Dispelling the Saddle Pulmonary Embolism Myth (from a Comparison of Saddle Versus Non-Saddle Pulmonary Embolism).

In the setting of an acute pulmonary embolism (PE), there is often an assumed association between a saddle PE (SPE) and increased clinical severity. We aimed to determine the magnitude of SPE proximal pulmonary artery (PA) flow obstruction and its impact on right ventricular (RV) function in the setting of acute PE in a single-center series. From 2005 to 2022, patients with acute PE presenting with acute RV dysfunction requiring intervention were classified as SPE and non-SPE based on presenting computed tomography (CT) scans. SPE flow obstruction was determined by the ratio of the orthogonal cross-sectional surface area measurements of clot and native PA at the location of maximum clot burden in the right PA and left PA. Presenting RV function based on clinical and imaging parameters (CT and transthoracic echocardiography) were compared between SPE and non-SPE cohorts. A total of 174 patients were identified (SPE 92 [52.9%] and non-SPE 82 [47.1%]). Demographics and co-morbidities were similar. In patients with SPE, there was a mean 25.9% total flow obstruction (right PA 26.9% and left PA 25.5%). Non-SPE had greater clinical RV dysfunction on presentation as reflected by more high-risk PE (43.9% vs 26.1%, p = 0.01), need for venoarterial extracorporeal membrane oxygenation (21.9% vs 10.9%, p = 0.05), and more preoperative cardiopulmonary resuscitation (16.7% vs 7.8%, p = 0.08). RV:left ventricular ratio (CT and transthoracic echocardiography) and RV fractional area change were statistically similar between groups. In-hospital mortality was statistically similar between cohorts (4.9% non-SPE vs 2.1% SPE, p = 0.32). In conclusion, in a single-center series of patients with acute PE with RV dysfunction, SPE did not cause proximal flow-limiting obstruction. Non-SPE was associated with more clinical RV dysfunction than SPE. Thus, it should not be assumed that a non-SPE is a marker of patient stability.

Minimalist transcatheter aortic valve replacement misses paravalvular regurgitation: Incidence and echocardiographic distribution of missed paravalvular regurgitation.

BACKGROUND: Paravalvular regurgitation (PVR) may be missed intraoperatively with transthoracic echocardiography (TTE) guided minimalist TAVR. We sought to determine the incidence and echocardiographic distribution of PVR missed on intra-op TTE, but detected on predischarge TTE. METHODS: From July 2015 to 2020, 475 patients with symptomatic severe native aortic stenosis underwent TTE-guided minimalist TAVR. Missed PVR was defined as predischarge PVR that was ≥1 grade higher than the corresponding intra-op PVR severity. PVR was classified as anterior or posterior on the four standard TTE views; parasternal short-axis (PSAX), parasternal long-axis (PLAX), apical 3-chamber (A3C), and 5-chamber (A5C). Location-specific risk of missed PVR was then determined. RESULTS: Mild or greater PVR was seen in 55 (11.5%) cases intra-op and 91 (19.1%) at predischarge, with no severe PVR. Among the 91 patients with ≥mild predischarge PVR, missed PVR was present in 42 (46.2%). Compared to the corresponding anterior jets, missed PVR rate was significantly higher for posterior jets in PLAX (62.5% vs. 25.0%, p = 0.005), A5C (56.9% vs. 25.0%, p = 0.009), PSAX (66.7% vs. 24.3%, 0.001), but not A3C (58.5% vs. 40.0%, p = 0.28). CONCLUSIONS: Intraoperative TTE-guided minimalist TAVR either misses nearly half of ≥mild PVR or underestimates PVR by ≥1 grade when compared to predischarge TTE. Posterior PVR jets are more likely to be missed. Transesophageal echo guidance may help minimize missing PVR. Further studies are warranted.

Comparison of Surgical Embolectomy and Veno-arterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism.

