Thirteen new patients and 174 patients previously reported with coronary arteriovenous fistula (CAVF) were reviewed to delineate the course and management of CAVF and to clarify the role of surgical ligation in the young asymptomatic patient. Patients were grouped according to age: 99 patients (four new and 95 reported) were less than 20 years old and 88 (nine new and 79 reported) were greater than or equal to 20 years old. Of those under 20 years of age, 19% had preoperative symptoms or CAVF-related complications, including congestive heart failure (CHF) in 6%, subacute bacterial endocarditis in 3% and death in one patient. Seventy-six patients younger than 20 years old had CAVF ligation with only one significant complication. In contrast, 63% of the older group and all of our nine older patients had preoperative symptoms or complications, including CHF in 19%, SBE in 4%, myocardial infarction (MI) in 9%, death in 14% and fistula rupture in one patient. Of the 43 ligated older patients, 23% had surgical complications, including MI in three and death in three. Mean pulmonic-to-systemic flow in the entire group was 1.6:1 and did not differ significantly in those with or without symptoms or complications. One of our patients and one previously reported had spontaneous CAVF closure. In summary, early elective ligation of CAVF is indicated in all patients because of the high incidence of late symptoms and complications and the increased morbidity and mortality associated with ligation in older patients.

OBJECTIVE.This study was designed to prospectively compare helical CT with

Head-out water immersion is known to increase cardiac filling pressure and volume in humans at rest. The purpose of the present study was to assess whether these alterations persist during dynamic exercise. Ten men performed upright cycling exercise on land and in water to the suprasternal notch at work loads corresponding to 40, 60, 80, and 100% maximal O2 consumption (VO2max). A Swan-Ganz catheter was used to measure right atrial pressure (PAP), pulmonary arterial pressure (PAP), and cardiac index (CI). Left ventricular end-diastolic (LVED) and end-systolic (LVES) volume indexes were assessed with echocardiography. VO2max did not differ between land and water. RAP, PAP, CI, stroke index, and LVED and LVES volume indexes were significantly greater (P less than 0.05) during exercise in water than on land. Stroke index did not change significantly from rest to exercise in water but increased (P less than 0.05) on land. Arterial systolic blood pressure did not differ between land and water at rest or during exercise. Heart rates were significantly lower (P less than 0.05) in water only during the two highest work intensities. The results indicate that indexes of cardiac preload are greater during exercise in water than on land.

Background Transesophageal echocardiography (TEE) has been used recently to detect atrial thrombi before cardioversion of atrial arrhythmias. It has been assumed that embolic events after cardioversion result from embolism of preexisting atrial thrombi that are accurately detected by TEE. This study examined the clinical and echocardiographic findings in patients with embolism after cardioversion of atrial fibrillation despite exclusion of atrial thrombi by TEE.Methods and Results Clinical and echocardiographic data in 17 patients with embolic events after TEE-guided electrical (n=16) or pharmacological (n=1) cardioversion were analyzed. All 17 patients had nonvalvular atrial fibrillation, including four patients with lone atrial fibrillation. TEE before cardioversion showed left atrial spontaneous echo contrast in five patients and did not show atrial thrombus in any patient. Cardioversion resulted in return to sinus rhythm without immediate complication in all patients. Thirteen patients had cerebral embolic events and four patients had peripheral embolism occurring 2 hours to 7 days after cardioversion.

Simultaneous estimates of cardiac output were made during graded upright maximal exercise in 10 male subjects by means of Doppler velocity spectrum of ascending aortic flow, apical two-dimensional echocardiograms, thermodilution, and Fick oximetry. In 15 subjects, aortic annular and root diameters were measured during similar exercise from parasternal two-dimensional echocardiograms. The linear correlation between Doppler, two-dimensional echocardiography, and the invasive estimates ranged from r = .78 to r = .92. Both echocardiographic techniques were able to predict changes in invasive flow estimates with reasonable accuracy. Two-dimensional echocardiographic flow estimates underestimated invasive values by about 60%. The accuracy of Doppler flow estimates varied with the method of estimating aortic cross-sectional area. Greatest accuracy was obtained with areas calculated from diameters measured at the aortic value anulus with the leading edge-to-leading edge method of measurement. Correlation coefficients comparing Doppler and thermodilution flow estimates were generally higher (r = .75 to .96, mean .86) for individuals than for the group, but accuracy of the Doppler estimates in single subjects was quite variable. Aortic diameters did not increase from rest to moderate levels of upright exercise. A 3% to 5% increase in resting aortic diameter was noted in the upright posture as compared with the supine. Doppler flow estimates were obtained in all subjects to maximal exertion but in only a minority of subjects with two-dimensional echocardiography or thermodilution. Thus two-dimensional and Doppler echocardiography offer a noninvasive means of estimating cardiac output during vigorous exercise. The Doppler technique is technically more suitable to the study of exercise than two-dimensional echocardiography. Aortic area estimates for Doppler flow calculations are best made from resting two-dimensional echocardiograms of the aortic anulus by means of the leading edge-to-leading edge method of measurement. There does not appear to be a significant change in aortic diameter during upright exercise, but there may be a postural effect on aortic dimensions. Circulation 76, No. 3, 539-547, 1987. STROKE VOLUME and cardiac output are fundamental descriptors of cardiovascular function. Cardiac output is the primary indicator of the functional capacity of the circulation to meet the increased demands of physical exertion. The relative contributions of changes in stroke volume and heart rate to cardiac output and other factors influencing cardiac output 12 It was selected for this study because it allowed for rapid volume calculation from easily obtained and reproducible measurements. This formula has previously been validated in our laboratory by comparing it to left ventricular volume measured by left ventricular angiography in 20 patients with symmetric left ventricular wall motion. The correlation between echocardiographic and cineangiographic estimates of volume (range 42 to 232 ml) was .92 (echocardiog...

