Hemodynamic Correlates of Blood Pressure in Older Adults: The Atherosclerosis Risk in Communities (ARIC) Study.

The primary aim of the present study was to identify the hemodynamic correlates of both steady and pulsatile blood pressure (BP) in community-dwelling older adults. In 3762 adults aged 70 to 89 years, significant hemodynamic determinants of both brachial and carotid systolic BP included arterial stiffness as measured by aortic pulse wave velocity, stroke volume (via echocardiography), arterial wave reflection, left ventricular ejection time, and upstroke time. The strongest influence was exerted by arterial stiffness. The steady-state component of blood pressure, mean arterial pressure, was associated with both cardiac index and total peripheral resistance (TPR), but was more strongly associated with TPR. Results were similar when participants taking antihypertensive medications were excluded from analyses. The overall findings suggest that mean arterial pressure is associated strongly with TPR and that significant hemodynamic correlates of systolic BP included arterial stiffness, stroke volume, and arterial wave reflection.

Echocardiography and cardiac MRI in mutation-negative hypertrophic cardiomyopathy in an older patient: a case defining the need for ICD.

We report the case of a 67-year-old man with hypertrophic cardiomyopathy who presented for a second opinion about implantable cardio-defibrillator (ICD) placement after a witnessed syncopal episode. Despite his older age, being mutation-negative, and having a maximal septal thickness of 2.2 cm on echocardiography, he demonstrated rapid progression of myocardial fibrosis on cardiac MRI, correlating to ventricular tachyarrhythmias and syncope. We review the role of echocardiography and cardiac MRI in optimizing medical care for such patients who may not otherwise meet criteria for an ICD placement or further interventions.

Rationale and design of a multicenter echocardiographic study to assess the relationship between cardiac structure and function and heart failure risk in a biracial cohort of community-dwelling elderly persons: the Atherosclerosis Risk in Communities study.

BACKGROUND: Heart failure is an important public health concern, particularly among persons>65 years of age. Women and blacks are critically understudied populations that carry a sizeable portion of the heart failure burden. Limited normative and prognostic data exist on measures of cardiac structure, diastolic function, and novel measures of systolic deformation in older adults living in the community. METHODS AND RESULTS: The Atherosclerosis Risk in Communities (ARIC) study is a large, predominantly biracial, National Heart, Lung, and Blood Institute-sponsored epidemiological cohort study. Between 2011 and 2013, ≈6000 surviving participants, now in their seventh to ninth decade of life, are expected to return for a fifth study visit during which comprehensive 2-dimensional, Doppler, tissue Doppler, and speckle-tracking echocardiography will be performed uniformly in all cohort clinic visit participants. The following objectives will be addressed: (1) to characterize cardiac structural and functional abnormalities among the elderly and to determine how they differ by sex and race/ethnicity, (2) to determine the relationship between ventricular and vascular abnormalities, and (3) to prospectively examine the extent to which these noninvasive measures associate with incident heart failure. CONCLUSIONS: We describe the design, imaging acquisition and analysis methods, and quality assurance metrics for echocardiography in visit 5 of the ARIC cohort. A better understanding of the differences in cardiac structure and function through the spectrum of heart failure stages in elderly persons generally, and between sexes and racial/ethnic groups specifically, will deepen our understanding of the pathophysiology driving heart failure progression in these at-risk populations and may inform novel prevention or therapeutic strategies.

Right ventricular imaging by two-dimensional and three-dimensional echocardiography.

PURPOSE OF REVIEW: The assessment of ventricular systolic performance is one of the most critical roles of echocardiography, often impacting the diagnosis, management, and prognosis of patients with suspected cardiovascular disease. RECENT FINDINGS: Historically, the echocardiographic assessment of diseases affecting the right ventricle has lagged behind that of the left ventricle, despite knowledge demonstrating that diseases affecting the right heart have been shown to have the same clinical consequences as those affecting the left heart. SUMMARY: This up-to-date review of right ventricular imaging by two-dimensional and three-dimensional echocardiography will emphasize the clinical situations for which assessment of right ventricular systolic function is particularly important, and review the systematic assessment of right ventricular regional wall motion in terms of coronary anatomy. Technical and scanning tips designed to optimize the visualization of the right heart with echocardiography with case examples will be presented. Qualitative and quantitative two-dimensional methods for assessing right heart function that are both well established and evolving will be summarized and the case for considering more routine use of ultrasound contrast agents to enhance right ventricular endocardial border definition will be made. The current state of three-dimensional imaging of the right ventricle will be highlighted along with the challenges for making this powerful tool more widespread.

