Kibar Yared

Cardiovascular screening in college athletes with and without electrocardiography: a cross-sectional study.

BACKGROUND Although cardiovascular screening is recommended for athletes before participating in sports, the role of 12-lead electrocardiography (ECG) remains uncertain. To date, no prospective data that compare screening with and without ECG have been available. OBJECTIVE To compare the performance of preparticipation screening limited to medical history and physical examination with a strategy that integrates these with ECG. DESIGN Cross-sectional comparison of screening strategies. SETTING University Health Services, Harvard University, Cambridge, Massachusetts. PARTICIPANTS 510 collegiate athletes who received cardiovascular screening before athletic participation. MEASUREMENTS Each participant had routine history and examination-limited screening and ECG. They received transthoracic echocardiography (TTE) to detect or exclude cardiac findings with relevance to sports participation. The performance of screening with history and examination only was compared with that of screening that integrated history, examination, and ECG. RESULTS Cardiac abnormalities with relevance to sports participation risk were observed on TTE in 11 of 510 participants (prevalence, 2.2%). Screening with history and examination alone detected abnormalities in 5 of these 11 athletes (sensitivity, 45.5% [95% CI, 16.8% to 76.2%]; specificity, 94.4% [CI, 92.0% to 96.2%]). Electrocardiography detected 5 additional participants with cardiac abnormalities (for a total of 10 of 11 participants), thereby improving the overall sensitivity of screening to 90.9% (CI, 58.7% to 99.8%). However, including ECG reduced the specificity of screening to 82.7% (CI, 79.1% to 86.0%) and was associated with a false-positive rate of 16.9% (vs. 5.5% for screening with history and examination only). LIMITATION Definitive conclusions regarding the effect of ECG inclusion on sudden death rates cannot be made. CONCLUSION Adding ECG to medical history and physical examination improves the overall sensitivity of preparticipation cardiovascular screening in athletes. However, this strategy is associated with an increased rate of false-positive results when current ECG interpretation criteria are used. PRIMARY FUNDING SOURCE None.

Cardiac Tumors: Optimal Cardiac MR Sequences and Spectrum of Imaging Appearances

OBJECTIVE This article reviews the optimal cardiac MRI sequences for and the spectrum of imaging appearances of cardiac tumors. CONCLUSION Recent technologic advances in cardiac MRI have resulted in the rapid acquisition of images of the heart with high spatial and temporal resolution and excellent myocardial tissue characterization. Cardiac MRI provides optimal assessment of the location, functional characteristics, and soft-tissue features of cardiac tumors, allowing accurate differentiation of benign and malignant lesions.

Multimodality Imaging of Pericardial Diseases

Pericardial disease is an important cause of morbidity and mortality in patients with cardiovascular disease. Inflammatory diseases of the pericardium constitute a spectrum ranging from acute pericarditis to chronic constrictive pericarditis. Other important entities that involve the pericardium include benign and malignant pericardial masses, pericardial cysts, and diverticula, as well as congenital absence of the pericardium. Recent advances in multimodality noninvasive cardiac imaging have solidified its role in the management of patients with suspected pericardial disease. The physiologic and structural information obtained from transthoracic echocardiography and the anatomic detail provided by cardiac computed tomography and magnetic resonance have led to growing interest in the complementary use of these techniques. Optimal management of the patient with suspected pericardial disease requires familiarity with the key imaging modalities and the ability to choose the appropriate imaging tests for each patient. This report reviews the imaging modalities most useful in the assessment of patients with pericardial disease, with an emphasis on the complementary value of multimodality cardiac imaging.

Significance of electrocardiographic right bundle branch block in trained athletes.

