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Concept: Echocardiography

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Several studies have correlated elevations in cardiac biomarkers of injury post marathon with transient and reversible right ventricular (RV) systolic dysfunction as assessed by both transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR). Whether or not permanent myocardial injury occurs due to repeated marathon running in the aging population remains controversial.

Concepts: Heart, Echocardiography, Muscle, Cardiac muscle, Circulatory system, Cardiovascular system, Running, Marathon

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BACKGROUND: A high index of suspicion is required to make this diagnosis of constrictive pericarditis (CP) in patients presenting with cirrhosis and volume overload, as they can otherwise go misdiagnosed for years. METHODS: Case report. FINDINGS: A 51 year-old man with a history of presumed alcoholic cirrhosis presented to the emergency department with anasarca. Abdominal ultrasound with Doppler demonstrated a nodular cirrhotic liver, but no evidence of portal hypertension or ascites. The chest x-ray, however, was significant for a right-sided pleural effusion and pericardial calcification, suggestive of (CP). Transthoracic echocardiogram and ECG-gated computerized tomography scan of the chest without IV contrast confirmed the diagnosis. The patient was referred to thoracic surgery for definitive pericardiectomy. CONCLUSION: The diagnosis of CP is often neglected by admitting physicians, who usually attribute the symptoms to another disease process. Although a multimodality approach is necessary for the diagnosis of CP, this case highlights the utility of chest x-ray, a relatively non-invasive and inexpensive test, in expediting the diagnosis.

Concepts: Heart failure, Echocardiography, Medical imaging, Cirrhosis, Ascites, Pleural effusion, Hepatorenal syndrome, Wilson's disease

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BACKGROUND: The presence of myocardial fibrosis is associated with worse clinical outcomes in hypertrophic cardiomyopathy (HCM). Cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) sequences can detect regional, but not diffuse myocardial fibrosis. Post-contrast T1 mapping is an emerging CMR technique that may enable the non-invasive evaluation of diffuse myocardial fibrosis in HCM. The purpose of this study was to non-invasively detect and quantify diffuse myocardial fibrosis in HCM with CMR and examine its relationship to diastolic performance. METHODS: We performed CMR on 76 patients - 51 with asymmetric septal hypertrophy due to HCM and 25 healthy controls. Left ventricular (LV) morphology, function and distribution of regional myocardial fibrosis were evaluated with cine imaging and LGE. A CMR T1 mapping sequence determined the post-contrast myocardial T1 time as an index of diffuse myocardial fibrosis. Diastolic function was assessed by transthoracic echocardiography. RESULTS: Regional myocardial fibrosis was observed in 84% of the HCM group. Post-contrast myocardial T1 time was significantly shorter in patients with HCM compared to controls, consistent with diffuse myocardial fibrosis (498 +/- 80 ms vs. 561 +/- 47 ms, p < 0.001). In HCM patients, post-contrast myocardial T1 time correlated with mean E/e' (r = -0.48, p < 0.001). CONCLUSIONS: Patients with HCM have shorter post-contrast myocardial T1 times, consistent with diffuse myocardial fibrosis, which correlate with estimated LV filling pressure, suggesting a mechanistic link between diffuse myocardial fibrosis and abnormal diastolic function in HCM.

Concepts: Cardiology, Cardiomyopathy, Heart, Echocardiography, Nuclear magnetic resonance, Hypertrophic cardiomyopathy, Diastolic dysfunction, Hypertrophy

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Introduction Atrial fibrillation (AF) increases risk of thromboembolic events by promoting clot formation in the left atrial appendage (LAA). Transesophageal echocardiography (TEE) is routinely used to exclude presence of LAA thrombus prior toAF ablation. The optimal combination of non-invasive parameters for thromboembolic risk stratification in this setting and the need for TEE in very low risk patients have not been established. Objectives To assess predisposing factors for LAA thrombus in patients scheduled for AF ablation and to identify those in whom pre-procedural TEE could be omitted. Patients and methods In consecutive 151 patients (107 males, mean age 57±10 years) the type of AF and renal function were used in addition to CHA2DS2VASc score to improve thromboembolic risk stratification. Results LAA thrombus or dense echo contrast with probable thrombus were detected in 15 (10%) patients. Diabetes, age≥65 years, persistent AF and eGFR<60 ml/min/1.73 m2 were predictors of LAA thrombus. Multivariate logistic regression showed that only persistent AF and eGFR<60 ml/min/1.73 m2 were independent predictors of LAA thrombus. The ROC curves showed that the greatest AUC (0.845) was achieved for CHA2DS2VASc+AF type+renal status (NS). A 100% sensitivity in identifying patients with LAA thrombus was achieved for CHA2DS2VASc-AFR≥2 or CHA2DS2VASc≥1 with a corresponding specificity of 54% and 36%, respectively. Conclusions LAA thrombus or dense contrast are often encountered in patients scheduled for AF ablation. Addition of AF type and renal function to the CHA2DS2VASc score slightly improves thromboembolic risk stratification and may help to identify patients who do not need pre-procedural TEE.

