Scott T. Reeves, MD, FASE, Kathryn E. Glas, MD, FASE, Holger Eltzschig, MD, Joseph P. Mathew, MD, FASE, David S. Rubenson, MD, FASE, Gregg S. Hartman, MD, and Stanton K. Shernan, MD, FASE, for the Council for Intraoperative Echocardiography of the American Society of Echocardiography, Charleston, South Carolina; Atlanta, Georgia; Tubingen, Germany; Durham, North Carolina; La Jolla, California; and Lebanon, New Hampshire

https://www.asefoundation.org/wp-content/uploads/2013/05/Performing-a-Comprehensive-Epicardial-Echo-Exam.pdf

Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.

TABLE OF CONTENTSIntroduction 921General Guidelines 922Training and Certification 922Indications for TEE 923Management of Patient Sedation 927Sedation and Anesthesia 929Probe Insertion Techniques 930Instrument Controls 930Instrument Manipulation 931Comprehensive Imaging Examination 932ME Views 932TG

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

/pdf/2019-hrs-ehra-aphrs-lahrs-expert-consensus-statement-on-3p2ufvqfaj.pdf

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias.

Nitric oxide (NO) is a small free radical with critical signaling roles in physiology and pathophysiology. The generation of sufficient NO levels to regulate the resistance of the blood vessels and...

Sources of Vascular Nitric Oxide and Reactive Oxygen Species and Their Regulation

Object Since the advent of MR imaging, an increasing number of asymptomatic or oligosymptomatic patients have been diagnosed with Chiari malformation Type I (CM-I). The decision of whether or not to operate is more difficult in these patients than in those with clear symptoms because of the lack of information about the natural course of this disease. Methods The authors report on their experience in a series of 22 patients with CM-I who were evaluated at the authors' institution, and for whom a conservative approach to treatment was adopted. The patients ranged in age from 1 to 16 years (mean 6.3 years) at diagnosis. Neuroradiological and complete clinical examinations were performed in all patients 6 months after the first observation and every year thereafter. The follow-up period ranged from 3 to 19 years (mean 5.9 years). Results Chiari malformation Type I was incidentally detected on MR images in 11 of 22 patients. The remaining 11 patients had minimal clinical signs at presentation that were not re...

The natural history of the Chiari Type I anomaly

Recent developments in cardiac pacing and trans-coronary vein ablations have demonstrated the increasing value of imaging of the cardiac venous system (CVS), especially computed tomographic (CT) mapping of the coronary veins. In contrast to that for coronary arteries, the literature for coronary veins is scarce. Moreover, a complete, highly efficient, and clinically useful classification of the CVS is not as straightforward as for the coronary arteries. The CVS comprises polymorphous types of venous conduits with notable anatomic variations. Recent anatomic classification divides the cardiac veins into two main groups: tributaries of the greater CVS and tributaries of the lesser CVS, consisting of the thebesian vessels. The greater CVS is subdivided into two groups: coronary sinus and non-coronary sinus tributaries. Imaging information about the CVS in this review is useful for a better understanding of the spatial orientation of the CVS and furthers proper use of the correct nomenclature for this important system. The authors describe the clinical implications of the different imaging techniques for assessment of the coronary veins, where cardiac CT venous mapping has major advantages. The role of CT in anatomic classification, assessment of anatomic variants, and diagnosis of pathologic changes of the CVS is discussed. The authors also underscore the particular role of CT venous mapping for cardiac interventions, especially for left ventricular pacing in cardiac resynchronization therapy and in percutaneous mitral annuloplasty.

Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.

As a result of the numerous clinical and surgical data accumulated so far, the classical image of the mitral valve-a bicuspid valve, with two leaflets and two papillary muscles-undergoes significant modifications. The valve, included into the larger concept of the mitral valvular complex unveils numerous important valences and characteristics, among which, some represent newer concepts, of clinical and surgical significance: the valvular complex is a subtle and finely-tuned system of elements acting in a coordinated manner; the mitral valve is an active valve and not a mere passive flap bordering the atrioventricular junction. Not least, the mitral valve contributes to the make up and function of the left ventricular outflow tract. The anatomical and functional interdependence between the mitral valve and the left ventricular myocardium is evident not only following their particularities of vascularization but also it is reflected in morbid states such as ischemic cardiac disease and dilated cardiomyopathy. All the new concepts and ideas, ask for a more profound study of the clinical anatomy of the mitral valve, underscoring the importance of a pertinent dialogue between specialists and by using a more appropriate and unitary terminology.

