Background Diastolic dysfunction is common immediately after coronary artery bypass surgery (CABG). The duration of this phenomenon is unknown. Intravenous calcium is frequently administered during separation from cardiopulmonary bypass (CPB). We sought to determine whether intravenous calcium influences perioperative diastolic function and whether diastolic dysfunction persists into the postoperative period. Methods and results Patients undergoing first-time elective CABG (n = 29) were randomly assigned to receive intravenous calcium chloride (n = 13) or placebo (n = 16) during separation from CPB. Diastolic function was assessed by the pressure-area relation with transesophageal echocardiography and pulmonary capillary wedge pressure (PCWP) measured simultaneously. Left ventricular end-diastolic area (LVEDA) and Doppler indexes were measured at comparable PCWP (within 2 mm Hg) at baseline, after separation from CPB, after sternal closure, and 3 hours after surgery. After CABG, both groups had a significant decrease in LVEDA and mitral E-wave deceleration time that persisted at 3 hours. Because there were no significant differences between the calcium and control groups at any time point, the data for the entire study cohort was analyzed. The LVEDA decreased (stiffness increased) progressively from 16.9 ± 3.4 cm 2 at baseline to 15.8 ± 2.9 cm 2 after CPB, 14.9 ± 2.5 cm 2 after sternal closure, and 14.3 ± 3.1 cm 2 at 3 hours after surgery ( P P = .0001). Conclusions An increase in left ventricular diastolic chamber stiffness is nearly universal after CABG, and it persists for at least 3 hours after surgery. An intravenous bolus of calcium chloride given during separation from CPB has no measurable negative effect on diastolic function. In the setting of increased chamber stiffness, the PCWP alone does not adequately reflect the volume status and effective preload of the left ventricle.

OBJECTIVES The purpose of this study was to determine the characteristics and outcomes of patients with acute myocardial infarction (MI) complicated by cardiogenic shock due to predominant right ventricular (RV) infarction. BACKGROUND Although RV infarction has been shown to have favorable long-term outcomes, the influence of RV infarction on mortality in cardiogenic shock is unknown. METHODS We evaluated 933 patients in cardiogenic shock due to predominant RV (n = 49) or left ventricular (LV) failure (n = 884) in the SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK? (SHOCK) trial registry. RESULTS Patients with predominant RV shock were younger, with a lower prevalence of previous MI (25.5 vs. 40.1%, p = 0.047), anterior MI, and multivessel disease (34.8 vs. 77.8%, p < 0.001) and a shorter median time between the index MI and the diagnosis of shock (2.9 vs. 6.2 h, p = 0.003) in comparison to patients with LV shock. In-hospital mortality was 53.1% versus 60.8% (p = 0.296) for patients with predominant RV and LV shock, respectively, and the influence of revascularization on mortality was not different between groups. Multivariate analysis revealed that RV shock was not an independent predictor of lower in-hospital mortality (odds ratio 1.07, 95% confidence interval 0.54 to 2.13). CONCLUSIONS Despite the younger age, lower rate of anterior MI, and higher prevalence of single-vessel coronary disease of RV compared with LV shock patients, and their similar benefit from revascularization, mortality is unexpectedly high in patients with predominant RV shock and similar to patients with LV shock.

Background and purpose A potential source of emboli is not detected in more than 50% of patients with retinal arterial occlusive events. Echocardiographic studies are not always included in the diagnostic workup of these patients. The authors studied the diagnostic yield of transthoracic (TTE) and/or transesophageal (TEE) echocardiography in identifying potential sources of emboli in patients with retinal ischemia or embolism. Methods In a prospective study, 73 consecutive patients with clinically diagnosed retinal ischemia or embolism received a standardized diagnostic workup including retinal photography, echocardiography, and imaging studies of the internal carotid arteries. TTE was performed in 83.6% of patients, TEE was performed in 5.5% of patients, and both TTE and TEE were performed in 11.0% of patients. Ophthalmological diagnoses consisted of amaurosis fugax (n = 28), asymptomatic cholesterol embolism to the retina (n = 34), and branch or central retinal artery occlusion (n = 11). Results Echocardiography identified a potential cardiac or proximal aortic source for embolism in 16 of 73 (21.9%) patients, including 8 who also had either atrial fibrillation or internal carotid artery stenosis of more than 50% on the side of interest. Thus, 8 of 73 (11.0%) patients had lesions detected only by echocardiography. The most commonly identified lesions were proximal aortic plaque of more than 4 mm thickness (n = 7, 9.6%) and left ventricular ejection fraction of less than 30% (n = 6, 8.2%). TEE was particularly helpful in identifying prominent aortic plaques. Conclusion Echocardiography frequently identifies lesions of the heart or aortic arch that can act as potential sources for retinal ischemia or embolism. Further studies are needed to evaluate the prognostic and therapeutic relevance of these findings.

