In-Hospital Therapy for Heart Failure With Reduced Ejection Fraction in the United States.

OBJECTIVES: This study sought to characterize in-hospital treatment patterns and associated patient outcomes among patients hospitalized for heart failure (HF) in U.S. clinical practice. BACKGROUND: Hospitalizations for HF are common and associated with poor patient outcomes. Real-world patterns of in-hospital treatment, including diuretic therapy, in contemporary U.S. practice are unknown. METHODS: Using Optum de-identified Electronic Health Record data from 2007 through 2018, patients hospitalized for a primary diagnosis of HF (ejection fraction ≤40%) and who were hemodynamically stable at admission, without concurrent acute coronary syndrome or end-stage renal disease, and treated with intravenous (IV) diuretic agents within 48 h of admission were identified. Patients were categorized into 1 of 4 mutually exclusive hierarchical treatment groups defined by complexity of treatment during hospitalization (intensified treatment with mechanical support or IV vasoactive therapy, IV diuretic therapy reinitiated after discontinuation for ≥1 day without intensified treatment, IV diuretic dose increase/combination diuretic treatment without intensified treatment or IV diuretic reinitiation, or uncomplicated). RESULTS: Of 22,677 patients hospitalized for HF with reduced ejection fraction (HFrEF), 66% had uncomplicated hospitalizations without escalation of treatment beyond initial IV diuretic therapy. Among 7,809 remaining patients, the highest level of therapy received was IV diuretic dose increase/combination diuretic treatment in 25%, IV diuretic reinitiation in 36%, and intensified therapy in 39%. Overall, 19% of all patients had reinitiation of IV diuretic agents (26% of such patients had multiple instances), 12% were simultaneously treated with multiple diuretics, and 61% were transitioned to oral diuretic agents before discharge. Compared with uncomplicated treatment, IV diuretic reinitiation and intensified treatment were associated with significantly longer median length of stay (uncomplicated: 4 days; IV diuretic reinitiation: 8 days; intensified: 10 days) and higher rates of in-hospital (uncomplicated: 1.6%; IV diuretic reinitiation: 4.2%; intensified: 13.2%) and 30-day post-discharge mortality (uncomplicated: 5.2%; IV diuretic reinitiation: 9.7%; intensified: 12.7%). CONCLUSIONS: In this contemporary real-world population of U.S. patients hospitalized for HFrEF, one-third of patients had in-hospital treatment escalated beyond initial IV diuretic therapy. These more complex treatment patterns were associated with highly variable patterns of diuretic use, longer hospital lengths of stay, and higher mortality. Standardized and evidence-based approaches are needed to improve the efficiency and effectiveness of in-hospital HFrEF care.

Changes in Left Ventricular Mass and Geometry in the Older Adults: Role of Body Mass and Central Obesity.

BACKGROUND: Left ventricular (LV) hypertrophy is an independent risk factor for cardiovascular outcomes. There are limited data about modifiable factors associated with progression of LV hypertrophy in older adults. Our objective is to describe the changes in LV mass and geometry over time in a predominantly older multiethnic cohort and to identify possible predictors of changes over time. METHODS: We analyzed data from participants in the Northern Manhattan Study who underwent serial echocardiographic studies, comparing the baseline and the most recent echocardiograms. We recorded changes in LV mass and geometry and correlated them with baseline characteristics using linear regression models. RESULTS: There were 826 participants (mean age, 64.2 ± 8.0 years) included in the analysis (time between measurements, 8.5 ± 2.7 years). Overall, LV mass index increased from 45.0 ± 12.7 to 50.3 ± 14.6 g/m2.7 (P < .001). There were 548 participants (66.3%) with LV mass increase; 258 individuals (31.2%) showed worsening LV geometry. Multivariable analysis showed that change in LV mass index was independently associated with baseline LV mass index (ß estimate, -17.000 [standard error, 1.508]; P < .001), hypertension (2.094 [0.816], P = .011), body mass index (0.503 [0.088], P < .001), and waist-to-hip ratio (1.031 [0.385], P = .008). Both waist-to-hip ratio and waist-to-height ratio remained significantly associated with LV mass increase even after adjusting for body mass index (P = .008 and P = .036, respectively). CONCLUSIONS: Regardless of race/ethnicity, LV mass progressed over time in older adults. We also observed that worsening geometry was frequent. Assessment of central obesity in the older population is important because indicators of central obesity add prognostic value over body mass index for the risk of LV mass increase.