We sought to determine the clinical and physiologic significance of electrocardiographic complete right bundle branch block (CRBBB) and incomplete right bundle branch block (IRBBB) in trained athletes. The 12-lead electrocardiographic and echocardiographic data from 510 competitive athletes were analyzed. Compared to the 51 age-, sport type-, and gender-matched athletes with normal 12-lead electrocardiographic QRS complex duration, the 44 athletes with IRBBB (9%) and 13 with CRBBB (3%) had larger right ventricular (RV) dimensions, as measured by the basal RV end-diastolic diameter (CRBBB 43 ± 3 mm, IRBBB 38 ± 6 mm, normal QRS complex 35 ± 4 mm, p <0.001) and RV end-diastolic area (CRBBB 33 ± 5, IRBBB 27 ± 7, and normal QRS complex 23 ± 3 cm(2); p <0.001). Athletes with CRBBB also had a relative reduction in the RV systolic function at rest as assessed by the RV fractional area change and peak systolic tissue velocity. Finally, QRS prolongation was associated with parallel increases in interventricular dyssynchrony (basal RV to basal lateral left ventricular peak systolic tissue velocity time difference: CRBBB 112 ± 15, IRBBB 73 ± 33, normal QRS complex 43 ± 39 ms, p <0.001). Despite these findings, no athlete with CRBBB or IRBBB was found to have pathologic structural cardiac disease. In conclusion, among trained athletes, CRBBB and IRBBB appear to be markers of a structural and physiological cardiac remodeling triad characterized by RV dilation, a relative reduction in the RV systolic function at rest, and interventricular dyssynchrony.

Impact of aortic regurgitation after transcatheter aortic valve implantation: results from the REVIVAL trial.

OBJECTIVES Understanding the severity of aortic regurgitation (AR) after transcatheter aortic valve implantation, its impact on left ventricular (LV) structure and function, and the structural factors associated with worsening AR could lead to improvements in patient selection, implantation technique, and valve design. BACKGROUND Initial studies in patients at high risk of surgical aortic valve replacement have reported both central valvular and paravalvular AR after transcatheter aortic valve implantation. METHODS Transthoracic echocardiograms were quantified from 95 patients in the REVIVAL (TRanscatheter EndoVascular Implantation of VALves) trial. Transthoracic echocardiograms were obtained before implantation of the Edwards-Sapien valve (Edwards Lifesciences, Irvine, California) and thereafter at selected intervals. Measurements included LV internal diameters and volumes, ejection fraction, aortic valve area, and the degree of aortic regurgitation. Measures of degree of native leaflet mobility, thickness, and calcification, as well as left ventricular outflow tract, aortic annulus, and aortic root diameters were also made. RESULTS Eighty-four patients remained after 11 were excluded; 26 (29.8%) died over a period of 3 years. At 24 h post-implantation, 75% had some degree of AR, mostly paravalvular. By 1 year, the mean AR grade increased slightly, but not significantly (1.1 ± 0.8 to 1.3 ± 0.9), and all measures of LV structure and function improved (LV ejection fraction, 50.7 ± 16.1% to 59.4 ± 14.0%). Native aortic leaflet calcification and annulus diameter correlated significantly with the severity of AR at 1 year (p < 0.05). CONCLUSIONS AR after transcatheter aortic valve implantation is frequent but is rarely more than mild. Although AR progresses, it is not associated with a harmful impact on LV structure and function over the first year. Native valve calcification and aortic annulus diameter influence the degree of AR at 6 months.

Echocardiographic Assessment of Percutaneous Patent Foramen Ovale and Atrial Septal Defect Closure Complications

