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Background There is a paucity of literature regarding outcomes of patients with mitral valve prolapse (MVP) and mitral annular disjunction (MAD) after mitral surgery, with many unanswered questions including the post-surgical persistence of MAD, effect of MAD on mitral valve reparability, and incidence of arrhythmia after mitral valve surgery. We aimed to examine the prevalence, imaging characteristics and clinical associations of mitral annular disjunction among patients undergoing mitral valve surgery for mitral valve prolapse, as well as outcomes after surgery including the persistence of MAD, arrhythmic events and excess mortality. Results A retrospective analysis of 111 consecutive patients who underwent mitral valve surgery for MVP was performed. A total of 32 patients (28.8%) had MAD. Patients with MAD were younger (64 vs 67 yrs, p = 0.04), with lower rates of hypertension (21.9% vs 50.6%, p = 0.01) and hyperlipidaemia (25% vs 50.6%; p = 0.01) and were more likely to be female (43.8% vs 21.4%, p = 0.04) with myxomatous leaflets > 5mm (90.6% vs 15.2%, p =  < 0.01) and bileaflet prolapse (31.3% vs 10.1%, p = 0.02). Mitral valve repair was performed in 29/32 patients (90.6%) in the MAD positive group, and no patients had the persistence of MAD post-surgery. Post-operative ventricular arrhythmia was higher in the MAD positive group (28.13% vs 11.69%, p = 0.04) with no difference in mortality, 30-day hospital re-admission, or post-operative mitral regurgitation between patients with and without MAD over 3.91 years of follow up. Conclusion In this study of consecutive patients with MVP undergoing surgery, MAD was a common finding (almost 1 in 3). MAD does not compromise mitral valve surgical reparability, and both repair and replacement are effective at correcting disjunction. Our data suggest that concurrent MAD in MVP patients undergoing surgery has no significant effect on post surgical outcomes. Further research as to whether this patient cohort requires post-surgical arrhythmia monitoring is warranted.

Primary cardiac lymphoma (PCL) is a rare, potentially fatal subtype of non-Hodgkin’s lymphoma. Thrombocytopenia has also infrequently been reported in association with other primary cardiac tumours and can add substantial morbidity to an already life-threatening diagnosis if present. We report a rare case of a 70-year-old man who presented with thrombocytopenia (91 × 109/L) and progressive right heart failure. Transthoracic echocardiogram revealed a large 8 × 4 cm right atrial mass with severe tricuspid obstruction, confirmed as PCL on subsequent endomyocardial biopsy and immunohistochemistry. He deteriorated into cardiogenic shock precipitated by atrial fibrillation, with worsening thrombocytopenia (18 × 109/L) in the setting of ischaemic hepatitis. The patient stabilised with initiation of high dose steroids prior to tissue diagnosis and platelet counts normalised following chemotherapy. This case demonstrates the importance of considering PCL as a diagnosis and preemptive initiation of high dose steroids to improve outcomes in PCL associated with cardiogenic shock. This case also elucidates a potential pathophysiological association between PCL and thrombocytopenia.

Objective Giant cell arteritis (GCA) is characterized by cranial ischemia at diagnosis and late aortic structural disease. Repeated combined cranial and large‐vessel fluoro‐2‐deoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) scans were performed to assess the distribution of vasculitis activity over time and the relationship with clinical outcomes. Methods Patients were eligible if they were enrolled in a 64‐patient inception suspected GCA cohort in 2016 to 2017 and had a positive temporal artery biopsy and/or PET/CT scan at diagnosis. At five years, patients underwent a PET/CT scan, magnetic resonance aortogram, and clinical assessment. Scans were reported for overall metabolic disease activity and a visual FDG avidity grade at each vascular territory. Results Sixteen patients met inclusion criteria, and 11 attended the five‐year visit. Median age was 75 years, 73% were women, and all were in remission. At five years, 4 (36%) patients had aortic dilatation (range 40–43 mm), and five (45%) had globally active scans. Cranial artery activity resolved in all patients between diagnosis and five years, but aortitis developed in four patients who previously had PET‐inactive aortas. Disease‐modifying rheumatic drug (DMARD) use at five years was associated with scan inactivity (P = 0.02). There was a trend toward a higher mean aortic diameter in those with aortitis at five years (40.2 mm vs 36.0 mm, P = 0.06) but not those with aortitis at diagnosis. Conclusion Vasculitis activity changed from cranial and large vessel to exclusively large vessel by five years. This may explain the preponderance of early cranial and late aortic complications in GCA. The potential role of long‐term DMARDs to mitigate smoldering vasculitis warrants further study.