Massive pulmonary embolism (MPE) is associated with a 20-50% mortality rate with guideline directed therapy. MPE treatment with surgical embolectomy (SE) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) have shown promising results. In the context of a surgical management strategy for MPE, a comparison of outcomes associated with VA-ECMO or SE was performed. A retrospective review of a single institution cardiac surgery database was performed, identifying MPE treated with SE or VA-ECMO between 2005-2020. Primary outcome was in-hospital survival. 59 MPE [27 (46.8%) VA-ECMO vs 32 (54.2%) SE] were identified. All presented with elevated cardiac biomarkers, tachycardia (mean heart rate 113 ± 20 beats/minute), hypotension (mean systolic blood pressure 85 ± 22 mm Hg) and vasopressors requirement, without significant differences between cohorts. Preoperative CPR was performed in 37.3% (22/59), without a significant difference between cohorts. More VA-ECMO presented with questionable neurologic status (GCS ≤ 4) [9/27 (33.3%) vs 2/32 (6.2%), P = 0.008] and more VA-ECMO failed thrombolysis [8/27 (29.6) vs 2/32 (6.3), P = 0.014]. All presented with severe RV dysfunction, by discharge all had normalization of echocardiographic RV function. Overall mortality was 10.2%, with a trend toward higher mortality among VA-ECMO [14.9% (4/27) vs 6.3% (2/32) P = 0.14]. CPR was independently associated with death (OR 10.8, P = 0.02) whereas treatment modality was not (OR 0.24). In an extremely unstable MPE population VA-ECMO and SE were safely performed with low mortality while achieving RV recovery. Adverse outcomes were more closely associated with preoperative CPR than with treatment modality.

Variations in Mitral Valve Leaflet and Scallop Anatomy on Three-Dimensional Transesophageal Echocardiography.

BACKGROUND: Textbook depictions of the mitral valve (MV) often illustrate it as composed of a single nonscalloped anterior leaflet, with the posterior leaflet having three symmetric and evenly spaced scallops. However, common variations in this anatomy have been noted in autopsy series for decades. Improved cardiac imaging with three-dimensional transesophageal echocardiography (TEE) now affords the ability to detect variations in scallop anatomy in vivo. The aims of this study were to catalog variations in mitral anatomy and to examine for association with mitral regurgitation in patients referred for clinical three-dimensional TEE. METHODS: Three-dimensional transesophageal echocardiographic images of the MV from 107 subjects were reviewed for MV variations. Three-dimensional analysis software was used to characterize mitral leaflet anatomy and assess the relative sizes of posterior leaflet scallops. RESULTS: Variations from the classic MV configuration were seen in 58.9%. Symmetric variations in the posterior leaflet (dominant P2 scallop, accessory P2 scallop, absent P2 scallop, and dichotomous P2 scallop) were seen in 33.6% of the study group. Asymmetric variants in the posterior leaflet (fused P1 and P2, fused P2 and P3, commissural scallop, accessory scallops, dichotomous P1 or P3, and dominant P2 or P3) were seen in 24.3%. Indentations or folds in the anterior leaflet were noted in 5.6%. Leaflet variations were not associated with patient demographics, indication for TEE, mitral regurgitation, mitral annular dimensions, or Carpentier class. CONCLUSIONS: Mitral leaflet morphologic variants were well characterized using three-dimensional TEE. Variants are common and were present with a frequency consistent with autopsy series. Mitral scallop variations were not associated with mitral regurgitation.

Pulmonary Artery Denervation as an Innovative Treatment for Pulmonary Hypertension With and Without Heart Failure.

Pulmonary hypertension (PH) is categorized into 5 groups based on etiology. The 2 most prevalent forms are pulmonary arterial hypertension (PAH) and PH due to left heart disease (PH-LHD). Therapeutic options do exist for PAH to decrease symptoms and improve functional capacity; however, the mortality rate remains high and clinical improvements are limited. PH-LHD is the most common cause of PH; however, no treatment exists and the use of PAH-therapies is discouraged. Pulmonary artery denervation (PADN) is an innovative catheter-based ablation technique targeting the afferent and efferent fibers of a baroreceptor reflex in the main pulmonary artery (PA) trunk and its bifurcation. This reflex is involved in the elevation of the PA pressure seen in PH. Since 2013, both animal trials and human trials have shown the efficacy of PADN in improving PAH, including improved hemodynamic parameters, increased functional capacity, decreased PA remodeling, and much more. PADN has been shown to decrease the rate of rehospitalization, PH-related complications, and death, and is an overall safe procedure. PADN has also been shown to be effective for PH-LHD. Additional therapeutic mechanisms and benefits of PADN are discussed along with new PADN techniques. PADN has shown efficacy and safety as a potential treatment option for PH.

