All echocardiographic studies were obtained using a Philips iE33 ultrasound system (Philips Medical Systems, Andover, MA) during routine clinical practice in our Heart Institute with an X7-2tBackground-Two-dimensional (2D) echocardiography studies have shown that the maximum length of vegetation (MLV) ≥10 mm is a predictor of embolic events (EEs) in patients with infective endocarditis. However, 2D measurements probably underestimate the vegetation dimensions. In this study, we evaluated the feasibility of real-time 3-dimensional transesophageal echocardiography (RT3DTEE) in determining MLV and its accuracy in identifying the risk for EEs compared with 2D transesophageal echocardiography (2DTEE). Methods and Results-We analyzed 60 patients with vegetations. RT3DTEE measurement of MLV was obtained with Advanced QLAB Quantification Software by cropping the 3D volume with the appropriate 2D plane to obtain the largest value. The standard 2DTEE images were also evaluated to determine the MLV. Major EEs were registered from medical records, and a logistic regression analysis was performed to determine the association between MLV and EEs. The RT3DTEE MLV was larger than the 2DTEE value with a mean difference of 3.2 mm (95% confidence interval, 2.1-4.2 mm). The best cut-off value for prediction of EEs was MLV ≥20 mm with RT3DTEE and MLV ≥16 mm with 2DTEE. The positive predictive value increased from 59.1% to 65.2% when RT3DTEE was used.

Background— Functional tricuspid regurgitation (TR) with a structurally normal tricuspid valve (TV) may occur secondary to chronic atrial fibrillation (AF). However, the clinical and echocardiographic differences according to functional TR subtypes are unclear. Therefore, characterization of functional TR because of chronic AF (AF-TR) remains undetermined. Methods and Results— To investigate the prevalence of AF-TR, 437 patients with moderate to severe TR underwent 3-dimensional (3D) transesophageal echocardiography. TR severity was determined by the averaged vena contracta width on apical and parasternal inflow views. The prevalence of AF-TR was 9.2%, whereas that of functional TR because of left-sided heart disease was 45.3%. Clinical features of AF-TR included advanced age, female sex, greater right atrial than left atrial enlargement and lower systolic pulmonary artery pressure compared with left-sided heart disease-TR with sinus rhythm (all P <0.05). In 3D TV assessment, patients with AF-TR had a larger TV annular area with weaker annular contraction (both P <0.001) but a smaller tethering angle ( P <0.001) despite a similar leaflet coaptation status compared with patients with left-sided heart disease-TR with sinus rhythm. On multivariable analysis, only the TV annular area in midsystole (coefficient, 0.059; 95% confidence interval, 0.041–0.078 per 100 mm 2 ; P <0.001) was associated with TR severity in AF-TR. The annular area was more closely correlated with the right atrial volume than right ventricular end-systolic volume in AF-TR ( P <0.001). Conclusions— AF-TR is not rare and is associated with advanced age and right atrial enlargement. TV deformations and their association with right heart remodeling differ between AF-TR and left-sided heart disease-TR. Our results suggest that in patients with TR secondary to AF, TV annuloplasty should be effective because this entity has annular dilatation without leaflet deformation.