Pulmonary artery systolic pressure (PASP) was examined in relationship to age, body mass index (BMI), the effects of comorbid disease, and standard echocardiographic measurements of cardiac chamber size, left ventricular filling patterns, and left ventricular systolic function in 5 large cohorts presenting with a primary problem of obesity. For subjects with a measurable PASP, means (± SD) across cohorts for age ranged from 46.0 ± 11.2 to 54.1 ± 12.8 years, for BMI from 26.0 ± 4.4 to 37.2 ± 6.1 kg/m 2 , and PASP (n = 1515) from 29.9 ± 7.7 to 33.8 ± 7.8 mm Hg. PASP 30 mm Hg or greater occurred in 46% to 66% of subjects and 35 mm Hg or greater in 16% to 36%. Age and BMI were the most significant correlates of PASP. Increased PASP was also significantly associated with systemic hypertension and a history of cardiovascular disease. The mean PASP in obese individuals is higher than previously reported with nearly one third having a PASP of 35 mm Hg or greater. Clinical interpretation of PASP should include BMI, age, blood pressure, and presence of cardiovascular disease. (J Am Soc Echocardiogr 2002;15:454-62.)

To clarify whether pulsed tissue Doppler imaging at multiple left ventricular LV sites could help to explain the mechanism of congestive heart failure (CHF) in patients with primary amyloidosis, we examined 86 consecutive patients with primary amyloidosis confirmed by biopsy (group I, 31 patients without cardiac involvement; group II, 31 patients with evidence of heart involvement but no CHF; and group III, 24 patients with heart involvement, clinical CHF, and normal fractional shortening >28%). Peak early diastolic myocardial velocities in group II were significantly lower than those in group I, and the values in group III were also significantly lower than those in group II at most sites. In contrast to diastolic abnormalities, peak systolic wall motion velocities in group III were significantly lower than those in group II, but there were no significant differences between groups I and II. Thus, cardiac amyloidosis is characterized by an initial impairment in early cardiac relaxation, whereas CHF is associated with an impairment of peak systolic wall motion velocities, most prominently seen in the longitudinal axis. This systolic dysfunction can be detected by pulsed tissue Doppler imaging, even when ejection fraction is in the normal range.

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.

Quantification of aortic regurgitation (AR) is a common and difficult clinical problem. The severity of regurgitation has traditionally been estimated with the use of contrast aortography, which is impractical as a screening tool or for serial examinations. In the past two decades, Doppler echocardiography has emerged as an important tool in the quantification of AR. Pulsed Doppler mapping of the depth of the regurgitant jet into the left ventricle was one of the initial echocardiographic methods used for this purpose. The slope and pressure (or velocity) half-time of continuous-wave Doppler profiles of regurgitant jets are also useful. These Doppler techniques may be used to determine the regurgitant volume or regurgitant fraction in patients with AR. The use of color Doppler to measure the height (or cross-sectional area) of the regurgitant jet relative to the height (cross-sectional area) of the left ventricular outflow tract is both sensitive and specific in the quantification of AR. More recently, the continuity principle has been used to determine the effective aortic regurgitant orifice area, which increases as AR becomes more severe. Although this is a promising tool, calculation of this value is not yet common practice in most echocardiography laboratories. Although no single echocardiographic technique is without limitations, all have some validity, and it is reasonable to use a combination of them to obtain a composite estimate of the severity of AR.

Although the annual risk of cardiovascular mortality has been well described for individuals with symptomatic aortic stenosis, the morbidity and mortality for those with asymptomatic severe aortic stenosis is not as well known. Currently the American Heart Association/American College of Cardiology recommends a “watchful waiting” strategy for those with asymptomatic aortic stenosis.1 This involves clinical examinations every 6 to 12 months and annual echocardiograms; however, it is unclear what to do with these data in the patient who remains asymptomatic. The asymptomatic patient is generally not referred for aortic valve replacement surgery until the development of symptoms (unless concurrent coronary artery bypass grafting is required or if systolic dysfunction develops). Article see p 69 Approximately 30% of asymptomatic patients will develop symptoms (angina, heart failure, syncope) within 2 years of diagnosis.2,3 For those patients who do not develop symptoms, the risk of sudden cardiac death is less than 1% per year, assuming that patients are well monitored for the development of symptoms.2,3 Although angina and syncope are relatively easy symptoms to elicit, manifestations of heart failure may be subtle. This is particularly true because many of these patients are elderly and attribute reduced exercise capacity to be part of the normal aging process or “slowing down.” Vigilance and careful attention to a patient’s history are important components of the regular evaluation of patients with aortic stenosis. However, even careful attention to the history may not predict sudden death in patients with severe aortic stenosis. The reluctance to perform surgery earlier than necessary is driven by the morbidity of cardiac surgery and a mortality rate for aortic valve surgery of approximately 3% to 5%, even in patients younger than 70 years.4 Thus for truly asymptomatic patients, the risk of potential complications like sudden cardiac death and irreversible …

