Update of clinical echocardiographic assessment of heart failure with preserved ejection fraction.

PURPOSE OF REVIEW: Heart failure with preserved ejection fraction (HFpEF) has an increasing global prevalence. Diastolic dysfunction is the predominant cause of symptoms, most commonly, exertional dyspnea. Although prevalent, the syndrome is challenging to identify due to the comorbid conditions that can present similarly. This paper will review established, guideline recommended, echocardiographic variables, and pathophysiology. RECENT FINDINGS: Echocardiography is the primary diagnostic modality. The latest advances in strain analysis, algorithmic use of multiple parameters, and deeper understanding of exercise hemodynamics have improved our classification of those with HFpEF. SUMMARY: There remains a paucity of therapies with mortality benefit in this subgroup. Thus, improving diagnostic efficacy is important as it can clarify epidemiologic, phenotypic, and pathologic features of HFpEF.

Statistical and machine learning methodology for abdominal aortic aneurysm prediction from ultrasound screenings.

A method of analysis of a database of patients (n = 10 329) screened for an abdominal aortic aneurysm (AAA) is presented. Self-reported height, weight, age, gender, ethnicity, and parameters "Heart Problems," "Hypertension," "High Cholesterol," "Diabetes Mellitus," "Smoker Past 2 Years," "Ever Smoked?," "Family History AAA," and "Family History Brain Aneurysm" were provided. Incidence of a AAA (defined as 3 cm diameter) was calculated as a function of age and body mass index (BMI) of greater than or less than a BMI 25 for various patient groups. Age was grouped into one of three categories in 15-year intervals (35-50 years, 50-65 years, and 65 to 80 years). Most patients were Caucasian (n = 8575) and the largest group of patients with a AAA was the Caucasian male (198 of 279 total detected AAAs). A machine learning algorithm was written, with learning inputs from the acquired patient database. Of all groups, Caucasian males were found to have the highest incidence of AAA, with males in general higher than females. Smoking within the past two years was highly associated with AAA incidence, and a past history of smoking to a lesser extent. The incidence of AAA increased with age. When dividing groups into two cohorts by a BMI of 25, generally middle-aged patients with a BMI > 25 had a higher incidence of a AAA. However, in general, the older age group with a BMI < 25 had a higher incidence of AAA. The addition of machine learning allows one to note the effect of an input keeping other input parameters constant. This helps identify a parameter that may be an independent predictor of a particular outcome. When using BMI as the single changing input, an increasing BMI was associated with an increased probability of a AAA, most significantly in middle-aged patients, and then narrowing to similar probabilities in older age. This AAA screening program is ongoing. As data continues to be collected with particularly those patient groups presently underrepresented, questions as to an association of AAA with BMI as a function of age, and also an improvement in machine learning algorithm accuracy for various patient populations will continue.

Peripheral saline contrast with Valsalva and a modified Müller's maneuver may improve detection of atrial level right-to-left shunts: A preliminary observation.

As part of an evaluation for source of embolism, transthoracic echocardiography with peripheral saline contrast injection during normal respirations and also Valsalva release is routinely performed to evaluate for an atrial level shunt. We present a preliminary observation of addition of a modified Müller's maneuver early during the Valsalva release. The Müller's maneuver has been described to occur with sleep apnea and will increase right-to-left shunting through a PFO. Of 34 patients, 24 were negative for a right-to-left shunt with normal respiration or Valsalva release. Of these 24 patients, 8 were then positive for a shunt by addition of a modified Müller's maneuver. One additional patient could not perform the modified Müller's maneuver. This preliminary observation suggests that in patients referred to an echocardiography laboratory for evaluation of source of embolism, adding the modified Müller's maneuver to those negative for shunting during normal respirations and Valsalva release may yield an increase in right-to-left atrial level shunt detection.

Identification of candidates for PFO closure in the echocardiography laboratory.