Advanced Cardiovascular Sonographer: a proposal of the American Society of Echocardiography Advanced Practice Sonographer Task Force.

Echocardiographic examinations require a well-trained and competent sonographer to obtain proper anatomic and physiologic data to establish an accurate diagnosis for clinical decision-making and patient management. Although the formal education and training of cardiovascular sonographers are evolving, many entry-level and staff sonographers may not have sufficient practical or clinical knowledge of the necessary components of the echocardiographic study for the individual patient's clinical presentation. In many clinical settings, echocardiograms are read after the patient has left the laboratory. Thus, there is a role for a sonographer who can practice at an advanced level in a cardiovascular ultrasound laboratory to ensure a proper echocardiographic examination is performed on every patient. In this setting, an Advanced Cardiovascular Sonographer (ACS) would be able to review the indication for and quality of the examination. If additional images were needed, the ACS would assist the sonographer in obtaining these images, which would lead to the performance of a complete and fully diagnostic examination before the patient had left the echocardiography laboratory. In clinical practice, the quality of the examinations performed would improve, advancements in echocardiographic methods could be taught and incorporated into daily practice, and patients would be better served. The present report is a proposal from the American Society of Echocardiography Advanced Practice Task Force that identifies the potential of cardiac sonographers to achieve the ACS level.

Cardiac manifestations of Alström syndrome: echocardiographic findings.

BACKGROUND: Alström syndrome is an extremely rare autosomal recessive genetic disorder characterized by infantile-onset cardiomyopathy (CMP), blindness, hearing impairment/loss, and obesity. Prior reports have demonstrated that the dilated CMP of Alström syndrome occurs in about 62% of patients with this syndrome. To date, there have been no reports examining the echocardiographic features of Alström-related heart disease. METHODS: Eleven patients diagnosed with Alström syndrome who underwent one or more transthoracic echocardiograms from 1994 to 2003 were retrospectively evaluated. A total of 16 transthoracic echocardiograms were comprehensively reviewed with an emphasis on chamber sizes, wall thickness, left ventricular (LV) and right ventricular (RV) systolic function, and valve function. RESULTS: Four of 11 patients (36%) had evidence of global LV systolic dysfunction (quantitative ejection fraction [EF] range 9%-29%). Three of these 4 patients also had severe generalized RV systolic dysfunction, whereas one had normal RV systolic function. LV and RV dilation was present in 3 of 4. All patients with low EF had an apically tethered mitral valve closure pattern although only one of 4 had more than mild mitral regurgitation. Although 3 of 4 patients with low EF had an apically tethered tricuspid valve closure pattern, none had more than mild tricuspid regurgitation. Reduced EF was not associated with regional wall-motion abnormalities. Three of 11 patients (27%) overall and two of 4 of the patients with low EF (50%) had pericardial effusions. CONCLUSIONS: The Alström CMP in this cohort of patients was typically dilated and nonsegmental with predominantly biventricular involvement. It was infrequently associated with myocardial hypertrophy. Apically tethered mitral and tricuspid valve closure patterns were visualized, although severe functional valvular insufficiency was not present. LV and left atrial dilation was observed in a number of patients without reduced EF, and may be an early stage in the development of the CMP.

Contrast echocardiography improves the diagnostic yield of transthoracic studies performed in the intensive care setting by novice sonographers.

BACKGROUND: Bedside portable echocardiography in the intensive care department (ICU) is technically difficult, but crucial for directing patient care. Prior studies have shown contrast echocardiography (CE) in the ICU clarifies left ventricular wall motion when performed by experienced sonographers (ESO). However, in most hospitals, ESO are unavailable around the clock, and less experienced cardiovascular fellows or trainees may be asked to perform these examinations. METHODS: Transthoracic echocardiograms were retrospectively evaluated by level III trained echocardiographers for 213 patients in the ICU. Most were performed to assess left ventricular function (65% or 139 of 213) and were scanned by cardiology fellows (70% or 149 of 213) with less than 3 months echocardiography experience. Contrast agent was used in 29% (62 of 213) of all patients. RESULTS: The conversion of suboptimal or diagnostically inadequate apical 4- and 2-chamber views to diagnostically adequate with contrast was statistically significant when performed by both cardiology fellows and ESO (Fischer exact test, P < .0002). CONCLUSIONS: CE is effective in improving the diagnostic yield of transthoracic echocardiographic ICU studies performed by both novice sonographers and ESO. Using cardiology fellows to perform CE in this setting can be appropriate, particularly in after-hour situations, when ESO are not always available and the clinical question is left ventricular function. Results also suggest cardiology fellows can easily learn CE.

