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Cancer patients may experience nonvalvular atrial fibrillation (AF) as a manifestation of cardiotoxicity. AF may be a direct effect of a neoplasm or, more often, appear as a postsurgical complication, especially after thoracic surgery. AF may also develop as a consequence of anticancer therapy (chemotherapy or radiotherapy), a condition probably underestimated. Cancer patients with AF require amultidisciplinary approach involving oncologists/hematologists, cardiologists, and coagulation experts. An echocardiogram should be performed to detect possible abnormalities of left ventricular systolic and diastolic function, as well as left atrial dilation and the existence of valvular heart disease, to determine pretest probability of sinus rhythm restoration, and identify the best treatment. The choice of antiarrhythmic treatment in cancer patients may be difficult because scanty information is available on the interactions between anticancer agents and antiarrhythmic drugs. A careful evaluation of the antithrombotic strategy with the best efficacy/safety ratio is always needed. The use of vitamin K antagonists (VKAs) may be problematic because of the unpredictable therapeutic response and high bleeding risk in patients with active cancer who are undergoing chemotherapy and who may experience thrombocytopenia and changes in renal or hepatic function. Low molecular weight heparins (in particular for short and intermediate periods) and non-VKA oral anticoagulants (NOACs) should be preferred. However, the possible pharmacological interactions of NOACs with both anticancer and antiarrhythmic drugs should be considered. Based on all these considerations, antiarrhythmic and anticoagulant therapy for AF should be tailored individually for each patient. [ABSTRACT FROM AUTHOR]

In the recent past, new ultrasound technologies, such as three‐dimensional echocardiography and strain imaging echocardiography, raised up in clinical practice leading to a better assessment of cardiac morphology and performance. These tools may assess regional cardiac mechanics, detecting clinical and subclinical myocardial dysfunction in different settings such as ischemic heart disease, cardiomyopathies, and heart valve diseases. Interesting results derive from patients affected from hypertrophic cardiomyopathy (HCM). Particularly, the mentioned techniques are progressively redefining the role of echocardiography in diagnostic evaluation of HCM variants such as apical HCM, detection of the underlying conditions of increased wall thickness, assessment of subclinical myocardial impairment, and potentially refine risk stratification and prognosis. In this review, we describe the clinical uses of these methodologies and the perspective application in HCM patients. [ABSTRACT FROM AUTHOR]

Background Little is known on right ventricular (RV) involvement in obstructive sleep apnoea (OSA). This study aimed at evaluating early RV dysfunction by standard and advanced echocardiography in OSA. Methods Fifty-nine OSA patients without heart failure and 29 age-matched controls underwent standard, speckle tracking and real time 3D echocardiography of right ventricle. OSA patients performed lung function tests and overnight cardio-respiratory monitoring with evaluation of apnea-hypopnea index (AHI). Results OSA had significantly higher body mass index and systolic blood pressure (BP) than controls. RV diameters and systolic pulmonary arterial pressure (sPAP) were significantly higher in OSA, in presence of comparable tricuspid annular plane systolic excursion (TAPSE). OSA showed marginally lower RV global longitudinal strain (GLS) (p < 0.05) and RV lateral wall strain (RV LLS) (p = 0.04). Three-dimensional RV ejection fraction did not differ between the two groups. By stratifying patients according to sPAP, 18 OSA patients with sPAP ≥ 30 mm Hg had lower TAPSE (p < 0.05), RV GLS and RV LLS (both p < 0.001) than 37 patients with normal sPAP. By separate multivariate analyses, RV GLS and RV LLS were independently associated with sPAP (both p < 0.0001), AHI (p = 0.035 and p = 0.015 respectively) and BMI (p < 0.05 and p = 0.034) but not with age and systolic BP in OSA. Conclusions A subclinical RV dysfunction is detectable by speckle tracking in OSA. The impairment of RV GLS and RV LLS is more prominent than that of TAPSE and is evident when RVEF is still normal. GLS is independently associated with sPAP and OSA severity. [ABSTRACT FROM AUTHOR]

