Epicardial and pericardial adipose tissue: physiological importance and role of imaging techniques.

Epicardial adipose tissue (EAT) is becoming a cardiovascular risk factor. Multiple imaging techniques are used to measure it, each one with its prons and cons. We will review the literature realizing that there is still a lot of work that needs to be done.

Left atrial appendage exclusion system for stroke prevention in atrial fibrillation: a percutaneous device delivery approach.

Atrial fibrillation (AF) is a well-known predisposing factor for stroke. Most of the thrombi responsible for these ischemic events originate in the left atrial appendage. Left atrium appendage (LAA) occlusion is a potential alternative to warfarin in patients with atrial fibrillation who have contraindications to anticoagulation. The Percutaneous LAA Transcatheter Occlusion (PLAATO System, ev3 Inc., Plymouth, Minnesota) and the WATCHMAN LAA system (Atritech Inc., Plymouth, Minnesota), are currently the two devices specifically designed for LAA occlusion. Although available data are still limited, LAA occlusion is technically feasible, with good intermediate results, but its long-term safety and ability to reduce stroke incidence remains unproven. Randomized studies will clarify the usefulness of the LAA occlusion devices as an alternative treatment strategy to long-term anticoagulation.

Candida infective endocarditis.

Candida infective endocarditis (IE) is uncommon but often fatal. Most epidemiologic data are derived from small case series or case reports. This study was conducted to explore the epidemiology, treatment patterns, and outcomes of patients with Candida IE. We compared 33 Candida IE cases to 2,716 patients with non-fungal IE in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS). Patients were enrolled and the data collected from June 2000 until August 2005. We noted that patients with Candida IE were more likely to have prosthetic valves (p < 0.001), short-term indwelling catheters (p < 0.0001), and have healthcare-associated infections (p < 0.001). The reasons for surgery differed between the two groups: myocardial abscess (46.7% vs. 22.2%, p = 0.026) and persistent positive blood cultures (33.3% vs. 9.9%, p = 0.003) were more common among those with Candida IE. Mortality at discharge was higher in patients with Candida IE (30.3%) when compared to non-fungal cases (17%, p = 0.046). Among Candida patients, mortality was similar in patients who received combination surgical and antifungal therapy versus antifungal therapy alone (33.3% vs. 27.8%, p = 0.26). New antifungal drugs, particularly echinocandins, were used frequently. These multi-center data suggest distinct epidemiologic features of Candida IE when compared to non-fungal cases. Indications for surgical intervention are different and mortality is increased. Newer antifungal treatment options are increasingly used. Large, multi-center studies are needed to help better define Candida IE.

The relation between viable segments and left ventricular ejection fraction improvement.

For patients with coronary artery disease and left ventricular dysfunction who undergo revascularization, it is important to estimate the left ventricular ejection fraction (LVEF) improvement after revascularization, as this is a strong indicator of the long-term outcome. Identification of viable segments from echocardiography has been considered a predictive sign of LVEF improvement. However, a quantitative relation between segmental function recovery and global ejection fraction improvement has not been established. There is a clinical need to determine parameters that are predictive to LVEF improvement. A cylindrical left ventricular model is proposed to establish the relation between segmental myocardial function and LVEF based on a 12-segment echocardiograph model. Model results show that LVEF improvement is directly related to the contraction ratio in normal segments and a weighted sum of the number of viable segments that recover to normal or hypokinetic, which is equal to a weighted sum of the change in wall motion scores. This new combined parameter is a better predictor of the amount of LVEF improvement than the total number of viable segments or preoperative ejection fraction. The predictive value of the model was illustrated in a group of four patients with coronary artery disease who underwent revascularization.

Transesophageal echo detection of postpartum coronary artery dissection.

A 40-year-old woman, 1 week postpartum, presented with an acute anterior-septal myocardial infarction, caused by an intrawall hematoma (dissection without intimal flap) in her proximal left anterior descending coronary artery-the diagnosis being initially suggested by transesophageal echo. Discussion of this entity follows.

The role of transesophageal echocardiography in the diagnosis and management of patients with aortic perivalvular abscesses.