A rare case of Listeria monocytogenes presenting as prosthetic valve bacterial endocarditis and aortic root abscess.

Listeria monocytogenes is a gram-positive bacillus that is rarely associated with infections in the general population. Those susceptible to this pathogen include neonates, pregnant women, and the immunocompromised. The most common clinical manifestations of listeriosis are bacteremia and meningitis. Endocarditis caused by L. monocytogenes is rare with less than 60 cases reported in the world literature. We report the case of an 81-year-old man who suffered aortic prosthetic valve listeria endocarditis, and examine the literature regarding this rare manifestation of human listeriosis.

Diagnosis of suspected cardiac echinococcosis with negative serologies: role of transthoracic, transesophageal, and contrast echocardiography.

The early recognition and treatment of hydatid disease of the heart is important as it can result in potentially lethal complications. We present the clinical and echocardiographic features of a 71 year old Afghanistani man who presented with left-sided chest pain. Transthoracic (TTE), transesophageal (TEE), and contrast echo demonstrated a calcified cystic structure within the distal anterior septum consistent with an echinococcal cyst, despite negative serologies. Treatment strategies for this patient are discussed.

Successful surgical repair of a giant left main coronary artery aneurysm with arteriovenous fistula draining into a persistent left superior vena cava and coronary sinus: role of intraoperative transesophageal echocardiography.

We report the case of a 74-year-old woman with a history of hypertension, hypercholesterolemia, and pacemaker who presented to the hospital with new onset New York Heart Association class IV congestive heart failure. Transthoracic echocardiography revealed a markedly dilated right ventricle with normal right ventricular systolic function. There was moderate pulmonary hypertension with an estimated pulmonary artery systolic pressure of 60 mm Hg. Her echocardiogram 1 year earlier had demonstrated normal right ventricular size and systolic function, and no pulmonary hypertension. Additional transthoracic imaging with saline contrast study through a left peripheral vein demonstrated the presence of a dilated coronary sinus with a persistent left superior vena cava. Color Doppler demonstrated turbulent flow within the coronary sinus with evidence of significant left-to-right shunting. Cardiac catheterization revealed a massively dilated left main coronary artery aneurysm with an arteriovenous fistula into the left superior vena cava and coronary sinus. The calculated Qp/Qs was 2:1. The patient underwent 2 unsuccessful attempts at percutaneous intervention to occlude the arteriovenous fistula. She then underwent successful surgical closure of the coronary arteriovenous fistula. The important role of intraoperative transesophageal echocardiography in guiding this technically challenging surgical case is discussed.

Echocardiographic features of patients with heart failure who may benefit from biventricular pacing.

BACKGROUND: Recent studies suggest that cardiac resynchronization therapy through biventricular pacing (BVP) may be a promising new treatment for patients with advanced congestive heart failure (CHF). This method involves implantation of pacer leads into the right atrium (RA), right ventricle (RV), and coronary sinus (CS) in patients with ventricular dyssynchrony as evidenced by a bundle branch block pattern on electrocardiogram (ECG). Clinical trials are enrolling stable patients with ejection fractions (EF) /= 54 mm, and QRS duration >/=140 msec. We compared echocardiography features of these patients (group 1) with other patients with EF /= 54 mm, and QRS < 140 msec (group 2 = presumably no dyssynchrony). METHODS: Nine hundred fifty-one patients with CHF, LVID 54 mm, EF 35% by echocardiography were retrospectively evaluated. One hundred forty-five patients remained after those with primary valvular disease, prior pacing systems, or chronic atrial arrhythmias were excluded. From this group of 145 patients, a subset of 50 randomly selected patients were further studied (25 patients [7 females, 18 males] from group 1, and 25 patients [7 females, 18 males] from group 2). Mean age group 1 = 75 years old, mean age group 2 = 67 years old. Mean QRS group 1 = 161 msec, mean QRS group 2 = 110 msec. Each group was compared for presence of paradoxical septal motion, atrial and ventricular chamber sizes, LV mass, LVEF, and RV systolic function. RESULTS: Of the initial group of 951 patients, 145 (15%) met inclusion criteria. In the substudy, 20/25 (80%) of group l and 7/25 (28%) of group 2 subjects had paradoxical septal motion on echo (Fisher's exact test, P = 0.0005). The t-tests performed on the other echocardiography variables demonstrated no differences in chamber size, function, or LV mass. CONCLUSIONS: Cardiac resynchronization therapy with BVP appears to target a relatively small population of our advanced CHF patients (15% or less). Although increasing QRS duration on ECG is associated with more frequent paradoxical septal motion on echo, it is not entirely predictive. Paradoxical septal motion on echo may therefore be more sensitive at identifying patients who respond to BVP. Further prospective studies are needed.

