OBJECTIVE: To compare two methods of mitral annular nonplanarity: the mathematically calculated annular height-to-commissural width ratio (AHCWR) and the echocardiographically derived nonplanarity angle. DESIGN: Prospective. SETTING: Tertiary care university hospital. INTERVENTIONS: Three-dimensional transesophageal echocardiography. PARTICIPANTS: Patients undergoing mitral valve surgery. MEASUREMENTS AND MAIN RESULTS: Using 3-dimensional transesophageal echocardiography, volumetric datasets were acquired from 22 patients undergoing mitral valve surgery. The intraoperative nonplanarity angle was calculated with Mitral Valve Assessment software (Tomtec GmbH, Munich, Germany). Furthermore, the datasets acquired during 3-dimensional transesophageal echocardiography were exported to Matlab software (MathWorks, Natick, MA), which was used to calculate the AHCWR. The nonplanarity angle was seen to correlate favorably with the AHCWR (r = 0.70). CONCLUSIONS: A favorable correlation was found between the nonplanarity angle and the AHCWR. This suggests that the nonplanarity angle can be used to assess mitral annular nonplanarity in a clinically feasible fashion.

BACKGROUND: Non-cardiac findings (NCFs) are seen in more than a third of cardiac computed tomographic and cardiac magnetic resonance imaging studies. The prevalence and importance of NCFs in transthoracic echocardiographic (TTE) imaging is unknown. The aim of this study was to determine the prevalence of NCFs on TTE imaging. METHODS: The subcostal images of all comprehensive adult TTE studies performed at one institution in December 2008 were retrospectively reviewed for NCFs by a radiologist with fellowship training in cardiovascular and abdominal radiology and blinded to the TTE report findings and clinical histories. Additional TTE image orientations were assessed in a subset of 300 studies. NCFs were categorized as benign (e.g., simple hepatic cyst), indeterminate (e.g., ascites), or worrisome (e.g., liver metastases). If an indeterminate or worrisome NCF was identified, the patient's electronic medical record was reviewed to determine if the NCF was previously known. RESULTS: Of 1,008 TTE studies (443 inpatient, 565 outpatient) in 922 patients, 77 NCFs were identified in 69 patients (7.5%). These included 20 benign (26%), 52 indeterminate (67%), and five worrisome (7%) NCFs. Intermediate and worrisome NCFs were more common in inpatient TTE studies (9% vs 3% outpatient, P = .002). The additional views demonstrated 2% more NCFs. Record review demonstrated that 60% of worrisome and 67% of indeterminate NCFs were previously known. No unknown NCF ultimately led to a change in patient management. CONCLUSIONS: Clinical TTE studies demonstrate NCFs in 7.5% of all patients, with an increased prevalence on inpatient studies. Although 75% of NCFs were potentially management changing, the majority of these were previously known and very unlikely to lead to management changes. Further study is needed to validate these findings in other populations and to assess their clinical impact.

Anticoagulation has proven to be a key component in the management of acute coronary syndromes (ACS). Pharmacological agents with various modes of action are utilized to reduce thrombus development by impairing thrombin formation, platelet activation, and platelet aggregation. The optimal management of these patients is to achieve maximal anti-ischemic benefit while avoiding bleeding complications. Synthetic "novel" agents have been developed to specifically target factor Xa or thrombin to achieve this goal. A growing amount of data show that these agents provide a net clinical benefit in the setting of stable ischemic heart disease, unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI).

We present the case of a 78-year-old woman who presented with acute anterior myocardial infraction. An intraoperative transesophageal echocardiogram revealed an akinetic apex with hyperkinesis of the basal segments causing systolic anterior motion of the mitral valve. The patient was immediately placed on cardiopulmonary bypass. Her postoperative course was uneventful. We present transesophageal and transthoracic echocardiographic videos showing this unique complication and describing the challenge of managing a patient who required opposing therapies.

We present the case of a 72-year-old male who was diagnosed with a saphenous vein graft pseudoaneurysm, detected on routine chest echocardiogram 13 years after undergoing coronary artery bypass graft surgery. Intraoperative transesophageal echocardiography revealed the pseudoaneurysm to be causing functional tricuspid stenosis, which was relieved after surgical excision of the mass.

