Eli V. Gelfand

Severity of Mitral and Aortic Regurgitation as Assessed by Cardiovascular Magnetic Resonance: Optimizing Correlation with Doppler Echocardiography

BACKGROUND Cardiovascular magnetic resonance (CMR) is widely recognized as a non-invasive gold standard for quantification of ventricular volumes. In addition, it is an emerging diagnostic modality for clinical evaluation of mitral regurgitation (MR) and aortic regurgitation (AR). CMR facilitates accurate quantitation of regurgitation volumes and regurgitant fraction, but referring physicians are often more comfortable with qualitative measures, and few data exist for correlation of qualitative CMR regurgitation severity with that obtained by more conventional qualitative Doppler echocardiography. Because patients with AR and MR may commonly be assessed by both echocardiography and CMR modalities, consistency between qualitative gradient of regurgitation severity is important for follow-up. Therefore, we sought to define the CMR regurgitant fractions that best correlate with qualitative mild, moderate, and severe regurgitation by color Doppler echocardiography. METHODS AND RESULTS Data from 141 consecutive patients (age 53 +/- 15 yr; 43% female) with contemporary (median, 31 days) CMR and echocardiographic data, including 107 regurgitant valves and 70 normal valves, were compared. Thresholds were developed on an initial cohort of patients with 55 regurgitant valves, and subsequently tested on a later cohort of patients with 52 regurgitant valves. Regurgitation fraction (RF) limits that optimized concordance of CMR and echo severity grades were similar for MR and AR and were: mild < or = 15%, moderate 16-25%, moderate-severe 26-48%, severe > 48%. CONCLUSIONS The current study provides simple qualititative threshold grades for MR and AR severity that allows for standardized reporting of regurgitation severity by CMR and excellent correlation with clinical echocardiography.

Rimonabant: a selective blocker of the cannabinoid CB1 receptors for the management of obesity, smoking cessation and cardiometabolic risk factors

Rimonabant is the first selective blocker of the cannabinoid CB1 receptors being developed for the treatment of obesity, tobacco smoking and cardiometabolic risk factors. Following 1 year of treatment, rimonabant 20 mg/day leads to greater weight loss compared with placebo. Therapy with rimonabant is also associated with favourable changes in serum lipids and an improvement in glycaemic control in Type 2 diabetics. At the same dose, rimonabant significantly increases the cigarette smoking quit rates compared with placebo. Rimonabant appears to be generally well tolerated, with primary side effects of mild nausea, diarrhoea, anxiety and depression. As an agent with a novel mechanism of action, rimonabant has the potential to be a useful adjunct to lifestyle modification in the treatment of obesity, metabolic syndrome and cigarette smoking.

Comparison of intracardiac echocardiography and transesophageal echocardiography for imaging of the right and left atrial appendages.

BACKGROUND Transesophageal echocardiography (TEE) is the standard for diagnosis of atrial thrombi and is performed before ablation of atrial arrhythmias. Intracardiac echocardiography (ICE) is routinely used during these procedures and may provide an alternative imaging modality. OBJECTIVE The purpose of this study was to compare TEE and ICE for right atrial appendage (RAA) and left atrial appendage (LAA) anatomy and thrombus. METHODS This prospective blinded study enrolled 71 patients with atrial arrhythmias who presented for ablation. TEE and ICE were performed simultaneously to assess the RAA and LAA for thrombi, spontaneous echo contrast, and dimensions. ICE images were acquired sequentially from the right atrium, right ventricular outflow tract, and the pulmonary artery. RESULTS Imaging of the RAA and LAA was achieved in all 71 patients using ICE but in only in 69 patients using TEE because of inability to intubate the esophagus. A total of 4 thrombi were diagnosed (3 LAA, 1 RAA). All were detected by ICE but only 1 by TEE. Diagnostic imaging of the LAA was achieved in 71 patients (100%) with ICE and in 62 patients (87.3%) with TEE (P < .002). Spontaneous echo contrast was more commonly diagnosed with ICE (P < .01). There was strong correlation between TEE and ICE for length (r = 0.71), width (r = 0.94), and area (r = 0.88) of the LAA. Image quality with ICE was highest from the pulmonary artery and lowest from the right atrium. CONCLUSION ICE imaging is a viable alternative to TEE for visualization of the LAA and RAA during catheter ablation procedures.

Myocardial infarction: contemporary management strategies

Myocardial infarction (MI) is a common clinical diagnosis, associated with significant morbidity and mortality, not only in the short term, but also years following the index event. A more complete understanding of the pathophysiology of MI has ushered the era of multipronged treatment approach, with a combination of goal‐directed revascularization, a broad adjunctive pharmacological therapy and aggressive secondary prevention measures. The goals of this article are to review the basic pathophysiological processes, which lead up to a clinical diagnosis of MI, to highlight the essential elements of clinical presentation and to summarize the evidence for comprehensive therapy. Emphasis has been placed on the choice of primary reperfusion therapy for ST‐elevation MI, on risk‐stratification of patients with non‐ST elevation MI, and on rationale behind the selection of anti‐ischaemic and antithrombotic therapy. Finally, evidence‐based approach to secondary prevention is outlined.

