Peter S. Rahko

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

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ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult—Summary Article

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines regularly reviews existing guidelines to determine when an update or full revision is needed. This process gives priority to areas where major changes in text, particularly recommendations,

Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography

1. Why is a guideline needed? 567 2. Definitions 568 a. What is FCU? 568 b. Terminology 568 3. Differentiation of FCU and ‘‘Limited TTE’’ 568 a. Examination Expectations 569 b. Equipment 570 c. Image Acquisition 570 d. Image Interpretation 570 e. Billing 571 4. Considerations for Successful Use of FCU as an Adjunct to Physical Examination 571 a. Personnel 571 b. Equipment 571 c. Potential Limitations of FCU 572 5. FCU Scope of Practice 573 a. FCU When Echocardiography is Not Promptly Available 573 b. FCU When Echocardiography is Not Practical 574

Lamin A/C mutation analysis in a cohort of 324 unrelated patients with idiopathic or familial dilated cardiomyopathy

BACKGROUND Lamin A/C mutations are a well-established cause of dilated cardiomyopathy (DCM), although their frequency has not been examined in a large cohort of patients. We sought to examine the frequency of mutations in LMNA, the gene encoding lamin A/C, in patients with idiopathic (IDC) or familial dilated cardiomyopathy (FDC). METHODS Clinical cardiovascular data, family histories, and blood samples were collected from 324 unrelated IDC probands, of whom 187 had FDC. DNA samples were sequenced for nucleotide alterations in LMNA. Likely protein-altering mutations were followed up by evaluating additional family members, when possible. RESULTS We identified 18 protein-altering LMNA variants in 19 probands or 5.9% of all cases (7.5% of FDC; 3.6% of IDC). Of the 18 alterations, 11 were missense (one present in 2 kindreds), 3 were nonsense, 3 were insertion/deletions, and 1 was a splice site alteration. Conduction system disease and DCM were common in carriers of LMNA variants. Unexpectedly, in 6 of the 19 kindreds with a protein-altering LMNA variant (32%), at least one affected family member was negative for the LMNA variant. CONCLUSIONS Lamin A/C variants were observed with a frequency of 5.9% in probands with DCM. The novel observation of FDC pedigrees in which not all affected individuals carry the putative disease-causing LMNA mutation suggests that some protein-altering LMNA variants are not causative or that some proportion of FDC may be because of multiple causative factors. These findings warrant increased caution in FDC research and molecular diagnostics.

Improved detection of infective endocarditis with transesophageal echocardiography

The incremental advantage of transesophageal echocardiography was determined by comparing results of paired transthoracic and transesophageal echocardiographic examinations performed in 61 patients for evaluation of suspected infective endocarditis. According to clinical and pathologic data, 31 of 61 (51%) patients had finding that were positive for infective endocarditis. Studies were graded as positive or negative for vegetations and were also graded for image quality. The sensitivity of transesophageal echocardiography in detecting vegetations was 88% versus 30% for transthoracic studies (p less than 0.01). For patients with aortic valve infective endocarditis, transesophageal sensitivity was 88% versus 25% for transthoracic sensitivity, because transesophageal echocardiography successfully separated vegetations from chronic valve disease caused by sclerosis or calcification (p less than 0.01). For patients with mitral valve infective endocarditis, transesophageal sensitivity was 100% versus 50% for transthoracic sensitivity, because transesophageal echocardiography distinguished vegetations from myxomatous changes or detected vegetations on prosthetic valves (p less than 0.01). Thus transesophageal echocardiography improves recognition of infective endocarditis, particularly in the presence of underlying valvular disease.

Adenosine Myocardial Protection: Preliminary Results of a Phase II Clinical Trial

OBJECTIVE To evaluate the safety, tolerance, and efficacy of adenosine in patients undergoing coronary artery bypass surgery. SUMMARY BACKGROUND DATA Inadequate myocardial protection in patients undergoing coronary artery bypass surgery contributes to overall hospital morbidity and mortality. For this reason, new pharmacologic agents are under investigation to protect the regionally and globally ischemic heart. METHODS In a double-blind, placebo-controlled trial, 253 patients were randomized to one of three cohorts. The treatment arms consisted of the intraoperative administration of cold blood cardioplegia, blood cardioplegia containing 500 microM adenosine, and blood cardioplegia containing 2 mM adenosine. Patients receiving adenosine cardioplegia were also given an infusion of adenosine (200 microg/kg/min) 10 minutes before and 15 minutes after removal of the aortic crossclamp. Invasive and noninvasive measurements of ventricular performance were obtained before, during, and after surgery. RESULTS The high-dose adenosine cohort was associated with a trend toward a decrease in high-dose dopamine support and a lower incidence of myocardial infarction. A composite outcome analysis demonstrated that patients who received high-dose adenosine were less likely to experience one of five adverse events: high-dose dopamine use, epinephrine use, insertion of intraaortic balloon pump, myocardial infarction, or death. The operative mortality rate for all patients studied was 3.6% (9/253). CONCLUSIONS Adenosine treatment is safe and well tolerated and may be associated with fewer postoperative complications.

