Eric S. Williams

Detection of left ventricular aneurysms by cross-sectional echocardiography.

SUMMARY Real-time cross-sectional echocardiographic studies of the left ventricle were performed in 31 consecutive patients with angiographically proven left ventricular aneurysms (group 1). In each of these patients the presence and location of the aneurysm was visualized by the cross-sectional echocardiography. In four patients discrepancy in the extent of the aneurysm was noted due either to failure of the cross-sectional technique to visualize the entire anterior wall of the ventricle (3) or failure of the single plane angiogram to adequately define the lateral extent of the aneurysm (1). Ventricular shape and contraction sequence in patients with aneurysms were compared with similar patterns in 20 patients with normal left ventricles (group II), and 20 patients with ischemic heart disease and localized ventricular dysfunction without aneurysm formation (group III). Other noninvasive methods for detecting aneurysms (including physical examination, chest roentgenography, electrocardiography, and M-mode echocardiography) were also evaluated in the aneurysm group. This report suggests that cross-sectional echocardiography is a useful method for detecting ventricular aneurysms noninvasively.

ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (Writing Committee to Revise the 2007 Clinical Competence Statement on Cardiac Interventional Procedures)

Granting clinical staff privileges to physicians is the primary mechanism institutions use to uphold quality care. The Joint Commission requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians themselves are charged with defining the

ACC 2009 survey results and recommendations: Addressing the cardiology workforce crisis A report of the ACC board of trustees workforce task force.

The prevalence of cardiovascular disease (CVD) is increasing by 1% to 2% per year, and will continue to do so over the next 2 decades ([1][1]). The American Heart Association predicts that by 2020, at least 20 million more people in the United States will be afflicted with heart disease than there

COCATS 4 Introduction.

Recommendations for training in adult cardiovascular medicine were first published in the Journal in 1995 as a consensus statement emanating from the Core Cardiology Training Symposium (COCATS) held at Heart House in Bethesda, Maryland, the previous year [(1)][1]. The term “COCATS” has since

A proposal for new clinical concepts in the management of atrial fibrillation

Atrial fibrillation (AF) represents a growing public health burden. It is a complex condition, involving a number of etiologic factors and arrhythmia mechanisms associated with atrial remodeling. Greater understanding of these mechanisms may improve therapy. Current AF classification schemes are limited by simplicity. A number of risk factors predict AF onset, and additional factors are being evaluated in registry studies. Doppler imaging and Holter monitoring in high-risk patients to predict the onset of AF and progression from paroxysmal to permanent AF are promising. There is a need for a novel multifactorial classification model encompassing AF duration, symptoms, markers of atrial remodeling, and a risk score for AF onset, persistence, progression, and complications to guide treatment and prognostication. Preventing AF onset with upstream therapy is of great interest, but current data are conflicting. More study is needed to optimize rhythm control with antiarrhythmic drugs and targeted ablation to specific patient populations at an earlier stage. There is little consensus on optimal rate control and no information relating to optimum rate control in specific populations. This article highlights new concepts in AF and directions for future research.

Mechanical dyssynchrony evaluated by tissue Doppler cross-correlation analysis is associated with long-term survival in patients after cardiac resynchronization therapy

AIMS Pre-implant assessment of longitudinal mechanical dyssynchrony using cross-correlation analysis (XCA) was tested for association with long-term survival and compared with other tissue Doppler imaging (TDI)-derived indices. METHODS AND RESULTS In 131 patients referred for cardiac resynchronization therapy (CRT) from two international centres, mechanical dyssynchrony was assessed from TDI velocity curves using time-to-peak opposing wall delay (OWD) ≥80 ms, Yu index ≥32 ms, and the maximal activation delay (AD-max) >35 ms. AD-max was calculated by XCA of the TDI-derived myocardial acceleration curves. Outcome was a composite of all-cause mortality, cardiac transplantation, or implantation of a ventricular assist device (left ventricular assist device) and modelled using the Cox proportional hazards regression. Follow-up was truncated at 1460 days. Dyssynchrony by AD-max was independently associated with improved survival when adjusted for QRS > 150 ms and aetiology {hazard ratio (HR) 0.35 [95% confidence interval (CI) 0.16-0.77], P = 0.01}. Maximal activation delay performed significantly better than Yu index, OWD, and the presence of left bundle branch block (P < 0.05, all, for difference between parameters). In subgroup analysis, patients without dyssynchrony and QRS between 120 and 150 ms showed a particularly poor survival [HR 4.3 (95% CI 1.46-12.59), P < 0.01, compared with the group with dyssynchrony and QRS between 120 and 150 ms]. CONCLUSION Mechanical dyssynchrony assessed by AD-max was associated with long-term survival after CRT and was significantly better associated compared with other TDI-derived indices. Patients without dyssynchrony and QRS between 120 and 150 ms had a particularly poor prognosis. These results indicate a valuable role for XCA in selection of CRT candidates.

