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Background Chest radiation therapy (CRT) for malignant thoracic neoplasms is associated with development of valvular heart disease years later. As previous radiation exposure can complicate surgical treatment, transcatheter aortic valve replacement (TAVR) has emerged as an alternative. However, outcomes data are lacking for TAVR patients with a history of CRT. Methods We conducted a retrospective study of all patients who underwent a TAVR procedure at a single institution between September 2012 and November 2018. Among 1341 total patients, 50 had previous CRT. These were propensity-matched in a 1:2 ratio to 100 patients without history of CRT. Thirty-day adverse events were analyzed with generalized estimating equation models. Overall mortality was analyzed with stratified Cox regression modelling. Results Median clinical follow-up was 24 months (interquartile range [IQR], 12–44 months). There was no difference between CRT and non-CRT patients in overall mortality (hazard ratio [HR] 0.84 [0.37–1.90], P = 0.67), 30-day mortality (HR 3.1 [0.49–20.03], P = 0.23), or 30-day readmission rate (HR 1.0 [0.43–2.31], P = 1). There were no differences in the rates of most adverse events, but patients with CRT history had higher rates of postprocedural respiratory failure (HR 3.63 [1.32–10.02], P = 0.01) and permanent pacemaker implantation (HR 2.84 [1.15–7.01], P = 0.02). Conclusions For patients with aortic valve stenosis and previous CRT, TAVR is safe and effective, with outcomes similar to those in the general aortic stenosis population. Patients with history of CRT are more likely to have postprocedural respiratory failure and to require permanent pacemaker implantation.

Graphical abstract, Highlights • Cor triatriatum dexter (CTD) can complicate percutaneous atrial septal interventions. • Clinically silent (forme fruste) CTD is detectable by new echocardiography techniques. • Using these techniques could improve patient selection and guide interventions.

Radiation treatment of thoracic malignancies is linked with development of valvular disease years after exposure. Given the challenges to surgical treatment related to previous radiation exposure, TAVR has emerged as an alternative. However, outcomes data for patients with history of mediastinal

Guidelines have been previously published for the use of echocardiography during each of the various phases of care for left ventricular assist device (LVAD) patients [1]. This chapter focuses on the use of surveillance echocardiography either before hospital discharge or during routine scheduled follow-up appointments. Surveillance examinations can confirm individual patients’ baseline echo parameters, which can later be used for problem solving if the patient presents with new abnormal signs or symptoms. Also, surveillance examinations can detect abnormalities of the native heart and pump malfunctions that might otherwise remain occult, particularly in less active patients.

Myxedema coma can mask cardiac causes of hypotension. Careful assessment is needed once initial therapy fails. A 43-year-old woman with untreated hypothyroidism presented with hypotension, respiratory distress, and somnolence after 6 months of progressive dyspnea and weight gain. She was

The American College of Cardiology Foundation (ACCF), in partnership with key specialty and subspecialty societies, conducted a review of common clinical scenarios where noninvasive vascular testing (venous ultrasound and physiological testing) is frequently considered. The indications (clinical

Peter Alagona, MD[⁎][1] Gerard Aurigemma, MD[‡][2] Javed Butler, MD, MPH[§][3] Don Casey, MD, MPH, MBA[∥][4] Ricardo Cury, MD[#][5] Scott Flamm, MD[¶][6] Tim Gardner, MD[⁎⁎][7] Rajesh Krishnamurthy, MD[††][8] Joseph Messer, MD[⁎][1] Michael W. Rich, MD[‡‡][9] Henry

Steven R. Bailey, MD, FACC, FSCAI, FAHA, Moderator Andrea M. Russo, MD, FACC, FHRS, Writing Group Liaison [⁎][1] Suraj Kapa, MD, Writing Group Liaison Michael B. Alexander, MD, FACC[§][2] Steven R. Bailey, MD, FACC, FSCAI, FAHA[∥][3] Ulrika Birgersdotter-Green, MD, FHRS[∥][3] Alan S.