Myocardial Microvascular Dysfunction in Rheumatoid ArthritisQuantitation by 13N-Ammonia Positron Emission Tomography/Computed Tomography.

BACKGROUND: The goal of this study was to assess the prevalence of myocardial microvascular dysfunction in rheumatoid arthritis (RA) patients without clinical cardiovascular disease and its association with RA characteristics and measures of cardiac structure and function. METHODS: Participants with RA underwent rest and vasodilator stress N-13 ammonia positron emission tomography and echocardiography. Global myocardial blood flow was quantified at rest and during peak hyperemia. Myocardial flow reserve (MFR) was calculated as peak stress myocardial blood flow/rest myocardial blood flow. A small number of asymptomatic and symptomatic non-RA controls were also evaluated. RESULTS: In RA patients, mean±SD MFR was 2.9±0.8, with 29% having reduced MFR (<2.5). Male sex and higher interleukin-6 were significantly associated with lower MFR, while the use of tumor necrosis factor inhibitors was associated with higher MFR. Lower MFR was associated with higher left ventricle mass index and higher left ventricle volumes but not with ejection fraction or diastolic dysfunction. RA and symptomatic controls had comparable MFR (mean±SD: 2.9±0.8 versus 2.55±0.6; P=0.48). In contrast, MFR was higher in the asymptomatic controls (mean±SD: 3.25±0.7) although not statistically different. CONCLUSIONS: Reduced MFR was observed in a third of RA patients without clinical cardiovascular disease and was associated with a measure of inflammation and with higher left ventricle mass and volumes. MFR in RA patients was similar to controls referred for clinical scans (symptomatic controls). Whether reduced MFR contributes to the increased risk for heart failure in RA remains unknown.

Night-time systolic blood pressure and subclinical cerebrovascular disease: the Cardiovascular Abnormalities and Brain Lesions (CABL) study.

AIMS: Although ambulatory blood pressure (BP) is a better predictor of cardiovascular outcomes than office BP, its association with subclinical cerebrovascular disease is not clarified. We investigated the associations of office and ambulatory BP values with subclinical cerebrovascular disease in a population based, predominantly elderly cohort without prior stroke. METHODS AND RESULTS: Eight hundred and twenty-eight participants underwent 24-h ambulatory BP monitoring (ABPM), 2D echocardiography and brain magnetic resonance imaging in the Cardiac Abnormalities and Brain Lesion (CABL) study. Daytime, night-time, and 24-h BPs, nocturnal dipping pattern, morning surge (MS), and 24-h variability were assessed. Subclinical cerebrovascular disease was defined as silent brain infarcts (SBIs) and white matter hyperintensity volume (WMHV). The association of BP measures with the presence of SBI and upper quartile of log-WMHV (log-WMHV4) was analysed. SBIs were detected in 111 patients (13.4%). Mean log-WMHV was -0.99 ± 0.94. In multivariable analysis, only night-time systolic BP (SBP) was significantly associated with SBI [odds ratio (OR) 1.15 per 10 mmHg, P = 0.042], independent of cardiovascular risk factors, and pertinent echocardiographic parameters. Although daytime, night-time, 24-h BPs, and non-dipping pattern were all significantly associated with log-WMHV4 (all P < 0.05), night-time SBP showed the strongest association (OR 1.21 per 10 mmHg, P = 0.003) and was the sole independent predictor when tested against the other BP parameters. Office BP measures, MS, and BP variability were not associated with subclinical cerebrovascular disease in adjusted analyses. CONCLUSION: Elevated night-time SBP is strongly associated with subclinical cerebrovascular disease. Night-time SBP by ABPM allows to identify individuals at higher risk of hypertensive brain injury.