Background Longitudinal strain is an early marker of left ventricular ( LV) dysfunction in several cardiac diseases. Our aim was to differentiate cardiac amyloidosis ( CA) at diagnosis from hypertensive LV hypertrophy ( LVH) by analysis of longitudinal myocardial deformation. Methods Thirty healthy controls (C), 30 newly diagnosed, never treated hypertensives with LVH ( H- LVH), and 33 patients with CA at diagnosis underwent echo Doppler including speckle tracking-based automated function imaging ( AFI). Averaged peak systolic global longitudinal strain ( GLS, 18 segments) and basal, middle, and apical longitudinal strain ( BLS, MLS, and ALS, respectively, six segments each) were calculated. Results Left ventricular mass index, relative wall thickness, and ejection fraction did not differ between H- LVH and CA. E/ e′ ratio was higher in CA than in H- LVH (P<.001) and C (P<.0001). GLS was lower in CA than in C (P<.0001), without difference with H- LVH. ALS did not differ among the three groups, MLS was significantly lower in both CA and H- LVH than in C but BLS was lower in CA compared to both H- LVH and C (both P<.0001). In the pooled population, E/ e′ was independently associated with BLS (β=−0.54, P<.0001). At receiver operating curve analysis, CA was predicted by BLS≤−11.3% (sensitivity=63.3%, specificity=100%) and E/ e′≥12.3 (sensitivity=69.7%, specificity=83.3%). The best AUC (=0.819) was obtained by the combination E/ e′+ BLS. Conclusions Our findings highlight a real difference of E/ e′ ratio and longitudinal strain of LV basal segments between hypertensive LVH and CA, which could be used to differentiate the two diseases. [ABSTRACT FROM AUTHOR]

Purpose: To investigate determinants of right ventricular (RV) function in competitive athletes by a combined assessment of speckle tracking (STE) and real time 3D echocardiography (RT3DE). Methods: Right ventricular function of 40 top-level rowers was compared to 43 sedentary normal controls by standard Doppler echocardiography, RT3DE, and STE. RV diameters and wall thickness, tricuspid annular plane systolic excursion (TAPSE), tricuspid E/A ratio, and pulsed tissue Doppler of lateral tricuspid annulus were analyzed. RV volumes, ejection fraction (EF), and stroke volume (SV) were determined. RV global longitudinal strain (GLS) (average of 6 regions), septal strain (average of 3 septal regions, septal longitudinal strain [SLS]), and lateral strain (average of 3 lateral regions, lateral longitudinal strain [LLS]) were estimated by STE. Results: The 2 groups were comparable for age, body mass index, and blood pressure, but heart rate was lower in rowers. RV diameters were larger and TAPSE, tricuspid E/A ratio, and tissue Doppler-derived s′ and e′ velocities were higher in rowers. By RT3DE, RV end-diastolic volume (EDV) and end-systolic volume were greater in rowers (both P < 0.0001), without difference in EF. GLS (P < 0.005) and LLS (P < 0.001), but not SLS, were greater in rowers. In pooled groups, LLS was related to EDV and SV, even after adjusting for heart rate, body mass index, and RV wall thickness by separate multiple linear regression analyses (β coefficient = 0.247, P < 0.01 and β = 0.225, P < 0.02, respectively). Conclusions: Right ventricular preload exerts its maximal influence on the longitudinal lateral fibers, which is independent on potential confounders and largely induces RV supranormal function in the athlete’s heart. [ABSTRACT FROM AUTHOR]

