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Background The relationship between visual and strain assessment of left ventricular ( LV) function during dobutamine stress echocardiography ( DSE) remains poorly investigated. We assessed systolic longitudinal strain ( SLS) and strain rate ( SLSR) in segments visually graded as normokinetic, hypokinetic, or akinetic at baseline (0) and peak stage (1) of DSE and compared deformation changes between segments with and without induced contractility worsening. Methods From 250 patients examined by DSE, 238 patients with diagnostic test were included, mean age of 62±9 years (105 females). Regional LV contractility was assessed visually and measured using SLS and SLSR in 4284 segments. Results The LV segments during baseline and peak stage of DSE revealed gradual decrease in absolute values of SLS (from 17.7±6.4% in normokinetic to 11.7±8.4% in akinetic segments at rest, and from 17.2±8.5% to 14.4±7.8% at peak, P<.001), as measured by automated function imaging ( AFI) and SLSR (from 1.1±0.37 s−1 in normokinetic to 0.9±0.29 s−1 in akinetic at rest, and from 2.32±0.92 to 2.13±0.85 s−1 at peak). The decrease in SLS in segments with contractility worsening was higher than in segments without induced impairment (Δ SLS 2% vs 0%, P<.0001 for all LV segments and 2% vs 1%, P=.02 in mid- LV segments). Absolute value of regional SLS <23% at peak DSE and decrease in SLS >2% from baseline showed 90% and 76% sensitivity for the detection of contractility impairment. Conclusion Strain analysis quantifies segmental LV contractility not only at rest and peak DSE but may be helpful in detection of stress-induced contractility worsening. [ABSTRACT FROM AUTHOR]

Introduction: Although global deformation parameters have been increasingly used for myocardial function analysis, there are sparse data concerning segmental deformation of the left ventricle (LV). Moreover, some studies suggest heterogeneity of strain among LV segments, which may be especially significant during stress echocardiography. We assessed quantitatively regional LV function in the setting of dobutamine stress echocardiography (DSE), to examine differences of longitudinal strain between basal, mid and apical LV segments and to compare variability of regional deformation between rest and the peak stage of DSE.Material and Methods: Among 250 patients examined by DSE applied for diagnosis of ischemia, a subset of 111 patients without significant coronary stenoses in angiography was selected (68 females, mean age: 60 ±10 years). Systolic longitudinal strain (SLS) in individual LV segments at baseline and the peak stage of DSE was analyzed with speckle tracking echocardiography.Results: Inhomogeneity of SLS among the LV segments (p < 0.001) was observed at baseline and the peak stage. Dispersion indices were higher at the peak stage of DSE than at baseline (p < 0.001), and the lowest heterogeneity was observed among mid segments. The analysis of changes in SLS during DSE showed SLS reduction in basal and mid-ventricular segments and an increase in apical segments.Conclusions: Significant heterogeneity of strain and the opposite direction of the longitudinal strain changes during DSE between apical and basal LV segments were observed. This variability among non-ischemic LV segments ought to be considered in quantification of LV function during DSE. [ABSTRACT FROM AUTHOR]

Purpose Speckle tracking echocardiography is widely used for the analysis of myocardial function. Recently, circumferential strain (CS) of carotid arteries was postulated as novel indicator of vascular function. Our aim was to characterize and compare CS of carotid arteries in patients with advanced coronary artery disease and controls without significant coronary stenoses. Patients/methods We compared CS of both common carotid arteries (CCA) in the 25 patients with three-vessel coronary artery disease (3VD) (mean age 69 ± 9 years, 9 male) and in 16 age-matched subjects without significant coronary lesions (C) (69 ± 8 years, 7 male). Additionally in 11 patients we estimated pulse wave velocity (PWV) and assessed the correlation between PWV and CS. Short-axis images of arteries were acquired for strain analysis with linear probe of echocardiograph. The assessment of CS was performed off-line by two observers. Results The intraobserver variability for the CS (coefficient of variation) were 4.9 and 5.4% for left and right CCA and interobserver variability were 11.7% and 12.5%, respectively. The mean CS for left and right CCA did not differ between compared groups. We did not find correlation between CS strain and PWV. The only difference was related to the more prevalent plaque presence and thicker intima-media complex (IMT) in 3VD ( p = 0.0039 for IMT of left CCA and p = 0.016 for IMT of right CCA). Conclusions The global CS of CCA, contrary to IMT, did not allow for differentiation between 3VD and C subjects. Despite good feasibility and concordance of CS measurements its clinical significance remains to be established. [ABSTRACT FROM AUTHOR]

Takotsubo cardiomyopathy (TC) is related to a transient systolic dysfunction of left ventricle (LV), accompanied by clinical and electrocardiographic symptoms of myocardial ischemia in the absence of hemodynamically significant coronary artery disease. Takotsubo cardiomyopathy is usually provoked by a psychologically or/and physically stressful event which may be related to occupational activities. Although visually assessed evolution of LV function is well documented, the data concerning strain changes is sparse and various patterns of deformation abnormalities are suggested. We have described a 72-year-old woman with chest pain related to a lecture given at the meeting of the Senior University, fulfilling all the Mayo Clinic criteria of the TC. The longitudinal strain analysis with automated function imaging (AFI) documented severe impairment and stepwise recovery of regional and global LV contractility. The case described confirms that accurate diagnosis, treatment and documenting of functional improvement in takotsubo cardiomyopathy may enable the return to occupational activities even for elderly persons. Int J Occup Med Environ Health 2017;30(4):681-683. [ABSTRACT FROM AUTHOR]