Treatment of Peripheral Pulmonary Artery Stenosis.

Peripheral pulmonary artery stenosis (PAS) is an abnormal narrowing of the pulmonary vasculature and can form anywhere within the pulmonary artery tree. PAS is a congenital or an acquired disease, and its severity depends on the etiology, location, and number of stenoses. Most often seen in infants and young children, some symptoms include shortness of breath, fatigue, and tachycardia. Symptoms can progressively worsen over time as right ventricular pressure increases, leading to further complications including pulmonary artery hypertension and systolic and diastolic dysfunctions. The current treatment options for PAS include simple balloon angioplasty, cutting balloon angioplasty, and stent placement. Simple balloon angioplasty is the most basic therapeutic option for proximally located PAS. Cutting balloon angioplasty is utilized for more dilation-resistant PAS vessels and for more distally located PAS. Stent placement is the most effective option seen to treat the majority of PAS; however, it requires multiple re-interventions for serial dilations and is generally reserved for PAS vessels that are resistant to angioplasty.

Pacing at accelerated heart rate during echocardiography-guided atrioventricular optimisation following cardiac resynchronisation therapy.

INTRODUCTION: Although echo-guided atrioventricular optimisation (AVO) is standardly performed at rest, this approach may not provide optimal AV synchrony during daily activities. MATERIAL AND METHODS: The AVO protocol at one of two hospital campuses had been modified to be performed while pacing at an accelerated heart rate. We tested if this approach would improve the yield from AVO compared to the other campus, where AVO was performed at the intrinsic sinus rate. RESULTS: Between campuses, no significant differences were seen in demographics, chamber sizes, left ventricular ejection fraction, and diastolic function grade. Those having AVO at C2 were more likely to demonstrate "fusion prone" physiology (36% vs. 9%; p = 0.006) and were more likely to display either "truncation- or fusion-prone" physiology (58% vs. 27%; p = 0.007). CONCLUSIONS: When AVO was performed at an accelerated heart rate, patients with "truncation-prone" or "fusion-prone" physiology were identified more readily.

Mechanistic validation of the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging Guidelines for the assessment of diastolic dysfunction in heart failure with reduced ejection fraction.

BACKGROUND: The American Society for Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI) 2016 guidelines for assessment of diastolic dysfunction (DD) are based primarily on the effects of diastolic dysfunction on left ventricular filling hemodynamics. However, these measures do not provide quantifiable mechanistic information about diastolic function. The Parameterized Diastolic Filling (PDF) formalism is a validated theoretical framework that describes DD in terms of the physical properties of left ventricular filling. AIMS: We hypothesized that PDF analysis can provide mechanistic insight into the mechanical properties governing higher grade DD. METHODS: Patients referred for echocardiography showing reduced left ventricular ejection fraction (< 45%) were prospectively classified into DD grade according to 2016 ASE/EACVI guidelines. Serial E-waves acquired during free breathing using pulsed wave Doppler of transmitral blood flow were analyzed using the PDF formalism. RESULTS: Higher DD grade (grade 2 or 3, n = 20 vs grade 1, n = 30) was associated with increased chamber stiffness (261 ± 71 vs 169 ± 61 g/s2, p < 0.001), increased filling energy (2.0 ± 0.9 vs 1.0 ± 0.5 mJ, p < 0.001) and greater peak forces resisting filling (median [interquartile range], 18 [15-24] vs 11 [8-14] mN, p < 0.001). DD grade was unrelated to chamber viscoelasticity (21 ± 4 vs 20 ± 6 g/s, p = 0.32). Stiffness was inversely correlated with ejection fraction (r = - 0.39, p = 0.005). CONCLUSIONS: Higher grade DD was associated with changes in the mechanical properties that determine the physics of poorer left ventricular filling. These findings provide mechanistic insight into, and independent validation of the appropriateness of the 2016 guidelines for assessment of DD.

Survival and Right Ventricular Function After Surgical Management of Acute Pulmonary Embolism.