Papillary fibroelastomas are uncommon benign tumors usually involving the heart valves, which historically have been diagnosed at autopsy. With the advent of echocardiography, however, the number of patients diagnosed in life has increased. Papillary fibroelastomas represent a surgically treatable cause of cerebrovascular and cardiovascular ischemia and infarction making their identification clinically important. We report three unusual cases of papillary fibroelastoma; two patients presenting with symptoms of cerebrovascular ischemia and one presenting with myocardial infarction. We also present a comprehensive review of the literature and provide a compilation of all case reports to date.

Background Regular exercise increases exercise capacity and physical fitness, but questions remain about the effects of exercise on left ventricle (LV) remodeling after myocardial infarction. This study investigated the effects of moderate to high intensity exercise training on LV remodeling after a first myocardial infarction. Methods An exercise group of 68 patients in cardiac rehabilitation after a first myocardial infarction had an initial echocardiogram and exercise stress test. Thirty patients completed the 12 weeks of training and had echocardiograms suitable for quantitative analysis. Follow-up echocardiograms and exercise tests were performed. A carefully matched control group of 30 patients with echocardiograms at fixed intervals after myocardial infarction and no formal exercise training were also studied. LV size was expressed as the endocardial surface area-to-body surface area (ESAi), whereas infarct size was characterized by the percent abnormal wall motion (%AWM) by echocardiography using an endocardial surface area mapping technique. Indices of LV shape (sphericity) were also assessed. Results In the exercise group, no significant changes were seen in ESAi (57.95 +/- 13.1 vs 57.80 +/- 12.04 cm2/m2) or in %AWM (19.33 +/- 15.27 vs 20.11 +/- 15.95) from the initial to the final echo. The indices of sphericity were also unchanged. None of these parameters changed in the control group. Within each group was found heterogeneity in LV remodeling. Multivariate regression analysis revealed initial ESAi and initial %AWM to predict change in ESAi over time. Conclusions In this study of patients with predominately small infarcts, exercise training did not adversely affect LV remodeling after myocardial infarction. Remodeling is heterogeneous and appears related to infarct and LV size.

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the appropriate use of diagnostic tests and therapies for patients with known or suspected cardiovascular disease. Coronary artery bypass graft (CABG) surgery is among the most common operations performed in the world and accounts for more resources expended in cardiovascular medicine than any other single procedure. Since the original Guidelines were published in 1991, there has been considerable evolution in the surgical approach to coronary disease, and at the same time there have been advances in preventive, medical, and percutaneous catheter approaches to therapy. These revised guidelines are based on a computerized search of the English literature since 1989, a manual search of final articles, and expert opinion. As with other ACC/AHA guidelines, this document uses ACC/AHA classifications I, II, and III as summarized below: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness or efficacy of a procedure. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. ### A. Hospital Outcomes Seven core variables (priority of operation, age, prior heart surgery, sex, left ventricular [LV] ejection fraction [EF], percent stenosis of the left main coronary artery, and number of major coronary arteries with significant stenoses) are the most consistent predictors of mortality after coronary artery surgery. The greatest risk is correlated with the urgency of operation, advanced age, and 1 or more prior coronary bypass surgeries. Additional variables that are related …

Assessment of cost issues has assumed increasing importance in cardiology, as it has in all medicine. As managed care organizations, Medicare, and other payers have come under increased pressure to contain rising health care costs, physicians have been increasingly forced to justify their clinical decisions by relying on evidence-based medicine and outcomes research. Accordingly, proponents of particular diagnostic or treatment strategies need to evaluate these strategies not only by clinical outcomes, but also by cost and cost-effectiveness. 18,26 Stress echocardiography (stress echo), which includes both exercise echocardiography and pharmacologic stress (usually dobutamine) echocardiography is a relatively new diagnostic testing strategy that has rapidly assumed an important role in cardiovascular diagnosis. 51 The diagnostic accuracy is similar to that of stress nuclear (SN) studies, such as exercise single photon emission computed tomography (SPECT) and dipyridamole-SPECT. Because it is one of several potentially useful diagnostic procedures in cardiovascular medicine, stress echo should be evaluated not simply in terms of its effectiveness in diagnosing coronary artery disease (CAD) and assessing prognosis, effectiveness of treatment, and myocardial viability, but should also be examined in terms of relative costs and benefits compared with other diagnostic modalities. 5