Background We assessed the impact of morbid obesity on systolic and diastolic heart function in severely obese, but otherwise healthy subjects and age-matched controls. Methods Overall, 27 obese patients: 19 female (F) and 8 male (M) mean age 37 ± 9, mean body mass index ( BMI) 46 ± 6 and 27 control subjects: mean age 36 ± 10, mean BMI 23 ± 3 were examined by transthoracic echocardiography, including tissue Doppler echocardiographic ( TDE) assessment and speckle tracking echocardiography to measure left ventricular longitudinal, circumferential, and radial strain (S) and strain rate ( SR) during systolic and early diastolic phase. Results Obese patients presented with enlargement of both ventricles and the left atrium, and thicker left ventricular wall. Although left ventricular ejection fraction ( EF) as well as amplitude of tricuspid annulus plane systolic excursion ( TAPSE) was similar, the amplitude of mitral annulus plane systolic excursion ( MAPSE) and ventricular systolic and early diastolic velocities measured by TDE were significantly lower for both ventricles in the obese group. ( RV S′ 13 ± 3 cm/sec vs. 15 ± 2 cm/sec, P = 0.0057; LV S′ lat 8.5 ± 1.6 cm/sec vs. 12.1 ± 2.8, P < 0.0001, E′ lat: 12.4 ± 2.9 vs. 16.4 ± 3.5 cm/sec for left ventricular and E′ 12 ± 3 cm/sec vs. 18 ± 4 for right ventricular velocities, P < 0.0001). Among the deformation parameters, systolic and diastolic circumferential and systolic radial strain and SR were decreased in the obese subjects, whereas longitudinal strain did not differ significantly. Conclusions TDE parameters documented reduced systolic and diastolic function of both ventricles in obese patients. 2-dimensional speckle tracking analysis revealed that circumferential and radial but not longitudinal strain and SR were impaired in the obese group. [ABSTRACT FROM AUTHOR]

The article is a subjective choice of studies presented during Hot-line sessions of the 60th congress of the ESC (European Society of Cardiology) in Munich. Trials and registers selected to prestigious debates were moslty concentrated on prevention, diagnosis and treatment of different forms of coronary artery disease, atrial fibrillation, valvular heart disease and chronic heart failure. Many of them were thematical-ly connected with the guidelines issued this year by the ESC. The authors would like to focus on studies and registers which in their opinion will impact future recommendations in cardiology and could inspire new directions in research like PURE, FAST-MI, CORE 320, FAME 2, IABP-SHOCKII, PROTECT, TRILOGY ACS, WOEST, PRAGUE-12, GARY, PARAMOUNT, ALDO-DHF, ALTITUDE. [ABSTRACT FROM AUTHOR]

Parachute and parachute‐like mitral valve are rarely encountered in adults congenital abnormalities in which diagnosis usually relies on detailed echocardiographic examination with special focus on three‐dimensional imaging. In children, these valves often coexist with other congenital anomalies such as aortic stenosis, atrial septal defect, hypoplastic left heart syndrome or form Shone complex together with supravalvular mitral ring, subaortic stenosis, and aortic coarctation. We described a woman with moderate stenosis and mild regurgitation of mitral valve diagnosed as congenital parachute‐like anomaly during transthoracic and transesophageal examination. Precise recognition of morphology disqualified the patient from percutaneous balloon angioplasty. [ABSTRACT FROM AUTHOR]

Age-dependency has been demonstrated for classic diastolic parameters but is less documented for novel markers. We compared wide spectrum of diastolic measurements in healthy subjects younger and older than 50 and 70 years. Method: In 80 subjects (17 to 91 year, 38 male, mean age 53 ± 16) we assessed in transthoracic echocardiography mitral inflow, pulmonary vein flow, propagation velocity, and tissue Doppler parameters. The data were compared between the groups: A < 50, B 50–70, and C > 70 years and their correlation with age was analyzed. Result: In the older groups a longer duration of isovolumic relaxation, higher velocity of mitral inflow atrial phase, and lower early to atrial mitral inflow velocity ratio (E/A) were observed. In pulmonary veins ratio of peak systolic to diastolic velocity (S/D) was higher and atrial reversal flow faster. Among the new parameters in older groups a lower propagation velocity of early wave (Ep) (30 ± 8 in C, 44 ± 10 in B vs 49±9 cm/s in A; P < 0.05) and peak early diastolic velocity of mitral annulus (E' 9.5 ± 1.8 in C and 11.2 ± 2.9 in B vs 15.8 ± 4.1 cm/s in A, P < 0.05) were recorded. Conclusions: Besides the evolution of mitral inflow toward the delayed relaxation profile in elderly, a decrease of propagation and tissue Doppler velocities were documented. The strongest positive correlation with age was observed for atrial velocity of mitral inflow (A , r = 0.63) and inverse correlation for E/A ratio (r =–0.6) and early diastolic velocity of mitral annulus (r =–0.69). [ABSTRACT FROM AUTHOR]