BACKGROUND: Acute pulmonary embolism (PE) is associated with high morbidity and mortality because of right ventricular (RV) failure. There is evidence suggesting surgical therapy (surgical embolectomy or venoarterial extracorporeal membrane oxygenation [ECMO]) is safe and effective. OBJECTIVES: The aim of this study was to assess the safety and efficacy of surgical management of acute PE. METHODS: Surgical embolectomy and/or venoarterial ECMO were compared, between 2005 and 2019, for massive PE (MPE) versus high-risk submassive PE (SMPE). RV recovery was defined as improvements in central venous pressure, pulmonary artery systolic pressure, RV/left ventricular ratio, and RV fractional area change. RESULTS: One hundred thirty-six patients with PE (92 with SMPE and 44 with MPE) were identified. Patients with MPE more often presented with syncope (59.1% [26 of 44] vs. 25.0% [23 of 92]; p = 0.0003), Glasgow Coma Scale score ≤4 (22.7% [10 of 44] vs. 0% [0 of 92]), and failed thrombolysis (18.2% [8 of 44] vs. 4.3% [3 of 92]; p = 0.008). Pre-operative cardiopulmonary resuscitation occurred in 43.2% of patients with MPE (19 of 44). Most patients with SMPE were treated with embolectomy (98.9% [91 of 92]), while ECMO was used more in those with MPE (ECMO in 40.9% [18 of 44], embolectomy in 59.1% [26 of 44]). RV function improved as measured by central venous pressure (from 23.4 ± 4.9 to 10.5 ± 3.1 mm Hg), pulmonary artery systolic pressure (from 60.6 ± 14.2 to 33.8 ± 10.7 mm Hg), RV/left ventricular ratio (from 1.19 ± 0.33 to 0.87 ± 0.23; p < 0.005), and fractional area change (from 26.8 to 41.0; p < 0.005). Mortality was 4.4% (6 of 136; SMPE, 1.1% [1 of 92]; MPE, 11.6% [5 of 44]). Subgroup analysis showed morbidity and mortality were highly associated with pre-operative cardiopulmonary resuscitation. CONCLUSIONS: Surgical management of patients with MPE and high-risk SMPE is safe and highly effective at achieving RV recovery.

Heightened risk of cardiac events following percutaneous coronary intervention for cocaine-associated myocardial infarction.

INTRODUCTION: Several works have suggested heightened risk for cardiac events in cocaine users following percutaneous coronary intervention (PCI). Such studies have generally been performed in small, poorly defined samples and have not utilised optimal control groups. We aimed to define the short-term risk for death or recurrent myocardial infarction (MI) when PCI was performed for myocardial infarction in subjects presenting with urine toxicology positive for cocaine in relation to subjects testing negative for cocaine use. MATERIAL AND METHODS: Our institutional electronic health record (EHR) was queried for all subjects with urine toxicology performed for cocaine exposure within 5 days before or after having elevated troponin-T assay between 1/1/08 and 12/31/13. Query results were cross-referenced with our institutional cardiology database to identify the sample who had PCI on the same admission as the cocaine test. Subsequent readmission for MI was assessed from the EHR, and deaths were identified from the National Death Index. RESULTS: PCI had been performed in 380 subjects who tested negative for cocaine and 44 subjects who tested positive. In the cocaine-positive group, incidences of death or MI at 30 days and 1 year were 18% and 23%, respectively. Those who tested positive for cocaine had increased odds (odds ratio (OR) = 2.3, 95% confidence interval (CI): 1.0-5.1, p = 0.04) for death or MI at 30 days post PCI, after adjustment for age, sex, prior MI, and comorbidity index. Although the odds for events 1-year post PCI were not increased (OR = 2.0, 95% CI: 0.9-4.3), the p-value approached significance in this small sample (p = 0.09). CONCLUSIONS: This retrospective study suggests that PCI performed in cocaine-associated myocardial infarction comes with a high 30-day and one-year risk. Further prospective studies are needed to better define this risk and to lend insight into better management strategies.

The left ventricular ejection fraction: new insights into an old parameter.