Background Remodeling of the left ventricle with the development of a spherical cavity occurs in dilated cardiomyopathy and is associated with a poor long-term prognosis. The early effects of myocarditis on left ventricular geometry have not been previously described or correlated with clinical outcome. Methods The baseline echocardiograms of 35 patients with biopsy-confirmed myocarditis were compared with 20 normal controls. Left ventricular end-diastolic volume, long axis length, and mid-cavity diameter were measured. The degree of sphericity was expressed as the ratio of the mid-cavity diameter to the long axis length. Left ventricular ejection fraction was assessed by radionuclide angiography. Results In patients with myocarditis, mean left ventricular volume of 81 ± 29 mL/m 2 was significantly greater than 50 ± 8 mL/m 2 in controls ( P = .001). Chamber dilatation occurred primarily along the mid-cavity diameter, which measured 5.3 ± 0.8 cm in patients with myocarditis versus 4.2 ± 0.4 cm in controls ( P = .001). The degree of left ventricular sphericity in patients with myocarditis, 0.64 ± 0.08, was significantly greater than that of controls, 0.54 ± 0.04 ( P = .001). When patients were stratified according to left ventricular volume, patients with increased left ventricular volume (>75 mL/m 2 ) were associated with a more spherical chamber and lower left ventricular ejection fraction than patients with a more normal left ventricular volume (≤75 mL/m 2 ). Conclusions Active myocarditis is associated with early left ventricular remodeling and the development of a spherical chamber. These changes correlate with ventricular dilatation and reduced left ventricular ejection fraction. (Am Heart J 1999;138:303-8.)

This study was designed to characterize the geometry and function of the right ventricle and its prognostic significance in patients with primary (AL) cardiac amyloidosis. AL amyloidosis is an infiltrative systemic disease that can result in thickening of heart structures and rapidly progressive congestive heart failure due to restrictive ventricular physiology and eventual systolic dysfunction. Thirty-seven patients with AL amyloid heart involvement and 20 normal control subjects were evaluated using 2-dimensional and Doppler echocardiography. Based on the ratio of left-to-right end-diastolic ventricular chamber areas, patients were classified into 2 groups: 25 patients with disproportionate right ventricular (RV) dilation (left ventricular to RV ratio 2. Patients with a relatively dilated right ventricle (ratio 2 (10 months, p

Background. Familial amyloidosis (FAP) is characterized by the progression of neurologic and cardiac impairment ultimately leading to death within 7 to 15 years after the onset of the disease. Liver transplantation represents the only definitive therapy for this disease and has been performed since 1990. Methods. To determine the effect of liver transplantation on disease progression, electrocardiography and Doppler echocardiography were performed and blindly analyzed on 11 patients with FAP who were followed 0.8 to 8.6 years before liver transplantation and 0.8 to 4.1 years after liver transplantation. Results. After liver transplantation, five patients showed progression of left ventricular wall thickening with increased left ventricular mass, and three of these five showed a reduction in electrocardiographic voltage despite abolition of the mutant protein from the serum. Of the five patients showing progressive wall thickening, four had the transthyretin variant Glu 42 Gly and one patient had the Ala 36 Pro variant; none of the remaining six patients, all of whom possessed the Val 30 Met variant, showed echocardiographic changes. Although 9 of the 11 patients have shown symptomatic improvement in neurologic symptoms, 1 patient has developed heart failure and a second patient has suffered a sudden cardiac death. Conclusions. After liver transplantation, patients with FAP should have regular clinical evaluations including electrocardiographic and echocardiographic examinations to look for continued deterioration in heart structure or function.