Aortic valve abscesses (AVAs) are a devastating complication of aortic valve endocarditis. Over 8 years, 25 patients were diagnosed with AVA by transesophageal echo (TEE). Management and outcomes were then analyzed. Eleven (44%) AVAs involved prosthetic valves, and 6 (24%) occurred in congenitally malformed valves. Twenty patients (80%) underwent surgical intervention; the rest were treated medically. Eleven (44%) of the patients died [6 (30%) surgery patients and all the medical patients]. Eight of 11 (73%) patients who died were culture positive for Staphylococcus aureus. All patients with congenitally malformed aortic valves underwent surgical intervention and survived. We conclude that: (1) despite advances in therapy and diagnosis, patients with AVAs have a high mortality rate; (2) prognosis with AVA is especially poor when S aureus is the infectious organism; (3) patients with AVAs in congenitally malformed valves have a great outcome with surgery; (4) patients treated medically have a very poor prognosis; earlier identification by TEE may be critical to improving survival.

A prospective evaluation of angiography-guided coronary stent implantation with high versus very high balloon inflation pressure.

BACKGROUND: High inflation pressure (HP) after coronary stent deployment has become a standard approach because it has been associated with a decreased subacute stent thrombosis (SAT) rate. However, the impact of HP on long-term outcomes is still unclear. We compared the long-term results of a strategy of increasing HP (>/=12 atm) until the achievement of angiographic success (<20% residual stenosis) with a prespecified very high inflation pressure (VHP) strategy of 20 atm without intermediate inflations. METHODS AND RESULTS: We conducted a parallel-group, nonrandomized study to evaluate the short- and long-term results in 136 consecutive eligible patients who underwent successful single Palmaz-Schatz stent implantation in vessels >/=3 mm. Major adverse cardiac events (MACE), that is, death, myocardial infarction, and target lesion revascularization (TLR), were monitored for a minimum of 6 months. No significant differences were observed between the two strategies in terms of final minimal lumen diameter (HP, 3.0 +/- 0.5 vs VHP, 3. 1 +/- 0.5 mm) and acute gain (HP, 2.1 +/- 0.7 vs VHP, 2.2 +/- 0.6). The overall rate of subacute stent thrombosis was 0.7%. During a 405 +/- 148-day follow-up, 21 (28.8%) patients in the VHP group and 6 (9. 5%) in the HP group (P =.005) had MACE, with a TLR rate of 27.4% versus 7.9% (P =.009), respectively. By multivariate analysis, the use of VHP increased the odds of long-term MACE by a factor of 3.48 (P =.009). Among patients undergoing TLR, those treated with VHP had a greater lumen loss (HP, 1.83 +/- 0.57 vs VHP, 2.15 +/- 0.36 mm, P =.02) and a more frequent pattern of diffuse restenosis (71% vs 16%, P =.06). CONCLUSIONS: In our study, the two strategies had similar acute and short-term results, but VHP was associated with a poorer long-term outcome. These data provide a rationale for a less aggressive strategy for stent deployment by optimizing rather than attempting to maximize inflation pressure and stent expansion.

Transesophageal echocardiography detection of an esophageal sarcoma mimicking aortic dissection.

This report shows that transesophageal echocardiography can detect thoracic pathology, in this case esophageal sarcoma, as well as cardiac and aortic abnormalities. Transesophageal echocardiography can help differentiate cardiac from aortic or other intrathoracic pathology when the patient's history and physical examination do not provide enough information.

Hypertrophic cardiomyopathy: presentation and pathophysiology.

HCM is a heterogeneous disease with various clinical presentations. Recent advances in understanding the genetic abnormalities responsible for ventricular hypertrophy promise to improve our ability to diagnose this condition and to identify subgroups who are at the highest risk of cardiovascular mortality. Numerous difficulties remain in treating patients with HCM, including obtaining relief of symptoms and preventing SCD, but several new treatment options are currently being evaluated. In the future, randomized trials comparing the major treatment options (eg, pharmacologic therapy, myotomy/myectomy, mitral valve replacement, pacemaker implantation, and nonsurgical septal reduction) will be needed to provide guidance concerning the optimal treatment of patients with HCM.

Relation of unstable angina and myocardial infarction to progression of coronary narrowing in patients undergoing coronary artery bypass grafting (utilizing an internal mammary artery).

We examined the relation of an ischemic syndrome with the progression of coronary disease early (<3 years) after multiple bypass grafting utilizing an internal mammary artery and saphenous vein grafts. Data indicate that an ischemic syndrome is associated with progression of native coronary disease distal to the graft or total occlusion of the saphenous vein graft in most cases.