DSE can be used to predict adverse outcomes after AMI.

Abstract-The purpose of the present study was to evaluate the relationship of aldosterone to blood pressure and left ventricular size in black American (nϭ109) and white French Canadian (nϭ73) patients with essential hypertension. Measurements were obtained with patients off antihypertensive medications and included 24-hour blood pressure monitoring, plasma renin activity and aldosterone, and an echocardiogram. Compared with the French Canadians, the black Americans had higher body mass indexes, higher systolic blood pressures, attenuated nighttime reduction of blood pressure, and lower serum potassium concentrations (PϽ0.01 for each). Left ventricular mass index, posterior wall thickness, interventricular septal thickness, and relative wall thickness were also greater (PϽ0.01 for each) in the black American patients. Supine and standing plasma renin activity was lower (PϽ0.01 and PϽ0.05, respectively) in the black Americans, whereas supine plasma aldosterone concentrations did not differ, and standing plasma aldosterone was greater (PϽ0.05) in the black Americans (9.2Ϯ0.7 ng/dL) than in the French Canadians (7.3Ϯ0.6 ng/dL). In the black Americans, supine plasma aldosterone was positively correlated with nighttime systolic (rϭ0. Key Words: race Ⅲ aldosterone Ⅲ echocardiography Ⅲ left ventricle Ⅲ obesity Ⅲ plasma renin activity A ldosterone is a potent mineralocorticoid that promotes sodium retention and elevation of arterial pressure. Independent of its effect on blood pressure, aldosterone may also play a role in cardiac hypertrophy. Within the myocardium, aldosterone acts via mineralocorticoid receptors to enhance extracellular matrix and collagen deposition. 1 In animal models, both cardiac load and high circulating aldosterone levels stimulate fibrosis within the myocardium, leading to left ventricular hypertrophy (LVH). 2 Pathological patterns of LV geometry have also been associated with elevations of plasma aldosterone concentrations in patients with essential hypertension, 3,4 and the early onset of LVH has been described in patients with primary aldosteronism. 5 The prevalence of hypertension in US blacks is 50% greater than that in whites in either the United States or Canada. 6,7 Plasma renin activity (PRA) tends to be suppressed in hypertensive blacks, 8 and blacks have a high prevalence of salt-sensitive hypertension. 9 In addition, among hypertensives, blacks have a higher prevalence of LVH and a 6-fold higher prevalence of concentric LV remodeling than do whites. 10 -14 The purpose of the present study was to evaluate the relationship of aldosterone to both blood pressure and LV geometry in both black and white patients with essential hypertension. MethodsIn conjunction with ongoing collaborative studies of the genetic determinants of hypertension, black American patients were studied

Background: Adherence to clinical practice guidelines for management of cardiovascular disease (CVD) is suboptimal. The purposes of this study were to identify practice patterns and barriers among U.S. general internists and family physicians in regard to cardiovascular risk management, and examine the association between physician characteristics and cardiovascular risk management. Methods:A case vignette survey focused on cardiovascular disease risk management was distributed to a random sample of 12,000 U.S. family physicians and general internists between November and December 2006. Results:Responses from a total of 888 practicing primary care physicians who see 60 patients per week were used for analysis. In an asymptomatic patient at low risk for cardiovascular event, 28% of family physicians and 37% of general internists made guideline-based preventive choices for no antiplatelet therapy (p < .01). In a patient at high risk for cardiovascular event, 59% of family physicians and 56% of general internists identified the guideline-based goal for serum fasting LDL level (< 100 mg/dl). Guideline adherence was inversely related to years in practice and volume of patients seen. Cost of medications (87.7%), adherence to medications (74.1%), adequate time for counseling (55.7%), patient education tools (47.1%), knowledge and skills to recommend dietary changes (47.8%) and facilitate patient adherence (52.0%) were cited as significant barriers to CVD risk management. Conclusion:Despite the benefits demonstrated for managing cardiovascular risks, gaps remain in primary care practitioners' management of risks according to guideline recommendations. Innovative educational approaches that address barriers may facilitate the implementation of guideline-based recommendations in CVD risk management.