Fred Kusumoto

Estimation of mean left atrial pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow.

To determine whether pulmonary venous flow and mitral inflow measured by transesophageal pulsed Doppler echocardiography can be used to estimate mean left atrial pressure (LAP), we prospectively studied 47 consecutive patients undergoing cardiovascular surgery. We correlated Doppler variables of pulmonary venous flow and mitral inflow with simultaneously obtained mean LAP and changes in pressure measured by left atrial or pulmonary artery catheters. Among the pulmonary venous flow variables, the systolic fraction (i.e., the systolic velocity-time integral expressed as a fraction of the sum of systolic and early diastolic velocity-time integrals) correlated most strongly with mean LAP (r = -0.88). Of the mitral inflow variables, the ratio of peak early diastolic to peak late diastolic mitral flow velocity correlated most strongly with mean LAP (r = 0.43), but this correlation was not as strong as that with the systolic fraction of pulmonary venous flow. Similarly, changes in the systolic fraction correlated more strongly with changes in mean LAP (r = -0.78) than did changes in the ratio of peak early diastolic to peak late diastolic mitral inflow velocity (r = 0.68). We conclude that in the surgical setting observed, pulmonary venous flow from transesophageal pulsed Doppler echocardiography can be used to estimate mean LAP. This technique may provide a rapid, simple, and relatively noninvasive means of gauging this variable in patients undergoing intraoperative transesophageal echocardiography.

The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers and Arrhythmia Monitors: Facilities and Patient Management: Executive Summary: This document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS)

a t C r a t a R The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers and Arrhythmia Monitors: Facilities and Patient Management This document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS)

Pulmonary venous flow patterns by transesophageal pulsed Doppler echocardiography: Relation to parameters of left ventricular systolic and diastolic function

We have previously shown that the systolic and diastolic pulmonary venous flow (PVF) distribution is predictive of left atrial pressure. This study was designed to define the confounding influences of left atrial expansion, descent of the mitral anulus, and left ventricular contractile function on that relationship; to define normal PVF patterns; and to document the interaction of PVF with mitral inflow. Therefore we studied 27 consecutive intraoperative patients with coronary artery disease (22 men and 5 women, ages 35 to 78 years) using transesophageal echocardiography. A group of 12 normal subjects served as a control. Doppler and two-dimensional echocardiographic parameters were obtained simultaneously with monitoring pulmonary capillary wedge pressure (PCWP). We found that neither left atrial expansion nor the descent of the mitral anulus influenced the relationship between PVF and PCWP, but that left ventricular fractional shortening confounded this relationship. In normal subjects PVF was dominant in systole, whereas PVF in patients with elevated PCWP was dominant in diastole (systolic fraction of 68 +/- 6% [SD] in normals versus 42 +/- 15% in patients with PCWP greater than or equal to 15 mm Hg). PVF velocities interacted with transmitral flow velocities. Peak early diastolic mitral inflow velocities increased linearly with peak early diastolic PVF velocities (r = 0.62). We conclude that systolic and diastolic PVF distribution is mainly determined by the level of PCWP and to a lesser extent by left ventricular contraction, but not by left atrial expansion or by mitral anulus descent. Transesophageal pulsed Doppler echocardiography of PVF provides useful clinical information about the level of PCWP in intraoperative patients with coronary artery disease.

Radiofrequency catheter ablation versus medical therapy for initial treatment of supraventricular tachycardia and its impact on quality of life and healthcare costs

We prospectively compared the impact on quality of life and cost effectiveness between ablation and medication as an initial strategy for patients with paroxysmal supraventricular tachycardia (SVT). Seventy-nine consecutive patients with newly documented paroxysmal SVT were treated with either ablation or medication. Health surveys (SF-36 and disease-specific questions) were obtained at baseline and after 12 months of follow up. Cost of health care utilization for the 6 months before and after treatment were measured. Both medication and ablation improved quality of life. However, ablation improved quality of life in more general health categories than medication. At follow up, ablation was associated with significantly improved quality of life in the bodily pain (63+/-24 vs 81+/-20, p <0.005), general health (69+/-21 vs 79+/-21, p <0.05), vitality (55+/-21 vs 66+/-22, p <0.05), and role emotion (78+/-36 vs 94+/-17, p <0.05) categories when compared with medication. Although both medication and ablation decreased frequency of disease-specific symptoms, ablation resulted in complete amelioration of symptoms in more patients (33% vs 74%). Potential long-term costs were similar for medication and ablation. In conclusion, ablation improves health-related quality of life to a greater extent, and in more aspects of general and disease-specific health than medication.