Valvular Heart Disease: Classic Teaching and Emerging Paradigms

Valvular heart disease is both prevalent and increases with age. The final pathway of valvular disease is heart failure and sometimes sudden death, so clinicians must identify and treat it before these endpoints occur. Noninvasive diagnostic modalities such as echocardiography, exercise tolerance testing, and cardiac magnetic resonance provide additional quantitative, qualitative, and prognostic data. Studies have elucidated predictors of disease progression and potential medical therapies, but the niche of valvular disease has benefited relatively less from randomized controlled clinical trials than other cardiovascular disease fields. New invasive techniques like transcatheter valve replacement offer hope for high-risk operative candidates. We review classic teaching with current guidelines and emphasize recent advances in disease management.

Venous Thromboembolism Guidebook, fourth edition.

The field of venous thromboembolism (VTE) has seen tremendous growth since the last edition of the “Venous Thromboembolism Guidebook.” This fifth edition incorporates contemporary concepts in diagnosis, management, and prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) into a practical and user-friendly format. The purpose of the guidebook is to provide a literature-based review of the current clinical approach to VTE as well as up-to-date references for further study.

Venous thromboembolism guidebook.

This venous thromboembolism guidebook incorporates evolving contemporary concepts in diagnosis and management of pulmonary embolism (PE) and deep venous thrombosis (DVT) into a user-friendly menu. The purpose of this document is to provide a literature-based review of the current clinical approach to venous thromboembolism and up-to-date references for further study in this important topic.

Multimodality CMR detection of coronary artery disease in patients with heart failure and depressed systolic function: superiority of coronary MRI compared to late gadolinium enhancement

Introduction Heart failure (HF) with depressed systolic function is increasingly prevalent in the United States with coronary artery disease (CAD) the most common etiology. Definitive determination of an ischemic vs. non-ischemic etiology of HF often requires invasive x-ray coronary angiography. Both coronary magnetic resonance imaging (cMRI) and late gadolinium enhancement (LGE) have shown promise in the non-invasive detection of CAD in HF patients.

Images in cardiovascular medicine. Sinus of Valsalva aneurysm with right ventricular outflow tract obstruction: evaluation with Doppler, real-time 3-dimensional and contrast echocardiography.

A 78-year-old man presented with new exertional dyspnea. Physical examination demonstrated a parasternal thrill that was associated with a systolic murmur, and mild edema of the lower extremities. Transthoracic 2-dimensional and real-time 3-dimensional echocardiography demonstrated a 5.3×4.5-cm aneurysm of the right sinus of Valsalva (Figures 1 and 2⇓ and Movie I). There was moderate to severe aortic regurgitation. The aneurysm protruded into the right ventricular outflow tract, and color Doppler showed turbulent flow around the aneurysm with a peak systolic pressure gradient of 49 mm Hg (Figure 3 and Movie II). Imaging after intravenous injection of perflutren ultrasound contrast agent demonstrated the partition of the right ventricle by the aneurysm (Figure 4 and Movie III). When injected into a peripheral vein, the contrast …A 78-year-old man presented with new exertional dyspnea. Physical examination demonstrated a parasternal thrill that was associated with a systolic murmur, and mild edema of the lower extremities. Transthoracic 2-dimensional and real-time 3-dimensional echocardiography demonstrated a 5.3×4.5-cm aneurysm of the right sinus of Valsalva (Figures 1 and 2⇓ and Movie I). There was moderate to severe aortic regurgitation. The aneurysm protruded into the right ventricular outflow tract, and color Doppler showed turbulent flow around the aneurysm with a peak systolic pressure gradient of 49 mm Hg (Figure 3 and Movie II). Imaging after intravenous injection of perflutren ultrasound contrast agent demonstrated the partition of the right ventricle by the aneurysm (Figure 4 and Movie III). When injected into a peripheral vein, the contrast …

Sinus of Valsalva Aneurysm With Right Ventricular Outflow Tract Obstruction: Evaluation With Doppler, Real-Time 3-Dimensional and Contrast Echocardiography

A 78-year-old man presented with new exertional dyspnea. Physical examination demonstrated a parasternal thrill that was associated with a systolic murmur, and mild edema of the lower extremities. Transthoracic 2-dimensional and real-time 3-dimensional echocardiography demonstrated a 5.3×4.5-cm aneurysm of the right sinus of Valsalva (Figures 1 and 2⇓ and Movie I). There was moderate to severe aortic regurgitation. The aneurysm protruded into the right ventricular outflow tract, and color Doppler showed turbulent flow around the aneurysm with a peak systolic pressure gradient of 49 mm Hg (Figure 3 and Movie II). Imaging after intravenous injection of perflutren ultrasound contrast agent demonstrated the partition of the right ventricle by the aneurysm (Figure 4 and Movie III). When injected into a peripheral vein, the contrast …A 78-year-old man presented with new exertional dyspnea. Physical examination demonstrated a parasternal thrill that was associated with a systolic murmur, and mild edema of the lower extremities. Transthoracic 2-dimensional and real-time 3-dimensional echocardiography demonstrated a 5.3×4.5-cm aneurysm of the right sinus of Valsalva (Figures 1 and 2⇓ and Movie I). There was moderate to severe aortic regurgitation. The aneurysm protruded into the right ventricular outflow tract, and color Doppler showed turbulent flow around the aneurysm with a peak systolic pressure gradient of 49 mm Hg (Figure 3 and Movie II). Imaging after intravenous injection of perflutren ultrasound contrast agent demonstrated the partition of the right ventricle by the aneurysm (Figure 4 and Movie III). When injected into a peripheral vein, the contrast …