The past several decades have seen rapid and extensive changes in the practice of cardiology, especially in the innovation and utilization practices of imaging, interventional, and electrophysiology procedures. Enhanced radionuclide imaging techniques, evolution of echocardiography, development of

Background The unique findings on transthoracic echocardiography of the HeartWare left ventricular assist device (LVAD) have not been previously described. Methods and Results HeartWare LVADs were implanted in 19 patients from May 2009 through December 2010; 152 comprehensive transthoracic echocardiograms (TTEs) performed postoperatively on these patients were retrospectively analyzed for device component visualization, inlet cannula/outflow conduit flow velocities, and imaging artifacts. The inlet cannula was adequately visualized in 66% of studies, incompletely visualized in 14%, and not visualized in 20%. Spectral Doppler interrogation of inlet cannula flow velocity was always uninterpretable due to artifact. Standard parasternal long-axis and apical views always included the inlet cannula in the imaging sector, resulting in a prominent “waterfall” color Doppler artifact obscuring the mitral valve. Inclusion of the inlet cannula in the imaging sector also precluded spectral Doppler interrogation of the mitral valve owing to artifact. The outflow conduit was partially visualized and interrogated by spectral Doppler in 68% of studies, and the average measured peak flow velocity was 1.4 m/s (range 1.0–1.9 m/s). Conclusions The HeartWare LVAD inlet cannula and outflow conduit are both readily visualized by TTE in a majority of patients. However, significant color and spectral Doppler artifacts occur when the inlet cannula is visualized in the imaging sector, necessitating routine off-axis Doppler interrogation of the mitral valve.

The American College of Cardiology Foundation, in collaboration with the Society for Cardiovascular Angiography and Interventions and key specialty and subspecialty societies, conducted a review of common clinical scenarios where diagnostic catheterization is frequently considered. The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of noninvasive imaging appropriate use criteria. The 166 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median 7 to 9), uncertain use (median 4 to 6), and inappropriate use (median 1 to 3). Diagnostic catheterization may include several different procedure components. The indications developed focused primarily on 2 aspects of diagnostic catheterization. Many indications focused on the performance of coronary angiography for the detection of coronary artery disease with other procedure components (e.g., hemodynamic measurements, ventriculography) at the discretion of the operator. The majority of the remaining indications focused on hemodynamic measurements to evaluate valvular heart disease, pulmonary hypertension, cardiomyopathy, and other conditions, with the use of coronary angiography at the discretion of the operator. Seventy-five indications were rated as appropriate, 49 were rated as uncertain, and 42 were rated as inappropriate. The appropriate use criteria for diagnostic catheterization have the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research. © 2012 Wiley Periodicals, Inc.

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally, percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

Recent advances in the field of left ventricular device support have led to an increased use of left ventricular assist devices (LVADs) in patients with end stage heart disease. The primary imaging modality to monitor patients with LVADs has been echocardiography. The purpose of this review is to highlight the clinical role of echo and other noninvasive imaging modalities in the assessment of cardiac structure and function in patients with pulsatile and continuous flow LVADs. In addition, we discuss the role of imaging with emphasis on echo to detect LVAD dysfunction and device related complications.

Michael H. Picard, MD, FASE, David Adams, RDCS, FASE, S. Michelle Bierig, RDCS, MPH, FASE, JohnM.Dent,MD,FASE, Pamela S.Douglas,MD,FASE,LindaD.Gillam,MD,FASE,AndrewM.Keller,MD,FASE, David J. Malenka, MD, FASE, Frederick A. Masoudi, MD, MSPH, Marti McCulloch, RDCS, FASE, Patricia A. Pellikka, MD, FASE, Priscilla J. Peters, RDCS, FASE, Raymond F. Stainback, MD, FASE, G.Monet Strachan, RDCS, FASE, andWilliam A. Zoghbi,MD, FASE, Boston, Massachusetts; Durham,North Carolina; St. Louis, Missouri; Charlottesville, Virginia; New York, New York; Danbury, Connecticut; Lebanon, New Hampshire; Denver, Colorado; Houston, Texas; Rochester, Minnesota; Pennsauken, New Jersey; San Diego, California