The flail mitral valve: Echocardiographic findings by precordial and transesophageal imaging and doppler color flow mapping

To determine the echocardiographic and Doppler characteristics of mitral regurgitation associated with a flail mitral valve, precordial and transesophageal echocardiography with pulsed wave and Doppler color flow mapping was performed in 17 patients with a flail mitral valve leaflet due to ruptured chordae tendineae (Group I) and 22 patients with moderate or severe mitral regurgitation due to other causes (Group II). Echocardiograms were performed before or during cardiac surgery; cardiac catheterization was also performed in 28 patients (72%). Mitral valve disease was confirmed at cardiac surgery in all patients. By echocardiography, the presence of a flail mitral valve leaflet was defined by the presence of abnormal mitral leaflet coaptation or ruptured chordae. Using these criteria, transesophageal imaging showed a trend toward greater sensitivity and specificity than precordial imaging in the diagnosis of flail mitral valve leaflet. By Doppler color flow mapping, a flail mitral valve leaflet was also characterized by an eccentric, peripheral, circular mitral regurgitant jet that closely adhered to the walls of the left atrium. The direction of flow of the eccentric jet in the left atrium distinguished a flail anterior from a flail posterior leaflet. By transesophageal echocardiography with Doppler color flow mapping, the ratio of mitral regurgitant jet arc length to radius of curvature was significantly higher in Group I than Group II patients (5.0 +/- 2.3 versus 0.7 +/- 0.6, p less than 0.001); all of the Group I patients and none of the Group II patients had a ratio greater than 2.5.(ABSTRACT TRUNCATED AT 250 WORDS)

Electromagnetic Interference and Implanted Cardiac Devices: The Nonmedical Environment (Part I)

The number of patients with cardiovascular implantable electronic devices (CIEDs), such as permanent pacemakers and implantable cardioverter‐defibrillators, is dramatically rising due to an aging population and recent clinical trials showing benefits in mortality and morbidity. Coupled with this increase in the number of patients with CIEDs is the proliferation of technology that emits electromagnetic signals, which can potentially interfere with CIED function through electromagnetic interference (EMI). Despite continuous efforts of manufacturers to create “EMI‐proof” CIEDs, adverse events from EMI still occur. Physicians caring for patients with CIEDs should be aware of potential sources of EMI and appropriate management options. This 2‐part review aims to provide a contemporary overview of the current knowledge regarding risks attributable to EMI interactions from the most common nonmedical (Part I) and medical (Part II) sources. Clin. Cardiol. 2012 doi: 10.1002/clc.21998

A prospective comparison of cardiac imaging using intracardiac echocardiography with transesophageal echocardiography in patients with atrial fibrillation: the intracardiac echocardiography guided cardioversion helps interventional procedures study.