IntroductionTwo dimensional echocardiographic (2DE) assessment of the right ventricle (RV) has limitations. Three-dimensional echocardiographic (3DE) assessment of RV volumes has been validated against cardiac magnetic resonance imaging (CMRI). We hypothesised the addition of 3DE would improve assessment of RV size and be comparable to CMRI in a public hospital setting.MethodConsecutive patients planned for inpatient CMRI for any indication underwent 3DE on the same day. CMRI, 3DE and 2DE data were analyzed.Results16 patients were included. 3DE and CMRI RV end systolic and end diastolic volumes were highly correlated (r=0.95 and 0.90 respectively). Mean RV end diastolic and end systolic volume was significantly lower on 3DE compared to CMRI; (175 ml +/-54.2 vs 193.69 ml +/- 59.9, p= 0.01) and (92.56 +/- 41.26 vs 106.06 +/- 49.93, p = 0.015) respectively. There was no significant difference between 3DE and CMRI RV ejection fraction (48.31% +/- 10.54 vs 45.75% +/- 11.22). Dilated RV on 2DE was seen in n=9 (56%). Of these, n=7 (78%) were reclassified to normal RV size based on 3DE and CMRI. The addition of 3DE to 2DE increased the specificity, as compared to CMRI, of detecting a dilated RV from 50% to 100%.Conclusion:These findings show 3DE RV volumes are highly correlated and consistently smaller than CMRI RV volumes. The addition of 3DE to 2DE improves the specificity of detecting a dilated RV. All patients with RV dilatation on 3DE were found to have RV dilatation on CMRI, a specificity of 100%.Conflict of InterestNil

Left atrial fibromuscular band is a rare congenital cardiac anomaly. We present a patient with an incidental finding of left atrial band on an intra-operative transesophageal echocardiogram and characterize its appearance on two-dimensional and three-dimensional echocardiograms.

PurposeThis research draws on the resource-based view of the firm from strategic management and applies it to a study of competitive advantage in the project management context. The relationship between the characteristics of project management resources, focusing on organizational support for the project management process, and outcomes of the project management process are examined.Design/methodology/approachThis study uses data gathered from 437 North American project management professionals with an existing survey tool that was used in a prior smaller sample study. The study uses Barney’s VRIO framework that assesses resources as valuable (V), rare (R), inimitable (I) and organizationally supported to leverage their value (O). The conceptual model hypothesizes relationships between the project management asset characteristics (valuable, rare, and inimitable), organizational support for the project management process, and project management performance outcomes (both project and firm level). Hypotheses are tested using factors extracted from a confirmatory factor analysis (CFA). The factors extracted include two factors representing valuable project management asset characteristics, one factor representing rare project management asset characteristics, one factor representing inimitable project management asset characteristics, two factors representing organizational support for the project management process, one factor representing project-level performance and one factor representing firm-level performance.FindingsProject management assets that are considered valuable and organizational support for the project management process are found to contribute positively to project management process outcomes. No advantage was perceived from rare and inimitable project management assets. Project-level performance was found to significantly mediate the relationship between organizational support and firm-level performance.Practical implicationsThis study draws managerial attention to organizational support for the project management process as a source of competitive advantage through its positive affect on both project-as well as firm-level performance.Originality/valueThe study uses a survey tool from previous research with a new, larger dataset to contribute to the understanding of the importance of organizational support for the project management process in a quest for both project success as well as a firm's competitive advantage.