Abstract: Background: Through integrated use of echo-Doppler and tissue Doppler imaging (TDI), it is possible to obtain a comprehensive evaluation of both left ventricular (LV) diastolic and longitudinal functions. In this study, we sought to assess the prevalence of LV diastolic dysfunction (LVDD) and its relation with indices of long-axis function in asymptomatic patients with arterial hypertension. Methods and results: A perspective echo-Doppler study was performed in 1556 consecutive asymptomatic patients with grade 2-to-3 arterial hypertension aged 40–80years enrolled in the SPHERE (multicenter proSPective study of ecHocardiography in hypERtEnsion) study. All patients had a LV ejection fraction (EF)≥50% and no history of heart failure or coronary artery disease. Advanced LVDD was identified by an average mitral-to-peak early diastolic annular ratio (E/e′)≥13. Less than advanced LVDD was identified by: 8

Purpose: The effect of Transcatheter Aortic Valve Implantation (TAVI) on left ventricular (LV) geometry and function was compared to traditional aortic replacement (AVR) by major surgery. Methods: 45 patients with aortic stenosis (AS) undergoing TAVI and 33 AVR were assessed by standard echo Doppler the day before and 2 months after the implantation. 2D echocardiograms were performed to measure left ventricular (LV) mass index (LVMi), relative wall thickness (RWT), ejection fraction (EF) and the ratio between transmitral E velocity and early diastolic velocity of mitral annulus (E/e' ratio). Valvular-arterial impedance (Zva) was also calculated. Results: At baseline, the 2 groups were comparable for blood pressure, heart rate, body mass index mean transvalvular gradient and aortic valve area. TAVI patients were older (p<0.0001) and had greater LVMi (p<0.005) than AVR group. After 2 months, both the procedures induced a significant reduction of transvalvular gradient and Zva but the decrease of LVMi and RWT was significant greater after TAVI (both p<0.0001). E/e' ratio and EF were significantly improved after both the procedure but E/e' reduction was greater after TAVI (p<0.0001). TAVI exhibited greater percent reduction in mean transvalvular gradient (p<0.05), Zva (p<0.02), LVMi (p<0.0001), RWT (p<0.0001) and E/e' ratio (p<0.0001) than AVR patients. Reduction of E/e' ratio was positively related with reduction of RWT (r = 0.46, p<0.002) only in TAVI group, even after adjusting for age and percent reduction of Zva (r =0.43, p<0.005). Conclusions: TAVI induces a greater improvement of estimated LV filling pressure in comparison with major prosthetic surgery, due to more pronounced recovery of LV geometry, independent on age and changes of hemodynamic load. [ABSTRACT FROM AUTHOR]

Purpose: We assessed the impact of type 2 diabetes, in the presence of other major cardiovascular risk factors, on coronary microvascular function and myocardial perfusion in patients without obstructive coronary artery disease (CAD). Methods: In this prospective study, 23 patients with type 2 diabetes and 26 nondiabetic patients matched for age, sex and other cardiovascular risk factors underwent a cold pressure test (CPT) and dipyridamole transthoracic echocardiography to determine their coronary flow (CF) ratio. Within 2 weeks, all diabetic patients also underwent dipyridamole-rest myocardial perfusion single-photon emission (MPS) CT. None of the patients with or without diabetes had significant CAD on invasive coronary angiography. Results: The CPT-CF ratio was significantly lower in diabetic patients than in nondiabetic patients (1.46 ± 0.26 vs. 1.71 ± 0.32, p = 0.006) and was correlated significantly with fasting glycaemia ( r = −0.35, p = 0.01), but not with glycated haemoglobin. The dipyridamole-CF ratio was also lower in diabetic patients than in nondiabetic patients (2.38 ± 0.74 vs. 2.75 ± 0.49, p = 0.04). On MPS imaging, 5 diabetic patients (22%) had stress-induced ischaemia and the remaining 18 (78%) had normal myocardial perfusion. The dipyridamole-CF ratio was not different in patients with and without reversible defects (2.3 ± 1.1 vs. 2.4 ± 0.6, p = 0.97). Conclusion: Coronary microvascular function is impaired in type 2 diabetic patients without significant CAD, compared to nondiabetic patients with similar other cardiovascular risk factors. In the majority of diabetic patients, microvascular dysfunction is associated with normal myocardial perfusion. [ABSTRACT FROM AUTHOR]

