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Background. Speckle tracking echocardiography (STE) provides valuable information about global and regional myocardial function. STE during dobutamine stress-echocardiography (DSE) enables more reliable ischemia diagnosis. The aim of the study was to evaluate STE feasibility as a DSE visualization method and its accuracy compared to coronary angiography (CAG) in the patients with moderate-to-high coronary arteries disease (CAD) risk. Methods. We prospectively examined 140 patients (84 [60.0%] men and 56 [40.0%] women) with suspected CAD in order to verify diagnosis and evaluate myocardial viability and coronary reserve. Results. Mean left ventricular ejection fraction (LVEF) was 54.4±15.8%. All the patients had normal blood pressure (BP) and heart rate (HR) during the test. There were no significant hemodynamics alterations during the test. There were no significant complications during DSE with only 15 (12.9%) cases of different relatively low grade supraventricular and ventricular arrhythmia, mainly transitory without interventions. There were 116 (82.9%) positive DSE results, of which 2 (1.72%) were false-positive. In 2 (8.3%) patients with negative DSE results, CAG revealed 1-vessel insignificant (50– 70%) lesions with developed collaterals (false-negative results). According to DSE and CAG results, 96 (82.3%) patients underwent revascularization interventions: 86 (89.6%) percutaneous coronary interventions (PCIs) and 10 (10.4%) coronary artery bypass grafting (CABG) surgery. Sensitivity and specificity of DSE with STE for primary CAD diagnosis according to the “golden standard” CAG results were 98.3% and 91.7%, respectively, with identical positive and negative predictive values and very high overall accuracy of the method (AUC = 0.98; OR = 627.0, p

Purpose: Although coronary artery bypass grafting alone (CABGa), or, with mitral annuloplasty (CABGmp), is considered the best therapeutic strategy for patients with ischemic mitral regurgitation (IMR), some recurrences are still reported. The aim of this study was to evaluate the use of the mitral deformation indices (MDI) as a predictor of recurrence of mitral regurgitation in a 12-month follow-up after CABG alone. Methods: A total of 145 patients after myocardial infarction with significant IMR, eligible for CABG, were prospectively enrolled in the study. Mitral valve morphology, left ventricle function, IMR degree as assessed by effective regurgitation orifice area (ERO), myocardial viability, and MDI were assessed prior to surgery. Patients were referred for CABGa (gr.1, n = 90) or CABGmp (gr.2, n = 55) based on clinical assessment, and the results of rest and stress echocardiography (exercise echocardiography and low dose dobutamine echocardiography-DBX). One year after surgery, each patient underwent the evaluation of cardiovascular events. Univariable logistic regression analysis was used to identify the factors of recurrence of IMR in 1 year follow-up. Serial echo examinations were performed in all patients at discharge, and at 1 and 12 months after surgery. Results: Logistic regression analysis revealed that in CABGa, group preoperative changes of tenting area (TA) and coaptation high (CH) during DBX remained the predictors of the recurrence of IMR in 12 months follow-up. TAdbx &gt, 1 cm2 provided a sensitivity of 90% and specificity of 29%, (AUC 0.6436). The best cut-off value for CHdbx was 0.4 cm (sensitivity 90%, specificity 34%, AUC 0.6432). In both groups (CABGa vs. CABGmp) no significant differences were observed in 12-month mortality (1.2% vs. 0%, p = 1.0), hospitalizations due to the heart failure (HF) exacerbation (5.9% vs. 8.5%, p = 0.72), and in the incidence of the composite endpoint (deaths/CV hosp/stroke) (7% vs. 8.5%, p = 0.742). Conclusions: The preoperative assessment of MDI changes during dbx can be used to identify patients with IMR qualified to CABG alone at increased risk of recurrence of IMR in 1 year follow-up. Mitral deformation analysis should be used for a better qualification of patients with IMR to the exact surgical approach.