Background and Aim: Patients after myocardial infarction (MI) differ according to the extend of myocardial damage and prognosis. Diastolic function impairment may have great impact on development of heart failure and outcomes. We evaluated the prognostic value of various echocardiographic measurements in 18-month and 3-year observation after MI. Methods: 60 patients after MI (44 male, mean age 60 ± 11) were examined by transthoracic echocardiography with the assessment of wide spectrum of parameters. Mortality and combined end points (cardiac deaths and heart failure exacerbation) were assessed after 18-month and 3-year observation and groups with and without end points were compared. Optimal cutoff values were estimated by receiver operating characteristic (ROC) analysis and resulting Kaplan–Meier curves were compared. Results and Conclusions: After 18 months, 11 deaths occurred and 20 subjects experienced hospitalization caused by heart failure exacerbation. Although the group with cardiac events showed a greater enlargement of the left ventricle and lower ejection fraction, the highest relative risk of poor outcome (RR = 5.0) was related to the left atrial enlargement above 44 mm. Although restrictive or pseudonormal inflows were connected with 2.1 relative risk of combined end point, all patients with E deceleration time ≤130 ms experienced heart failure exacerbation or death. Despite tissue Doppler and propagation parameters describing elevated end-diastolic pressure differed between groups with various outcomes in multivariate analysis, only enlarged left atrium was an independent predictor for both combined end point and cardiac death. Further 3-year follow-up solely confirmed the role of above described predictors. [ABSTRACT FROM AUTHOR]

Background: We assessed the changes of mitral inflow during Valsalva maneuver (VM) in patients with different stages of left ventricular dysfunction and evaluated their value for the differentiation between normal and pseudonormal filling pattern. Methods: A total of 190 patients (120 with coronary artery disease, and 70 healthy subjects) were examined by transthoracic echocardiography. Mitral E/A ratio, early wave deceleration time (Edt), and pulmonary vein flow (especially atrial reversal parameters (Ar)), were used for the initial stratification to normal, delayed relaxation, pseudonormal, and restrictive profiles. Changes of mitral inflow during VM were compared between 54 normal (N) and 15 pseudonormal (PN). Results: During VM, a similar decrease in early wave peak velocity (–30 ± 18 vs –35 ± 17 cm/sec), peak velocity of atrial wave (–6 ± 16 vs –8 ± 17 cm/sec), and E/A ratio (–0.4 ± 0.4 vs –0.4 ± 0.4) was observed in both groups. Only two filling variables, related to atrial phase of inflow, changed in the opposite direction. In normal pattern, the duration and velocity-time integral of atrial wave diminished during VM as opposed to pseudonormal subjects (ΔAt –7 ± 39 vs 20 ± 44 msec; P < 0.05 and ΔA vti –0.7± 1.8 vs 0.4± 2 cm; P < 0.05). Increase in peak atrial velocity and marked decrease in E/A ratio during VM were specific for the restrictive group. Conclusions: Changes of mitral inflow during VM have a moderate diagnostic value for the differentiation of normal and pseudonormal pattern. Increased duration of atrial phase but not increase in atrial velocity allowed the diagnosis of pseudonormalization. [ABSTRACT FROM AUTHOR]

Objective: The evaluation of diagnostic value of pulsed tissue Doppler (TD) parameters (calculated from six points of mitral annulus and separately measured in the lateral part of mitral annulus) for the detection of pseudonormal mitral inflow pattern. Methods and Results: Among 200 persons examined by transthoracic echocardiography group with E/A value between 1 and 2 was selected and divided to normal (54 subjects, early wave deceleration time, Edt ≥ 150 msec) and pseudonormal (23 patients, Edt < 150 msec together with prolonged difference between duration of atrial reversal flow in pulmonary vein and mitral flow in atrial phase, delta Ar ≥ 20 msec) inflow. Wide spectrum of TD parameters was compared between the selected groups. In normal inflow, average peak velocities of early and atrial phase of diastolic mitral annulus motion were significantly higher: 11.0 ± 2.6 versus 8.9 ± 3.5 cm/sec; (P = 0.005) and 12.0 ± 2.2 versus 10.0 ± 3.0 cm/sec; (P = 0,002), respectively. Ratio of peak early mitral wave velocity to peak velocity of annulus motion in early phase (Ev/E'v avr) was higher in the pseudonormal pattern: 9.8 ± 3.7 versus 7.0 ± 2.0, respectively (P < 0.001). For the value of Ev/E'v avr > 10.2, 70% accuracy for the diagnosis of pseudonormalization was detected. For the parameters measured in the lateral part of mitral annulus similar relationships in the early filling phase were detected but did not reach statistical significance in the atrial phase. Conclusions: Pulsed TD offers good accuracy for the diagnosis of pseudonormalization with increased ratio of peak early mitral wave velocity to peak velocity of mitral annulus being the optimal predictor of advanced diastolic dysfunction. [ABSTRACT FROM AUTHOR]

The article presents information on the case of a 17-year-old woman with mitral valve prolapse who was admitted to the Department of Cardiology because of syncope during exercise preceded by severe chest pain. Medical history of the patient is presented. The result of the echocardiogram is revealed. The outcome of surgical angioplasty of left coronary ostium undergone by the patient is discussed.

It is known that both psoriasis (PSO) limited to the skin and psoriatic arthritis (PSA) increase the risk of cardiovascular complications and atherosclerosis progression by inducing systemic inflammatory response. In recent decades, the introduction of biological medications directed initially against TNF-α and, later, different targets in the inflammatory cascade brought a significant breakthrough in the efficacy of PSO/PSA treatment. In this review, we present and discuss the most recent findings related to the interplay between the genetics and immunology mechanisms involved in PSO and PSA, atherosclerosis and the development of cardiac dysfunction, as well as the current PSO/PSA treatment in view of cardiovascular safety and prognosis. [ABSTRACT FROM AUTHOR]