Three patients from different centers with pacemaker or ICD leads endocardially implanted in the left ventricle are described. All leads, two ventricular pacing leads and one ICD lead, were inserted through a patent foramen ovale or an atrial septum defect. The diagnosis was made 9 months, 14 months, and 16 years, respectively, after implantation. All patients had right bundle branch block configuration during ventricular pacing. Chest X ray was suggestive of a left-sided positioned lead except in the ICD patient. Diagnosis was confirmed with echocardiography in all patients. One patient with a ventricular pacing lead presented with a transient ischemic attack at 1-month postimplantation. During surgical repair of the atrial septum defect 14 months later, the lead was extracted and thrombus was attached to the lead despite therapy with aspirin. The other patients were asymptomatic without anticoagulation (9 months and 16 years after implant). No thrombus was present on the ICD lead at the time of the cardiac transplantation in one patient. We reviewed 27 patients with permanent leads described in the literature. Ten patients experienced thromboembolic complications, including three of ten patients on antiplatelet therapy. The lead was removed in six patients, anticoagulation with warfarin was effective for secondary prevention in the four remaining patients. In the asymptomatic patients, the lead was removed in five patients. In the remaining patients, 1 patient was on warfarin, 2 were on antiplatelet therapy, and in 3 patients the medication was unknown. After malposition was diagnosed, three additional patients were treated with warfarin. In conclusion, if timely removal of a malpositioned lead in the left ventricle is not preformed, lifelong anticoagulation with warfarin can be recommended as the first choice therapy and lead extraction reserved in case of failure or during concomitant surgery.

The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting. The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1 to 9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes. Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to low-risk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.

Sinus of Valsalva aneurysms appear to be rare. They occur most frequently in the right sinus of Valsalva (52%) and the noncoronary sinus (33%). More of these aneurysms originate from the right coronary cusp than from the noncoronary cusp. Surgical intervention is usually recommended when symptoms become evident. We report the case of a 34-year-old woman who presented with a congenital, ruptured sinus of Valsalva aneurysm that originated from the noncoronary cusp. Moderate aortic regurgitation was associated with this lesion. Simple, direct patch closure of the ruptured aneurysm resolved the patient's left-to-right shunt and was associated with decreased aortic regurgitation to a degree that valve replacement was not necessary. Only trace residual aortic regurgitation was evident after 3 months, and the patient remained free of symptoms after 6 months. Our observations support the idea that substantial runoff blood flow in the immediate supra-annular region can be responsible for aortic regurgitation in the absence of a notable structural defect in the aortic valve, and that restoring physiologic flow in this region and equalizing aortic-cusp closure pressure can largely or completely resolve aortic insufficiency. Accordingly, valve replacement may not be necessary in all cases of ruptured sinus of Valsalva aneurysms with associated aortic valve regurgitation.