In diabetes mellitus, structural and functional alterations of the heart can be already present at the time of first diagnosis. However, how early these alterations may occur has never been fully clarified. The present study aimed at investigating cardiac functional abnormalities in uncomplicated hypertensive or normotensive patients with a recent diagnosis of diabetes mellitus. We studied 40 diabetics (24 normotensives and 16 hypertensives) by means of routine echocardiography plus pulse tissue Doppler analysis. Data were compared with those obtained in healthy age- and sex-matched controls. Left ventricular remodelling was more evident in hypertensive diabetics than in normotensive diabetics vs controls. Diastolic function was altered in diabetic patients only when detected by pulse tissue Doppler analysis and not by conventional transmitral Doppler evaluation. Normotensive patients with type 2 diabetes with little or no evidence at standard echocardiography of alterations in cardiac structure and function, already displayed an alteration in diastolic function when the evaluation was based on the tissue Doppler approach. Patients with type 2 diabetes combined to hypertension showed more evident functional cardiac alterations at echocardiography. These findings support the conclusion that cardiac abnormalities are very early phenomena in type 2 diabetes. [ABSTRACT FROM AUTHOR]

Miniaturization has evolved in the creation of a pocket-size imaging device which can be utilized as an ultrasound stethoscope. This study assessed the additional diagnostic power of pocket size device by both experts operators and trainees in comparison with physical examination and its appropriateness of use in comparison with standard echo machine in a non-cardiologic population. Three hundred four consecutive non cardiologic outpatients underwent a sequential assessment including physical examination, pocket size imaging device and standard Doppler-echo exam. Pocket size device was used by both expert operators and trainees (who received specific training before the beginning of the study). All the operators were requested to give only visual, qualitative insights on specific issues. All standard Doppler-echo exams were performed by expert operators. One hundred two pocket size device exams were performed by experts and two hundred two by trainees. The time duration of the pocket size device exam was 304 ± 117 sec. Diagnosis of cardiac abnormalities was made in 38.2% of cases by physical examination and in 69.7% of cases by physical examination + pocket size device (additional diagnostic power = 31.5%, p < 0.0001). The overall K between pocket size device and standard Doppler-echo was 0.67 in the pooled population (0.84 by experts and 0.58 by trainees). K was suboptimal for trainees in the eyeball evaluation of ejection fraction, left atrial dilation and right ventricular dilation. Overall sensitivity was 91% and specificity 76%. Sensitivity and specificity were lower in trainees than in experts. In conclusion, pocket size device showed a relevant additional diagnostic value in comparison with physical examination. Sensitivity and specificity were good in experts and suboptimal in trainees. Specificity was particularly influenced by the level of experience. Training programs are needed for pocket size device users. [ABSTRACT FROM AUTHOR]

Background The intensive physical activity is often associated with cardiac changes. Objectives (i) To evaluate the IGF-I system and myocardial structure and function by standard Doppler echocardiography and Tissue Doppler in athletes and sedentary controls; and (ii) to determine any relationship between IGF-I system and echocardiographic parameters. Methods Nineteen male top-level rowers and 19 age-matched healthy sedentary male controls underwent blood determination of fasting serum IGF-I, IGFBP-3 and acid-labile subunit levels and standard Doppler echocardiography combined with pulsed Tissue Doppler of posterior septal wall, left ventricular (LV) lateral mitral annulus and right ventricular (RV) tricuspid annulus. Myocardial presystolic (PSm), systolic (Sm), the ratio of early diastolic (Em) to atrial (Am) velocities as well as myocardial time intervals were calculated. Results Rowers had higher serum IGF-I levels ( P = 0·04), higher biventricular cavity dimensions and wall thicknesses compared to controls. They also had better LV and RV myocardial function than controls. In the rowers, IGF-I was associated with LV ejection fraction ( r = 0·50, P = 0·03), RV PSm velocity (r = 0·55, P = 0·01) and with RV myocardial precontraction time (r = −0·57, P = 0·01). These associations remained significant after adjusting for age and heart rate. Conclusions Top-level athletes showed higher IGF-I levels and a better myocardial performance than controls, particularly for the RV systolic activity. The independent correlations between IGF-I and systolic parameters of the left (ejection fraction) and right (PSm velocity and precontraction time) ventricles may possibly indicate a role of IGF-I system in the modulation of myocardial inotropism in athletes. Further studies are needed to confirm this hypothesis. [ABSTRACT FROM AUTHOR]