Successful repair of aortic and mitral incompetence induced by methylsergide maleate: confirmation by intraoperative transesophageal echocardiography.

Methylsergide maleate, an effective anti-migraine medication, has a well-documented association with left-sided cardiac valve dysfunction. Prior reports have described cardiac valve dysfunction in patients using methylsergide chronically for a minimum of 6 years, with surgical intervention consisting of valve replacement for patients with intractable congestive heart failure. We report a 51-year-old woman who developed severe mitral and aortic valvular dysfunction after taking methylsergide maleate for migraine headaches for a period of 19 months, and who subsequently underwent aortic and mitral valve repair with excellent short-term results.

Role of contrast echocardiography in the assessment of myocardial rupture.

Left ventricular free wall rupture is known to complicate acute myocardial infarction and is the second most common cause of inhospital mortality in this patient population. Contrary to widely held medical belief, this does not always result in immediate fatal pericardial tamponade with hemodynamic collapse. Up to 40% of such occurrences are subacute and may evolve over hours or even days. A high index of suspicion and accurate diagnostic tests are required to identify and treat these patients with emergent surgery. Echocardiography has emerged as an important diagnostic modality to identify this catastrophic condition. Although the literature has scattered reports on the role of transesophageal and transthoracic echocardiography in diagnosing free wall rupture, to date, only one report in the literature used ultrasound contrast agents to better delineate echocardiographic findings. We will present two cases in which echocardiography with use of intravenous ultrasound contrast agents was instrumental in helping to exclude rupture in one case and help identify rupture in another.

Extensive neoplastic cardiac infiltration in a patient with acute myelogenous leukemia: role of echocardiography.

We present the case of a 34-year-old man with a history of relapsed acute myelogenous leukemia with extensive metastatic infiltration of the endomyocardium. Transesophageal echocardiography revealed masses within all the cardiac chambers and associated vascular structures. Biopsy of the superior vena cava mass had the histological features of a granulocytic sarcoma (GS, chloroma). Massive involvement of the heart with GS is very rare, and only a few reports have been published in the literature.

A rare case of Alström syndrome presenting with rapidly progressive severe dilated cardiomyopathy diagnosed by echocardiography.

Alström Syndrome is an extremely rare, autosomal recessive genetic disorder characterized by a group of signs and symptoms including infantile onset dilated cardiomyopathy, blindness, hearing impairment/loss, and obesity; with diabetes, and hepatic and renal dysfunction later on in life. Since the first description of the syndrome in 1959, there have been fewer than 100 reported cases in the world. We report a case of a 7-month-old girl whose initial presentation of Alström syndrome was a rapidly progressive severe dilated cardiomyopathy, diagnosed by echocardiography. Unique characteristics of the cardiomyopathy in Alström syndrome and the important role of echocardiography in Alström syndrome and other genetically transmitted disorders, especially with known cardiovascular manifestations, is discussed.

Intracardiac echocardiography using the AcuNav ultrasound catheter during percutaneous balloon mitral valvuloplasty.

During the past 10 years, there has been a trend toward and an interest in the use of catheter-based interventions to perform procedures that were once only approached surgically. The problem with the catheter-based approach has been procedure-related complications. Improved imaging of cardiac structures while undertaking interventional procedures may help to prevent or allow for early identification of these complications. Transesophageal echocardiography has been used during catheter-based procedures as a guide, and has both advantages and disadvantages. Intracardiac echocardiography is a relatively new imaging technique that also provides an enhanced view of cardiac structures and may also allow for the safe and efficient performance of catheter-based procedures. We report the first case of successful percutaneous balloon mitral valvuloplasty done under ultrasound guidance using an intracardiac echocardiography catheter (10F, 5-10 MHz) (Acunav). The strengths and weaknesses of this approach are described and compared with transesophageal echocardiography and older intracardiac echocardiography devices.

Anomalous right coronary artery from the main pulmonary artery in a patient with double-chambered right ventricle.

We describe a rare case of double-chambered right ventricle (DCRV) in a 32-year-old female presenting to the echocardiography lab for evaluation of congenital heart disease. We identified a unique constellation of findings, including the DCRV, a perimembranous ventricular septal defect, aortic valve prolapse, patent foramen ovale, and an anomalous right coronary artery coming off the main pulmonary artery. To the best of our knowledge, this is the first reported case describing the association of an anomalous right coronary artery coming off the main pulmonary artery in a patient with DCRV.