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Background: Use of echocardiography (echo) has exponentially increased in recent decades. Concerned about this scientific society developed appropriate use criteria (AUC). Clinical management still suffers geographical variations, and no objective data are available about echo AUC in developing countries. We aimed to evaluate (1) the appropriateness of referrals and (2) their relation to changes in clinical decision management., Methods: Prospective analysis of referrals from January to December 2014. Appropriateness and endpoints analyzed in different time points from medical archives., Endpoints: (1) change in the diagnosis, (2) indication for another method to complete the diagnosis, (3) change in clinical treatment, (4) indication for a treatment intervention, or (5) no change in management. Descriptive statistical analysis, Fisher's or chi-square tests, and Cox regression used as appropriate (significance if P < .05)., Results: One thousand one hundred referrals were analyzed (55.5 ± 16.1 years, 44.6% male). 80.5% of referrals were appropriate (A), 11.2% "Rarely Appropriate" (RA), and 8.3% "May Be Appropriate" (MBA). Proportion of (A) did not differ between modalities (TTE-80.5% vs TEE-87.7% vs STR-81.2%, P = .67). (A) referrals were more related to clinical decision than (RA)+(MBA) (38.9% [A] vs 15% [RA]+[MBA], P < .001). The most frequent clinical indications of (RA) and (MBA) TTE were reevaluation of ventricular function without clinical change (AUC 10 and 11) and search of infectious endocarditis when low clinical probability (53)., Conclusions: In a developing country, appropriateness of echo was similar to the United States and Europe. However, a significant proportion of referrals were still (RA) or (MBA), with no effect in clinical management. Controlling referrals 10, 11, and 53 can optimize echo use in developing countries., (© 2017 Wiley Periodicals, Inc.)

Endomyocardial fibrosis, which is a cause of restrictive cardiomyopathy, is characterized by the deposition of fibrous tissue in the apical region of 1 or both ventricles. The condition not only affects the diastolic dynamics of the ventricles, but also the function of the atrioventricular valves. The disease occurs predominantly in tropical regions worldwide and in sub-Saharan Africa. This condition is not well understood, with varied manifestations, from subclinical presentations to chronic and progressive edematous syndromes. Here, we present the challenging case of a patient with an indeterminate echocardiographic image, suggesting apical hypertrophy, plus severe aortic stenosis and fibrosis of the left ventricular outflow tract. An electrocardiogram revealed symmetrical T-wave inversion, which is a characteristic manifestation of apical hypertrophy. The importance of cardiac imaging examinations such as echocardiography and cardiac magnetic resonance for differentiating between endomyocardial fibrosis and apical hypertrophy is highlighted in this patient's case., (© 2016, Wiley Periodicals, Inc.)

Background: Although the influence of respiration on ventricular filling, as evaluated by Doppler technique, and the evaluation of diastolic velocities of mitral valve annulus (MVA), as measured by Doppler tissue imaging (DTI), can provide valuable information for the study of left ventricular (LV) diastolic function, the concomitant effects of aging, tidal volume (TV), and respiratory rate (RR) on these velocities have not been quantitatively investigated., Methods: We evaluated 12 normal male volunteers (Group I) aged 20-26 years (mean: 22.8) and 8 normal subjects aged 41 to 54 years old (mean: 45.9) (Group II). Using DTI we measured peak early (E(a)) and late (A(a)) velocities of longitudinal axis expansion at lateral and medial MVA. Doppler mitral and tricuspid flow velocities were measured: peak early (E) and late (A) inflow velocity, early (E(i)) and late (A(i)) flow integral, and deceleration time of peak early mitral flow velocity (DT). Respiratory cycles were simultaneously recorded at RR of 9, 12, 15, and 18 cycles/min and TV of 600 and 900 mL during respiration (RESP)., Results and Conclusions: (1) E, A, and A(i) in MV had negligible change during respiration, but E(i) was significantly reduced during inspiration; (2) DT reduced slightly with inspiration, but the change was significant only with TV of 900 mL; (3) an important increase of E in right ventricular flow was observed during inspiration; (4) variations of RR and TV did not significantly influence right and left ventricular inflow in normal subjects, in the conditions of this investigation; (5) a significant increase of E(a) at medial MVA was documented during inspiration only in young subjects; (6) a significant decrease of A(a) at medial MVA was observed during inspiration in both groups of volunteers; (7) RR and TV did not influence MVA velocities in young and adult subjects; (8) a consistent reduction in E(a) and a significant increase in A(a) were observed with increasing age; (9) these changes were more conspicuous and consistent than those documented in ventricular filling when young and middle-age men are compared, suggesting that the DTI is more sensitive to detect changes in diastolic function; and (10) in addition, these data suggest that, for evaluation of diastolic function, in clinical context, it is not necessary to control rigorously RR or TV.

Transient increase in diastolic wall thickness (pseudohypertrophy) during pacing stress echocardiography has been reported in normal myocardium. To evaluate the occurrence of pseudohypertrophy and to investigate the contribution of myocardial ischemia on its production during pacing and dobutamine stress echocardiography, we produced a physiologically significant coronary stenosis in 14 open chest dogs. The stenosis in the circumflex artery was measured by quantitative coronary angiography (range: 50% to 89% reduction in luminal diameter), and no resting segmental wall-motion abnormalities were observed by epicardial echocardiography (short-axis, papillary level). In each study, dobutamine (5-40 microg/kg/min) and pacing (up to 260 beats/min) were performed randomly. Positivity of stress echocardiography tests was quantitatively determined by a significant (P < 0.05) reduction or failure to increase in absolute and percent systolic wall thickening in the myocardial area supplied by the stenotic artery as compared to the left anterior descending (LAD) artery-related areas. Diastolic wall thickness and left ventricular diastolic area were compared before and after each stress test in the circumflex and LAD artery-related regions. Pseudohypertrophy was observed in 57% and 86% of dogs for pacing and dobutamine, respectively, in the circumflex region, and in 50% and 64% in the LAD region. Despite its increased incidence in the circumflex region, the augmented diastolic wall thickness did not correlate with coronary stenosis severity or stress test positivity, but correlated inversely with changes in left ventricular diastolic area. In addition, it correlated directly with changes in heart rate only for pacing. In conclusion, pseudohypertrophy was a frequent finding during pacing and dobutamine stress echocardiography tests but was not related to myocardial ischemia in this animal model.