Purpose The purpose of this paper is to study how project-level performance mediates the effect of project management assets on firm-level performance by examining the direct and mediated relationships between the project management process characteristics: valuable, rare, inimitable and organizationally supported on project-level and firm-level performance outcomes. Design/methodology/approach This paper analyzes data from an online survey completed by 198 North American Project Management Institute® members. Linear regression and Sobel Tests are used to examine the relationships between nine factors extracted from an exploratory factor analysis that comprise project management asset characteristics, one factor that comprises project-level performance outcomes, and one factor that comprises firm-level performance outcomes. Findings Not only does project-level performance positively and significantly affect firm-level performance, but project-level performance also significantly mediates the effect of project management asset characteristics (for all nine factors) on firm performance. Research limitations/implications Limitations of this study include sample size and self-report bias, calling for a larger sample in ongoing research. Practical implications This study contributes to the stream of literature on project management assets as sources of competitive advantage and makes the case for sustained organizational investments in the project management process. Originality/value This paper contributes to the limited, but increasing interest in applying the resource-based view of the firm to project management capabilities as a source of competitive advantage.

Purpose The purpose of this paper is to draw on the resource-based view of the firm from strategic management and apply it to a study of competitive advantage in the project management context. Confirmatory factor analysis (CFA) is used to examine the factors that constitute strategic characteristics of project management resources and outcomes of the project management process. Design/methodology/approach This study gathered data from 437 North American project management professionals using an existing survey tool from prior research involving a smaller sample. Findings The final model derived from CFA demonstrated construct validity, meaning acceptable convergent and discriminant validity. It showed only minor differences from a prior exploratory factor analysis (EFA). The final model consisted of two factors representing valuable project management characteristics, one factor representing rare project management characteristics, one factor representing inimitable project management characteristics, three factors representing organizational support for project management assets, one factor representing project-level performance and one factor representing firm-level performance. Research limitations/implications Limitations of the study include self-report bias and the use of a panel for data collection. Practical implications This study draws managerial attention to project management characteristics that constitute a source of competitive advantage. Originality/value The study validates a survey tool from previous research, reflects few deviations from factor structure of the prior EFA, and sets the stage for future research to elaborate on the conceptual model. It extends understanding of the characteristics of project management assets that lead to a firm’s competitive advantage.

Secondary cardiac device infection is particularly common (over 40%) in patients with cardiac devices and staphylococcal bacteraemia.2 Present ation can vary from a superficial postimplantation wound infection with local findings at the generator pocket to a deep-seated infection involving the intra vascular portion of the lead and occasionally the valve. Septic emboli to the lungs, as suggested by the gallium scan, are relatively common in cardiac device infection.5 All patients should have multiple blood cultures and, because it is much more sensitive than TTE, a TOE, if there is a high index of suspicion.

Purpose - The purpose of this paper is to examine characteristics of project management assets and project management performance outcomes as a step towards exploring the link between assets being valuable, rare, inimitable, and having organizational support and the achievement of competitive advantage.Design methodology approach - This paper analyzes data from responses to an online survey by 198 North American Project Management Institute® members. Exploratory factor analysis is used to identify characteristics of project management assets and project management performance outcomes.Findings - In total, six factors that comprised the characteristics of project management assets, three factors that comprised organizational support for project management assets, and two factors that comprised the project management performance outcomes were extracted.Research limitations implications - Limitations of this study include sample size, response rate, and self-report bias, calling for a larger sample in ongoing research. This study is a step towards making the link between project management assets and performance outcomes.Practical implications - This study draws managerial attention to project management assets as sources of competitive advantage, applying the resource based view of the firm that assets are sources of competitive advantage if they add economic value, are rare, are difficult to imitate, and have organizational support.Originality value - Few papers have applied the resource based view of the firm to examine project management capabilities as a source of competitive advantage. This paper contributes to the literature on the resource based view of the firm and contributes to an improved understanding of project management as a source of competitive advantage.