Background . Recently, endoaneurysmorrhaphy has been proposed as a more physiologic repair of postinfarction left ventricular aneurysm than is linear repair. There are only a few studies comparing the short-term and long-term results of the two techniques. Methods . Clinical outcomes and echocardiographic measurements of left ventricular volume and sphericity in 27 patients who underwent endoaneurysmorrhaphy were compared with those in 20 patients who had linear repair. Results . The two groups were matched with respect to age, gender, comorbid risk factors, functional class, urgency of the operation, and concomitant procedures. Preoperatively, left ventricular ejection fraction was lower in the endoaneurysmorrhaphy group (0.25 ± 0.08 versus 0.30 ± 0.09; p = 0.03). Follow-up was available in 44 patients (94%) and ranged from 2 to 86 months (mean, 41.0 ± 26.5 months). Thirty-day operative mortality, perioperative complications, 5-year survival, and freedom from cardiac death were similar. Early postoperative percentage increase in left ventricular ejection fraction was greater after endoaneurysmorrhaphy (0.51 ± 0.64 versus 0.18 ± 0.48; p = 0.036). Long-term functional improvement was significantly better in the endoaneurysmorrhaphy group: At the time of last follow-up, 88% of patients were in New York Heart Association class I/II, compared with 53% after linear repair ( p = 0.01). There were no measurable differences between the groups with respect to left ventricular ejection fraction (0.28 ± 0.11 versus 0.27 ± 0.11; p = 0.90), left ventricular volume (171.6 ± 59.1 versus 169.9 ± 54.4 mL; p = 0.94), and sphericity index (0.61 ± 0.09 versus 0.61 ± 0.12; p = 1.0). Conclusions . Despite having a similar effect on left ventricular geometry, endoaneurysmorrhaphy resulted in a greater increase in postoperative left ventricular ejection fraction and a substantially improved long-term clinical outcome.

Doppler pressure half-time is a reliable method for estimating mitral valve area when net left atrial and ventricular compliance remain stable. The accuracy of Doppler pressure half-time in estimating mitral valve area in older patients is unknown. We studied 80 patients (65 women and 15 men, aged 56 ± 14 years) with cardiac catheterization and echocardiography. Mitral valve area was calculated using the Gorlin formula and by the Doppler pressure half-time method. Patients were stratified into those aged

Three cases of rapidly reversible severe myocardial depression are described in patients with status asthmaticus. Initial echocardiograms obtained within 1 day of hospital admission revealed global left ventricular hypokinesis with ejection fractions of 11 to 34%. Follow-up echocardiograms obtained only 3 to 8 days later revealed marked improvement of left ventricular function. Possible mechanisms responsible for the observed rapidly reversible myocardial depression and the clinical implications of this finding are discussed.

Objectives. This study attempted to determine the importance of severe proximal right coronary artery disease as a predictor of atrial fibrillation in patients after coronary artery bypass surgery.Background. Studies in patients undergoing noncardiac surgery have suggested that ischemia in the right coronary artery distribution is associated with a high incidence of atrial fibrillation. However, the importance of right coronary artery disease as a predictor of atrial fibrillation after bypass surgery is unknown.Methods. The occurrence of sustained postoperative atrial fibrillation was studied prospectively in 168 consecutive patients undergoing coronary artery bypass grafting. Patients were followed up postoperatively until discharge. Severe right coronary artery stenosis was defined as ≥70% lumen narrowing.Results. Of 104 patients with proximal or mid right coronary artery stenosis, 45 (43%) had atrial fibrillation postoperatively compared with 12 (19%) of the 64 patients without significant right coronary disease (p = 0.001). Univariate predictors of atrial fibrillation included right coronary artery stenosis (p = 0.001), advancing age (p = 0.0001) and lack of beta-adrenergic blocking agent therapy after bypass surgery (p = 0.0004). Multivariate adjusted risk of developing atrial fibrillation after bypass surgery increased with the presence of severe right coronary artery disease (odds ratio 3.69, 95% confidence interval [CI] 1.61 to 8.48), advancing age (odds ratio 2.24/10 years, CI 1.48 to 3.41) and male gender (odds ratio 2.36, CI 1.01 to 5.49). The use of beta-blockers postoperatively was associated with a protective effect (odds ratio 0.4, CI 0.17 to 0.80).Conclusions. The presence of severe right coronary artery stenosis is an independent and powerful predictor of atrial fibrillation after coronary artery bypass surgery. In association with age, gender and postoperative beta-blocker therapy, these variables can be used to identify patients at increased risk for developing this arrhythmia.

Objectives . The aim of this study was to assess the incidence and severity of left ventricular diastolic dysfunction immediately after coronary artery bypass surgery by utilizing simultaneous transesophageal echocardiographic and hemodynamic monitoring. Background . Left ventricular diastolic dysfunction has been documented after coronary bypass surgery, but its measurement has been technically difficult to acquire and limited by dependence on loading conditions. Methods . End-diastolic pressure-area curves were constructed before and immediately after coronary bypass surgery in 20 patients. Transesophageal echocardiographic images at the mid-papillary level of the left ventricle and hemodynamic data were recorded. Volume status was manipulated to alter loading conditions, and muitiple measurements were taken at each loading condition. Results . Diastolic function worsened in all patients, as manifested by a postoperative leftward shift of the end-diastolic pressure-area curve. At a comparable preload, mean end-diastolic area ± SEM decreased by 15% from 17.6 ± 0.8 to 14.9 ± 0.8 cm 2 postoperatively (p = 0.0001). Conclusions . Left ventricular diastolic chamber stiffness frequently increases immediately after coronary artery bypass surgery. Simultaneous hemodynamic and transesophageal echocardiographic monitoring, through the construction of end-diastolic pressure-area curves, is a useful method to evaluate diastolic function and guide management after cardiac surgery.

