Samuel Daneshvar

Biventricular Pacemaker Optimization Guided by Comprehensive Echocardiography—Preliminary Observations Regarding the Effects on Systolic and Diastolic Ventricular Function and Third Heart Sound

BACKGROUND Doppler echocardiography of mitral inflow or aortic outflow or both has been validated and advocated to guide biventricular (Biv) pacemaker optimization. A comprehensive and tailored Doppler echocardiographic evaluation may be required in patients with heart failure to assist with Biv pacemaker optimization. The third heart sound (S(3)), an acoustic cardiographic parameter, has been demonstrated to be a highly specific finding for hemodynamic evaluation in patients with heart failure. The aims of this study were to evaluate the use of comprehensive Doppler echocardiography as a guide during Biv pacemaker optimization in patients after cardiac resynchronization therapy and to evaluate the feasibility of S(3) intensity to be a cost-efficient parameter for Biv pacemaker optimization compared with Doppler echocardiography. METHODS Comprehensive Doppler echocardiographic evaluations were performed during Biv pacemaker optimization in 44 patients referred for pacemaker optimization (mean age, 71 + or - 12 years; mean left ventricular ejection fraction, 34 + or - 11%). Blinded assessment of S(3) intensity was performed simultaneously using acoustic cardiography. The correlation and improvement in cardiac hemodynamics were analyzed between the methods. RESULTS Echocardiographically guided optimization resulted in significant improvements in the left ventricular outflow velocity-time integral (15.92 + or - 4.77 to 18.51 + or - 5.19 cm, P < .001), ejection time (278 + or - 40 to 293 + or - 40 ms, P < .001), myocardial performance index (0.57 + or - 0.19 to 0.44 + or - 0.14, P < .002), and peak pulmonary artery systolic pressure (42 + or - 13 to 36 + or - 11 mm Hg, P < .04) and decreased S(3) intensity from 4.81 + or - 1.84 at baseline to 3.96 + or - 1.22 after optimization (P < .02) for the overall study group and from 6.63 + or - 1.37 to 4.85 + or - 1.13 (P < .001) in the 18 patients with baseline S(3) intensity > 5.0. The correlation between echocardiographic and acoustic cardiographic S(3) intensity for optimal atrioventricular delay was 0.86 (P < .001) and for optimal interventricular delay was 0.64 (P < .001). Optimal atrioventricular delay was identical by echocardiographic and acoustic cardiographic S(3) intensity in 56%, and optimal interventricular delay was identical in 75% of patients. Pacemakers were permanently programmed on the basis of echocardiographic evaluation. In 35 patients available for follow up, the mean New York Heart Association class reduced from 2.55 + or - 0.81 to 1.77 + or - 0.90 (P < .001) and the mean quality-of-life score as assessed by Minnesota Living With Heart Failure Questionnaire improved from 45 + or - 28 to 32 + or - 28 (P = .08) at 2.5 + or - 2.1 months. CONCLUSION Comprehensive echocardiographically guided Biv pacemaker optimization produces significant improvement in Doppler echocardiographic hemodynamics, a reduction in S(3) intensity, and an improvement in functional class in patients after cardiac resynchronization therapy.

Caseous mitral annular calcifications: Multimodality imaging characteristics.

The authors report herein a series of 3 patients with caseous mitral annular calcifications (MAC). One of the patients presented with mass-like, caseous MAC as an incidental finding on a staging computed tomography (CT) for metastatic colorectal carcinoma. Another patient presented with a nodule on a chest radiograph, which was later found on CT to be due to caseous MAC. In the third patient, caseous MAC was initially detected on echocardiography, and was further evaluated with CT and cardiac magnetic resonance imaging. In all three patients, the appearances posed a diagnostic dilemma. The appearance of caseous MAC is dissimilar to non-caseous MAC and is usually seen as an ovoid, mass-like structure, with homogeneous hyperattenuation, representing a liquefied form of calcium and proteinaceous fluid. This homogeneous center is surrounded by peripheral, shell-like calcifications. Caseous MAC is likely an under-recognized entity and may present a diagnostic dilemma at CT, magnetic resonance imaging, or echocardiography.

Still searching for the elusive Scarlet Pimpernel of today

This editorial refers to ‘The impact of prosthesis–patient mismatch on long-term survival after aortic valve replacement: a systematic review and meta-analysis of 34 observational studies comprising 27 186 patients with 133 141 patient-years†, by S.T. Head et al. , on page 1518 Since the first description of valve prosthesis–patient mismatch (VP-PM) in 1978,1 the problem has been addressed in a large number of studies that have evaluated its effect on patient outcomes. Data regarding the reduction of long-term survival in those with VP-PM have been conflicting. To resolve this conflict, using pooled estimates, Head et al. have provided a systematic review of 34 selected studies assessing the impact of VP-PM after aortic valve replacement (AVR).2 In these 34 studies, 44.2% of the patients had severe or moderate VP-PM which was associated with an increased incidence of all-cause mortality that was statistically significant; however, the incidence of VP-PM associated with cardiac-related mortality was not statistically significant. In seven of these 34 studies, when both moderate and severe VP-PM were analysed …

CT angiography for all patients with inconclusive noninvasive test? Clinical perspective: "not yet".

It has been known since the early 1970s that the extent and severity of coronary artery disease (CAD) is a predictor of outcomes ([1][1]). Multidetector coronary computed tomography (MD-CCT) is a useful diagnostic test in the assessment of CAD ([2][2]). Although it is a minimally invasive test, MD-

Letter by Daneshvar Regarding Article, “Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction”

To the Editor: I read with great interest the study by Jander et al,1 in which patients in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study with low-gradient severe aortic stenosis (AS) were compared with those with moderate AS and were found to have similar outcomes in terms of aortic valve events, cardiovascular events, and cardiovascular death. Earlier, Bahlmann et al …

ORIGINAL INVESTIGATIONS: Potential Faces of Patent Foramen Ovale (PFO PFO): Potential Faces of PFO

Background: Patent foramen ovale (PFO) is diagnosed on echocardiography by saline contrast study with or without color Doppler evidence of shunting. PFO is benign except when it causes embolic events. Methods and Results: In this report, we describe unique additional manifestations related to the diagnosis and presentation of PFO. These include demonstration of PFO during the release phase of “sigh” on the ventilator in the operating room, use of a separate venipuncture to allow preparation of blood‐saline‐air mixture after multiple failed saline bubble injections, resting and stress hypoxemia related to left to right shunting across a PFO in the absence of pulmonary hypertension, presentation of quadriperesis secondary to an embolic event from a PFO and development of a thrombus on the left atrial aspect of PFO in a patient with atrial fibrillation, and on the right atrial aspect of PFO in a patient who had undergone repair of a flail mitral valve. Finally, in one patient with end‐stage renal disease, aortic valve endocarditis and periaortic abscess, PFO acted as a vent valve relieving right atrial pressure following development of aortoatrial fistula. Conclusion: PFO diagnosis can be elusive if appropriate techniques are not used during saline contrast administration. PFO can present as hypoxemia in the absence of pulmonary hypertension, can be a rare cause of quadriperesis, and can be associated with thrombus formation on either side of interatrial septum. Finally, PFO presence can be lifesaving in those with sudden increase in right atrial pressure such as with aortoatrial fistula. (Echocardiography 2010;27:897‐907)