Myocardial Inflammation, Measured Using 18-Fluorodeoxyglucose Positron Emission Tomography With Computed Tomography, Is Associated With Disease Activity in Rheumatoid Arthritis.

OBJECTIVE: To determine the prevalence and correlates of subclinical myocardial inflammation in patients with rheumatoid arthritis (RA). METHODS: RA patients (n = 119) without known cardiovascular disease underwent cardiac 18-fluorodeoxyglucose (FDG) positron emission tomography with computed tomography (PET-CT). Myocardial FDG uptake was assessed visually and measured quantitatively as the standardized uptake value (SUV). Multivariable linear regression was used to assess the associations of patient characteristics with myocardial SUVs. A subset of RA patients who had to escalate their disease-modifying antirheumatic drug (DMARD) therapy (n = 8) underwent a second FDG PET-CT scan after 6 months, to assess treatment-associated changes in myocardial FDG uptake. RESULTS: Visually assessed FDG uptake was observed in 46 (39%) of the 119 RA patients, and 21 patients (18%) had abnormal quantitatively assessed myocardial FDG uptake (i.e., mean of the mean SUV [SUVmean ] ≥3.10 units; defined as 2 SD above the value in a reference group of 27 non-RA subjects). The SUVmean was 31% higher in patients with a Clinical Disease Activity Index (CDAI) score of ≥10 (moderate-to-high disease activity) as compared with those with lower CDAI scores (low disease activity or remission) (P = 0.005), after adjustment for potential confounders. The adjusted SUVmean was 26% lower among those treated with a non-tumor necrosis factor-targeted biologic agent compared with those treated with conventional (nonbiologic) DMARDs (P = 0.029). In the longitudinal substudy, the myocardial SUVmean decreased from 4.50 units to 2.30 units over 6 months, which paralleled the decrease in the mean CDAI from a score of 23 to a score of 12. CONCLUSION: Subclinical myocardial inflammation is frequent in patients with RA, is associated with RA disease activity, and may decrease with RA therapy. Future longitudinal studies will be required to assess whether reduction in myocardial inflammation will reduce heart failure risk in RA.

Association Between Heart Rate and Subclinical Cerebrovascular Disease in the Elderly.

BACKGROUND AND PURPOSE: Although increased heart rate (HR) is a predictor of cardiovascular events and mortality, its possible association with subclinical cerebrovascular disease, which is prevalent in the elderly, has not been evaluated. This study aimed to investigate the association of daytime, nighttime, 24-hour HR, and HR variability with subclinical cerebrovascular disease in an elderly cohort without history of stroke. METHODS: The study cohort consisted of 680 participants (mean age, 73±7 years; 42% men) in sinus rhythm who underwent 24-hour ambulatory blood pressure and HR monitoring, 2-dimensional echocardiography, and brain magnetic resonance imaging as part of the CABL study (Cardiac Abnormalities and Brain Lesion). Subclinical cerebrovascular disease was defined as silent brain infarcts and white matter hyperintensity volume (WMHV). The relationship of HR measures with the presence of silent brain infarct and upper quartile of log WMHV (log WMHV4) was analyzed. RESULTS: Presence of silent brain infarct was detected in 93 participants (13.7%); mean log WMHV was -0.92±0.93 (median, -1.05; min, -5.88; max, 1.74). Multivariate analysis showed that only nighttime HR (adjusted odds ratio, 1.29 per 10 bpm; 95% confidence interval, 1.03-1.61; P=0.026) was significantly associated with log WMHV4, independent of traditional cardiovascular risk factors, ambulatory systolic blood pressure, and echocardiographic parameters. No similar association was observed for daytime HR and HR variability. There was no significant association between all HR measures and silent brain infarct. CONCLUSIONS: In a predominantly elderly cohort, elevated nighttime HR was associated with WMHV, suggesting an independent role of HR in subclinical cerebrovascular disease.

Association of body size metrics with left atrial phasic volumes and reservoir function in the elderly.