Ensuring safety of young athletes and employees who perform hard physical work within the scope of their professional duties, with a special focus on prevention of a sudden cardiac death at sports fields or during hard physical work is one of the most important tasks, which demands joint effort of cardiologists and sport physicians or occupational physicians, who qualify patients for a job or a sport discipline. Apart from hypertrophic and arhythmogenic right ventricular cardiomyopathy, coronary anomalies and aortic dissection belong to the most frequent causes of dramatic complications during competitive exercise or work with an increased energy expenditure. Although a detailed medical history and a physical examination combined with 12-lead ECG assessment may significantly improve the safety in competitive sports, adding echocardiography examination gives a detailed and noninvasive insight into the heart morphology and function. Therefore, in our opinion, it should constitute a standard part of the evaluation of candidates for competitive sports. The practice indicates that beyond subjects with severe heart diseases and those classified as normal, there is a group of individuals with abnormalities which should be more closely monitored, but are not contraindications against professional sports or work with an increased energy expenditure. We describe the case of a young female with a diagnosis of rare congenital aortic valve disease, quadricuspid valve, with mild regurgitation and atrial septal aneurysm which was established during transthoracic echocardiography and confirmed and expanded during TEE examination. [ABSTRACT FROM AUTHOR]

Simultaneously with the development of echocardiography its potential in the assessment of coronary arteries increases. We reported previously that the anomalous circumflex (Cx) originating from right coronary artery (RCA) with retroaortic course may be observed in transesophageal examination (TEE) as vessel cross section in the mitroaortic angle—”bleb sign” or visualized in modified apical four‐chamber view behind left atrium during transthoracic study (TTE). In present case, we propose novel finding indicating on this anomaly in apical five‐chamber view in TTE forming “crossed aorta” sign. Additionally, the presence of stents in Cx enhanced echocardiographic presentation of anomalous artery course. [ABSTRACT FROM AUTHOR]

An origin of the circumflex coronary artery (Cx) from the right coronary artery or right Valsalva sinus is usually clinically silent coronary anomaly. Nevertheless, retroaortic course of aberrant Cx involving mitro‐aortic continuity may become significant in the setting of mitral or aortic valve intervention, leading to compression of Cx and ischemic complication. For that reason, the early and accurate recognition of this anomaly is important and should be considered also during echocardiography. We described a man with severe mitral valve stenosis and anomalous Cx found during TEE on the base of detected “bleb sign” and retroaortic course of the artery. [ABSTRACT FROM AUTHOR]

We present the images of giant aneurysm of Valsalva sinus (SVA) in 79‐year‐old woman that was not diagnosed in first transthoracic echocardiographic study, because of problematic presentation suggesting defect of aortic wall or additional structure inside right ventricle. Although the majority of aneurysm of Valsalva sinuses are diagnosed by echocardiography, our case illustrates diagnostic doubts evoked by big aneurysm which seemed to fill completely right ventricular cavity. Nevertheless, repeated detailed examination with support of 3D technique and verification by computed tomography elucidated the correct diagnosis. On grounds of high surgical risk, the patient was classified for treatment with losartan and echocardiographic monitoring. [ABSTRACT FROM AUTHOR]

Background: Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS) but sometimes occult at rest and elicited by stress. Aim: This study sought to assess LA volume and function at rest and during stress across the spectrum of AF. Methods: In a prospective, multicenter, observational study design, we enrolled 3042 patients [age = 64 ± 12; 63.8% male] with known or suspected CCS: 2749 were in sinus rhythm (SR, Group 1); 191 in SR with a history of paroxysmal AF (Group 2); and 102 were in permanent AF (Group 3). All patients underwent stress echocardiography (SE). We measured left atrial volume index (LAVI) in all patients and LA Strain reservoir phase (LASr) in a subset of 486 patients. Results: LAVI increased from Group 1 to 3, both at rest (Group 1 = 27.6 ± 12.2, Group 2 = 31.6 ± 12.9, Group 3 = 43.3 ± 19.7 mL/m2, p < 0.001) and at peak stress (Group 1 = 26.2 ± 12.0, Group 2 = 31.2 ± 12.2, Group 3 = 43.9 ± 19.4 mL/m2, p < 0.001). LASr progressively decreased from Group 1 to 3, both at rest (Group 1 = 26.0 ± 8.5%, Group 2 = 23.2 ± 11.2%, Group 3 = 8.5 ± 6.5%, p < 0.001) and at peak stress (Group 1 = 26.9 ± 10.1, Group 2 = 23.8 ± 11.0 Group 3 = 10.7 ± 8.1%, p < 0.001). Stress B-lines (≥2) were more frequent in AF (Group 1 = 29.7% vs. Group 2 = 35.5% vs. Group 3 = 57.4%, p < 0.001). Inducible ischemia was less frequent in SR (Group 1 = 16.1% vs. Group 2 = 24.7% vs. Group 3 = 24.5%, p = 0.001). Conclusions: In CCS, rest and stress LA dilation and reservoir dysfunction are often present in paroxysmal and, more so, in permanent AF and are associated with more frequent inducible ischemia and pulmonary congestion during stress. [ABSTRACT FROM AUTHOR]

We sought to investigate aortic stenosis (AS) progression rate (pr) with the comparison between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) morphology. We compared ASpr in patients with BAV and TAV examined by transthoracic echocardiography (TTE) in the years 2004–2019. Data from 363 TTEs in 161 AS patients (median age 70 [61–77] years; 63% men; 25% with BAV; 20% with severe AS) performed at different time points (median time interval 10 months) was analyzed. We assessed changes of AS severity with peak velocity through aortic valve (Vmax), mean/peak pressure gradients (MG/PG), aortic valve area by planimetry and continuity equation (AVAce). We compared pr (defined as parameter change per year) between the BAV and the TAV groups. BAV patients showed faster ASpr with odds ratio 3.467 and 95% confidence intervals 1.36 to 8.86, moreover, expressed as a quicker AVAce decrease 0 (−0.4-0.0) in the BAV vs. 0 (−0.15 – 0.0) cm2/year in the TAV group, p ​= ​0.02. Furthermore, in BAV, female sex was associated with lower ASpr (p ​= ​0.01), and in the whole group a larger aortic diameter was a predictor of faster progression (p ​< ​0.001). The ASpr, expressed as a decrease in the AVAce, was faster in BAV. Moreover, ASpr depends on both: valve morphology being faster in BAV and Vmax increase. Furthermore, the female sex was related to slower pace of AVA reduction in BAV subgroup whereas the larger baseline aortic diameter associated to faster AS progression in the whole studied group. [ABSTRACT FROM AUTHOR]