To assess the predictive value of right ventricular systolic function in patients with active myocarditis, the echocardiograms of 23 patients with biopsy-confirmed myocarditis were reviewed. Right ventricular systolic function was evaluated qualitatively and quantitatively by descent of the right ventricular base. Patients were divided into those with normal right ventricular function, in whom right ventricular descent was 1.9 +/- 0.1 cm, and those with abnormal right ventricular function, in whom right ventricular descent was 0.8 +/- 0.1 cm (p0.001). There were no differences between the two groups in age, duration of symptoms, baseline hemodynamics, or histologic assessment. Initial left ventricular ejection fraction was significantly lower in patients with depressed right ventricular function (27.5 +/- 4.9%) compared with that in patients with normal right ventricular function (47.5 +/- 6.3%) (p = 0.01). The likelihood of an adverse outcome, defined as death or need for cardiac transplantation, was greater in patients with abnormal right ventricular function (right ventricular descentor = 1.7 cm) than in patients with normal right ventricular function (right ventricular descent1.7 cm) (p0.03). Multivariate analysis revealed that right ventricular dysfunction as quantified by right ventricular descent was the most powerful predictor of adverse outcome.

Myocardial ischemia and infarction are known to cause changes in both ventricular shape and function. Little is known about the recovery of ventricular geometry after transient myocardial ischemia and its relationship to recovery of function. To examine the pattern of recovery of ventricular geometry following transient coronary artery occlusion and to assess the relationship of this to the return of systolic function, we used echocardiography to study 13 dogs following 15-minute occlusion of the left anterior descending coronary artery. During ischemia, total endocardial surface area (ESA) increased from 32.55 +/- 1.77 to 45.36 +/- 3.18 cm2 (p = 0.001). The most striking increase was at the apex, where circumference increased from 5.04 +/- 0.24 at baseline to 7.86 +/- 0.43 cm at the end of occlusion (p = 0.0001), an increase of 58%. During reperfusion, ventricular geometry rapidly returned toward normal (baseline), with recovery of 80% of the increase in ESA evident by 15 minutes of reperfusion. Recovery of systolic function was substantially slower (p < 0.005 for all periods of observation during the 2 hours of reperfusion). During reperfusion, recovery of ventricular geometry and function was not uniform throughout the ischemic bed. The apex recovered most slowly, with the centroid of the area of abnormal contraction progressively moving along the long axis of the left ventricle toward the apex. There was also a progressive decrease in the radius of the area of dysfunction, from 2.0 +/- 0.15 at end occlusion to 0.13 +/- 0.07 cm at 120 minutes of reperfusion (p = 0.0001). There was no difference in blood flow between the apical and anterior segments during ischemia or reperfusion. Reperfusion favorably reduced the ischemic zone dilation before recovery of active systolic function and geometric recovery thus may be important in determining ultimate functional recovery. In addition, recovery of function proceeded inward towards the center of the ischemic territory and in a wavefront from the base to apex. This heterogeneous and asymmetric recovery suggests that sampling at one point within the ischemic zone may not reflect the true temporal pattern of recovery.

Aortic stenosis (AS) is 1 of the most common valve disorders encountered in clinical practice and 1 of the most frequent indications for valve replacement surgery. Decades of research and clinical experience have resulted in the development of guidelines that provide the clinician with an evidence-based approach to the management of patients with valvular disease.1 Nonetheless, there remain patients with AS for whom management decisions are less clearly defined and who continue to pose significant diagnostic and therapeutic dilemmas. Severe AS has been defined as that associated with a valve area 40 mm Hg, and a peak flow velocity >4.0 m/s1. Patients with severe AS have a significant risk of cardiac morbidity and mortality2,3 and have improved symptoms and reduced mortality following aortic valve replacement (AVR).3 Traditionally, the decision to proceed with AVR in patients with AS has been based on the assessment of aortic valve area (AVA) and the presence of associated symptoms. However, as many as 30% of patients who have a calculated AVA in the severe range have other parameters suggesting mild or moderate disease (ie, mean gradient