Concepts: Cardiology, Echocardiography, Stroke, Atrial fibrillation, Warfarin, Thrombus, Left atrial appendage occlusion, Left atrial appendage

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A patent foramen ovale (PFO) is common and found in nearly 25% of healthy individuals. The majority of patients with PFO remain asymptomatic and they are not at increased risk for developing a stroke. The presence of PFO, however, has been found to be higher in patients with cryptogenic stroke, suggesting there may be a subset of patients with PFO who are indeed at risk for stroke. Paradoxical embolization of venous thrombi through the PFO, which then enter the arterial circulation, is hypothesized to account for this relationship. Although aerated-saline transesophageal echocardiography is the gold standard for diagnosis, aerated-saline transthoracic echocardiography and transcranial Doppler are often used as the initial diagnostic tests for detecting PFO. Patients with cryptogenic stroke and PFO are generally treated with antiplatelet therapy in the absence of another condition for which anticoagulation is necessary. Based on the findings of 3 large randomized clinical trials, current consensus guidelines do not recommend percutaneous closure, though this is an area of controversy. The following review discusses the relationship of PFO and cryptogenic stroke, focusing on the epidemiology, pathophysiological mechanisms, diagnostic tools, associated clinical/anatomic factors and treatment.

Concepts: Epidemiology, Doppler echocardiography, Echocardiography, Contrast-enhanced ultrasound, Atrial septal defect, Foramen ovale, Ostium primum, Cardiac shunt

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According to current ESC Guidelines for the diagnosis and treatment of heart failure cardiac resynchronization therapy (CRT) is indicated in patients suffering from heart failure (HF) with reduced ejection fraction (EF) with significantly widened QRS complexes. Presence of vital myocardium proved by dobutamine stress echocardiography (DSE) is considered as a good prognostic factor for responsiveness to this treatment. Chronotropic incompetence is on the other hand known factor of unfavorable outcome in HF.

Concepts: Myocardial infarction, Cardiology, Heart failure, Ejection fraction, Echocardiography, Heart disease, QRS complex, Purkinje fibers

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A 58-year-old woman presented with intermittent, nonexertional chest pain. She had been admitted for similar symptoms 2 months earlier; a coronary angiogram had revealed normal anatomy. A transthoracic echocardiogram revealed a pericardial effusion. A video is available at NEJM.org.

Concepts: Myocardial infarction, Atherosclerosis, Cardiology, Echocardiography, Atheroma, Angiography, Cardiovascular system, Pericardial effusion

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A 56-year-old woman with a history of stage II cancer of the left breast presented with progressive shortness of breath and fatigue. Transthoracic echocardiography revealed a large pericardial effusion with the heart freely swinging in an anterior-posterior fashion, shown in a video.

Concepts: Cancer, Breast cancer, Cancer staging, Cardiology, Echocardiography, Pericardium, Cardiac tamponade, Pericardial effusion

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Background Cardiac-resynchronization therapy (CRT) reduces morbidity and mortality in chronic systolic heart failure with a wide QRS complex. Mechanical dyssynchrony also occurs in patients with a narrow QRS complex, which suggests the potential usefulness of CRT in such patients. Methods We conducted a randomized trial involving 115 centers to evaluate the effect of CRT in patients with New York Heart Association class III or IV heart failure, a left ventricular ejection fraction of 35% or less, a QRS duration of less than 130 msec, and echocardiographic evidence of left ventricular dyssynchrony. All patients underwent device implantation and were randomly assigned to have CRT capability turned on or off. The primary efficacy outcome was the composite of death from any cause or first hospitalization for worsening heart failure. Results On March 13, 2013, the study was stopped for futility on the recommendation of the data and safety monitoring board. At study closure, the 809 patients who had undergone randomization had been followed for a mean of 19.4 months. The primary outcome occurred in 116 of 404 patients in the CRT group, as compared with 102 of 405 in the control group (28.7% vs. 25.2%; hazard ratio, 1.20; 95% confidence interval [CI], 0.92 to 1.57; P=0.15). There were 45 deaths in the CRT group and 26 in the control group (11.1% vs. 6.4%; hazard ratio, 1.81; 95% CI, 1.11 to 2.93; P=0.02). Conclusions In patients with systolic heart failure and a QRS duration of less than 130 msec, CRT does not reduce the rate of death or hospitalization for heart failure and may increase mortality. (Funded by Biotronik and GE Healthcare; EchoCRT ClinicalTrials.gov number, NCT00683696 .).

Concepts: Death, Mortality rate, Myocardial infarction, Cardiology, Heart failure, Ejection fraction, Echocardiography, Randomness

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Echocardiography is pivotal in the diagnosis and management of the shocked patient. Important characteristics in the setting of shock are that it is non-invasive and can be rapidly applied.In the acute situation a basic study often yields immediate results allowing for the initiation of therapy, while a follow-up advanced study brings the advantage of further refining the diagnosis and providing an in-depth hemodynamic assessment. Competency in basic critical care echocardiography is now regarded as a mandatory part of critical care training with clear guidelines available. The majority of pathologies found in shocked patients are readily identified using basic level 2D and M-mode echocardiography. A more comprehensive diagnosis can be achieved with advanced levels of competency, for which practice guidelines are also now available. Hemodynamic evaluation and ongoing monitoring are possible with advanced levels of competency, which includes the use of colour Doppler, spectral Doppler, and tissue Doppler imaging and occasionally the use of more recent technological advances such as 3D or speckled tracking.The four core types of shock-cardiogenic, hypovolemic, obstructive, and vasoplegic-can readily be identified by echocardiography. Even within each of the main headings contained in the shock classification, a variety of pathologies may be the cause and echocardiography will differentiate which of these is responsible. Increasingly, as a result of more complex and elderly patients, the shock may be multifactorial, such as a combination of cardiogenic and septic shock or hypovolemia and ventricular outflow obstruction.The diagnostic benefit of echocardiography in the shocked patient is obvious. The increasing prevalence of critical care physicians experienced in advanced techniques means echocardiography often supplants the need for more invasive hemodynamic assessment and monitoring in shock.

Concepts: Doppler echocardiography, Echocardiography, Medical ultrasound, Shock, Physician, Septic shock, Hypovolemia