Background and objectives: Some experimental studies demonstrated adverse modulation of atherothrombosis by interleukin-1beta (IL-1b). To assess the relationship between the five most common variants of three polymorphisms of the IL1b gene cluster and the complexity of coronary atherosclerosis expressed in Gensini Score (GS), and the age of onset of the first acute coronary syndrome (ACS), we assessed the patients (pts) hospitalized due to ACS in this aspect. Materials and Methods: 250 individuals were included. The single nucleotide polymorphisms of IL1b gene: transition T/C at -31 position, C/T at -511, and those of IL1 receptor antagonist gene (IL1RN)—variable number of tandem repeats allele 1, 2, 3, or 4—were determined by PCR. GS was calculated from the coronary angiogram performed at the index ACS. The impact of the presence of T or C and allele 1 to 4 at the investigated loci on the mean GS, GS greater than 40, mean age of onset of ACS, and the fraction of pts over 60 years of age at ACS were compared between the five most common genotype variants. Results: The five most common variants were present in 203 pts (81.2%). Patients with pair 22 in ILRN had the lowest rate and those with pair 12 had the highest rate of ACS before 60 years of age (29.4 vs. 67.8%; p = 0.004). GS > 40 entailed an eight-fold increase of risk, as observed when pts with one T allele at locus -31 were compared with carriers of 2 or no T allele at this locus: OR 8.73 [CI95 4.26–70.99] p = 0.04. Conclusion: Interleukin-1 beta is subject to frequent genetic variability and our results show a potential relationship of this polymorphism with the extent of coronary atherosclerosis and age at the first ACS. [ABSTRACT FROM AUTHOR]

For the past 40 years, the methodology for stress echocardiography (SE) has remained basically unchanged. It is based on two-dimensional, black and white imaging, and is used to detect regional wall motion abnormalities (RWMA) in patients with known or suspected coronary artery disease (CAD). In the last five years much has changed and RWMA is not enough on its own to stratify patient risk and dictate therapy. Patients arriving at SE labs often have comorbidities and are undergoing full anti-ischemic therapy. The SE positivity rate based on RWMA fell from 70% in the eighties to 10% in the last decade. The understanding of CAD pathophysiology has shifted from a regional hydraulic disease to a systemic biologic disease. The conventional view of CAD encouraged the use of coronary anatomic imaging for diagnosis and the oculo-stenotic reflex for the deployment of therapy. This has led to a clinical oversimplification that ignores the lessons of pathophysiology and epidemiology, and in fact, CAD is not synonymous with ischemic heart disease. Patients with CAD may also have other vulnerabilities such as coronary plaque (step A of ABCDE-SE), alveolar-capillary membrane and pulmonary congestion (step B), preload and contractile reserve (step C), coronary microcirculation (step D) and cardiac autonomic balance (step E). The SE methodology based on two-dimensional echocardiography is now integrated with lung ultrasound (step B for B-lines), volumetric echocardiography (step C), color- and pulsed-wave Doppler (step D) and non-imaging electrocardiogram-based heart rate assessment (step E). In addition, qualitative assessment based on the naked eye has now become more quantitative, has been improved by contrast and based on cardiac strain and artificial intelligence. ABCDE-SE is now ready for large scale multicenter testing in the SE2030 study. [ABSTRACT FROM AUTHOR]

Background: The assessment of coronary flow velocity reserve (CFVR) in left anterior descending coronary artery (LAD) expands the risk stratification potential of stress echocardiography (SE) based on stress-induced regional wall motion abnormalities (RWMA).Objectives: The purpose of this study was to assess the feasibility and functional correlates of CFVR.Methods: This prospective, observational, multicenter study initially screened 3,410 patients (2,061 [60%] male; age 63 ± 11 years; ejection fraction 61 ± 9%) with known or suspected coronary artery disease and/or heart failure. All patients underwent SE (exercise, n = 1,288; vasodilator, n = 1,860; dobutamine, n = 262) based on new or worsening RWMA in 20 accredited laboratories of 8 countries. CFVR was calculated as the stress/rest ratio of diastolic peak flow velocity pulsed-Doppler assessment of LAD flow. A subset of 1,867 patients was followed up.Results: The success rate for CFVR on LAD was 3,002 of 3,410 (feasibility = 88%). Reduced (≤2.0) CFVR was found in 896 of 3,002 (30%) patients. At multivariable logistic regression analysis, inducible RWMA (odds ratio [OR]: 6.5; 95% confidence interval [CI]: 4.9 to 8.5; p < 0.01), abnormal left ventricular contractile reserve (OR: 3.4; 95% CI: 2.7 to 4.2; p < 0.01), and B-lines (OR: 1.5; 95% CI: 1.1 to 1.9; p = 0.01) were associated with reduced CFVR. During a median follow-up time of 16 months, 218 events occurred. RWMA (hazard ratio: 3.8; 95% CI: 2.3 to 6.3; p < 0.001) and reduced CFVR (hazard ratio: 1.5; 95% CI: 1.1 to 2.2; p = 0.009) were independently associated with adverse outcome.Conclusions: CFVR is feasible with all SE protocols. Reduced CFVR is often accompanied by RWMA, abnormal LVCR, and pulmonary congestion during stress, and shows independent value over RWMA in predicting an adverse outcome. [ABSTRACT FROM AUTHOR]