Aims: General obesity, defined by increased body mass index (BMI), is associated with left atrial (LA) enlargement, a marker of cardiovascular risk in the general population. The association between abdominal adiposity, defined by increased waist circumference (WC) or waist-to-hip ratio (WHR), and LA phasic volumes and reservoir function is not well known. The aim of this study was to evaluate the association between different body size metrics and LA phasic volumes and reservoir function in the elderly. Methods and results: Participants from the CABL (Cardiovascular Abnormalities and Brain Lesions) study underwent measurement of BMI, WC, and WHR. The LA maximum (LAVmax) and minimum (LAVmin) volumes, and LA reservoir function, measured as total emptying volume index (LAEVI), total emptying fraction (LAEF), and expansion index (LAEI), were assessed by real-time 3D echocardiography. The study population included 629 participants (mean age 71 ± 9 years, 61% women). Mean BMI was 27.9 ± 4.6 kg/m2, WC was 95.0 ± 11.7 cm, WHR was 0.91 ± 0.08. After adjusting for multiple potential confounders (demographics, cardiovascular risk factors, left ventricular mass index, and diastolic function), higher WC was significantly associated with higher LA phasic volumes (LAVmax, ß = 0.10, P = 0.007 and LAVmin, ß = 0.12, P = 0.002) and reduced reservoir function (LAEVI, ß = -0.15, P = 0.001 and LAEI, ß = -0.09, P = 0.027). WHR was significantly associated only with reduced reservoir function (LAEVI, ß = -0.11, P = 0.012), whereas BMI was not associated with either LA phasic volumes or reservoir function. Conclusion: In the elderly, WC may have more impact on LA phasic volumes and reservoir function, and therefore risk for cardiovascular events, than WHR and BMI.

Association of Blood Pressure Control Level With Left Ventricular Morphology and Function and With Subclinical Cerebrovascular Disease.

BACKGROUND: Left ventricular (LV) hypertrophy and subclinical cerebrovascular disease are early manifestations of cardiac and brain target organ damage caused by hypertension. This study aimed to investigate whether intensive office systolic blood pressure (SBP) control has beneficial effects on LV morphology and function and subclinical cerebrovascular disease in elderly patients with hypertension. METHODS AND RESULTS: We examined 420 patients treated for hypertension without history of heart failure and stroke from the CABL (Cardiovascular Abnormalities and Brain Lesions) study. All patients underwent 2-dimensional echocardiographic examination and brain magnetic resonance imaging. Subclinical cerebrovascular disease was defined as silent brain infarcts and white matter hyperintensity volume. Patients were divided into 3 groups: SBP <120 mm Hg (intensive control); SBP 120 to 139 mm Hg (less intensive control); and SBP ≥140 mm Hg (uncontrolled). Prevalence of LV hypertrophy and diastolic dysfunction were lowest in the intensive control, intermediate in the less intensive control, and highest in the uncontrolled groups (12.8%, 31.8%, and 44.7%, respectively [P<0.001], for LV hypertrophy; 46.8%, 61.7%, and 72.6%, respectively [P=0.003], for diastolic dysfunction). Patients with less intensive SBP control had greater risk of LV hypertrophy than those with intensive control (adjusted odds ratio, 3.26; P=0.013). A similar trend was observed for LV diastolic dysfunction but did not reach statistical significance (adjusted odds ratio, 1.65; P=0.144). Conversely, intensive SBP control was not significantly associated with reduced risk of silent brain infarcts and white matter hyperintensity volume compared with less intensive control. CONCLUSIONS: Compared with less intensive control, intensive SBP control may have a stronger beneficial effect on cardiac than cerebral subclinical disease.

Left ventricular mass-geometry and silent cerebrovascular disease: The Cardiovascular Abnormalities and Brain Lesions (CABL) study.