Coronary flow reserve (CFR) is the maximal increase in coronary blood flow (CBF) above its resting level for a given perfusion pressure when coronary vasculature is maximally dilated. Normally, hyperaemic CBF reaches values at least 2- to 3-fold greater than resting CBF. Reduction of CFR is mainly due to epicardial coronary artery stenosis or to coronary microvascular dysfunction. CFR can be determined by several techniques that measure CBF itself (e.g. positron emission tomography) or CBF velocities (Doppler methods) from which coronary flow velocity reserve is calculated. Hyperaemic coronary vasodilation can be obtained by pharmacological agents (e.g. adenosine and dipyridamole), but also by the cold pressure test. Long-term antihypertensive treatment induces significant improvement of CFR, which is parallel to the regression of left ventricular (LV) hypertrophy.First- and second-generation ß-adrenergic receptor antagonists (ß-blockers) have shown contradictory influences on CFR. This can be explained by the interaction of the effects on CBF at rest, generally reduced by these drugs, and after hyperaemia, when minimal coronary resistance appears to be either increased or reduced. Third-generation ß-blockers (e.g. carvedilol and nebivolol), which have vasodilating capacity, improve hyperaemic CBF. This occurs as a result of a reduction in minimal resistance, which can be attributed to α-adrenergic blockade and/or to a nitric oxide-mediated effect. This improvement is clearly beneficial in patients with coronary artery disease and indicates an improved coronary microvascular function. Changes of CFR due to vasodilating ß-blockers improve microvascular angina pectoris or silent ischaemia in patients without epicardial artery stenosis, and are also helpful in predicting the response or the further improvement of LV function to treatment. [ABSTRACT FROM AUTHOR]

Abstract: Background: Myotonic dystrophy is associated with arrhythmias and risk of sudden death but also with symptoms of heart failure. Our study aimed to identify early biventricular dysfunction in asymptomatic patients with myotonic dystrophy by tissue Doppler. Methods: Thirty-six patients with myotonic dystrophy (M/F=20/16, mean age=36.4 years), asymptomatic for heart failure, and 36 age- and sex-matched healthy controls underwent Doppler echocardiography and pulsed tissue Doppler of lateral mitral annulus and of tricuspid annulus. Results: The two groups had similar body mass index, blood pressure, heart rate, cardiac mass and endocardial shortening. Standard Doppler showed significantly lower transmitral early (E) diastolic peak velocity, longer transmitral deceleration and isovolumic relaxation times and higher tricuspid inflow atrial peak velocity in myotonic dystrophy than in controls. Tissue Doppler of mitral annulus showed lower myocardial systolic velocity (p <0.02), lower early diastolic velocity (E m) (p <0.05) and atrial velocity (A m) (p <0.005), but no difference of E m/A m ratio. At tricuspid annulus, E m and E m/A m ratio were lower (p <0.02 and p <0.005, respectively). The ratio between tricuspid inflow E velocity and E m, index of the degree of right ventricular filling pressure, was higher (p <0.001) than in controls. Tissue Doppler derived left ventricular and right ventricular measurements were all associated with the disease condition, independent of age and heart rate. Conclusions: Tissue Doppler identifies subclinical biventricular involvement in myotonic dystrophy. Early left ventricular myocardial systolic and diastolic changes are evident. Right ventricular dysfunction, involving myocardial relaxation and right ventricular filling pressure, might be the arrhythmogenic substratum of these patients. [Copyright &y& Elsevier]