Background: The detection of regional wall motion abnormalities is the cornerstone of stress echocardiography. Today, stress echo shows increasing trends of utilization due to growing concerns for radiation risk, higher cost and stronger environmental impact of competing techniques. However, it has also limitations: underused ability to identify factors of clinical vulnerability outside coronary artery stenosis; operator-dependence; low positivity rate in contemporary populations; intermediate risk associated with a negative test; limited value of wall motion beyond coronary artery disease. Nevertheless, stress echo has potential to adapt to a changing environment and overcome its current limitations.Integrated-quadruple Stress-echo: Four parameters now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-stress echo. They are: 1- regional wall motion abnormalities; 2-B-lines measured by lung ultrasound; 3-left ventricular contractile reserve assessed as the stress/rest ratio of force (systolic arterial pressure by cuff sphygmomanometer/end-systolic volume from 2D); 4- coronary flow velocity reserve on left anterior descending coronary artery (with color-Doppler guided pulsed wave Doppler). IQ-Stress echo allows a synoptic functional assessment of epicardial coronary artery stenosis (wall motion), lung water (B-lines), myocardial function (left ventricular contractile reserve) and coronary small vessels (coronary flow velocity reserve in mid or distal left anterior descending artery). In "ABCD" protocol, A stands for Asynergy (ischemic vs non-ischemic heart); B for B-lines (wet vs dry lung); C for Contractile reserve (weak vs strong heart); D for Doppler flowmetry (warm vs cold heart, since the hyperemic blood flow increases the local temperature of the myocardium). From the technical (acquisition/analysis) viewpoint and required training, B-lines are the kindergarten, left ventricular contractile reserve the primary (for acquisition) and secondary (for analysis) school, wall motion the university, and coronary flow velocity reserve the PhD program of stress echo.Conclusion: Stress echo is changing. As an old landline telephone with only one function, yesterday stress echo used one sign (regional wall motion abnormalities) for one patient with coronary artery disease. As a versatile smart-phone with multiple applications, stress echo today uses many signs for different pathophysiological and clinical targets. Large scale effectiveness studies are now in progress in the Stress Echo2020 project with the omnivorous "ABCD" protocol. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the impact of the 2 most common bicuspid aortic valve (BAV) morphology patterns [right‐left (RL) vs right‐noncoronary (RN) cusp fusion] on the aortic diameters and the impact of gender, aortic stenosis (AS), aortic regurgitation (AR), and age on the observed effects. Methods: The PubMed databases was searched up to December 31, 2016 to identify studies investigating the morphology of BAV and aortic diameters. Inclusion criteria were as follows: the data on diameter of sinuses of Valsalva (SVD) and/or ascending aorta (AAD) and BAV morphology. The additional characteristics [gender, AS and AR (% of patients with moderate or severe AS/AR) and mean age] were collected to perform a meta‐regression analysis. Results: A total of 12 studies with 2192 patients with indexed AAD, 15 studies with 3104 patients with nonindexed AAD and 8 studies with 1271 patients with indexed SVD, and 16 studies with 3454 patients with nonindexed SVD were included. There was no difference between RL and RN group in indexed/nonindexed AAD—mean difference (MD): 0.06 mm/m2 (95% CI: −0.65 to 0.77 mm/m2, P = .87) and −0.06 mm (95% CI: 1.10–0.97 mm, P = .91). Differently, the RL BAV was associated with larger indexed/nonindexed SVD than RN phenotype—MD: 1.66 mm/m2 (95% CI: 0.83–2.49 mm/m2, P < .001) and 2.03 mm (95% CI: 0.97–3.09 mm, P < .001). Age, gender, AS, and AR had no influence on observed differences. Conclusions: RL BAV phenotype is associated with larger SVD than RN BAV, and the observed differences are independent from aortic valve dysfunction degree, age, and gender. [ABSTRACT FROM AUTHOR]

Takotsubo cardiomiopathy (TTC) (known also as "ampulla cardiomyopathy," "apical ballooning" or "broken heart syndrome") is connected with a temporary systolic left ventricular dysfunction without the culprit coronary lesion. Takotsubo cardiomyopathy was first described in 1990 in Japan after octopus trapping pot with a round bottom and narrow neck similar in shape to left ventriculogram in TTC patients. The occurrence of TTC is usually precipitated by a stressful event with a clinical presentation mimicking myocardial infarction: chest pain, ST-T segment elevation or T-wave inversion, a rise in cardiac troponin, and contractility abnormalities in echocardiography. A left ventricular dysfunction is transient and improves within a few weeks. Takotsubo cardiomyopathy typically occurs in postmenopausal women and the postulated mechanism is catecholamine overstimulation. Moreover, the distribution of contractility impairments usually does not correspond with typical region supplied by a single coronary artery. Therefore, the assessment of regional pattern of systolic dysfunction with speckle-tracking echocardiography and automated function imaging (AFI) technique may be important in diagnosis of TTC and may improve our insight into its patophysiology. We described a 55-year-old female teacher with TTC diagnosed after acute psychological stress in workplace. The provoking factor related with occupational stress and pattern of contraction abnormalities documented with AFI technique including basal segments of left ventricle make this case atypical. [ABSTRACT FROM AUTHOR]