Objectives.This study sought to determine the prognostic yield and utility of transesophageal echocardiography in critically ill patients with unexplained hypotension.Background.Transesophageal echocardiography is increasingly utilized in the intensive care setting and is particularly suited for the evaluation of hypotension; however, the prognostic yield of transesophageal echocardiography in these patients is unknown.Methods.We prospectively studied 61 adult patients in the intensive care unit with sustained (>60 min) unexplained hypotension. Both transthoracic and transesophageal echocardiography were performed, and results were immediately disclosed to the primary physician, who reported any resulting changes in management. Patients were classified on the basis of transesophageal echocardiographic findings into one of three prognostic groups: 1) nonventricular (valvular, pericardial) cardiac limitation to cardiac output; 2) ventricular failure; and 3) noncardiac systemic disease (hypovolemia or low systemic vascular resistance, or both). Primary end points were death or discharge from the intensive care unit.Results.A transesophageal echocardiographic diagnosis of nonventricular limitation to cardiac output was associated with improved survival to discharge from the intensive care unit (81%) versus a diagnosis of ventricular disease (41%) or hypovolemia/ low systemic vascular resistance (44%, p = 0.03). Twenty-nine (64%) of 45 transthoracic echocardiographic studies were inadequate compared with 2 (3%) of 61 transesophageal echocardiographic studies (p < 0.001). Transesophageal echocardiography contributed new clinically significant diagnoses (not seen with transthoracic echocardiography) in 17 patients (28%), leading to operation in 12 (20%).Conclusions.Transesophageal echocardiography makes a clinically important contribution to the diagnosis and management of unexplained hypotension and predicts prognosis in the critical care setting.

Exposing the heart to external beam radiotherapy (EBRT) increases the risk of heart disease sevenfold. We report 23 patients with previous EBRT and critical aortic stenosis (AS) who were treated with transcatheter aortic valve implantation (TAVI). Of the 424 consecutive patients who underwent TAVI

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Isolated ventricular myocardial noncompaction is a cardiomyopathy that is being diagnosed more frequently in patients of all ages because of increased awareness and improvements in imaging methods. It is an extremely rare cause of heart failure in nonagenarians. We describe the case of a man who presented with heart failure for the first time at 90 years of age. The diagnosis was isolated left ventricular noncompaction. Transthoracic echocardiography showed a trabeculated, sponge-like appearance of the left ventricular apical and inferolateral segments. After medical management, the patient was asymptomatic at the 3-month follow-up examination. Knowledge of ventricular noncompaction is increasing within the cardiology community. Patients who have isolated noncompaction with a limited number of involved ventricular segments can live beyond normal life expectancy without developing heart failure. In addition to discussing our patient's case, we briefly review the relevant medical literature.

The American College of Cardiology Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac computed tomography (CCT) is frequently considered. The present document is an update to the original CCT/cardiac magnetic resonance appropriateness criteria published in 2006, written to reflect changes in test utilization, to incorporate new clinical data, and to clarify CCT use where omissions or lack of clarity existed in the original criteria.1 The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Ninety-three clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of CCT angiography for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease was viewed favorably, whereas testing in high-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Use of noncontrast computed tomography for calcium scoring was rated as appropriate within intermediate- and selected low-risk patients. Appropriate applications of CCT are also within the category of cardiac structural and functional evaluation. It is anticipated that these results will have an impact on physician decision making, performance, and reimbursement policy, and that they will help guide future research. In an effort to respond to the need for the rational use of imaging services in the delivery of high-quality care, the ACCF has undertaken a process to determine the appropriate use of cardiovascular imaging for selected patient indications. Appropriate use criteria publications reflect an ongoing effort by the ACCF to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures …

Although the long-term prognosis for patients with a normal dobutamine stress echocardiographic result is good, most studies have focused on men. We assessed the long-term cardiac prognosis for women by reviewing the cases of 100 women who underwent dobutamine stress echocardiography for suspected coronary artery disease and found that women with a normal result have an excellent long-term cardiac prognosis.

Contrast echocardiography is recognized to be a safe, effective technique for evaluating the endocardial border and left ventricular function in patients who have suboptimal non-contrast echocardiograms. However, its use in diagnosing right-heart conditions is less well established. Herein, we report our experience with the use of contrast echocardiography for diagnosing 3 distinct right-sided heart conditions (hypokinesis of the right ventricular free wall, severe tricuspid regurgitation, and cardiac tamponade) in patients who had suboptimal echocardiograms. Further studies should be done to validate the use of contrast echocardiography for diagnosing right-heart conditions.