BACKGROUND: Although abnormal left ventricular geometric patterns have prognostic value for morbidity and mortality, their possible association with silent cerebrovascular disease has not been extensively evaluated. METHODS: We examined 665 participants in the CABL study who underwent transthoracic echocardiography and brain magnetic resonance imaging. Participants were divided into 4 geometric patterns: normal geometry (n=397), concentric remodeling (n=89), eccentric hypertrophy (n=126), and concentric hypertrophy (n=53). Subclinical cerebrovascular disease was defined as silent brain infarcts (SBIs) and white matter hyperintensity volume (WMHV; expressed as log-transformed percentage of the total cranial volume). RESULTS: Silent brain infarcts were observed in 94 participants (14%). Mean log-WMHV was -0.97±0.93. Concentric hypertrophy carried the greatest risk for both SBI (adjusted odds ratio [OR] 3.39, P<.001) and upper quartile of log-WMHV (adjusted OR 3.35, P<.001), followed by eccentric hypertrophy (adjusted ORs 2.52 [P=.001 for SBI] and 1.96 [P=.004] for log-WMHV). Concentric remodeling was not associated with subclinical brain disease. In subgroup analyses, concentric and eccentric hypertrophies were significantly associated with SBI and WMHV in both genders and nonobese participants, but differed for SBI by age (all ages for eccentric hypertrophy, only patients ≥70years for concentric hypertrophy) and by race-ethnicity (Hispanics for eccentric hypertrophy, blacks for concentric hypertrophy; no association in whites). CONCLUSIONS: Left ventricular hypertrophy, with both eccentric and concentric patterns, was significantly associated with subclinical cerebrovascular disease in a multiethnic stroke-free general population. Left ventricular geometric patterns may carry different risks for silent cerebrovascular disease in different sex, age, race-ethnic, and body size subgroups.

Association of chronic kidney disease with impaired left atrial reservoir function: A community-based cohort study.

Background Chronic kidney disease (CKD) is an independent risk factor for atrial fibrillation, although the pathophysiological mechanisms remain unclear. This study investigated the relationship between CKD and left atrial (LA) volume and function in a sample of the general population without overt cardiac disease. Design and methods We examined 358 participants from the Cardiovascular Abnormalities and Brain Lesions study. The LA minimum volume index (LAVImin), LA maximum volume index (LAVImax), and LA emptying fraction (LAEF) were assessed by real-time three-dimensional echocardiography. Based on their estimated glomerular filtration rate (eGFR), the participants were divided into a CKD group (eGFR <60 ml/min/1.73 m2) and a non-CKD group (eGFR ≥60 ml/min/1.73 m2). Results Of the 358 participants, 69 (19%) were classified as having CKD and 289 (81%) as non-CKD. Participants with CKD were older, had a greater prevalence of hypertension and use of antihypertensive drugs, a larger left ventricular (LV) mass index, and a higher prevalence of diastolic dysfunction than those without CKD (all p < 0.05). There was no significant difference in LAVImax between the CKD and non-CKD groups (23.4 ± 7.1 vs. 22.8 ± 5.8 ml/m2, p = 0.47), whereas significant differences were observed for LAVImin (13.6 ± 5.5 vs. 12.0 ± 4.6 ml/m2, p = 0.01) and LAEF (42.7 ± 11.4 vs. 47.8 ± 11.5%, p = 0.001). Multivariate regression analysis revealed that the eGFR was significantly associated with LAEF independent of age, LV mass index, and diastolic dysfunction (all p < 0.05). Conclusions Participants with CKD in an unselected community-based cohort had significantly impaired LA reservoir function. Assessment of LA function may add important information in the prognostic assessment of patients with CKD even in the absence of overt cardiac disease.

Atherosclerotic Plaques in the Aortic Arch and Subclinical Cerebrovascular Disease.