Background: Antibodies to glutamic acid decarboxylase (GAD ab) have been found in patients with limbic encephalitis (LE) and chronic pharmacoresistant focal epilepsy (FE). The objectives of the study were to: (1) analyze the clinical and neuroimaging course of patients with FE+GAD ab, (2) compare these characteristics with a control group, and (3) describe the most affected cerebral areas with structural and functional imaging.Methods: Patients with FE + high titers of GAD ab and a follow-up of at least 5 years were selected. Titers of serum GAD ab exceeding 2,000 UI/ml were considered high. Evolutive clinical and radiological characteristics were studied in comparison to two different control groups: patients with bilateral or with unilateral mesial temporal sclerosis (BMTS or UMTS) of a non-autoimmune origin.Results: A group of 13 patients and 17 controls were included (8 BMTS, 9 UMTS). The most frequent focal aware seizures (FAS) reported by patients were psychic (5/13: 33%). Somatosensorial, motor, and visual FAS (4/13:32%) (p: 0.045), musicogenic reflex seizures (MRS), and a previous history of cardiac syncope were reported only patients (2/13:16% each) (p: NS). Comparing EEG characteristics between patients and controls, a more widespread distribution of interictal epileptiform discharges (IED) was observed in FE+ GAD ab patients than in controls (p:0.01). Rhythmic delta activity was observed in all controls in anterior temporal lobes while in patients this was less frequent (p: 0.001). No IED, even in 24 h cVEEG, was seen in 6 patients (46%).First MRI was normal in 4/5 (75%) patients. During the follow-up mesial temporal lobe (MTsL) sclerosis was observed in 5/8 (62%) of patients. All patients had abnormal FDG-PET study. MTL hypometabolism was observed in 10/11 (91%) patients, being bilateral in 7/11 (63%). In controls, this was observed in 16/17 (94%), and it was bilateral in 8/17 (47%) (p: NS). Insular hypometabolism was observed in 5/11 (45%) patients (P:0.002).Conclusions: Clinical, EEG, and FDG-PET findings in FE+GAD ab suggest a widespread disease not restricted to the temporal lobe. Progressive MTL sclerosis may be observed during follow-up. In comparison to what is found in patients with non-autoimmune MTL epilepsy, insular hypometabolism is observed only in patients with GAD ab, so it may be an important diagnostic clue.

A lthough mitral regurgitation (MR), including functional MR, is present in a large proportion of patients who undergo transcatheter aortic valve replacement (TAVR) for severe aortic stenosis, it is predominantly left untreated.1 Previous articles reported not only the influence of moderate or severe MR on clinical outcomes after TAVR but also the effect of TAVR on MR degree after the implantation of the Edwards SAPIEN or the Medtronic CoreValve. [1][2][3][4][5][6][7] Particularly after the implantation of the SAPIEN, short-term reduction of MR has been observed in previous reports.1,3-6 However, there is a paucity of investigation that demonstrates the effect of TAVR on mitral valve anatomy, including mitral leaflet coaptation and identification of the cause of acute MR reduction with or without mitral leaflet tethering. The aims of the present study were to (1) demonstrate the effect of the SAPIEN deployment on mitral valve anatomy, including mitral leaflet coaptation by 3-dimensional (3D) transesophageal echocardiography (TEE); and (2) identify the predictors of MR reduction with or without mitral leaflet tethering after TAVR. Clinical Perspective on p 351 Methods Study PopulationWe studied 332 consecutive patients with aortic stenosis who underwent TAVR and had intraprocedural 3D TEE from December 2010 to January 2013 in our institute. In total, 233 patients were excluded because pre-and postprocedural 3D TEE data, including mitral valve apparatus, were not available. We also excluded 9 patients with surgical history of mitral valve replacement, mitral valve repair, or aortic valve replacement. Finally, we included 90 patients in this study. Data were retrieved from our computerized database. This study was approved by the institutional review board. Comprehensive Transthoracic EchocardiographyComprehensive two-dimensional and Doppler transthoracic echocardiography (TTE) was performed routinely at our institute on all patients at baseline and 1 day after TAVR. The iE33 ultrasound system (Philips Medical Systems, Andover, MA) equipped with S5-1 phased array transducer (Philips Medical Systems) was used. In accordance with the American College of Cardiology/American Heart Association guideline, MR severity was graded as none, trivial, mild, moderate, or severe by primarily MR jet area, and, if necessary, other echocardiographic methods, including vena contracta, proximal isovelocity Background-The effect of transcatheter aortic valve replacement (TAVR) on the mitral valve apparatus and factors influencing the reduction of mitral regurgitation with or without mitral leaflet tethering after TAVR are poorly understood. The present 3-dimensional (3D) transesophageal echocardiography study aimed to elucidate early changes further in the structure and function of the mitral valve apparatus after TAVR. Methods and Results-We analyzed 90 patients (nontenting group, 56 patients and tenting group, 34 patients) who underwent TAVR using the Edwards SAPIEN and had intraprocedural 3D transesophageal echocardiography evaluat...