Takotsubo cardiomiopathy (TTC) (known also as "ampulla cardiomyopathy," "apical ballooning" or "broken heart syndrome") is connected with a temporary systolic left ventricular dysfunction without the culprit coronary lesion. Takotsubo cardiomyopathy was first described in 1990 in Japan after octopus trapping pot with a round bottom and narrow neck similar in shape to left ventriculogram in TTC patients. The occurrence of TTC is usually precipitated by a stressful event with a clinical presentation mimicking myocardial infarction: chest pain, ST-T segment elevation or T-wave inversion, a rise in cardiac troponin, and contractility abnormalities in echocardiography. A left ventricular dysfunction is transient and improves within a few weeks. Takotsubo cardiomyopathy typically occurs in postmenopausal women and the postulated mechanism is catecholamine overstimulation. Moreover, the distribution of contractility impairments usually does not correspond with typical region supplied by a single coronary artery. Therefore, the assessment of regional pattern of systolic dysfunction with speckle-tracking echocardiography and automated function imaging (AFI) technique may be important in diagnosis of TTC and may improve our insight into its patophysiology. We described a 55-year-old female teacher with TTC diagnosed after acute psychological stress in workplace. The provoking factor related with occupational stress and pattern of contraction abnormalities documented with AFI technique including basal segments of left ventricle make this case atypical. [ABSTRACT FROM AUTHOR]

Toxic myocardial injury can be misdiagnosed as a myocardial infarction, resulting in the patient undergoing standard treatment for cardiac rehabilitation. However, such inadequate therapeutic strategies can lead to cardiovascular complications including dilated cardiomyopathy. This study presents a case of a 65-year-old man after accidental ingestion of organic solvents (toluene and xylene), whose condition demonstrated all the criteria for diagnosis of myocardial infarction. The qualitative determinations of the above mentioned volatile organic compounds (VOCs) in whole blood were carried out using a headspace sampling by means of gas chromatography. Cardiac catheterization revealed no specific coronary lesions, only a muscular bridge causing a 30-50% stenosis in the middle of the circumflex branch of the left coronary artery. [ABSTRACT FROM AUTHOR]

Background: In patients with Ischemia and non-obstructive coronary artery stenosis (INOCA) wall motion is rarely abnormal during stress echocardiography (SE). Our aim was to determine if patients with INOCA and reduced coronary flow velocity reserve (CVFR) have altered cardiac mechanics using two-dimensional speckle-tracking echocardiography (2DSTE) during SE. Methods: In a prospective, multicenter, international study, we recruited 135 patients with INOCA. Overall, we performed high dose (0.84 mg/kg) dipyridamole SE with combined assessment of CVFR and 2DSTE. The population was divided in patients with normal CVFR (>2, group 1, n = 95) and abnormal CVFR (≤2, group 2, n = 35). Clinical and 2DSTE parameters were compared between groups. Results: Feasibility was high for CFVR (98%) and 2DSTE (97%). A total of 130 patients (mean age 63 ± 12 years, 67 women) had complete flow and strain data. The two groups showed similar 2DSTE values at rest. At peak SE, Group 1 patients showed lower global longitudinal strain (p < 0.007), higher mechanical dispersion (p < 0.0005), lower endocardial (p < 0.001), and epicardial (p < 0.0002) layer specific strain. Conclusions: In patients with INOCA, vasodilator SE with simultaneous assessment of CFVR and strain is highly feasible. Coronary microvascular dysfunction is accompanied by an impairment of global and layer-specific deformation indices during stress. [ABSTRACT FROM AUTHOR]

To investigate the effect of intracoronary injection of autologous mononuclear bone marrow stem cells (BMSCs) in patients with ST-elevation myocardial infarction (STEMI) on left ventricular (LV) systolic and diastolic function using standard echocardiography and 2-dimensional systolic strain. A total of 60 patients with first anterior wall STEMI and LV ejection fraction of <40%, treated with successful primary percutaneous coronary intervention were randomly assigned to the treatment group (BMSC group) or the control group in a 2:1 ratio. Transcatheter intracoronary injection of BMSCs into the infarct-related artery was performed 7 days after STEMI. Standard echocardiography and speckle tracking analysis was performed at baseline and 6 months after STEMI. No differences were found in the baseline echocardiographic parameters of LV systolic and diastolic dysfunction—the LV ejection fraction was 35 ± 6% in the BMSC group, similar to that in the control group (33 ± 7%, p = 0.42). After 6 months, the absolute change in the LV ejection fraction was significantly greater in the BMSC group than in the control group (10 ± 9% versus 5 ± 8%, p = 0.04). Significant improvement was seen in 2-dimensional systolic strain in all segments (12 ± 4 vs 14 ± 4; p = 0.0009) and in the infarcted area (5 ± 2 vs 6 ± 2; p = 0.0038) only in the BMSC group. Of the diastolic function parameters, we observed improvement in the early filling propagation velocity (30 ± 8 cm/s vs 37 ± 13 cm/s; p = 0.0008), early diastolic velocity − E′ (4.5 ± 1.5 vs 5.0 ± 1.3, p = 0.02), and the E/E′ ratio (17 ± 7 vs 14 ± 5; p = 0.03) in the BMSC group. In conclusion, intracoronary injection of unselected BMSCs in patients with STEMI improved both LV systolic and diastolic function at 6 months of follow-up. [Copyright &y& Elsevier]