Accurate evaluation of cardiac function has become increasingly important as the treatment of cardiac disease has become more complex. At the same time, technological advances allow greater accuracy and precision in cardiac measurements. Measurement of left ventricular ejection fraction (LVEF) has been a pillar of cardiac evaluation. Several noninvasive modalities are available to assess LVEF; each has advantages and limitations. This review examines various modalities used to measure LVEF and focuses on the relative strengths and weaknesses of each modality. In some clinical settings, however, LVEF may be too insensitive to convey subtle changes in LV contractility. In certain clinical situations, use of LVEF may be an insufficient measure of left ventricular systolic function. Global longitudinal strain is one such parameter that has shown promise for detecting subtle reductions in left ventricular contractility in subjects with chemotherapy-induced cardiotoxicity.

Severely blunted early heart rate response during treadmill exercise is associated with above average exercise capacity.

INTRODUCTION: Chronotropic response with exercise is evaluated by peak heart rate (HR) achieved. Since most of the exercise-related chronotropic response occurs early after exercise is initiated, we investigated whether the HR achieved with a standard dose of exercise (Bruce stage 2) is associated with exercise capacity. We hypothesized that those with a blunted or disproportionate HR response at this exercise dose would have reduced exercise capacity compared to those with a typical HR response. MATERIAL AND METHODS: We reviewed 3,084 consecutive normal maximal treadmill stress echocardiographic reports acquired from individual adults over a 1.5-year period. We examined for association between stage 2 Bruce HR with age and sex-adjusted exercise capacity. RESULTS: After adjustment for age and sex, Bruce stage 2 HR was inversely associated (ß = -0.08, p < 0.01) with exercise duration. Thus for every additional 10 beats per minute achieved in stage 2, exercise duration was generally shortened by about 45 s. Most of the subjects (92%) who had a stage 2 Bruce HR response below the 10th percentile had above average or average exercise capacity for their age and sex. CONCLUSIONS: Lower Bruce stage 2 HR was associated with increased exercise capacity. Severely blunted HR response was associated with above average exercise capacity. Caution should therefore be exercised in attributing exercise intolerance to a blunted HR response when making a diagnosis of chronotropic incompetence.

Can the echocardiographic LV mass equation reliably demonstrate stable LV mass following acute change in LV load?

BACKGROUND: Limited data are available on performance of the left ventricular (LV) mass equation when there is a dynamic change to LV load. We aimed to test this equation in the immediate post-operative period following aortic valve replacement (AVR) for aortic regurgitation (AR) to see if it would reliably demonstrate stable LV mass before and after surgery. Since LV mass would be unlikely to change in the immediate postoperative period, we hypothesized that a decrease in LV diameter postoperatively would be accompanied by concomitant increases in LV wall thickness as predicted by the LV mass equation. METHODS: We reviewed echocardiograms of adult patients with AR who underwent AVR from 2007-2017 at Montefiore Medical Center (n=28). Three independent readers performed septal wall thickness (SWT), posterior wall thickness (PWT) and left ventricular internal diameter (LVID) measurements on pre-operative and post-operative echocardiograms. LV masses were calculated using the American Society of Echocardiography (ASE) equation. RESULTS: Post-operatively, LVID decreased from 5.7±1.2 to 4.9±1.0 cm, P<0.001. SWT was noted to increase from 1.08±0.20 to 1.18±0.27 cm, P=0.03, but PWT was unchanged, 1.11±0.21 to 1.16±0.27 cm, P=0.21. Accordingly, the LV mass equation calculated a decrease in LV mass from 266±126 to 232±99 gm, P=0.01. A control group of coronary artery bypass grafting alone (n=14) did not demonstrate any significant change in SWT, LVID, PWT and LV mass measurements. Similar findings were found for all three readers. CONCLUSIONS: Following aortic valve replacement for regurgitation, the LV mass equation calculated a reduction in LV mass in the immediate postoperative period. Since an immediate change in LV mass after AVR is unlikely, we feel that these results highlight an important limitation of the mass equation, when used with acutely changing loading conditions.

Outcomes of Coronary Artery Revascularization Procedures in Patients with Antiphospholipid Syndrome.

