Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

Background Left atrial (LA) enlargement is associated with adverse events in heart failure with preserved ejection fraction (HFpEF). However, the role of LA mechanics (i.e., LA strain measures) in HFpEF has not been well studied. We hypothesized that in HFpEF, reduced (worse) LA strain is a key pathophysiologic abnormality and is a stronger correlate of adverse events than left ventricular (LV) or right ventricular (RV) longitudinal strain. Methods and Results We evaluated baseline LA function in 308 patients with HFpEF who were followed longitudinally for adverse outcomes. All patients underwent speckle-tracking echocardiography for measurement of LV longitudinal strain, RV free wall strain, and LA booster, conduit, and reservoir strains. The clinical and prognostic significance of LV, RV, and LA strain measures was assessed by regression analyses. The mean age was 65±13 years; 64% were female; 26% had atrial fibrillation; and LA enlargement was present in the majority (67%) of patients. Decreased LA reservoir strain was associated with increased pulmonary vascular resistance (P<0.0001) and decreased peak oxygen consumption (P=0.0001). Of the LV, RV, and LA strain measures, LA reservoir strain was the strongest correlate of adverse events, and was independently associated with the composite outcome of cardiovascular hospitalization or death (adjusted HR per 1-SD decrease in LA strain = 1.54; 95% CI = 1.15–2.07; P=0.006). Conclusions Abnormal indices of LA mechanics (particularly LA reservoir strain) are powerful clinical and prognostic factors in HFpEF. Unloading the LA and/or augmentation of LA function may be important future therapeutic targets in HFpEF. Registration Information URL: http://www.clinicaltrials.gov. Unique identifier: NCT01030991.

Valvular heart disease (VHD) encompasses a number of common cardiovascular conditions that account for 10% to 20% of all cardiac surgical procedures in the United States. A better understanding of the natural history coupled with the major advances in diagnostic imaging, interventional cardiology, and surgical approaches have resulted in accurate diagnosis and appropriate selection of patients for therapeutic interventions. A thorough understanding of the various valvular disorders is important to aid in the management of patients with VHD. Appropriate work-up for patients with VHD includes a thorough history for evaluation of causes and symptoms, accurate assessment of the severity of the valvular abnormality by examination, appropriate diagnostic testing, and accurate quantification of the severity of valve dysfunction and therapeutic interventions, if necessary. It is also important to understand the role of the therapeutic interventions vs the natural history of the disease in the assessment of outcomes. Prophylaxis for infective endocarditis is no longer recommended unless the patient has a history of endocarditis or a prosthetic valve.

eperfusion therapies have led to a substantial reduction in the frequency of mechanical complications of acute myocardial infarction (MI). 1,2 Recent studies estimate that following ST-elevation MI, 0.27% to 0.91% of patients develop mechanical complications; papillary muscle rupture (PMR), ventricular free-wall rupture (FWR), and ventricular septal rupture (VSR) are estimated to occur in 0.05% to 0.26% of patients, 0.01% to 0.52% of patients, and 0.17% to 0.21% of patients, respectively. 3,4 However, unfortunately, there has been no significant decrease in associated mortality rates over the past 2 decades, and patients with mechanical complications are more than 4-fold more likely to experience in-hospital mortality than those without mechanical complications. 1,3 Mechanical complications are therefore infrequent but remain an important determinant of outcomes after MI. The purpose of this review is to highlight key clinical and diagnostic findings that may assist in the early diagnosis of mechanical complications and present an update on current management strategies. FWR Clinical FeaturesThree morphologies of FWR were originally described as follows: type 1 rupture is an abrupt tear usually within the first 24 hours of MI, type 2 rupture is a slower tear with localized myocardial erosion, and type 3 rupture is a thin-walled aneurysm perforation, which usually occurs more than 7 days after MI. 5 FWR usually occurs within 7 days after MI, 6 with a mean time to diagnosis of 2.6 days in a 2018 series. 7 Early autopsy studies demonstrated that an abrupt large tear would likely lead to sudden cardiac tamponade, cardiogenic shock, and cardiac arrest, whereas a smaller, more gradual tear may be limited by thrombus formation or a compliant pericardium but with hemodynamic instability and pericardial effusion. 8 These 2 types are also described in the surgical literature as the blowout and oozing types, respectively. 7,9 In the SHOCK trial registry, 10 there was no significant sex difference in the incidence of FWR, but patients with FWR were less likely to have diabetes or a history of prior MI. It is postulated that the absence of certain cardiovascular risk factors denotes individuals who are less likely to have coronary artery disease and thus less likely to have developed collateral circulations that protect the myocardium in the setting of acute vessel occlusion.Patients with FWR may present with chest pain, restlessness, hemodynamic compromise, or cardiogenic shock (Table ). In a 2018 series, 7 more than 80% of patients presented with cardiac tamponade. FWR occurring late in the first week or beyond may also be associated with a history of straining, such as with coughing or vomiting. 11 Examination findings may be significant for a raised jugular venous IMPORTANCE Mechanical complications of acute myocardial infarction include left ventricular free-wall rupture, ventricular septal rupture, papillary muscle rupture, pseudoaneurysm, and true aneurysm. With the introduction of early reperfusion therapies, these co...

Cardiac rehabilitation provides healthy living and disease management goals for people with heart disease.