Atrial septal defect (ASD) is a common congenital defect (1 in 1000 live births) and accounts for up to 40% of clinically relevant acyanotic shunts in adults.1 Patent foramen ovale (PFO) is much more common and is present in more than 25% of adults.2,3 The clinical syndromes associated with ASD/PFO represent a significant health burden. Surgical closure is the most common therapy for these defects, and it is associated with low morbidity and mortality. However, it remains a surgical procedure requiring cardiopulmonary bypass, a significant postoperative recovery, and a sternotomy scar that may be undesirable to young patients. Catheter-based techniques for the treatment of ASD/PFO were pioneered by King and Mills in 1975.4 Since then, significant device development and modifications have been made (Table 1). Percutaneous therapy is now the preferred strategy for ASD/PFO closure, by patients and physicians alike, in the absence of complicated anatomy or another indication for traditional cardiac surgery, because it is technically simple and associated with negligible morbidity and mortality.5 Longer-term follow-up, however, remains necessary to more completely evaluate the safety and efficacy of such devices. View this table: Table 1. Summary of Devices Most Frequently Used for Percutaneous Closure of ASD or PFO The role of 2-dimensional (2D) transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) during the assessment and management of ASD/PFO has been demonstrated.6–8 Although universal practice standards, in the form of consensus committee guidelines or professional society recommendations, still have to be established for the use of echocardiography in this context, it is used by a majority of groups who perform these procedures. In our institution, TTE with color Doppler and/or agitated saline contrast injection is most frequently the method used to diagnose interatrial communication. Once the diagnosis has been made and percutaneous closure is deemed clinically appropriate, a careful …

Cardiac MR imaging of nonischemic cardiomyopathies: imaging protocols and spectra of appearances.

Cardiac MR is an excellent noninvasive imaging technique for the detection and assessment of the morphology, function, and myocardial contrast-enhancement characteristics of the nonischemic cardiomyopathies.

Cardiac Sarcoidosis Imitating Arrhythmogenic Right Ventricular Dysplasia

A 59-year-old male was admitted to Massachusetts General Hospital, Boston, Mass, with a 2-month history of exertional dyspnea (New York Heart Association class II to III). The patient denied dyspnea at rest, chest pain, palpitations, or syncope. There was no history of fevers or recent weight loss. An outpatient echocardiogram (Figure 1), performed as part of the workup of the patient’s dyspnea, demonstrated normal left ventricular size and function. The right ventricle (RV) was normal in size but diffusely hypokinetic. There was evidence of segmental RV dysfunction, with 2 discrete aneurysmal areas in the RV free wall at the base and apex, which measured 1.5 and 3.0 cm in width. Both areas appeared thinned and dyskinetic. The echocardiographic appearance was suggestive of arrhythmogenic RV dysplasia/cardiomyopathy (ARVD/C).1 A CT scan ruled out the presence of pulmonary embolism but was notable for marked mediastinal lymphadenopathy (Figure 2 …

Is Marathon Running Hazardous to Your Cardiovascular Health? The Jury Is Still Out

There is not enough evidence to implicate marathon running in the development of a dangerous substrate for coronary events; however, an improvement in lifestyle, even with complete cessation of risky activities, may not completely eliminate the potentially dangerous sequelae of such activities.

Impact of Family Hypertension History on Exercise-Induced Cardiac Remodeling

Left ventricular (LV) hypertrophy is a well-established, but highly variable, finding among exercise-trained persons. The causes for the variability in LV remodeling in response to exercise training remain incompletely understood. The present study sought to determine whether a family history of hypertension is a determinant of the cardiac response to exercise training. The cardiac parameters in 60 collegiate rowers (30 men/30 women; age 19.8 +/- 1.1 years) with (family history positive [FH+], n = 22) and without (family history negative [FH-], n = 38) a FH of hypertension were studied with echocardiography before and after 90 days of rowing training. The LV mass increased significantly in both groups. However, the LV mass increased significantly more in FH- persons (Delta 17 +/- 5 g/m(2)) than in FH+ persons (Delta 9 +/- 6 g/m(2), p <0.001) with distinctly differently patterns of LV hypertrophy between the 2 groups. FH- athletes experienced eccentric LV hypertrophy (relative wall thickness index 0.39 +/- 0.4) characterized by LV dilation. In contrast, FH+ athletes developed concentric LV hypertrophy (relative wall thickness index 0.44 +/- 0.3; p <0.001) characterized by LV wall thickening. Furthermore, the eccentric LV remodeling in FH- athletes was associated with a more robust enhancement of LV diastolic function than the concentric LV remodeling that occurred in FH+ athletes. In conclusion, these findings suggest that patterns of exercise-induced LV remodeling are strongly associated with FH history status.