Cancer therapy has shown terrific progress leading to important reduction of morbidity and mortality of several kinds of cancer. The therapeutic management of oncologic patients includes combinations of drugs, radiation therapy and surgery. Many of these therapies produce adverse cardiovascular complications which may negatively affect both the quality of life and the prognosis. For several years the most common noninvasive method of monitoring cardiotoxicity has been represented by radionuclide ventriculography while other tests as effort EKG and stress myocardial perfusion imaging may detect ischemic complications, and 24-hour Holter monitoring unmask suspected arrhythmias. Also biomarkers such as troponine I and T and B-type natriuretic peptide may be useful for early detection of cardiotoxicity. Today, the widely used non-invasive method of monitoring cardiotoxicity of cancer therapy is, however, represented by Dopplerechocardiography which allows to identify the main forms of cardiac complications of cancer therapy: left ventricular (systolic and diastolic) dysfunction, valve heart disease, pericarditis and pericardial effusion, carotid artery lesions. Advanced ultrasound tools, as Integrated Backscatter and Tissue Doppler, but also simple ultrasound detection of "lung comet" on the anterior and lateral chest can be helpful for early, subclinical diagnosis of cardiac involvement. Serial Doppler echocardiographic evaluation has to be encouraged in the oncologic patients, before, during and even late after therapy completion. This is crucial when using anthracyclines, which have early but, most importantly, late, cumulative cardiac toxicity. The echocardiographic monitoring appears even indispensable after radiation therapy, whose detrimental effects may appear several years after the end of irradiation. [ABSTRACT FROM AUTHOR]

Morbidity and mortality rates are higher in patients with severe left ventricular (LV) systolic dysfunction and ECG-derived prolonged QRS interval than in those with normal QRS duration. QRS duration is currently used on the grounds that it reflects the presence of ventricular dyssynchrony. However, 30-40% of patients selected on the basis of a prolonged QRS do not receive benefit by cardiac resynchronization therapy (CRT) since they do not show any significant inverse LV remodeling and QRS duration does not accurately distinguish responders to CRT. Consequently, mechanical dyssynchrony (particularly intra-ventricular dyssynchrony) seems to be much more important than electrical dyssinchrony. Pre- and post-echocardiographic assessment should require the combination of conventional and specific applications ranging from M-mode and pulsed/continuous Doppler, to pulsed Tissue Doppler, the off-line analysis of colour Tissue Velocity Imaging, Strain Rate Imaging, and real time three-dimensional reconstruction However, there is not no consensus about the best approach and the best ultrasound parameter for selecting candidates to CRT and ECG representation of abnormal cardiac conduction still remains as the main criterion in guidelines. This review is a practical update of ultrasound methods and measurements of atrioventricular, inter-ventricular and intra-ventricular dyssynchrony and describes experiences which used either conventional Doppler echocardiography and more advanced techniques. By these experiences, the global amount of LV dyssynchrony seems to be critical: the greater intraventricular dyssynchrony, the higher the possibility of significant LV inverse remodeling. After CRT, it is necessary also to evaluate the optimal atrio-ventricular delay and ventricular-ventricular delay setting that maximizes LV systolic function. [ABSTRACT FROM AUTHOR]