Introduction Prevalence of coronary artery disease (CAD) has increased to alarming levels globally. There is a significant improvement in the noninvasive modalities for the early CAD detection by costly investigations such as computed tomographic (CT) coronary angiogram. The authors want to see the efficacy of adding pulse and tissue Doppler parameters, which is a cheaper modality, to the TMT (treadmill test) stress testing, for the detection of CAD. Materials and Methods The authors have recruited 51 patients, who were referred for TMT for detection of inducible ischemia. Mean age of the patients was 51.9 years. Patients with renal failure, rhythm disturbances, and hypertension more than stage 1 were excluded. Along with the TMT, basal and exercise pulse wave and tissue Doppler parameters were recorded. These echocardiogram parameters were compared with presence and absence of CAD, along with the severity of CAD (SVD [single-vessel disease], DVD [double-vessel disease], and TVD [triple-vessel disease]) on a conventional coronary angiogram (CAG).There was no statistical difference between basal and after TMT in pulse wave diastolic parameters (basal E-wave velocities: 0.76 ± 0.18 vs. 0.88 ± 0.22, p = 0.29: after TMT: 1.03 ± 0.22 vs. 1.12 ± 0.21, p = 0.29) for detection of CAD on CAG. However, most tissue Doppler velocities were significantly different both in basal and after TMT in CAD group when compared with no-CAD group (S′ septal, basal, and after TMT, p = 0.002, E′ septal, basal, and after TMT, p = 0.0015, A′ septal, basal, and after TMT, p = 0.0195, S′ lateral, basal, and after TMT, p = 0.0018, E′ lateral, basal, and after TMT, p = 0.0016, S′ Inferior, basal, and after TMT, p = 0.0036, A′ inferior, basal, and after TMT, p = 0.023). Average E/E′ after TMT for DVD was 12.29 ± 2.09 (vs. no-CAD 10.70 ± 2.00) and for TVD it was 12.2 ± 2.19 (vs. no-CAD 10.69 ± 2.1), which were statistically significantly higher than no-CAD (p = 0.02, p = 0.02). Conclusion Tissue Doppler velocities of different left ventricular (LV) walls (S′, E′, A′ of septal; S′, E′, of lateral; S′, A′ of inferior) in CAD at basal and after TMT were different from the no-CAD group, which were statistically different. Ratios such as E/E′, E/A′ of septal, lateral, and inferior, after TMT were useful for the detection of not only the presence of CAD but also for the severity of the CAD (for DVD: 12.29 ± 2.09 vs. 10.70 ± 2.00, p = 0.023; TVD: 12.2 ± 2.19 vs. 10.69 ± 2.1, p = 0.023). In conclusion, diastolic stress evaluation is useful to predict the occurrence of CAD and its severity.

Background Dipyridamole stress echocardiography (DSE) represents a fundamental test in patients with suspected coronary artery disease (CAD). The diagnosis of microvascular disease is still challenging. We aimed to determine the diagnostic value of left ventricular (LV) layer-specific longitudinal (LS) and circumferential strain (CS) by Speckle Tracking in detecting CAD during DSE and to study if they can help in discriminate between a negative echo and a suspected microvascular angina. Methods and results We enrolled 66 patients with known or suspected CAD. All underwent standard DSE. We identified 3 groups according to the result of DSE (36 negative DSE, 19 positive DSE, 11 indicatives for microvascular disease). Wall motion score index, global LV LS and CS (global longitudinal strain [GLS] and global circumferential strain [GCS]), and layer-specific LV LS and CS were measured at rest and peak stress. The Delta between rest and peak stress values was calculated. GLS increased after injection in negative DSE and microvascular disease while reducing in positive DSE. Endocardial GCS and transmural GCS values were stable in microvascular disease while increasing significantly in negative DSE, helping in the diagnosis. The specific analysis of endocardial LS showed the most powerful difference between healthy and macrovascular CAD patients, both for LS and CS. Conclusions Global circumferential strain can be a new valuable added tool in the echocardiographic diagnosis of microvascular disease. Endocardial GLS is the best indicator of an altered wall deformation in the presence of macrovascular ischemia.

Stress echo (SE) 2030 study is an international, prospective, multicenter cohort study that will include &gt, 10,000 patients from ≥20 centers from ≥10 countries. It represents the logical and chronological continuation of the SE 2020 study, which developed, validated, and disseminated the “ABCDE protocol” of SE, more suitable than conventional SE to describe the complex vulnerabilities of the contemporary patient within and beyond coronary artery disease. SE2030 was started with a recruitment plan from 2021 to 2025 (and follow-up to 2030) with 12 subprojects (ranging from coronary artery disease to valvular and post-COVID-19 patients). With these features, the study poses particular challenges on quality control assurance, methodological harmonization, and data management. One of the significant upgrades of SE2030 compared to SE2020 was developing and implementing a Research Electronic Data Capture (REDCap)-based infrastructure for interactive and entirely web-based data management to integrate and optimize reproducible clinical research data. The purposes of our paper were: first, to describe the methodology used for quality control of imaging data, and second, to present the informatic infrastructure developed on RedCap platform for data entry, storage, and management in a large-scale multicenter study.

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.

BACKGROUND Speckle-tracking echocardiography (STE) can be applied in a large variety of clinical conditions. Global longitudinal strain (GLS) shows high diagnostic accuracy for the detection of myocardial ischemia as it reflects changes in subendocardial fibers deformation that are more exposed to ischemic damage, even before alterations in segmental kinetics are revealed. PURPOSE Aim of our study was to assess whether the measurement of global longitudinal strain during stress-echo can provide additional information compared to the assessment of conventional parameters such as left ventricular ejection fraction (LVEF) and wall motion abnormalities. We also evaluated the added value of strain in patients with complete (CRP) and incomplete revascularization (IRP). METHODS We enrolled 69 patients, 39 with known (IHD) and 30 with suspected ischaemic heart disease (SIHD) with indication to perform a stress echocardiogram. Inclusion criteria were: known or suspected CAD, age 18, adeguate acoustic window. Cardiological evaluation and stress echo were performed in all patients. Primary end point was evaluating whether in patients with negative stress test the presence of reduced GLS identifies patients with an adverse prognosis at follow up and to assess if in IRP and negative stress test there is evidence of left subclinical ventricular dysfunction identifiable by GLS analysis compared to CRP. RESULTS LVEF was significantly reduced in IHD patients compared to SIHD patients (54 ± 7vs 60 ± 4 at rest; 55 ± 8vs62 ± 3 at peak; p compared to SIHD patients (-16.7 ± 4,3vs-19 ± 2.2 - p = 0.07 at rest, -18 ± 4.6vs22 ± 3.4-p = 0.004 at peak). In CRP patients GLS did not change significantly with a tendency to improve (-17.6 ± 4 at rest vs -19 ± 4.5 at peak - p = 0.4). Instead in IRP patients, significant reduction of GLS was observed at peak (17.5 ± 0.7 at rest vs 14.2 ± 0.3 at peak, p value 0,03). LVEF did not significantly differ in CRP (54 ± 5 at baseline vs 55 ± 7 at peak, p = 0.5) and IRP (52 ± 9 at baseline vs. 52 ± 9 at peak, p = 0.9) . CONCLUSIONS Our study shows that strain analysis during stress echocardiography can provide additional information in identifying a subclinical reduction of myocardial function at baseline and a reduction in contractile reserve under stress, secondary to coronary flow reduction. Being GLS a powerful prognostic marker probably patients with negative stress test and incomplete revascularization, reduced baseline GLS and reduction of GLS at peak exercise represent a population at higher risk of coronary artery disease progression and development of left ventricular dysfunction who need a closer follow up. To verify our hypothesis we plan to increase our sample size and to prospectively follow up our patients.

OBJECTIVE The aim of the work was to evaluate STE feasibility as DSE visualization method and its accuracy compared to coronary angiography (CAG) in the patients with moderate-tohigh coronary arteries disease (CAD) risk. PATIENTS AND METHODS Materials and methods: We prospectively examined 140 pts (84 (60.0%) men) with suspected CAD in order to verify diagnosis and evaluate myocardial viability and coronary reserve. RESULTS Results: Mean LV EF was 54.4±15.8%. All pts had normal BP and HR during the test. There were no significant hemodynamics alterations during the test. There were no significant complications during DSE - 15 (12.9%) cases of different relatively low-grade supraventricular and ventricular arrhythmia, mainly transitory without interventions. There were 116 (82.9%) positive DSE results, of which 2 (1.72%) were false-positive. In 2 (8.3%) pts with negative DSE results CAG revealed 1-vessel insignificant (50 - 70%) lesions with developed collaterals (false-negative results). According to DSE and CAG results, 96 (82.3%) pts underwent revascularization interventions - 86 (89.6%) PCI's and (10.4%) CABG surgeries. Sensitivity and specificity of DSE with STE for primary CAD diagnosis according to "golden standard" CAG results were 98.3% and 91.7%, respectively, with identical positive and negative predictive value and very high method overall accuracy (AUC = 0.98) and OR = 627.0 (p

Background In previous publications, we have proposed new algorithm of pharmacologic Stress Echo with possibility of stepwise adenosine triphosphate (ATP) i/v dose increase (Figure 1). Purpose In this study we decided to compare the effectiveness of detection of symptom related coronary arteries in patients with coronary artery disease (CAD) by ATP 4D Stress Echo of left ventricle (LV) and a) traditional visual evaluation of LV segmental hypokinesis b) Automatic Function Imaging (AFI) technology longitudinal LV strain (LS) analysis. Material and methods. 26 patients with CAD (male 24, mean age 63.1 ± 7.5 years, single vessel obstructive disease 7, multivessel - 19) underwent ATP LV 4D Stress Echo (Vivid E95, GE). Number of cases when it was possible to detect symptom related arteries by visual analysis of LV segmental hypokinesis and by AFI LV LS analysis were compared. Results In 11 (42.3%) patients expansion of existing hypokinetic areas and appearance of new LV segments with hypokinesis during stress test were detected by visual analysis. Using AFI technology expansion of initial areas of LS disturbances and appearance of new LV segments with LS disturbances were found in 21 (80,7%) patients (р=0.0044). Conclusion Utilization of AFI LV LS analysis during ATP LV 4D Stress Echo significantly increases the frequency of symptom related coronary arteries detection in patients with CAD. Abstract P1550 Figure1

Cardiopulmonary exercise test (CPET) is a functional assessment that helps to detect disorders affecting the system involved in oxygen transport and utilization through the analysis of the gas exchange during exercise. The clinical application of CPET is various, it including training prescription, evaluation of treatment efficacy and outcome prediction in a broad spectrum of conditions. Furthermore, in patients with shortness of breath it provides pivotal information to bring out an accurate differential diagnosis between physical deconditioning, cardiopulmonary disease and muscular diseases. Modern software allows the breath-by-breath analysis of the volume of oxygen intake (VO2), volume of carbon dioxide output (VCO2) and expired air (VE). Through this analysis, CPET provides a series of additional parameters (peak VO2, ventilatory threshold, VE/VCO2 slope, end-tidal carbon dioxide exhaled) that characterize different patterns, helping in diagnosis process. Limitations to the routine use of CPET are mainly represented from the lack of measurement standardization and limited data from randomized multicentric studies. The integration of CPET with exercise stress echocardiography has been recently introduced in the clinical practice by integrating the diagnostic power offered by both the tools. This combined approach has been demonstrated to be valuable for diagnosing several cardiac diseases, including heart failure with preserved or reduced ejection fraction, cardiomyopathies, pulmonary arterial hypertension, valvular heart disease and coronary artery disease. Future investigations are needed to further promote this intriguing combination in the clinical and research setting.

Quality in stress echocardiography interpretation is often gauged against coronary angiography (CA) data but anatomic obstructive coronary disease on CA is an imperfect gold standard for a stress induced wall motion abnormality. We examined the utility of crowd-sourcing a “majority-vote” consensus as an alternative ‘gold standard’ against which to evaluate the accuracy of an individual echocardiographer’s interpretation of stress echocardiography studies. Participants independently interpreted baseline and post-exercise stress echocardiographic images of cases that had undergone follow up CA within 3 months of the stress echo in two surveys, 2 years apart. We examined the agreement of consensus on survey (survey participant response (> 60%) for one decision) with the stress echocardiography clinical read and with CA results. In the first survey, 29 participants reviewed and independently interpreted 14 stress echo cases. Consensus was reached in all 14 cases. There was good agreement between clinical and consensus (kappa = 0.57), survey participant response and consensus (kappa = 0.68) and consensus and CA results (kappa = 0.40). In the validation survey, the agreement between clinical reads and consensus (kappa = 0.75) and survey participant response and consensus (kappa = 0.81) remained excellent. Independent consensus is achievable and offers a fair comparison for stress echocardiographic interpretation. Future validation work, in other laboratories, and against hard outcomes, is necessary to test the feasibility and effectiveness of this approach.

The evolution of stress echocardiography never stopped since the first publication of feasibility studies. Reshaping the way it is performed has been one of the main tasks of the stress echo commun...

Constrictive pericarditis (CP) is an uncommon, but serious complication that can manifest as heart failure in transplant patients. 51 year old male with history of hypertrophic cardiomyopathy status post heart transplant presents with several months of abdominal distention. Recent stress echo shows

Background The effectiveness trial “Stress echo (SE) 2020” evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion. Purpose To provide web-based upstream quality control and harmonization of B-lines reading criteria. Methods 60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module ( http://se2020.altervista.org ). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics. Results All 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p

The B-Profile of normal lung sliding with B-lines by lung ultrasound (LUS) identifies pulmonary congestion at rest and during exercise stress echocardiography (SE) in coronary artery disease (CAD) [(1)][1] or heart failure (HF) patients with either reduced [(2)][2] or preserved [(3)][3] resting

Introduction: Stress echocardiography is the combination of 2D echocardiography with physical, pharmacological or electrical stress. The diagnostic endpoint of the detection of myocardial ischemia is the induction of a transient change in regional function during stress.1 Myocardial ischemia results in a typical “cascade” of events in which the various markers are hierarchically ranked in a well-defined time sequence. Flow heterogeneity between subendocardial and subepicardial perfusion is the forerunner of ischemia, followed by metabolic changes, alteration in regional mechanical function, and only at a later stage by electrocardiographic (ECG) changes, global left ventricular dysfunction (LV) and pain.2 Wall motion and perfusion or coronary flow reserve (CFR) changes are highly accurate, and more accurate than ECG changes for detection and location of underlying coronary artery disease. However, wall motion is more specific and requires ischemia; perfusion changes are more sensitive and may occur in the absence of true ischemia (microvascular disease, or LV hypertrophy).1 The three most common ischemic stressor are exercise, dobutamine, and vasodilators (dipyridamole, adenosine). They are equally potent for inducing wall abnormalities in the presence of a critical epicardial coronary artery stenosis. Dobutamine and exercise manly act through increased myocardial oxygen demand. Vasodilators act by stimulating A2 adenosinergic receptors present on the endothelial and smooth muscle cells of coronary arterioles and induce ischemia due to reduced subendocardial flow supply subsequent to inappropriate arteriolar vasodilatation and steal phenomena.1 Dipyridamole was the first pharmacological stress agent used for the diagnosis of coronary artery disease, with a pioneering indication proposed in Europe for the identification of ischemia during 12-lead ECG3, and later in the USA by Lance Gould as hyperemic stress perfusion imaging.4 Dipyridamole stress echocardiography pioneered in the year of 1985 (Picano et al). The safety record of high dose dipyridamole is well established on the basis of large scale multicentric studies with data from thousands of patients. The incidence of major complications, i.e. myocardial infarction, atrioventricular block, cardiac asystole, sustained ventricular tachycardia, is about 1/1500 cases. The mortality rate is about 1/10000 cases, similar to that of the exercise stress test. Dipyridamole has a better safety profile than when stress testing with dobutamine, where the incidence of major adverse reactions is about 1/300 studies.5 Many centers from 1988 until today, have used high doses administered in a short time (syringe-based infusion of 0.84 mg/kg). Later, some studies were reproduced with these doses, and today, most centers worldwide use high dose delivered in 4-6 min.6 Center experience: In 2017 we started to perform stress echocardiography in Čakovec County Hospital. The first method was exercise echocardiography using treadmill protocol, with imperative do accomplish postexercise imaging as soon as possible (

Dr Porter in his editorial comment (1) on a physiologist-led stress echo service (2) acknowledges that the service was safe in terms of adverse effects but is concerned that ‘the interpretation of the study was also done by the cardiac physiologist’. He reminds us ‘that the biggest danger associated with dobutamine stress echocardiography is in misinterpreting the data obtained…’.

Background The presence of left ventricular contractile reserve (LVCR) during stress echo (SE) may provide favorable response to cardiac resynchronization therapy (CRT) in heart failure patients. The aim of the study was to perform a meta-analysis of available SE data in this set of patients. Methods From a Pubmed and Advance Google Scholar database web based search scan up to December 2016, we initially identified 5906 records. From this initial set, we removed that did not include SE and duplicate studies. We assessed for eligibility 71 full-text articles assessed for eligibility, and 60 of them did not meet the inclusion criteria as follow: 1) heart failure patients with NYHA class III and IV, depressed ejection fraction (EF

Summary Background: The patients with episodes of chest pain and no electrocardiographic or biomarker abnormalities are currently monitored and subjected to non-invasive testing. Stress echocardiography is one of the most often used provocative tests, being the most cost- and risk-effective imaging technique. Some concerns about this technique have been raised regarding potential drug-induced myocardial injury. Our study hence aimed to establish whether or not dipyridamole stress echocardiography elicits release of troponin I (TnI) and T (TnT), as reliable bio-markers of myocardiocyte injury. Methods: Thirty-two patients, after exclusion of ongoing acute coronary syndrome (ACS) during evaluation in the emergency department (ED), were studied with echocar-diography both at the baseline and after pharmacological stress with dipyridamole. Results: All subjects had biomarkers assessment immediately before the stress-test (T1), 1 h from conclusion of the test (T2), and 6 h afterwards (T3). Cardio specific troponins were assessed with one contemporary-sensitive (TnI) and two highly-sensitive (HS) methods (HS-TnI and HS-TnT). The concentration of TnI, HS-TnI and HS-TnT did not differ throughout the three time points. At no time point the concentration of either HS-TnI or HS-TnT was significantly different among patients with negative or positive stress test. Conclusions: The data shows that dipyridamole stress testing does not trigger release of troponin in patients with and without inducible reversible ischemia.

There is a burgeoning population of adults with congenital heart disease (CHD) due to successful medical and surgical intervention in childhood. This group of patients requires careful echocardiographic evaluation and follow-up of the residua and sequellae of their cardiac anomalies. This review addresses the guidelines for evaluation and management of the grown-up with CHD, the contributions of 3D echo in their assessment, and the current status and new developments in noninvasive determination of ventricular volumes and function. The contribution of stress and contrast echocardiography for the adult with CHD is considered. The application of transcatheter interventions for this population is included with particular regard for the role of echocardiography pre- and postprocedure. Particular problems presented by pregnancy for the adult CHD patient are also reviewed.

Background Cardiac resynchronization therapy (CRT) is effective in patients with heart failure, but 30% to 50% of subjects are classified as nonresponders. Identifying responders remains a challenging task. Aims The LODO-CRT trial investigated the association between left ventricular contractile reserve (LVCR) and clinical and echocardiographic long-term CRT response. Methods This is a multicenter, prospective, observational study. Left ventricular contractile reserve was detected using a dobutamine stress echocardiography test , defined as an ejection fraction increase of >5 points. Clinical CRT response was defined as the absence of major cardiovascular events (ie, cardiovascular death or heart failure hospitalization). Echocardiographic response was defined as a left ventricle end-systolic volume reduction of >10%. Results A total of 221 CRT-indicated patients were studied (80% presented LVCR). During a mean follow-up of 15 ± 5 months, 17 patients died and 16 were hospitalized due to heart failure. The proportion of clinical responders was 155 (88%) of 177 and 33 (75%) of 44 ( P = .036) in the groups with and without LVCR, respectively. Kaplan-Meier analysis showed a significant difference in cardiac survival/hospitalization between patients with and without LVCR. The proportion of echocardiographic responders was 144 (87%) of 166 and 16 (42%) of 38 in the groups with and without LVCR ( P Conclusion The presence of LVCR helps in predicting a clinical and echocardiographic CRT response. Concomitant assessment of LVCR and interventricular dyssynchrony accurately stratifies responder and nonresponder patients.

Cardiac Calcification at Transthoracic EchocardiographyPredicts Stress EchoResults: a Multicentre StudyNicola Gaibazzi, Rosa Sicari, Eustachio Agricola, Giovanni Cioffi, CarmineMazzone, Lisa Albertini, Giacomo Faden, Sabrina Molinaro, DamianoRegazzoli, Andrea Di Lenarda,Pompilio FaggianoPII: S0167-5273(14)00666-4DOI: doi: 10.1016/j.ijcard.2014.04.007Reference: IJCA 17908To appear in

Health-care payment is a subject on the mind of virtually every citizen today. Are there areas where expenses can be cut without undermining the quality of care provided? One of these areas is certainly the misuse and overuse of medical imaging [1]. Imaging is a major culprit for several reasons. For instance, diagnostic imaging tests are performed to protect against malpractice exposure, a high-cost diagnostic procedure is used for patients at low risk for the condition, a diagnostic test is applied despite no expected impact on the course of the treatment, or there may simply be a lack of communication and inadequate exchange of information among physicians. As a result, more than 95 million high-tech scans are done each year in the USA, and medical imaging (including CT, MRI, and PET scans) has ballooned into a $100 billion a year industry in the USA, with Medicare paying for $14 billion of that [1].

Aim Exertional angina in patients with no coronary flow limiting lesions remains a clinical puzzle. We aimed to assess the extent of coronary artery calcification (CAC) and its relationship to ventricular wall motion function using stress echocardiography in a group of patients limited by exertional angina, but no obstructive lesions. Methods We compared CT coronary calcium score (CACS) and dobutamine stress echocardiography in 55 patients (age 64.7 ± 7.7 years), divided into Group 1 (CACS ≤ 100) and Group 2 (CACS > 100). No patient had LV ejection fraction-EF

Aim: Interobserver variability is an important limitation of the stress echocardiography and depends on the echocardiographer training. Our aim was to evaluate if the use of contrast agents during dipyridamole stress echocardiography would improve the agreement between an experienced and a non-experienced observer in stress echo and therefore if contrast would affect the learning period of dypyridamole stress echo. Methods and results: Two independent observers without knowledge of any patient data interpreted all stress studies. One observer was an experienced one and the other had experience in echocardiography but not in stress echo. Two observers analysed 87 non-selected and consecutive studies. Out of the 87 studies, 46 were performed without contrast administration, whereas i.v. contrast (2.5 g Levovist® by two bolus at rest and at peak stress) was administered in 41. In all cases, second harmonic imaging and stress digitalisation pack was used. The agreement between observers showed a κ index of 0.58 and 0.83 without and with contrast administration, respectively. Conclusions: The use of contrast agents provides a better agreement in the evaluation of stress echo between an experienced and a non-experienced observer in stress echo. Adding routinely contrast agents could probably reduce the number of exams required for the necessary learning curve in stress echocardiography.

Aortic stenosis (AS) is characterized by increased afterload and functional disability. Exercise intolerance may incur even without overt symptoms. Cardiopulmonary exercise testing (CPET) provides pathophysiological insights on mechanisms affecting exercise intolerance. Nonetheless, it has never

Up-regulation of Ca§ssup§2+§esup§ entry through Ca§ssup§2+§esup§ channels by high rates of beating is involved in the frequency-dependent regulation of contractility: this process is crucial in adaptation to exercise and stress and is universally known as force-frequency relation (FFR). Disturbances in calcium handling play a central role in the disturbed contractile function in myocardial failure. Measurements of twitch tension in isolated left-ventricular strips from explanted cardiomyopathic hearts compared with non-failing hearts show flat or biphasic FFR, while it is up-sloping in normal hearts. Starting in 2003 we introduced the FFR measurement in the stress echo lab using the end-systolic pressure (ESP)/End-systolic volume index (ESVi) ratio (the Suga index) at increasing heart rates. We studied a total of 2,031 patients reported in peer-reviewed journals: 483 during exercise, 34 with pacing, 850 with dobutamine and 664 during dipyridamole stress echo. We demonstrated the feasibility of FFR in the stress echo lab, the clinical usefulness of FFR for diagnosing latent contractile dysfunction in apparently normal hearts, and residual contractile reserve in dilated idiopathic and ischemic cardiomyopathy. In 400 patients with left ventricular dysfunction (ejection fraction 30 ± 9%) with negative stress echocardiography results, event-free survival was higher (p < 0.001) in patients with ΔESPVR (the difference between peak and rest end-systolic pressure-volume ratio, ESPVR) ≥ 0.4 mmHg/mL/m2. The prognostic stratification of patients was better with FFR, beyond the standard LV ejection fraction evaluation, also in the particular settings of severe mitral regurgitation or diabetics without stress-induced ischemia. In the particular setting of selection of heart transplant donors, the stress echo FFR was able to correctly select 34 marginal donor hearts efficiently transplanted in emergency recipients. Starting in 2007, we introduced an operator-independent cutaneous sensor to monitor the FFR: the force is quantified as the sensed pre-ejection myocardial vibration amplitude. We demonstrated that the sensor-derived force changes at increasing heart rates are highly related with both max dP/dt in animal models, and with the stress echo FFR in 220 humans, opening a new window for pervasive cardiac heart failure monitoring in telemedicine systems. © 2013 Bombardini et al.; licensee BioMed Central Ltd.

Aim To assess whether ‘eye education’ through short-term, high-intensity joint reading sessions may improve diagnostic accuracy and inter-observer agreement among beginners. Methods and Results Seventeen cardiologists with absent to minimal ( 14 readers giving the same response) interpretation occurred in three out of nine studies before and in eight out of nine studies after the training (33% vs 88%, P

The diagnostic value of echocardiography hinges on the reader's ability to adequately visualize the endocardium of the left ventricle. This study was designed to evaluate the potential benefit of noncontrast harmonic imaging to enhance endocardial visualization. Eighty consecutive outpatients who underwent treadmill stress echocardiography were randomly assigned to either fundamental or harmonic imaging. The echoes were interpreted by 2 experienced readers. Compared with fundamental imaging, harmonic imaging of tissue improved the overall endocardial visualization score by 35% and 21% for readers 1 and 2, respectively (P

Coronary MR angiography has developed rapidly over the past several years. Not only is research being performed at academic centers but industry is also investing in dedicated contrast agents and cardiac MR imaging platforms. Although current coronary MR angiography has limited clinical utility, its place within the assessment of ischemic cardiac disease is evolving. The technology currently under investigation holds much promise, especially when one considers that MR has the potential to provide information currently supplied by the performance of a number of screening tests. It would be far more cost-effective to perform a single MR examination than to perform a stress echo, rest-stress nuclear medicine examination and a conventional coronary angiogram. In addition, clinicians need information about coronary flow and myocardial perfusion. Although some of this information can be currently obtained with an intravascular Doppler flow wire or by positron emission tomography, MR angiography offers the advantages of being both noninvasive and more easily accessible in comparison to either method. The combined information promised by a comprehensive cardiac MR examination that includes coronary MR angiography as a component is an exciting prospect.

Dipyridamole stress is the forerunner and prototype of pharmacological stress echo tests in the diagnosis of coronary artery disease. Among the various stress echo tests, it is probably the least technically demanding to perform and the easiest to interpret. Its accuracy is similar to dobutamine stress echocardiography but its feasibility is higher. The prognostic impact of dipyridamole stress echo has also been proven for presentation of hard end-points such as cardiac death. The safety and prognostic value of this test has been conclusively demonstrated as a result of extensive experience in large scale multicentre projects. Dipyridamole stress is many different tests in one: dipyridamole atropine is best for diagnosis; dipyridamole dobutamine or dipyridamole-exercise is highly sensitive for the detection of minor forms of coronary artery disease; low and high dose dipyridamole is best suited for prognostic stratification; infra-low dipyridamole with low dose dobutamine administration is probably best suited for selective myocardial viability identification. Each patient should have their own test, tailored on the basis of the clinical picture and the diagnostic issue.

Background: There is conflicting data in contemporary literature concerning the best way to treat patients with stable coronary artery disease; specifically, whether medical treatment alone or invasive strategies combined with medical treatment are better. The purpose of this study was to evaluate the clinical outcomes of patients with and without revascularization after stress echocardiography and to create formulas for detecting patients with a very high risk of cardiac death/major adverse cardiac event (MACE) in their present conditions. Methods: We assessed 323 patients (53.9 ± 8.4 years, 247 men), undergoing upright bicycle stress echocardiography in 2006 - 2007. During a median follow-up of 5.2 ± 0.2 years, 21 cardiovascular and 5 confirmed non-cardiac deaths occurred. Eighty-three patients underwent revascularization. Results: Stress echocardiography was normal in 32% and abnormal in 68%. All the patients with CAD were prescribed acetylsalicylic acid, statins, beta-blockers and ACE inhibitors. Eighty-seven percents of the patients took medication regularly. The percentage taking medication didn ’ t significantly differ in the subgroups. Two formulas were created for detecting a very high risk of cardiac death (25%) or MACE (68%) within 5 years. All the patients with abnormal stress tests were divided into two subgroups: 80 patients with revascularization and 138 subjects without revascularization. There was a significant difference in 5 year cardiac mortality if the patients had an index of wall motion abnormality (IWMA) after exercise greater than or equal to 1.3. Conclusion: It is possible to identify during stress echocardiography subjects with a very high risk for cardiac death/MACE. Patients with IWMA ≥ 1.3 had improved outcomes following revascularization. Cardiol Res. 2013;4(4-5):152-158 doi: https://doi.org/10.4021/cr294e

The hemodynamic adaptation to exercise in heart failure preserved ejection fraction (HFpEF) has never been studied in terms of left atrial adaptations and right ventricular to pulmonary circulation (RV to PC) coupling. We aimed at investigating these responses. Ten HFpEF patients (LVEF >50%

Physical inactivity and obesity are major public health problems. We sought to evaluate the temporal trends in obesity and exercise capacity among 223,707 patients referred fo stress testing over a 25 year period All patients referred to our lab for stress testing (exercise ECG, stress echo and

Diagnostic stress echo testing is commonly performed in patients with known or suspected cardiovascular disease. There has been considerable debate in management of exercise induced non-sustained ventricular tachycardia (NSVT). In this case report, we present our experience with a case of exercise induced NSVT, and subsequent angiographically significant left anterior descending (LAD) coronary artery lesion.

It is generally accepted that Doppler echocardiography is the mainstay investigation for the diagnosis and management of patients with heart failure. Its noninvasive nature makes it patient friendly as well as a unique tool for repeat studies during various stages of the disease process. It provides detailed information, with high temporal resolution, on cardiac structure and function, which guide clinicians to the optimum management plan. Even if resting information fails to explain the patient’s symptoms, stress echo findings usually provide accurate explanation and guide toward direct management. We hereby discuss the use of echocardiography in heart failure in detail.

The immense clinical and scientific benefits of cardiovascular imaging are well-established, but are also true that 30 to 50% of all examinations are partially or totally inappropriate. Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome. Mr. Ulysses, a typical middle-aged “worried-well” asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war. After a long journey across imaging laboratories, he will have stress echo, myocardial perfusion scintigraphy, PET-CT, 64-slice CT, and adenosine-MRI performed, with a cumulative cost of >100 times a simple exercise-electrocardiography test and a cumulative radiation dose of >4,000 chest x-rays, with a cancer risk of 1 in 100. Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

Background The inherent ability of ventricular myocardium to increase its force of contraction in response to an increase in contraction frequency is known as the cardiac force-frequency relation (FFR). This relation can be easily obtained in the stress echo lab, where the force is computed as the systolic pressure/end-systolic volume index ratio, and measured for increasing heart rates during stress. Ideally, the noninvasive, imaging independent, objective assessment of FFR would greatly enhance its practical appeal. Objectives 1 – To evaluate the feasibility of the cardiac force measurement by a precordial cutaneous sensor. 2 – To build the curve of force variation as a function of the heart rate. 3 – To compare the standard stress echo results vs. this sensor operator-independent built FFR. Methods The transcutaneous force sensor was positioned in the precordial region in 88 consecutive patients referred for exercise, dipyridamole, or pacing stress. The force was measured as the myocardial vibrations amplitude in the isovolumic contraction period. FFR was computed as the curve of force variation as a function of heart rate. Standard echocardiographic FFR measurements were performed. Results A consistent FFR was obtained in all patients. Both the sensor built and the echo built FFR identifiy pts with normal or abnormal contractile reserve. The best cut-off value of the sensor built FFR was 15.5 g * 10-3 (Sensitivity = 0.85, Specificity = 0.77). Sensor built FFR slope and shape mirror pressure/volume relation during stress. This approach is extendable to daily physiological exercise and could be potentially attractive in home monitoring systems.