Successful reversal by chelation therapy of congestive cardiomyopathy due to iron overload.

A patient who developed severe iron overload cardiomyopathy is described. Venesection could not be performed because the patient had chronic anemia. Deferoxamine mesylate, a chelating agent, was administered daily for more than 2 years and produced significant improvement in ventricular function which was associated with a biopsy-proven decrease in myocardial iron stores. This is the first reported case in which a severe cardiomyopathy due to iron overload was reversed by chelation therapy alone.

Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography

STUDY OBJECTIVE To determine the relation between heart valve regurgitation detected by Doppler echocardiography and audible regurgitant murmurs. DESIGN Consecutive sample. SETTING Adult echocardiography laboratory in a tertiary care university hospital. PATIENTS Sequential sample of 408 patients presenting for clinical echocardiographic studies who had technically satisfactory studies and were available for auscultation. MEASUREMENT AND MAIN RESULTS Valvular regurgitation occurred in 43% of patients at the mitral valve, 39% of patients at the tricuspid valve, 33% of patients at the aortic valve, and 15% of patients at the pulmonic valve. Corresponding regurgitant murmurs were frequently absent. A murmur corresponding to Doppler-detected regurgitation was detected in 56% of patients with mitral regurgitation, 61% of patients with aortic regurgitation, 28% of patients with tricuspid regurgitation, and 15% of patients with pulmonic regurgitation. There was a highly significant positive correlation of audibility with severity of valve regurgitation for the aortic, tricuspid, and mitral valves. Audibility ranged from 10% to 40% for mild regurgitation to 86% to 100% for severe regurgitation. Murmur audibility was not related to the type of valvular disease present. CONCLUSIONS Doppler echocardiography is a sensitive method for detecting valve regurgitation. Corresponding regurgitant murmurs are frequently not present. The audibility of regurgitant murmur is highly dependent on the severity of valve regurgitant and has little relation to the type of valve disease present.

Ultrasonic Imaging of Myocardial Strain Using Cardiac Elastography

Clinical assessment of myocardial ischemia based on visually-assessed wall motion scoring from echocardiography is semiquantitative, operator dependent, and heavily weighted by operator experience and expertise. Cardiac motion estimation methods such as tissue Doppler imaging, used to assess myocardial muscle velocity, provides quantitative parameters such as the strain-rate and strain derived from Doppler velocity. However, tissue Doppler imaging does not differentiate between active contraction and simple rotation or translation of the heart wall, nor does it differentiate tethering (passively following) tissue from active contraction. In this paper, we present a strain imaging modality called cardiac elastography that provides two-dimensional strain information. A method for obtaining and displaying both directional and magnitude cardiac elastograms and displaying strain over the entire cross-section of the heart is described. Elastograms from a patient with coronary artery disease are compared with those from a healthy volunteer. Though observational, the differences suggest that cardiac elastography may be a useful tool for assessment of myocardial function. The method is two-dimensional, real time and avoids the disadvantage of observer-dependent judgment of myocardial contraction and relaxation estimated from conventional echocardiography.

The 5-Minute Screening Echocardiogram for Athletes

BACKGROUND Echocardiography is an accurate way to identify common cardiac abnormalities that lead to sudden death. We report a screening echocardiogram protocol incorporated into the routine athletic medical assessment for all incoming college freshman athletes. METHODS A limited 2-dimensional echocardiogram was performed on athletes as part of a routine sports physical examination. The examination was performed by sonographers and senior cardiovascular medicine fellows and interpreted in real time by cardiologists using a 1-page checklist. No images were recorded. RESULTS Of the 395 athletes representing 14 sports, 192 were female. The limited 2-dimensional echocardiogram took approximately 5 minutes per athlete. The majority of studies revealed normal findings (84%). A total of 55 had minor abnormalities not requiring follow-up. Five had abnormalities requiring a full echocardiogram and consultation with a cardiologist. CONCLUSION This study demonstrates that a rapid screening echocardiogram is feasible and can be incorporated into the routine athletic medical examination for incoming varsity athletes.