BACKGROUND AND PURPOSE: Aortic arch plaque (AAP) is a risk factor for ischemic stroke, but its association with subclinical cerebrovascular disease is not established. We investigated the association between AAP and subclinical cerebrovascular disease in an elderly stroke-free community-based cohort. METHODS: The CABL study (Cardiovascular Abnormalities and Brain Lesions) was designed to investigate cardiovascular predictors of silent cerebrovascular disease in the elderly. AAPs were assessed by suprasternal transthoracic echocardiography in 954 participants. Silent brain infarcts and white matter hyperintensity volume (WMHV) were assessed by brain magnetic resonance imaging. The association of AAP thickness with silent brain infarcts and WMHV was evaluated by logistic regression analysis. RESULTS: Mean age was 71.6±9.3 years; 63% were women. AAP was present in 658 (69%) subjects. Silent brain infarcts were detected in 138 participants (14.5%). In multivariate analysis adjusted for potential confounders, AAP thickness and large AAP (≥4 mm in thickness) were significantly associated with the upper quartile of WMHV (WMHV-Q4; odds ratio =1.17; 95% confidence interval, 1.04-1.32; P=0.009 and odds ratio =1.79; 95% confidence interval, 1.40-3.09; P=0.036, respectively), but not with silent brain infarcts (odds ratio =1.08; 95% confidence interval, 0.94-1.23; P=0.265 and odds ratio =1.46; 95% confidence interval, 0.77-2.77; P=0.251, respectively). CONCLUSIONS: Aortic arch atherosclerosis was associated with WMHV in a stroke-free community-based elderly cohort. This association was stronger in subjects with large plaques and independent of cardiovascular risk factors. Aortic arch assessment by transthoracic echocardiography may help identify subjects at higher risk of subclinical cerebrovascular disease, who may benefit from aggressive stroke risk factors treatment.

LA volumes and reservoir function are associated with subclinical cerebrovascular disease: the CABL (Cardiovascular Abnormalities and Brain Lesions) study.

OBJECTIVES: The purpose of this study was to assess the relationship of left atrial (LA) phasic volumes and LA reservoir function with subclinical cerebrovascular disease in a stroke-free community-based cohort. BACKGROUND: An increase in LA size is associated with cardiovascular events including stroke. However, it is not known whether LA phasic volumes and reservoir function are associated with subclinical cerebrovascular disease. METHODS: The LA minimum (LAV(min)) and maximum (LAV(max)) volumes, and LA reservoir function, measured as total emptying volume (LAEV) and total emptying fraction (LAEF), were assessed by real-time 3-dimensional echocardiography in 455 stroke-free participants from the community-based CABL (Cardiovascular Abnormalities and Brain Lesions) study. Subclinical cerebrovascular disease was assessed as silent brain infarcts (SBI) and white matter hyperintensity volume (WMHV) by brain magnetic resonance imaging. RESULTS: Prevalence of SBI was 15.4%; mean WMHV was 0.66 ± 0.92%. Participants with SBI showed greater LAV(min) (17.1 ± 9.3 ml/m(2) vs. 12.5 ± 5.6 ml/m(2), p < 0.01) and LAV(max) (26.6 ± 8.8 ml/m(2) vs. 23.3 ± 7.0 ml/m(2), p < 0.01) compared to those without SBI. The LAEV (9.5 ± 3.4 ml/m(2) vs. 10.8 ± 3.9 ml/m(2), p < 0.01) and LAEF (38.7 ± 14.7% vs. 47.0 ± 11.9%, p < 0.01) were also reduced in participants with SBI. In univariate analyses, greater LA volumes and smaller reservoir function were significantly associated with greater WMHV. In multivariate analyses, LAV(min) remained significantly associated with SBI (adjusted odds ratio per SD increase: 1.37, 95% confidence interval: 1.04 to 1.80, p < 0.05) and with WMHV (ß = 0.12, p < 0.01), whereas LAVmax was not independently associated with either. Smaller LAEF was independently associated with SBI (adjusted odds ratio: 0.67, 95% confidence interval: 0.50 to 0.90, p < 0.01) and WMHV (ß = -0.09, p < 0.05). CONCLUSIONS: Greater LA volumes and reduced LA reservoir function are associated with subclinical cerebrovascular disease detected by brain magnetic resonance imaging in subjects without history of stroke. In particular, LAV(min) and LAEF are more strongly associated with SBI and WMHV than the more commonly measured LAVmax, and their relationship with subclinical brain lesions is independent of other cardiovascular risk factors.

Direct measurement of multiple vena contracta areas for assessing the severity of mitral regurgitation using 3D TEE.