BACKGROUND: Published data on the outcome of coronary artery revascularization in patients with antiphospholipid syndrome (APS) are limited. Because APS is associated with a high rate of arterial thrombosis, there is concern that coronary revascularization in this group may be complicated by increased need for repeat revascularization. We aimed to determine the incidence and timing of repeat revascularization performed in patients with APS undergoing percutaneous coronary interventions (PCI) or coronary artery bypass grafting (CABG). METHODS: Our institutional database was queried for individuals (n = 575) testing positive for antiphospholipid antibodies between 2000 and 2012. From this group, 46 patients underwent cardiac catheterization. Charts were reviewed to identify subsequent revascularization procedures. RESULTS: The study sample consisted of 15 patients (67 ±â€¯11 years, 11 females) who underwent revascularization. All of the study subjects had prior history of arterial (stroke, TIA n = 7) or venous (n = 10) thrombosis. Ten of the subjects had initial revascularization (6 CABG, 4 PCI) at an outside facility, while another five underwent initial PCI at our hospital. Repeat revascularization occurred in five patients (33%) at a median of 6 years (range 4, 13) following the initial revascularization. The median follow-up for patients who did not require repeat revascularization (n = 10) was 10 years (range 2, 15). CONCLUSION: Amongst patients with APS who underwent CABG or PCI the need for repeat revascularization was infrequent and occurred several years after initial procedure. Based on this small sample size the periprocedural risk associated with coronary artery revascularization in subjects with APS is not prohibitively high.

Prevalence of myocardial infarction with non-obstructive coronary arteries (MINOCA) amongst acute coronary syndrome in patients with antiphospholipid syndrome.

Antiphospholipid antibody syndrome (APLS) is well known to cause thrombotic events and premature atherosclerosis leading to coronary artery occlusion. The association of non-thrombotic acute myocardial infarctions (AMI) with APLS is not as clearly delineated. The objective of this study was to determine the relative prevalence of myocardial infarction with non obstructive coronary arteries (MINOCA) compared to MI from vaso-occlusive disease amongst patients with known APLS at our institution. Out of 575 patients with positive antiphospholipid antibodies, cardiac catheterizations were performed in 40 patients presented with AMI and had cardiac catheterizations. MINOCA was found in 8 patients. We found that MINOCA is common in patients with APLS presenting with ACS and that spasm may also play a role in AMI in patients with APLS.

Cardiac structure and function with and without metabolic syndrome: the Echocardiographic Study of Latinos (Echo-SOL).

OBJECTIVE: We assessed the hypothesis that metabolic syndrome is associated with adverse changes in cardiac structure and function in participants of the Echocardiographic Study of Latinos (Echo-SOL). METHODS: Non-diabetic Echo-SOL participants were included in this cross-sectional analysis. Metabolic syndrome was defined according to the American Heart Association/National Heart, Lung, and Blood Institute 2009 Joint Scientific Statement. Survey multivariable linear regression analyses using sampling weights were used adjusting for multiple potential confounding variables. Additional analysis was stratified according to the presence/absence of obesity (body mass index (BMI) ≥25 kg/m2) and the presence/absence of metabolic syndrome. RESULTS: Within Echo-SOL, 1260 individuals met inclusion criteria (59% female; mean age 55.2 years). Compared with individuals without metabolic syndrome, those with metabolic syndrome had lower medial and lateral E' velocities (-0.4 cm/s, (SE 0.1), p=0.0002; -0.5 cm/s (0.2), p=0.02, respectively), greater E/E' (0.5(0.2), p=0.01) and worse two-chamber left ventricular longitudinal strain (0.9%(0.3), p=0.009), after adjusting for potential confounding variables. Increased left ventricular mass index (9.8 g/m2 (1.9), p<0.0001 and 7.5 g/m2 (1.7), p<0.0001), left ventricular end-diastolic volume (11.1 mL (3.0), p=0.0003 and 13.3 mL (2.7), p<0.0001), left ventricular end-systolic volume (5.0 mL (1.4), p=0.0004 and 5.7 mL (1.3) p<0.0001) and left ventricular stroke volume (10.2 mL (1.8), p<0.0001 and 13.0 mL (2.0), p<0.0001) were observed in obese individuals with and without metabolic syndrome compared with individuals with normal weight without metabolic syndrome. In sensitivity analyses, individuals with normal weight (BMI <25 kg/m2) and metabolic syndrome had worse left ventricular global longitudinal strain (2.1%(0.7), p=0.002) and reduced left ventricular ejection fraction (-3.5%(1.4), p=0.007) compared with normal-weight individuals without metabolic syndrome. CONCLUSIONS: In a sample of US Hispanics/Latinos metabolic syndrome was associated with worse left ventricular systolic and diastolic function. Adverse changes in left ventricular size and function were observed in obese individuals with and without metabolic syndrome but decreased left ventricular function was also present in normal-weight individuals with metabolic syndrome.