Stress echocardiography has become a valuable clinical tool in recent years. Different forms of cardiovascular stresses, ranging from treadmill exercise to pharmacologic agents, may be coupled with two dimensional echocardiography to accurately assess the presence and significance of coronary artery disease. Stress echocardiography also provides important prognostic and diagnostic information in a variety of clinical settings such as after myocardial infarction, before noncardiac surgery, and postrevascularization with bypass surgery or coronary angioplasty. In patients unable to exercise, pharmacologic stress echocardiography using dobutamine, dipyridamole or adenosine may be used. When compared with thallium imaging, stress echocardiography has a comparable accuracy for the detection of coronary artery disease, safer risk profile, and lower cost, and may represent the ideal form of noninvasive imaging for coronary disease. (Cardiol Rev 1993;1:6, 350-362)

Previous studies demonstrated changes in aortic valve area calculated by the Gorlin equation under conditions of varying transvalvular flow in patients with valvular aortic stenosis (AS). To distinguish between flow-dependence of the Gorlin formula and changes in actual orifice area, the Gorlin valve area and 2 other measures of severity of AS, continuity equation valve area and valve resistance, were calculated under 2 flow conditions in 12 patients with AS. Transvalvular flow rate was varied by administration of dobutamine. During dobutamine infusion, right atrial and left ventricular end-diastolic pressures decreased, left ventricular peak systolic pressure and stroke volume increased, and systolic arterial pressure did not change. Heart rate increased by 19%, cardiac output by 38% and mean aortic valve gradient by 25%. The Gorlin valve area increased in all 12 patients by 0.03 to 0.30 cm2. The average Gorlin valve area increased from 0.67 +/- 0.05 to 0.79 +/- 0.06 cm2 (p0.001). In contrast, the continuity equation valve area (calculated in a subset of 6 patients) and valve resistance did not change with dobutamine. The data support the conclusion that flow-dependence of the Gorlin aortic valve area, rather than an increase in actual orifice area, is responsible for the finding that greater valve areas are calculated at greater transvalvular flow rates. Valve resistance is a less flow-dependent means of assessing severity of AS.

Although the presence of abnormal late gadolinium enhancement (LGE) in cardiac amyloidosis has been well established, its prognostic implication and utility to identify cardiac involvement in patients with systemic amyloidosis is unknown. The aim of this study was to assess the diagnostic and prognostic significance of cardiovascular magnetic resonance imaging in patients with amyloid light-chain amyloidosis but unknown cardiac involvement. Cardiovascular magnetic resonance imaging with LGE was performed in 28 patients with systemic amyloidosis. The presence of cardiac amyloidosis was determined by separate clinical evaluation. The performance of LGE for the prediction of cardiac amyloidosis and prognostic implications of LGE were determined. LGE was observed in 19 patients (68%). The sensitivity, specificity, positive predictive value, and negative predictive value of LGE for the identification of clinical cardiac involvement were 86%, 86%, 95%, and 67%, respectively. During a median follow-up period of 29 months, there were 5 deaths (82% survival). LGE itself did not predict survival (p = 0.62). LGE volume was positively correlated with serum level of B-type natriuretic peptide (BNP; R = 0.64, p < or =0.001), and in multivariate analysis, LGE volume proved the strongest independent predictor of BNP. BNP was correlated with New York Heart Association class (p = 0.03). Reduced right ventricular end-diastolic volume (p

Background The purpose of this retrospective analysis was to define the incidence of severe adverse events after exposure to ultrasound contrast agents. Methods Data between January 1, 2001, and September 30, 2007, were collected using invited responses to an on-line web-based questionnaire from 1 general and 12 cardiac ultrasound laboratories. During a period of 4.5 ± 2.4 years, a total of 66,164 doses of Definity (Lantheus Medical Imaging, North Billerica, MA) and 12,219 doses of Optison (GE Healthcare, Buckinghamshire, UK) were administered, reflecting contrast use in 5% of transthoracic and 28% of stress echocardiographic procedures. More than 10,000 doses were given to critically ill patients in intensive care unit settings or to patients with acute chest pain of suspected cardiac origin. The median age of patients who received an ultrasound contrast agent was 60 years, 49% were male, and the mean body mass index was 32 ± 1.4 g/m −2 . Results Severe reactions that were considered "probably" related to an ultrasound contrast agent developed in 8 patients (0.01%), all of whom were outpatients, and 4 (0.006%) of these were consistent with anaphylactoid reactions. There were no deaths reported. All patients recovered with treatment. No serious events were seen in inpatients. Conclusion This multicenter, retrospective analysis includes the largest number of doses of ultrasound contrast agents ever published and a large number of patients evaluated in a wide variety of settings, including the critically ill. It shows that these agents have a good safety profile in both cardiac and abdominal ultrasound applications. The incidence of severe adverse reactions to ultrasound contrast agents is no greater, and may be lower, than that reported for contrast agents commonly used in other cardiac imaging tests.