OBJECTIVES: The aim of this study was to determine whether direct measurement of multiple-jet vena contracta (VC) areas by real-time 3-dimensional (3D) transesophageal echocardiography is an accurate method for measuring the severity of mitral regurgitation (MR) in patients with multiple MR jets. BACKGROUND: Because of the conflicting requirements of Doppler and imaging physics, measuring VC using 2-dimensional (2D) echocardiography is a difficult procedure for assessing MR severity. A real-time 3D echocardiographic measurement of the VC area has been validated in a single jet of MR, but the applicability of this method for multiple jets is unknown. METHODS: Two-dimensional and 3D transesophageal echocardiography was performed in 60 patients with multiple functional MR jets. MR severity was assessed quantitatively using the effective regurgitant orifice area derived from 3D left ventricular volume and thermodilution data (EROAstd). Manual tracings of multiple 3D VC areas in a cross-sectional plane through the VC were obtained, and the sum of the areas was compared using EROAstd. Similarly, 2D measurement of VC diameter was obtained from a 2D transesophageal echocardiographic view to optimize the largest legion size in each jet. All VC diameters were summed and compared with EROAstd. RESULTS: The correlation of the sum of the multiple 3D VC areas with EROAstd (r = 0.90, p < 0.01) was higher than that of the sum of the multiple 2D VC diameters (r = 0.56, p < 0.01), particularly with MR degrees greater than mild (r = 0.80, p < 0.01 vs. r = 0.05, p = 0.81) and in cases of 3 or more regurgitant jets (r = 0.91, p < 0.01 vs. r = 0.46, p = 0.05). CONCLUSIONS: Direct measurement of multiple VC areas using 3D transesophageal echocardiography allows for assessing MR severity in patients with multiple jets, particularly for MR degrees greater than mild and in cases of more than 2 jets, for which geometric assumptions may be challenging.

Accurate measurement of mitral annular area by using single and biplane linear measurements: comparison of conventional methods with the three-dimensional planimetric method.

AIMS: The planimetry method using three-dimensional (3D) echocardiography is useful for providing an accurate mitral annulus area (MAA) value. However, this method is relatively unavailable. Therefore, we evaluated the accuracy of conventional methods for MAA measurement compared with that of 3D planimetry. METHODS AND RESULTS: Two-dimensional (2D) and 3D transoesophageal echocardiography (TEE) were performed in 70 patients. The mitral annulus diameter (MAD) was measured using four standard TEE imaging planes: four-chamber (4Ch), two-chamber (2Ch), anterior-posterior (LAX), and commissure-commissure (CC). MAA was calculated using a single diameter based on that of a circle and using two diameters based on that of an ellipse. MAA measurements using the single 4Ch MAD method (r = 0.84, P < 0.001), and two anatomically orthogonal MAD method in 4Ch/2Ch (r = 0.93, P < 0.001) and LAX/CC (r = 0.97, P < 0.001) planes correlated with 3D planimetric MAA measurements. Further analysis with Bland-Altman plots revealed that the LAX/CC MAD measurement exhibited the closest limits of agreement with the 3D planimetric MAA measurement. Notably, in patients showing an elliptical annulus shape, only LAX/CC MAD, but not 4Ch or 4Ch/2Ch MAD, provided results comparable with those of 3D planimetric MAA measurements. However, in patients with a circular annulus shape, reliable MAA measurements can be achieved using either single 4Ch MAD or any biplane MAD. CONCLUSION: Conventional LAX/CC MAD can be recommended for MAA measurements in a diverse patient population. This method is applicable as an alternative to the 3D planimetric method, regardless of the mitral annulus shape.

Septal pouch in the left atrium and risk of ischemic stroke.