INTRODUCTION: Although omphalitis (umbilical infections) among newborns is common and a major cause of neonatal deaths in developing countries, information on its burden and etiology from community settings is lacking. This study aimed to determine the incidence and etiology of omphalitis in newborns in high neonatal mortality settings in Karachi, Pakistan. METHODOLOGY: Trained community health workers surveyed all new births in three low-income areas from September 2004 to August 2007. Pus samples from the umbilical stumps were obtained from babies with pre-defined signs of illness and subjected to culture and antimicrobial susceptibility testing. RESULTS: Among 6904 births, 1501 (21.7%) newborns were diagnosed with omphalitis. Of these, 325 (21.6%) were classified as mild, 1042 (69.4%) as moderate, and 134 (8.9%) as severe; 141 (9.3%) were associated with clinical signs of sepsis. The incidence of omphalitis was 217.4/1000 live births; moderate-severe omphalitis 170.3 per 1000 live births; and associated with sepsis 20.4 per 1000 live births. Of 853 infants with purulent umbilical discharge, 64% yielded 583 isolates. The most common pathogens were Staphylococcus aureus, of which 291 (95.7%) were methicillin-susceptible Staphylococcus aureus (MSSA) and 13 (4.2%) methicillin-resistant S. aureus (MRSA); Streptococcus pyogenes 105 (18%); Group B beta-hemolytic streptococci 59 (10 %); Pseudomonas spp., 52 (8.9 %); Aeromonas spp. 19 (3.2%); and Klebsiella spp. 12 (2%). CONCLUSIONS: A high burden of omphalitis can be associated with sepsis among newborns in low-income communities in Pakistan. S. aureus is the most common pathogen isolated from umbilical pus. Appropriate low-cost prevention strategies need to be implemented.

OBJECTIVE: This study was designed to test the hypothesis that simulator-based transesophageal echocardiographic training was a more effective method of training anesthesia residents with no prior experience in echocardiography as compared with conventional methods of training (books, articles, and web-based resources). STUDY DESIGN: A prospective randomized study. SETTING: An academic medical center (teaching hospital). PARTICIPANTS: The participants consisted of first-year anesthesia residents. INTERVENTION: The study design was composed of 2 groups: a control group (group 1, conventional group) and a study group (group 2, simulator group). The residents belonging to group 2 (simulator group) received a 90-minute simulator-based teaching session moderated by a faculty experienced in transesophageal echocardiography. Residents belonging to group 1 (conventional group) were asked to review the guidelines of the comprehensive intraoperative transesophageal echocardiographic examination published by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. They also were encouraged to use other learning resources (eg, textbooks, electronic media, and web-based resources) to understand the underlying concepts of echocardiography. Written pre- and post-test was administered to both groups. MEASUREMENTS AND MAIN RESULTS: The groups were compared for the pretest scores by the nonparametric Mann-Whitney U test. Pre- and post-test scores were compared with a Wilcoxon paired test in the individual groups. The results showed a statistically significant difference between the scores of the 2 groups with better scores in the simulation group in the post-training test. CONCLUSION: The simulator-based teaching model for transesophageal echocardiography is a better method of teaching the basic concepts of transesophageal echocardiography like anatomic correlation, structure identification, and image acquisition.

PURPOSE: The authors analyze a commercially available software package capable of geometrically reconstructing the mitral valve (MV) dynamically throughout systole. DESCRIPTION: Three-dimensional echocardiography has revolutionized the understanding of MV geometry. Advanced quantification software can be used to assess geometric changes in the MV, which have been shown to have important implications for MV surgery. EVALUATION: The authors performed geometric analysis on 24 patients, with both anatomically normal and abnormal MVs to assess the feasibility of this new software. The application of this new software is briefly reviewed. CONCLUSION: This new software, despite its limitations, allows an improved perspective on MV geometry with implications for MV repair and surgical decision making.

INTRODUCTION: Although omphalitis (umbilical infections) among newborns is common and a major cause of neonatal deaths in developing countries, information on its burden and etiology from community settings is lacking. This study aimed to determine the incidence and etiology of omphalitis in newborns in high neonatal mortality settings in Karachi, Pakistan. METHODOLOGY: Trained community health workers surveyed all new births in three low-income areas from September 2004 to August 2007. Pus samples from the umbilical stumps were obtained from babies with pre-defined signs of illness and subjected to culture and antimicrobial susceptibility testing. RESULTS: Among 6904 births, 1501 (21.7%) newborns were diagnosed with omphalitis. Of these, 325 (21.6%) were classified as mild, 1042 (69.4%) as moderate, and 134 (8.9%) as severe; 141 (9.3%) were associated with clinical signs of sepsis. The incidence of omphalitis was 217.4/1000 live births; moderate-severe omphalitis 170.3 per 1000 live births; and associated with sepsis 20.4 per 1000 live births. Of 853 infants with purulent umbilical discharge, 64% yielded 583 isolates. The most common pathogens were Staphylococcus aureus, of which 291 (95.7%) were methicillin-susceptible Staphylococcus aureus (MSSA) and 13 (4.2%) methicillin-resistant S. aureus (MRSA); Streptococcus pyogenes 105 (18%); Group B beta-hemolytic streptococci 59 (10 %); Pseudomonas spp., 52 (8.9 %); Aeromonas spp. 19 (3.2%); and Klebsiella spp. 12 (2%). CONCLUSIONS: A high burden of omphalitis can be associated with sepsis among newborns in low-income communities in Pakistan. S. aureus is the most common pathogen isolated from umbilical pus. Appropriate low-cost prevention strategies need to be implemented.