We describe a new variant of transient left ventricular (LV) ballooning in North American Caucasian patients in which only the midventricle is affected. The patients described in this case series initially presented with emotional or physical stress and had similarities to transient apical ballooning syndrome; however, this variant is unique in that the transient ballooning involves the midventricle with hypercontractility of the apical and basal segments. The presentation, clinical features, and transient nature of the reported cases in this series are similar to transient LV apical ballooning and suggest a shared pathophysiologic etiology. Sparing of the apical segment with involvement of midventricle only supports etiologies not related to an epicardial coronary artery distribution. Although the pathophysiologic mechanism of the transient ventricular ballooning syndromes and other cases of catecholamine-associated transient ventricular dysfunction are not well understood, the emergence of this new variant raises further questions in the understanding of the "brain-heart" relationship.

Cardiovascular (CV) complications are the leading cause of non-graft-related death in orthotopic liver transplant (OLT) patients. Pretransplant cardiac evaluation using dobutamine stress echocardiography (DSE) is commonly utilized for risk stratification of OLT candidates. To determine if clinical and echocardiographic variables identify patients with increased CV risk, we performed a retrospective chart review of all 284 patients that underwent OLT at our institution between June 1999 and August 2005. Of these patients, 157 had a DSE prior to their OLT. Serious adverse CV events occurring during surgery and up to 4 months post-transplantation were defined as cardiac-related death, myocardial infarction (MI), new heart failure, or asystole or unstable ventricular arrhythmia requiring acute treatment. Sixteen of 157 patients (10%) had an adverse CV event with 2 deaths. These included ventricular tachycardia (n ϭ 8), asystole (n ϭ 2), MI (n ϭ 5), and new heart failure (n ϭ 1). Nine of the 16 CV events occurred at the time of surgery (including both deaths), 5 occurred postoperatively, and 3 occurred after hospital discharge. Variables that correlated with increased CV events were inability during DSE to achieve Ͼ82% of the maximum predicted heart rate (22% versus 6%, P ϭ 0.01), a peak rate pressure product during DSE of Ͻ16,333 (17% versus 5%, P ϭ 0.02), and a Model for End-Stage Liver Disease (MELD) score of Ͼ24 at the time of OLT. A multivariate model calculated from the DSE maximum achieved heart rate (MAHR) and MELD score (result ϭ 3.78 ϩ 0.07 MELD Ϫ 0.05 MAHR) identified a 47% risk for a value Ͼ 0 versus a 6% risk for a value Ͻ 0 (P Ͻ 0.001). In conclusion, the maximum heart rate achieved during DSE together with the MELD score may be a predictor of adverse CV events up to 4 months post-OLT. A large prospective study is needed to more decisively support this conclusion.

Significant differences exist among these 3 commonly used methods for measuring LA volume. Standardization of the measurement of LA volume is recommended.

Practical applications of tissue Doppler imaging for evaluation of possible constrictive pericarditis include reversal of the relationship between lateral and medial e' velocities (i.e. 'annulus reversus').

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