The clinical anatomy of the mitral valve.

Human monocytes and macrophages express NADPH oxidase 5; a potential source of reactive oxygen species in atherosclerosis.

The fibrous skeleton is concentrated at the base of the ventricular mass. It provides electrical insulation at the atrioventricular level and fibrous continuity for the leaflets of the mitral, aortic, and tricuspid valves. Its components include the fibrous trigones, the fibrous area of aortic-mitral continuity, the subvalvar collar of the mitral valve, the membranous septum, the interleaflet triangles, the tendon of Todaro, and likely the conus ligament. The majority of the mitral annulus is fibrous, but the only true fibrous part of the tricuspid annulus is where the valvar leaflets are attached to the central fibrous body. At the aortic annulus, the fibrous elements support only the noncoronary aortic sinus and parts of the right and left coronary sinuses. The ring-shaped annulus of the arterioventricular valves as localized with imaging techniques (imaging annulus) differs from the crown-shaped hemodynamic annulus of the arterial valves. The imaging annulus corresponds to the plane passing through the nadirs of the hinge-lines of the leaflets. The hinges of the pulmonary valve are not part of the fibrous skeleton. Computed tomography (CT) and magnetic resonance (MR) imaging are excellent modalities for evaluation of the anatomy, physiologic variations, and pathologic conditions of the fibrous skeleton. The submillimeter isotropic three-dimensional datasets obtained with CT and the high contrast resolution of MR imaging are the main advantages of these modalities in assessing anatomy. The function of the valves and associated annuli can best be studied with MR imaging. Pathologic conditions involving the area, including paravalvar leaks, abscesses, perforation, and pseudoaneurysms, usually occur as a complication of infective endocarditis or extensive calcifications after valvar surgery. MR imaging and CT can demonstrate these lesions equally well. CT is the preferred technique for showing the extent of calcifications in the fibrous skeleton. Large calcifications involving the central fibrous body can cause heart block by interfering with the normal function of the His bundle and its branches. ©RSNA, 2017.

Fibrous Skeleton of the Heart: Anatomic Overview and Evaluation of Pathologic Conditions with CT and MR Imaging

Chiari anomalies in the human right atrium ostensibly are encountered rarely. There is only sporadic mention in the literature of these fenestrated, net-like valves of the inferior vena cava, coronary sinus, or various strands connecting these with other right atrial structures. The effects of such structural anomalies on heart function are unknown. We report here gross observations of the right atrial net from among 213 cadavers, 38 autopsied, and 11 fetal hearts. Histological and ultrastructural examination of inferior vena cava and coronary sinus valves demonstrated that only the anomalous coronary sinus valves contained cardiac muscle. Chiari anomalies typically have referred to perforations or tissue strands related to the inferior vena cava valve and possibly the coronary sinus valve. The anomaly commonly is cited as occurring in 2% of individuals, although there has been no study to support this. We observed Chiari malformations in 13.6% of the 213 cadaver hearts, and 10.5% of the autopsied hearts examined. Of these malformations, the coronary sinus valve was fenestrated most frequently. We propose the term "right atrial net" for "Chiari net," for anomalies involving valves of the inferior vena cava and coronary sinus, and strands within the right atrium connecting these valves with the crista terminalis, right atrial wall, or interatrial septum.

Horia Muresian

Papers

Coronary veins: comprehensive CT-anatomic classification and review of variants and clinical implications.

The clinical anatomy of the mitral valve.

Human monocytes and macrophages express NADPH oxidase 5; a potential source of reactive oxygen species in atherosclerosis.

Fibrous Skeleton of the Heart: Anatomic Overview and Evaluation of Pathologic Conditions with CT and MR Imaging

Chiari anomalies in the human right atrium.