The rationale and design of the Micra Transcatheter Pacing Study: Safety and efficacy of a novel miniaturized pacemaker

AIMS Recent advances in miniaturization technologies and battery chemistries have made it possible to develop a pacemaker small enough to implant within the heart while still aiming to provide similar battery longevity to conventional pacemakers. The Micra Transcatheter Pacing System is a miniaturized single-chamber pacemaker system that is delivered via catheter through the femoral vein. The pacemaker is implanted directly inside the right ventricle of the heart, eliminating the need for a device pocket and insertion of a pacing lead, thereby potentially avoiding some of the complications associated with traditional pacing systems. METHODS AND RESULTS The Micra Transcatheter Pacing Study is currently undergoing evaluation in a prospective, multi-site, single-arm study. Approximately 720 patients will be implanted at up to 70 centres around the world. The study is designed to have a continuously growing body of evidence and data analyses are planned at various time points. The primary safety and efficacy objectives at 6-month post-implant are to demonstrate that (i) the percentage of Micra patients free from major complications related to the Micra system or implant procedure is significantly higher than 83% and (ii) the percentage of Micra patients with both low and stable thresholds is significantly higher than 80%. The safety performance benchmark is based on a reference dataset of 977 subjects from 6 recent pacemaker studies. CONCLUSIONS The Micra Transcatheter Pacing Study will assess the safety and efficacy of a miniaturized, totally endocardial pacemaker in patients with an indication for implantation of a single-chamber ventricular pacemaker. CLINICALTRIALSGOV REGISTRATION ID NCT02004873.

Race and gender variation in the QT interval and its association with mortality in patients with coronary artery disease: Results from the Duke Databank for Cardiovascular Disease (DDCD)

BACKGROUND In several studies, prolongation of the corrected QT (QTc) interval has been associated with an increased risk of cardiac events. However, data on race and gender variation in the QTc and its associated risk of death are lacking. METHODS We prospectively followed 19,252 subjects who underwent cardiac catheterization and had at least 1 native coronary artery stenosis ≥75%. Automated QTc measurements were obtained from a baseline electrocardiogram. RESULTS The mean age of the population was 62.4 years, with 35% being female and 20% being black. The QTc varied by gender and race (417.9 ± 34.4 ms in men and 433.4 ± 33.6 ms in women, 422.1 ± 34.3 ms in whites and 428.1 ± 36.9 ms in blacks; P < .0001 for both). Risk factors most strongly associated with a prolonged QTc were lower ejection fraction, higher diastolic blood pressure, history of myocardial infarction, and lower glomerular filtration rate. Black race and female gender were also independently associated with a prolonged QTc, after adjustment for cardiac risk factors. Moreover, there was an independent association between QTc and all-cause mortality (hazard ratio 1.037 per 10-ms increase, P < .0001). The increased mortality risk associated with a 10-ms increase in the QTc interval was significantly greater for men compared with women (4.6% vs 2.4%, P = .004) and slightly greater for blacks compared with other races (5.0% vs 3.3%, P = .057). CONCLUSIONS Among patients with coronary artery disease, QTc prolongation is independently associated with all-cause mortality. The increased mortality risk is higher for men than for women, with a trend toward higher mortality in blacks.

The effect of chronic alcohol administration on fatty acid metabolism and pyruvate oxidation of heart mitochondria

It has been proposed that the mechanism for myocardial triglyceride (TG) accumulation and diminished fatty acid oxidation in chronic alcoholic animals is mitochondrial damage and, possibly, altered palmitylcarnitine trasnferase (PCAT) activity. We have studied the fatty acid metabolism and PCAT activity of isolated heart mitochondria from 80 male rats pair-fed 52±7 days a liquid diet (35% fat) containing all essential nutrients but with ethanol or dextrin-maltose (control) as 36% of the total calories. Myocardial TG increased two to four times in alcohol-fed animals, but tissue free, acetyl- and acylcarnitine levels were unchanged. PCAT specific activity was not diminished in the alcoholic group (10.76±0.90 vs 13.38±1.60 nmol/min/mg) and Vmax and Km for carnitine were identical. Mitochondrial respiration rates with glutamate and palmityl- and acetylcarnitine were unchanged. However, pyruvate oxidation (states III and IV) in alcoholic animals was consistently reduced (200±23 and 28.3±4.0 vs 161±19 and 23.0±4.0 natoms oxygen/min/mg, respectively; P<0.001 and <0.02). These findings show that fat accumulation occurs despite the normal ability of the myocardium to transport and oxidize fatty acid. Furthermore, pyruvate dehydrogenase inhibition may be an early marker of alcohol induced myocardial damage.

2016 ACC Lifelong Learning Competencies for General Cardiologists: A Report of the ACC Competency Management Committee

Eric S. Williams, MD, MACC, Chair Jonathan L. Halperin, MD, FACC, Co-Chair James A. Arrighi, MD, FACC Eric H. Awtry, MD, FACC Eric R. Bates, MD, FACC John E. Brush, Jr, MD, FACC Salvatore Costa, MD, FACC Lori Daniels, MD, MAS, FACC Susan Fernandes, LPD, PA-C Rosario Freeman, MD, MS, FACC