Association of Transthoracic Echocardiography Findings and Long-Term Outcomes in Patients Undergoing Workup of Stroke.

BACKGROUND: Transthoracic echocardiography (TTE) has become routine as part of initial stroke workup to assess for sources of emboli. Few studies have looked at other TTE findings such as ejection fraction, wall motion abnormalities, valve disease, pulmonary hypertension and left ventricular hypertrophy and their association with various subtypes of stroke, long-term outcomes of recurrent stroke, and all-cause mortality. METHODS AND RESULTS: Computed tomography and magnetic resonance imaging brain imaging and TTE reports were reviewed for 2464 consecutive patients referred for TTE as part of a workup for acute stroke between 1/1/01 and 9/30/07. Study patients were 67 ± 15years, 60% female, 75% minorities and had hypertension (76%), diabetes (41%), chronic kidney disease (27%) and atrial fibrillation (18%). On TTE, a mass, thrombus, or vegetation was identified in only 4 cases (0.2%), whereas a clinically significant abnormality (ejection fraction < 50%, left ventricle or right ventricle wall motion abnormalities, severe valve disease, pulmonary hypertension, or left ventricular hypertrophy) was identified in 16%. Those with an abnormal TTE had increased risk for death at 10years (hazard ratio [HR] 1.8; 95% confidence interval [CI]: 1.6, 2.0; P < .01), although risk for readmission with stroke was not increased. Abnormal TTE remained associated with increased risk of death at 10years after adjustment for age, sex, race, and cardiovascular risk factors (HR 1.4; 95% CI: 1.2, 1.7; P < .01). CONCLUSIONS: TTE performed as part of an initial workup for stroke had minimal yield for identifying sources of embolism. Clinically important abnormalities found on TTE were independently associated with increased long-term mortality, but not recurrent stroke.

Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain: A Randomized Controlled Trial.

OBJECTIVES: This study sought to compare early emergency department (ED) use of coronary computed tomography angiography (CTA) and stress echocardiography (SE) head-to-head. BACKGROUND: Coronary CTA has been promoted as the early ED chest pain triage imaging method of choice, whereas SE is often overlooked in this setting and involves no ionizing radiation. METHODS: The authors randomized 400 consecutive low- to intermediate-risk ED acute chest pain patients without known coronary artery disease and a negative initial serum troponin level to immediate coronary CTA (n = 201) or SE (n = 199). The primary endpoint was hospitalization rate. Secondary endpoints were ED and hospital length of stay. Safety endpoints included cardiovascular events and radiation exposure. RESULTS: Mean patient age was 55 years, with 43% women and predominantly ethnic minorities (46% Hispanics, 32% African Americans). Thirty-nine coronary CTA patients (19%) and 22 SE patients (11%) were hospitalized at presentation (difference 8%; 95% confidence interval: 1% to 15%; p = 0.026). Median ED length of stay for discharged patients was 5.4 h (interquartile range [IQR]: 4.2 to 6.4 h) for coronary CTA and 4.7 h (IQR: 3.5 to 6.0 h) for SE (p < 0.001). Median hospital length of stay was 58 h (IQR: 50 to 102 h) for coronary CTA and 34 h (IQR: 31 to 54 h) for SE (p = 0.002). There were 11 and 7 major adverse cardiovascular events for coronary CTA and SE, respectively (p = 0.47), over a median 24 months of follow-up. Median/mean complete initial work-up radiation exposure was 6.5/7.7 mSv for coronary CTA and 0/0.96 mSv for SE (p < 0.001). CONCLUSIONS: The use of SE resulted in the hospitalization of a smaller proportion of patients with a shorter length of stay than coronary CTA and was safe. SE should be considered an appropriate option for ED chest pain triage (Stress Echocardiography and Heart Computed Tomography [CT] Scan in Emergency Department Patients With Chest Pain; NCT01384448).