Background In patients with cardiogenic shock (CS) complicating an acute myocardial infarction, a strategy of early revascularization (ERV) versus initial medical stabilization (IMS) improves survival. Intra-aortic balloon counterpulsation (IABC) provides hemodynamic support and facilitates coronary angiography and revascularization in CS patients.Methods and Results We evaluated 499 patients with record of systemic hypoperfusion status as an early response to IABC from the SHOCK trial (n = 185) and registry (n = 314) to determine the association between rapid complete reversal of systemic hypoperfusion (CRH) after 30 minutes of IABC and in-hospital, 30-day and 1-year mortality. Rapid complete reversal of systemic hypoperfusion was highly associated with lower in-hospital mortality (29% versus 65%, P < .001) in all patients. In the SHOCK trial, among patients assigned to ERV versus IMS, 30-day mortality was 26% versus 29%, respectively, with CRH and 61% versus 81%, respectively, without CRH after commencing IABC. The corresponding 1-year mortality rates were 35% versus 52% for ERV and 69% versus 87% for IMS (interaction P >= .25 at both time points). After adjusting for important correlates of outcome (left ventricular ejection fraction, age, and randomization to ERV), a significant association remained between CRH and registry and trial in-hospital mortality (odds ratio 0.23, 95% CI 0.14-0.39, P < .001) and trial 1-year mortality (odds ratio .28, 95% CI 0.12-0.67, P < .001).Conclusions In CS patients, CRH after commencing IABC was independently associated with improved in-hospital, 30-day and 1-year survival regardless of early revascularization. In CS patients, CRH with IABC is an important early prognostic feature. (Am Heart J 2011;162:268-75.)

Background Paravalvular abscess is a complication of endocarditis that may lead to persistent infection, conduction abnormalities, fistula formation, worsening congestive heart failure, and death. Methods Between 1991 and 2001, paravalvular abscess was identified on transesophageal echocardiography in 24 patients who subsequently underwent surgical treatment. Echocardiographic findings were reviewed for location of abscess, presence of a valvular prosthesis, valvular function, and presence of vegetations. Information gathered included the time interval between transesophageal echocardiography diagnosis and operation, inhospital mortality, and microbiologic data. Results Of 24 patients, 9 died, for a mortality of 38%. Of the patients who died, the average survival after operation was 43 days, with a range of 1 to 238 days. Of the 14 patients with significant valvular or paravalvular regurgitation, 8 died (57%). However, of the 10 patients with mild or no regurgitation, only 1 died (10%). This difference was statistically significant (P = .02). Conclusion Patients without preserved valve function (those with moderate or severe regurgitation) have a significantly worse outcome (57% mortality) than do those with normal valvular function (10% mortality).

BACKGROUND Aortic valve thickening (AVT) without aortic stenosis (AS) is common and was often considered benign. However, it has recently been found to be associated with increased morbidity and mortality. It is unknown whether patients with AVT are at risk for the development of AS. METHODS Our echocardiography database from 1987 to 1993 was searched for cases of AVT with at least 1 year of echocardiographic follow-up. The risk of the development of AS was compared in patients with and without AVT. RESULTS There were 2131 patients with AVT and at least 1 year of echocardiographic follow-up. Aortic stenosis developed in 338 patients (15.9%) (mild, 10.5%; moderate, 2.9%; and severe, 2.5%). Multivariate analysis, including age, left ventricular hypertrophy, and mitral annular calcification, revealed that only mitral annular calcification was independently and significantly associated with progression to AS. CONCLUSIONS Aortic valve thickening without stenosis is common, and it may progress to significant AS. It is possible that this development of AS may be responsible for some of the increased morbidity and mortality in patients with AVT.