OBJECTIVES: We sought to assess the association between the presence of a septal pouch in the left atrium and ischemic stroke. BACKGROUND: It has been suggested that the presence of a left septal pouch (LSP) may favor the stasis of blood and possibly result in thromboembolic complications. However, the embolic potential of an LSP is not known. METHODS: The association between an LSP and risk of stroke was assessed using a population-based case-control study design. The presence of an LSP was assessed by transesophageal echocardiography in 187 patients >50 years of age with a first-ever ischemic stroke (96 men, mean age 70.6 ± 9.0 years) and in 157 control subjects matched to patients by age, sex, and race/ethnicity. The association between an LSP and risk of stroke was assessed after adjustment for other stroke risk factors. RESULTS: Patients with LSPs were younger than control subjects (67.5 ± 9.1 years vs. 69.6 ± 8.8 years; p = 0.046), with a lower prevalence of hypertension (68.0% vs. 80.3%; p = 0.01). There were no differences in the prevalence of LSPs between stroke patients and control subjects (28.9% vs. 29.3%, respectively; p = 0.93). The subgroup of 69 patients (36.9%) with cryptogenic stroke showed a similar prevalence of LSPs (31.9% vs. 29.3%; p = 0.70). Multivariable analysis showed that the presence of an LSP was not associated with ischemic stroke (odds ratio: 1.09; 95% confidence interval: 0.64 to 1.85) or cryptogenic stroke (odds ratio: 1.41; 95% confidence interval: 0.71 to 2.78). CONCLUSIONS: This study does not demonstrate evidence of the association of the presence of an LSP with ischemic stroke or cryptogenic stroke. The stroke risk associated with LSPs requires further evaluation in the younger stroke populations. The cofactors that may turn an LSP from an innocent bystander to a causative mechanism for stroke remains to be elucidated.

A survival case of painless chronic type A aortic dissection with a history of stroke and anticoagulant use.

We report the case of a patient with completely painless chronic aortic dissection, who presented to another hospital with a left hemiparesia 3 months ago and received anticoagulation therapy with a diagnosis of ischemic stroke. Most of her symptoms had resolved when she presented to our outpatient clinic except for numbness of her left hand and dysphasia. Physical examination found a diastolic murmur at the left sternal border and a bruit over the right carotid artery. Transthoracic echocardiography and carotid sonography demonstrated aortic dissection with extension into the internal right carotid artery and severe aortic regurgitation. Surgery was performed successfully and the patient was discharged. This case emphasizes that the diagnosis of a completely painless aortic dissection with only neurologic symptoms at presentation can be extremely difficult and should always be considered as a cause of ischemic stroke to avoid catastrophic antithrombolytic or anticoagulation therapy.

Evaluation of subclinical right ventricular dysfunction in obstructive sleep apnea patients using velocity vector imaging.

BACKGROUND: The aims of this study were to evaluate subclinical regional right ventricular (RV) dysfunction in newly diagnosed obstructive sleep apnea (OSA) patients without systemic and pulmonary arterial (PA) hypertension, and to correlate OSA severity to RV dysfunction, using both velocity vector imaging (VVI)-derived strain imaging and tissue Doppler imaging (TDI). METHODS AND RESULTS: The OSA group consisted of 27 patients and the control group consisted of 26 healthy participants. All participants underwent 24-h ambulatory blood pressure monitoring. Peak systolic myocardial velocities, strain, and strain rate (SR) were determined at the basal and mid segments of the RV free wall by VVI. Additionally, RV myocardial velocities were assessed by pulsed-wave TDI. Patients with OSA had significantly impaired VVI-derived peak systolic myocardial velocities, strain, and SR (P<0.0001 for all). RV isovolumic acceleration (IVA) was the only TDI-derived parameter that was significantly impaired (P<0.0001). RV IVA (r=-0.512, P<0.0001), RV mid free wall strain (r=0.568, P<0.0001) and SR (r=0.519, P<0.0001) revealed the best correlations with apnea hypopnea index (AHI). CONCLUSIONS: Subclinical RV dysfunction is present in OSA patients despite normal systemic and PA pressures. Tissue Doppler-derived RV IVA and VVI-derived RV deformation can accurately recognize and quantify RV function abnormalities in this subgroup of patients.

Mycotic ascending aortic pseudoaneurysm causing a large mediastinal abscess.

Mycotic aneurysm is a rare, life-threatening condition with high mortality rates and challenging diagnosis. A 46-year-old man, with a history of subaortic membranectomy, was admitted with a new onset fever and dyspnea. Transesophageal echocardiography and computed tomography demonstrated a mycotic pseudoaneurysm of the ascending aorta and mediastinal abscess due to aneurysm rupture. The patient fully recovered after an immediate diagnose and urgent surgery.