Background—The Intracardiac Echocardiography Guided Cardioversion Helps Interventional Procedures study evaluated the concordance of intracardiac echocardiography (ICE) with transesophageal echocardiography (TEE) in patients with atrial fibrillation (AF). Methods and Results—Patients with AF undergoing right heart catheterization underwent left atrium (LA) and interatrial septal (IAS) imaging by TEE and ICE. A blinded comparison of the 2 modalities was performed at a core laboratory. Ninety-five patients aged 58±12 years completed the study. The LA was profiled in all patients with both techniques, and concordance for image quality was 96%. LA appendage (LAA) imaging was achieved in 85% with ICE and 96% with TEE. There was no difference in the presence of spontaneous echo contrast between ICE and TEE during LA imaging, but there was a trend toward a greater incidence in the LAA with TEE (P=0.109). Intracardiac thrombus was uncommonly seen (TEE, 6.9%; ICE, 5.2%). The concordance for the presence or absence of thrombus was 97% in the LA and 92% in the LAA, but the latter was detected more frequently with TEE. IAS imaging was achieved in 91% with ICE and in 97% with TEE (P=0.177). Concordance for patent foramen ovale and atrial septal aneurysms was 100% and 96%, respectively. A negative ICE examination was associated with absence of dense echo contrast or thrombus on TEE in 86%. Conclusions—This study provides validation for the use of ICE for LA and IAS imaging. ICE imaging was less sensitive compared to TEE for LAA thrombus identification. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00281073.

Response of the interatrial septum to transatrial pressure gradients and its potential for predicting pulmonary capillary wedge pressure: An intraoperative study using transesophageal echocardiography in patients during mechanical ventilation☆☆☆

OBJECTIVES We hypothesized that the directional movement of the interatrial septum and its curvature may reflect the pressure relations between the left and right atria. BACKGROUND Interventricular septal shape is primarily dependent on the pressure gradient between the left and the right ventricle. No analogous study has carefully evaluated the determinants of interatrial septum shape and motion. METHODS Patients (n = 52) undergoing cardiac or vascular surgery were studied intraoperatively at multiple intervals with transesophageal echocardiography and simultaneous measurement of central venous pressure, pulmonary capillary wedge pressure and airway pressure. RESULTS Overall interatrial septum shape, which usually curved toward the right atrium, changed concordantly with the interatrial pressure gradient (pulmonary capillary wedge pressure-central venous pressure difference). The degree of interatrial septum curvature was also primarily dependent on the interatrial pressure gradient and, to a lesser extent, was affected by changes in left atrial size (F = 130.4 vs. F = 14.1). During passive mechanical expiration, the interatrial pressure gradient, usually positive, often reverses transiently and the interatrial septum momentarily bows toward the left atrium. Midsystolic reversal was seen in 64 of 72 episodes when the pulmonary capillary wedge pressure was < or = 15 mm Hg but in only 2 of 40 episodes when it was > 15 mm Hg (sensitivity = 0.89, specificity = 0.95, positive predictive value = 0.97). CONCLUSIONS These findings suggest that overall interatrial septum shape depends on the pressure gradient between the left and right atria. Midsystolic reversal of the interatrial septum, which probably reflects the increased venous return in the right relative to the left atrium during mechanical expiration, may be a useful indicator of the pulmonary capillary wedge pressure.

Atrial fibrillation ablation leads to long-term improvement of quality of life and reduced utilization of healthcare resources.

In some patients, rapid activation from one or several foci can lead to atrial fibrillation. This study evaluated long-term changes in quality of life and healthcare resource utilization in patients with atrial fibrillation treated by ablation of focal triggers. Thirty-three patients underwent ablation for paroxysmal atrial fibrillation. Health surveys (SF-36) were obtained at baseline, and after 1 year and 3 years of follow-up. Health care costs were measured for the 3 years before and after ablation. Ablation was successful in 82%, partially successful in 12% (no sustained episodes but on antiarrhythmic drug therapy), and unsuccessful in 6% of patients. The average number of ablation procedures was 1.6 ± 0.6 per patient. After ablation, patients reported significantly improved quality of life in all SF-36 categories except bodily pain. Healthcare resource utilization was significantly reduced after ablation (Clinic visits: 7.4 ± 2.5 per year vs. 1.1 ± 0.6 per year, p < 0.05; Emergency room visits: 1.7 ± 0.90 per year vs. 0.03 ± 0.17 per year, p < 0.05; Hospitalization: 1.6 ± 0.81 vs. 0, p < 0.05). Cost of healthcare (not including procedural costs) was significantly reduced after ablation (Pre-ablation:

The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers and Arrhythmia Monitors: Facilities and Patient Management: Executive Summary

1,920 ± 889/year vs. post-ablation: