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Speckle tracking echocardiography (STE) is a widespread method for calculating myocardial strains and estimating left ventricle function. Since echocardiographic clips are corrupted by speckle decorrelation noise, resulting in irregular, nonphysiological tissue displacement fields, smoothing is performed on the displacement data, affecting the strain results. Thus, strain results may depend on the specific implementations of 2-D STE, as well as other systems’ characteristics of the various vendors. A novel algorithm (called K-SAD) is introduced, which integrates the physiological constraint of smoothness of the displacement field into an optimization process. Simulated B-mode clips, modeling healthy and abnormal cases, were processed by K-SAD. Peak global and subendocardial longitudinal strains, as well as regional strains, were calculated. In addition, 410 healthy subjects were also processed. The results of K-SAD are compared with those of one of the leading commercial product. K-SAD provides global mid-wall strain values, as well as subendocardial and regional strain values, all in good agreement with the ground-truth-simulated phantom data. K-SAD peak global longitudinal systolic strain values for 410 healthy subjects are quite similar for the different regions: − 17.02 ± 4.02%, − 19.00 ± 3.45%, and − 19.72 ± 5.06% at the basal, mid, and apical regions, respectively. Improved performance under noisy conditions was demonstrated by comparing a subgroup of 40 subjects with the best image quality with the remaining 370 cohort: K-SAD provides statistically similar global and regional results for the two cohorts. Our study indicates that the sensitivity of strain values to speckle noise, caused by the post block-matching weighted smoothing, can be significantly reduced and accuracy enhanced by employing an integrated one-stage, physiologically constrained optimization process.

A 56-year-old male presented with new onset of congestive heart failure symptoms and a continuous murmur. Transthoracic and transesophageal echocardiography showed severely reduced left ventricle function and shunt flow from an aneurysm in the non-coronary cusp of the aortic valve to the right atrium. The patient underwent surgery with 3 coronary artery bypass grafts and direct closure of the fistula with no residual flow

Background Aortic stenosis (AS) is the most common valvular disease. Endothelial progenitor cells (EPCs) have a role in the repair of endothelial surfaces after injury. Reduced numbers of EPCs are associated with endothelial dysfunction and adverse clinical events, suggesting that endothelial injury in the absence of sufficient repair by circulating EPCs promotes the progression of vascular and possibly valvular disorders. The aim of this study was to assess EPC number in patients with AS and to study the predictive value of their circulating levels on prognosis. Methods The number of EPCs was determined by flow cytometry in 241 patients with AS and a control group of 73 pts. Thirty-eight, 52 and 151 patients had mild, moderate and severe AS, respectively. We evaluated the association between baseline levels of EPCs and death from cardiovascular causes during follow up. Results EPC level was significantly higher in patients with AS compared to the control group (p = 0.017). Two hundred and three patients with moderate and severe AS were followed for a median of 20 months. One hundred and twenty patients underwent an intervention. Thirty four patients died during follow up, 20 patients died due to cardiac causes. Advanced age, the presence of coronary artery disease, AS severity index (combination of high NYHA class, smaller aortic valve area and elevated pulmonary artery pressure) and a low EPC number were predictors of cardiac death in the univariate analysis. Multivariate logistic regression model identified low EPCs number and AS severity index as associated with cardiac death during follow up (p = 0.026 and p = 0.037, respectively). Conclusions EPC number is increased in patients with AS. However, in patients with moderate or severe AS a relatively low number of EPCs is associated with cardiac death at follow up. These results may help to identify AS patients at increased cardiovascular risk.

BACKGROUND: Shortness of breath (SOB) is common among healthy women with normal pregnancies. However, when no overt cardiac or extra cardiac etiology is found, a subtle cardiac source must be excluded. HYPOTHESIS: Pregnancy may induce or unmask myocardial dysfunction that may cause SOB. METHODS: Healthy pregnant women with significant SOB were recruited for this study. We performed a comprehensive echocardiographic assessment including tissue Doppler imaging (TDI) and 2‐ dimensional strain imaging (2DS). The echocardiographic data obtained were compared with that of a control group of pregnant women without SOB. RESULTS: Thirty pregnant women with SOB were enrolled in the study (age, 31.8 ± 4.9 years, and gestation, 38.2 ± 2.8 weeks) for whom no overt etiology for SOB was detected. Patients with SOB compared with controls had thicker hearts (septum: 10.1 ± 1.1 vs 8.9 ± 0.9 mm; P

Aims. Hemochromatosis is a condition in which iron loading impairs the function of many organs, including the heart. Congestive heart failure with left ventricular dilatation is commonly found in patients with hemochromatosis. Two missense mutations (C282Y and H63D) have been shown to be responsible for the majority of cases of hemochromatosis. Methods and results. We examined 156 patients with congestive heart failure due to dilated cardiomyopathy. Details were recorded of clinical and echocardiographic parameters. DNA was extracted from peripheral blood and checked for the presence of the C282Y and H63D mutations by a commercially available single nucleotide primer extension assay. A control group of 98 healthy blood donors was also checked for the presence of these mutations. Of the 157 patients, 42 (26.75%) had at least one mutation. Five (3.65%) were homozygotic for the H63D mutation and 37 (23.6%) were heterozygotic for the H63D mutation. The C282Y mutation was not present. In a control population of 98 healthy blood donors, 27 (27.6%) were heterozygous for the H63D population and none had the C282Y mutation (no significant difference between the patients with cardiomyopathy and the healthy blood donors, χ2 test 0.754). There was a non-significant trend to a difference in the prevalence of homozygotic H63D between the cardiomyopathy patients and the healthy blood donors (3.18% vs. 0%, P=0.076, χ2 test). There was no statistically significant difference between the cardiomyopathy patients with and without the mutations in terms of age, gender, hemoglobin, iron, transferrin, ferritin, presence of diabetes mellitus, hypertension and previous coronary artery bypass grafting. Conclusion. In our population of patients with dilated cardiomyopathy, there was no evidence for hemochromatosis being an important etiology.

Evaluation of: Damani S, Bacconi A, Libiger O et al. Characterization of circulating endothelial cells in acute myocardial infarction. Sci. Transl. Med. 4(126), 126ra33 (2012).Acute coronary syndromes are the most common cause of death in the Western world. Plaque rupture is most commonly associated with acute coronary events, although they primarily involve a complex interplay of numerous initiating and perpetuating factors. The identification of coronary atherosclerotic plaques that are prone to rupture and can lead to acute coronary events is being intensely studied. Circulating endothelial cells (CECs) have been detected in association with endothelial injury and may reflect damage to the vascular tree. In this article, the authors evaluate a recent publication investigating CECs using an automated and clinically feasible CEC three-channel fluorescence microscopy assay.

Objective Hemodynamic forces are potential determinants of aortic atherosclerosis. Aortic regurgitation (AR) alters the flow pattern in the aorta. However, the association between AR and aortic atherosclerosis is not well known. Methods We assessed the presence, extent and distribution of atherosclerotic lesions in the aorta of 42 patients with chronic AR and compared them to 40 patients with similar risk factor profile for atherosclerosis and no valvular disease. Results There was no difference in the extent of atheroma in the ascending aorta and aortic arch between patients with and without AR. Descending aortic atheroma was evident in 25 patients with AR (60%) and 12 patients without AR (30%, p =0.01). AR was found to be the only predicting factor for the presence of aortic atherosclerosis in the descending aorta (odds ratio 4.1; 95% CI 1.2–14.3, p =0.03). Conclusions There is an increased prevalence of descending aortic atherosclerosis in patients with significant AR.

Transcatheter aortic valve implantation (TAVI) is a relatively novel procedure first performed in 2002 and has undergone rapid development since then. Its main indication is treatment of severe symptomatic aortic valve stenosis. Initially, the procedure was indicated for very sick patients who were not eligible for surgical aortic valve replacement. However, rapid development of the technology and operator skill required for TAVI allowed widening of the indications for its use. Currently, there is evidence that TAVI could be better than the surgical intervention in a broad population and not only in the most sick. This paper reviews the medical literature regarding TAVI, including the relevant medical equipment, different modes of its deployment, main complications of the procedure, main indications and contraindications, and the outcome of the patients who undergo it.

The pathophysiology of aortic stenosis (AS) involves inflammatory features including infiltration of the aortic valve (AV) by activated macrophages and T cells, deposition of lipids, and heterotopic calcification.To evaluate the correlation between white blood cell (WBC) differential count and the occurrence and progression of AS.We identified in our institutional registry 150 patients with AS who underwent two repeated echo studies at least 6 months apart. We evaluated the association between the average of repeated WBC differential counts sampled during the previous 3 years and subsequent echocardiographic AS indices.There was no significant difference in total WBC, lymphocyte or eosinophil count among mild, moderate or severe AS groups. There was a progressive decrease in monocyte count with increasing AS severity (P = 0.046), more prominent when comparing the mild and severe groups. There was a negative correlation between AV peak velocity or peak or mean gradient and monocyte count in the entire group (r = -0.31, -0.24, and -0.25 respectively, all P0.01). Similar partial correlations controlling for age, gender, hypertension, smoking, dyslipidemia and ejection fraction remained significant. The median changes over time in peak velocity and peak gradients in AS patients were 0.44 (0-1.3) m/sec/ year and 12 (0-39) mmHg/year, respectively. There was no correlation between any of the WBC differential counts and the change in peak velocity or peak gradient per year.Severe AS is associated with decreased total monocyte count. These findings may provide further clues to the mechanism underlying the pathogenesis of aortic stenosis.

Background Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this study was to assess the predictive value of two-dimensional longitudinal strain in the detection of longitudinal LV dysfunction and the identification of coronary artery disease (CAD) in patients hospitalized with angina. Methods Two-dimensional strain software was extended to allow the analysis of numerous longitudinal strain traces in the entire left ventricle and generate a histogram of peak systolic strain (PSS) values for the left ventricle and for each coronary territory. In each histogram, the value of the 10% worst strain values (PSS 10% ) was determined. Global strain, segmental PSS, and PSS 10% were analyzed in 97 patients hospitalized with angina and had normal LV function, who underwent coronary angiography, and 51 patients with low probability of CAD. Echocardiography was performed 2.9 ± 2 days after admission. Results Sixty-nine patients had significant CAD on coronary angiography. Significant differences were observed in all strain parameters between patients with and without CAD. PSS 10% showed the best accuracy in detecting CAD, with an area under the receiver operating characteristic curve of 0.85. The areas under the curve for global strain and segmental PSS were 0.80 and 0.76, respectively. The optimal cutoff for PSS 10% was −13.9%, with sensitivity and specificity of 86% and 75%, respectively. PSS 10% was better than segmental PSS in the detection of CAD in each coronary territory. Conclusions In patients hospitalized with angina who have significant CAD on coronary angiography, longitudinal systolic function is impaired. Histogram analysis improved the accuracy of longitudinal strain analysis in detecting global and regional impaired function.

The aim of this study was to compare the diagnostic value and safety of sublingual isosorbid dinitrate (ISDN) with intravenous isoproterenol (ISOP) during head-up tilt table testing (HUTT) in pediatric patients with suspected neurocardiogenic syncope.One hundred thirty-six consecutive pediatric patients complaining of presyncope or syncope were submitted to HUTT for the first time. Those who did not develop syncope or presyncope during passive HUTT for 20 minutes underwent repeated HUTT with either 1.25 to 2.5 mg sublingual ISDN or intravenous ISOP (1-3 mug/min) for 20 minutes. There were 54 boys and 82 girls, aged 10 to 18 years with an average of 15.5 +/- 2.4 years and a median of 16 years. Among the patients with cardioinhibition or mixed responses, the severity of the bradyarrhythmia was scored 1 to 3 (restoration of effective rhythm within 10 seconds, 10-20 seconds, and20 seconds while back to supine position, respectively).During the passive period, 24 (17.6%) of 136 patients had a positive response to HUTT. Syncope was observed in another 44 patients during either ISDN or ISOP period (14/58 [24.1%] and 30/54 [55.5%] with ISDN vs ISOP, respectively, P.05). The time to symptoms was shorter with both ISDN and ISOP compared with passive period (6.5 +/- 2.9, 6.3 +/- 5.9, and 10.3 +/- 4.4, minutes, respectively, P.05). The severity score for cardioinhibition response was significantly higher with ISDN compared with the passive period and ISOP (2 +/- 0.8, 1.25 +/- 0.45, and 1.26 +/- 0.45, respectively, P.01).Sublingual ISDN is less sensitive and less safe compared to intravenous ISOP in assessing pediatric age patients with suspected neurocardiogenic syncope and with a negative result in tilt test without provocation. The simplicity of ISDN use should be weighed against the risk of longer symptoms with ISDN.

Background: The clinical approval of speckle tracking echocardiography (STE) as an accepted measure of myocardial strain and of LV function is hindered by the discordance of the results among the vendors. Since echocardiography images are noisy, the measured displacements are smoothed or regularized, an operation affecting the strain results. We introduce an “Error-dependent weighted speckle tracking” (EWST) algorithm that allows sensitivity analysis to the different operations affecting noise and accuracy. The aim here was to study whether by modifying the properties of the post block-matching weighted smoothing in the EWST algorithm it was possible to assess the expected inter-vendor strain differences. Methods and r esults: 48 echocardiographic clips generated by a software-based phantom were used as “gold standard” for validation of the EWST algorithm. Also, a cohort of 435 normal subjects and a cohort of 47 patients, scanned/re- scanned at 2 frame-rates (~70; ~35), were studied using the EWST. The results were compared to those produced by a commercial product of a leading manufacturer ( STE LV ). Peak global longitudinal strains [ PRLS, (%)] and peak regional longitudinal strains [ PRLS, (%)] were calculated and compared. Sensitivity to the region (ROI) determination was tested by shifting the apical endocardial boundary. The differences between the measured PGLS and the ground truth produced by the software-based phantom (average ± standard deviation) were 0.4 % ± 0.6% and 1.0 % ± 0.7% for the EWST and STE LV , respectively. Normal values were calculated for 435 subjects: -18.82 % ± 2.45%, -20.2 % ± 5.6%, -19.62 % ± 3.62%, 18.77 % ± 4.31% by the EWST, and -21.24 % ± 2.91%, -26.5 % ± 5.0%, -21.1 % ± 3.7%, -18.0 % ± 3.9%, by the STE LV , respectively, for the PGLS, the peak longitudinal apical, mid-ventricle and basal regions, respectively. A low bias, but significant, was found between PGLS, when calculated for the cohort of 47 patients scanned/re-scanned at 2 frame-rates: -0.80 % ± 2.61% and -1.66 % ± 2.66% for the EWST and STE LV , respectively. When the apex location (and thus the ROI) was shifted, the bias ( mm ) (average ± standard deviation) relative to the default position was: 0.82 ± 1.04; 0.61 ± 0.72; -1.06 ± 0.75; and -1.87 ± 0.72, for displacement of 5 cm, 2.5 cm, -2.5 cm, and -5 cm, respectively, for the STE LV . The EWST proved similarly sensitive to the shifting of the apex location. Conclusions: STE is sensitive to the characteristics and amount of smoothing, as well as to the ROI positioning. Modification of the smoothing can produce different stain results, and different distribution of the regional strains. Thus it is preferable to use automatic determination of the ROI and methods that employ minimal smoothing or regularization.

Nonalcoholic fatty liver disease (NAFLD) is linked to the metabolic syndrome. The aim of the present study is to determine the effect of the metabolic syndrome on left ventricular (LV) geometry and function using as a model patients with NAFLD. Thirty-eight patients with NAFLD, less than 55 years of age and with a normal exercise test, were compared with an age and sex-matched control group. Patients with diabetes mellitus, hypertension, and body mass index>40 were excluded. A complete echocardiographic study including tissue Doppler imaging (TDI) was performed. The following parameters were assessed by echo Doppler: peak velocities of early (E) and late (A) diastolic filling, E/A ratio, flow propagation velocity (Vp). Using TDI early diastolic velocity (E'), and systolic velocity (S') of mitral annulus were obtained. The patients with NAFLD had a significantly higher body mass index (31.4+/-5 vs. 26.4+/-4 kg/m, P=0.01), higher glucose (100.6+/-13 vs. 83.0+/-10 mg/dL, P=0.01), and triglyceride levels (126.5+/-44 vs. 206.5+/-67 mg/dL, P

The Case: A 31-year-old woman, an immigrant from Ethiopia, was admitted to hospital with a 2-week history of general weakness, cough and fever. She denied recent dental treatment or intravenous drug use and had not undergone any invasive procedures. She had a temperature of 38.8° C, with a pulse of