Hypertrophic cardiomyopathy and cardiac amyloidosis result in thickening of the left ventricle, as visualized by 2-dimensional echocardiography. Hemodynamically, hypertrophic cardiomyopathy can be typified by a left ventricular outflow tract gradient and systolic anterior motion of the mitral apparatus, findings rarely seen in cardiac amyloidosis. This case series reports 4 patients with cardiac light-chain amyloidosis and left ventricular outflow tract obstruction at rest, suggesting that there may be echocardiographic overlap between these 2 disparate disease processes. In a series of consecutive patients with cardiac light-chain amyloidosis over a 2-year period, the prevalence of these echocardiographic findings was approximately 4%. In conclusion, awareness of this overlap in echocardiographic presentation may permit more accurate diagnosis, particularly at early stages of amyloid disease, when more treatment options exist.

The intersection of cancer and cardiovascular disease occurs on several levels. The present miniseries, within Circulation ’s Contemporary Reviews in Cardiovascular Medicine series, will highlight important areas within the emerging discipline of cardio-oncology. The miniseries will straddle a number of topics, as outlined …

An update of new developments with multidetector computed tomography (MDCT) coronary angiography is presented. Similar to what has occurred with the introduction of other new technologies such as electron beam computed tomography (EBCT), life insurance medical directors are expected to evaluate a technology before there are sufficient data from large clinical trials. Well-performed studies of the performance of MDCT coronary angiography have only recently appeared. MDCT appears to perform well for excluding significant coronary disease, and will perhaps be useful in emergency room "rule-out" situations. Other applications may be for the diagnosis of significant coronary obstruction (75% stenosis), as well as for the evaluation of bypass grafts. Limitations include the requirement for radiologic contrast administration and significant radiation exposure. MDCT does not provide information on atheroma morphology. Given these limitations, MDCT coronary angiography utilization will grow, and it will prove to be a useful tool in specific situations.

Patients with multivessel coronary artery disease (CAD) are now faced with a number of treatment choices, including coronary artery bypass graft surgery, medical therapy, and percutaneous coronary interventions (using bare-metal or drug-eluting stents). Each carries certain benefits and risks: bypass surgery is favored in the subset of patients with multivessel disease and diabetes or impaired left ventricular systolic function who are able to receive a left internal mammary artery graft; medical therapy consisting of beta-blockers, angiotensin-converting enzyme inhibitors, statins, aspirin, and nitrates is offered to patients with stable angina. Percutaneous procedures have previously been limited in their efficacy by restenosis and resulting morbidity, but contemporary stenting procedures appear to show equivalent mortality and morbidity outcomes (to bypass surgery) at 5 years. Drug-eluting stents are the newest percutaneous technique and show significant reduction in restenosis compared with older catheter-based therapies, but further investigation is needed to definitively define the role of drug-eluting stents in the treatment of multivessel CAD. This review summarizes the data comparing medical, surgical, and percutaneous treatment approaches for patients with multivessel CAD.

Small deposits of amyloid are often found in the hearts of elderly patients. However, extensive deposition of transthyretin-derived amyloid fibrils in the heart (senile systemic amyloidosis [SSA]) can cause heart failure. The clinical features of SSA that involve the heart are ill defined, and the condition may be overlooked as a cause of heart failure. We sought to better define the clinical, echocardiographic, and electrocardiographic features of cardiac involvement in SSA and to compare them with the findings in patients with light chain-associated (AL) amyloidosis that affects the heart.Eighteen consecutive patients with SSA and heart failure evaluated at a tertiary referral center for the diagnosis and treatment of amyloidosis were compared with 18 randomly selected patients with AL amyloidosis that involved the heart. All patients underwent a complete clinical and biochemical evaluation. Echocardiograms and electrocardiograms were interpreted by blinded investigators.Patients with SSA were older than those with AL amyloidosis and were all male. Proteinuria (protein output of1 g per 24 hours) was common in AL amyloidosis but was not present in SSA. Left ventricular wall thickness was greater in patients with SSA than those with AL amyloidosis, but despite thicker walls and older age, the severity of heart failure was less in the SSA group and the median survival was much longer (75 vs 11 months; P = .003).Senile systemic amyloidosis is a disorder of elderly men and is characterized by amyloidosis clinically limited to the heart. In contrast to the rapid progression of heart failure in AL amyloidosis, SSA results in slowly progressive heart failure. The difference in survival, despite evidence of more myocardial disease in the senile group, suggests that heart failure in AL amyloidosis may have a toxic component, possibly related to the circulating monoclonal light chain.