Background. Systemic arterial hypertension (HTN) is the main risk factor for the development of heart failure with preserved ejection fraction (HFpEF). The aim of the study was was to assess the trends in PASP, E/E' and TAPSE during exercise Doppler echocardiography (EDE) in hypertensive (HTN) patients vs. healthy subjects stratified by age. Methods. EDE was performed in 155 hypertensive patients and in 145 healthy subjects (mean age 62 ± 12.0 vs. 54 ± 14.9 years respectively, p < 0.0001). EDE was undertaken on a semi-recumbent cycle ergometer with load increasing by 25 watts every 2 min. Left ventricular (LV) and right ventricular (RV) dimensions, function and hemodynamics were evaluated. Results. Echo-Doppler parameters of LV and RV function were lower, both at rest and at peak exercise in hypertensives, while pulmonary hemodynamics were higher as compared to healthy subjects. The entire cohort was then divided into tertiles of age: at rest, no significant differences were recorded for each age group between hypertensives and normotensives except for E/E' that was higher in hypertensives. At peak exercise, hypertensives had higher pulmonary artery systolic pressure (PASP) and E/E' but lower tricuspid annular plane systolic excursion (TAPSE) as age increased, compared to normotensives. Differences in E/E' and TAPSE between the 2 groups at peak exercise were explained by the interaction between HTN and age even after adjustment for baseline values (p < 0.001 for E/E', p = 0.011 for TAPSE). At peak exercise, the oldest group of hypertensive patients had a mean E/E' of 13.0, suggesting a significant increase in LV diastolic pressure combined with increased PASP. Conclusion. Age and HTN have a synergic negative effect on E/E' and TAPSE at peak exercise in hypertensive subjects. [ABSTRACT FROM AUTHOR]

Background: Left ventricular contractile reserve (LVCR), coronary flow velocity reserve (CFVR), and heart rate reserve (HRR) affect outcome in heart failure (HF). They can be simultaneously measured during dipyridamole stress echocardiography (DSE). Aim: To assess the value of comprehensive DSE in patients with non-ischemic HF. Methods: We evaluated 610 patients with HF, no history of coronary artery disease, and no inducible regional wall motion abnormalities: 270 patients with preserved ejection fraction (≥50%), 146 patients with mid-range ejection fraction (40–49%), and 194 patients with reduced ejection fraction (<40%). All underwent DSE (0.84 mg/kg in 6′) in 7 accredited laboratories. We measured LVCR (abnormal value ≤ 1.1), CFVR in left anterior descending artery (abnormal value: ≤2.0), and HRR (peak/rest heart rate; abnormal value: ≤1.22). All patients were followed up. Results: Abnormal CFVR, LVCR, and HRR occurred in 29%, 45%, and 47% of patients, respectively (p < 0.001). After a median follow-up time of 20 months (interquartile range: 12–32 months), 113 hard events occurred in 105 patients with 41 deaths, 8 myocardial infarctions, 61 admissions for acute HF, and 3 strokes. The annual mortality rates were 0.8% in 200 patients with none abnormal criteria, 1.8% in 184 patients with 1 abnormal criterion, 7.1% in 130 patients with 2 abnormal criteria, 7.5% in 96 patients with 3 abnormal criteria. Conclusions: Abnormal LVCR, CFVR, and HRR were frequent during DSE in non-ischemic HF patients. They target different pathophysiological vulnerabilities (myocardial function, coronary microcirculation, and cardiac autonomic balance) and are useful for outcome prediction. [ABSTRACT FROM AUTHOR]

Introduction: Some studies reported utility of microRNAs in myocardial infarction diagnostic process, whereas their prognostic remains unclear. Hypothesis: We aimed to evaluate the prognostic value of five circulating miRs (miR-1, miR-21, miR-133a, miR-208, miR-499) levels for predicting major adverse cardiac events (MACE), including death, nonfatal myocardial infarction (MI) or cardiovascular rehospitalization (reh.) in patients with NSTE-ACS. Methods: In our prospective, single-center observational study we recruited patients (pts) with NSTE-ACS with symptoms onset <24 hours before the hospital admission and age, gender-matched patients with stable coronary artery disease (SCAD) as controls. Blood was sampled twice (at admission and 4 h after in NSTE-ACS and once in SCAD). Relative expression of miRs were calculated using the ΔΔCt method after normalization to the cel-miR-39 spiked-in control. The mean value of miRs relative expression from two time samples in NSTE-ACS pts were used for further analysis. Subjects were categorized according to mean miRs expression at hospital admission into two group (≤ or >median level of miRs). Results: 103 NSTE-ACS pts (median age 67 years, 68% male) were included in this study. During median 1432 (IQR 961 - 1544) days of follow-up the primary endpoint (MACE) occurred in 66 (64.1%) pts: 16 pts (15.5%) died, 28 pts (27.2%) presented with MI and 60 pts (58.3%) were readmitted. In a Cox proportional-hazards regression model miR-499 expression>median level (HR=2.01, 95% CI 1.23 - 3.29) and body mass index (HR=1.07, 95% CI 1.01 - 1.13) were independent predictors of MACE in long term observation, even after adjustment for other covariates (including other miRNAs and high sensitivity cardiac troponins levels). Incidence of MI [44.4 vs 15.4%, HR=3.8 (1.8 - 8.2)], rehospitalization for cardiovascular reasons [71.1% vs 51.9%, HR=2.0 (1.2 - 3.4)] and MACE [80% vs 55.8%, HR=2.1 (1.3 - 3.5)] was significantly higher in pts with elevated (>median) miR-499 levels at hospital admission. None of analyzed miRNAs was related to long-term mortality, whereas the left ventricular ejection fraction (EF) has been identified as the only one survival predictor (HR=0.95, 95% CI 0.92 - 0.98). Conclusions: Elevated miR-499 levels in early phase of NSTE-ACS are related to increased rate of MACE in 4-year follow-up. [ABSTRACT FROM AUTHOR]