A patent foramen ovale (PFO) is implicated in several pathologic processes, including that of cryptogenic stroke (cCVA). Recent trials identify "high-risk" PFOs in patients with cCVA as likely to benefit from percutaneous closure. The younger the patient (<60 years old) the more likely a PFO may be attributable to the cCVA. The RoPE Score index helps determine the likelihood that an existing PFO is related to a cCVA. This may help guide the clinician and patient when contemplating percutaneous PFO closure. When evaluating a patient for possible percutaneous closure, one should identify the CVA as a typical ischemic type stroke. In order to "rule-out" other causes of CVA, imaging of the intracranial arteries, cervical, and aortic arch vessels should be performed. Small vessel disease or a lacunar-type infarct should be excluded. To rule out atrial fibrillation, prolonged monitoring should be performed. An index has been developed to determine the probability that a PFO is the causative etiology and calculates the risk of recurrence. This may help guide the clinician and patient in the decision for PFO closure. In addition, one should consider a work-up for a hypercoagulable state. We will obtain an ultrasound of the lower extremities or consider deep pelvic vein thrombosis (prolonged sitting or malignancy). If the closure is to be performed, the Food and Drug Administration (FDA) has approved the Amplatzer PFO Occluder and the GORE Cardioform Septal Occluder for percutaneous closure. These devices are both approved in patients predominately between ages 18 and 60 years with a cCVA due to presumed paradoxical embolism as verified by a neurologist and cardiologist and when other causes of ischemic CVA have been excluded. "High-risk" PFOs appear to achieve the most potential benefit from percutaneous closure.

Coronary risk assessment using traditional risk factors with CT coronary artery calcium scoring in clinical practice.

As coronary artery calcium (CAC) is atherosclerosis and not just a marker of cardiovascular (CV) disease, measurement of a patient's coronary artery calcium score (CACS) is a strong predictor of risk. Clinically performed in asymptomatic patients, the CACS, along with several CV risk factors, namely age, sex, ethnicity, diabetes, tobacco use, family history, cholesterol level, blood pressure, and use of cholesterol or hypertensive medications, provide a predictive model of 10 year risk for CV events. A smartphone "App" makes this quick to obtain and use. This helps the clinician in making recommendations for both lifestyle changes and statin therapy. Those patients in which the most benefit occur from measurement of a CACS are those at an intermediate CV risk. Measurement of the CACS has become an integral part of the clinician's assessment of a patient's CV risk and for guiding preventative therapies.

Polyvalvular heart disease syndrome.

An adult case of polyvalvular heart disease syndrome diagnosed in an adult is presented. The characteristic facies and echocardiographic features of this rare autosomal dominant connective tissue disorder are presented.

Adult presentation of ALCAPA: Echo and CT diagnosis.

A healthy 20-year-old male presented with aborted sudden death. Both thoracic echocardiography and cardiac computed tomographic angiography demonstrated the characteristic findings of ALCAPA noting a dilated and tortuous right coronary artery, dilated coronary collateral arteries within the interventricular septum or along the surface of the heart, and visualization of the left coronary artery origin from the posterior aspect of the main pulmonary artery. Both imaging modalities demonstrated all three characteristic findings of this rare coronary anomaly and served as complementary imaging studies for surgical correction.

"Diagnosis" of a hiatal hernia from a CT coronary artery calcium scan.

Identification of a hiatal hernia by computed tomography (CT) scanning, and particularly with axial imaging from a coronary artery calcium score exam, is often subjective. There are several CT features that are diagnostic or at least suggestive of a hiatal hernia. As a hiatal hernia may be the etiology of a chest pain syndrome, it is important to be aware of CT findings suggestive of such.

Transesophageal echocardiography during pulmonary vein cryoballoon ablation for atrial fibrillation.

We describe our first 20 cases of cryoablation of atrial fibrillation (AF) using transesophageal echocardiography (TEE). Continuous procedural monitoring with TEE by a cardiologist and senior sonographer assists the electrophysiologist in performance of the cryoballoon procedure of AF. Previously using intracardiac echocardiography (ICE) we have found TEE to have better overall procedural imaging, and monitoring for pericardial effusion or thrombus formation. We have found TEE monitoring to be helpful with positioning for interatrial septal (IAS) puncture, catheter tip avoidance of the left atrial appendage (LAA), and guidance of the balloon catheter into each pulmonary vein (PV), with proper positioning within each PV orifice, and documentation of PV occlusion for the cryoballoon procedure. Procedural equipment and the cryoballoon protocol used are presented in detail. The role of TEE imaging during the procedure and in preventing potential dangers is illustrated. It is the goal of this study to demonstrate how the electrophysiology and echocardiography laboratories work together in this cryoablation procedure.