Doppler echocardiography has largely contributed to show the existence of a distinct diabetic cardiomyopathy. Several studies have pointed out the evidence of left ventricular (LV) remodeling and hypertrophy in alterations of both midwall systolic mechanics and LV diastolic filling in diabetes mellitus (DM), independent of the coexistence of concomitant risk factors. Further progress will be provided by new ultrasound technologies in this clinical setting. The combination of pulsed tissue Doppler study of mitral annulus with transmitral inflow may be clinically valuable for obtaining information about left ventricular filling pressure (LVFP) and unmasking Doppler inflow pseudonormal pattern, a hinge point for the progression toward advanced heart failure. In the absence of epicardial coronary artery stenosis, the ultrasound assessment of coronary flow reserve (CFR) may identify the dysfunction of coronary microcirculation, in relation with glycemic levels, insulin resistance, sympathetic overdrive, endothelial dysfunction, abnormalities of the angiotensin-renin system, and LV remodeling/hypertrophy. Diastolic dysfunction and impairment of CFR may be associated in DM, with a likely common origin. In this view, a comprehensive transthoracic Doppler evaluation of diabetic patients should include the assessment of diastolic function and estimation of LVFP by tissue Doppler, and coronary microvascular function by CFR test. Additional analysis of regional wall motion during a stress test would be required in patients with suspected coronary artery disease, another cause of diastolic dysfunction. [Copyright &y& Elsevier]

Objective The aim of this study was to assess the role of pulsed tissue Doppler (TD) to identify left (LV) and right ventricular (RV) myocardial regional involvement in acromegaly. Patients and measurements Thirty active acromegaly patients, free of diabetes mellitus, thyroid dysfunction, valvular and coronary heart disease, clinically overt heart failure, and 30 sex- and age-matched healthy controls underwent standard Doppler echocardiography and pulsed TD, by placing the sample volume at the level of basal posterior septum, LV lateral mitral annulus and RV lateral tricuspid annulus. Myocardial systolic (Sm) and diastolic velocities (Em/Am ratio) and time-intervals of relaxation (RTm), precontraction (PCTm) and contraction (CTm) and the PCTm/CTm ratio were measured at each level. Results The two groups had similar heart rate, whereas acromegaly patients had higher body mass index, systolic and diastolic blood pressure, LV mass and impaired Doppler indexes of LV and RV diastolic function, without any difference in the global systolic function. At TD, acromegaly patients showed significantly delayed RTm and PCTm, reduced Em/Am, Sm and increased PCTm/CTm of posterior septum, mitral annulus and tricuspid annulus in comparison with controls. By separate multilinear regression analyses, after adjusting for body mass index, heart rate, diastolic blood pressure and LV mass index, age was the main independent determinant of tissue Doppler diastolic but not of systolic indexes. Conclusions In active acromegaly, pulsed TD confirms LV and RV diastolic abnormalities detectable by standard Doppler, additionally identifying subclinical biventricular impairment of systolic function. [ABSTRACT FROM AUTHOR]

Postsystolic motion (PSM) is a delayed ejection motion of the myocardium occurring after the aortic valve closure, during a generally prolonged isovolumic relaxation time (IVRT). In this review we analyze the physiopathologic mechanisms underlying PSM and the contribution of tissue Doppler for its understanding. By using various techniques, this phenomenon has been described in experimental observations and related to myocardial ischemia produced by gradual or abrupt coronary occlusion. In clinical studies, it is associated with recovery of regional myocardial function. Tissue Doppler, providing a velocity map of myocardial motion, allows an easy, noninvasive detection of PSM in the clinical setting. PSM, as identified by tissue Doppler, appears a hallmark of myocardial ischemia and viability but it may occur also in nonischemic conditions as left ventricular (LV) hypertrophy and volume overload, left bundle branch block and even in normal individuals. Strain and strain rate (SR), obtainable by off-line color tissue Doppler, may be useful to identify the mechanisms underlying PSM since these measurements reflect, respectively, the intrinsic rate and the percentage of deformation of a given myocardial segment, and are relatively independent of both overall cardiac movement and tethering of the neighboring LV segments. By using SR imaging, the ratio of PSM to regional systolic longitudinal strain can be used to separate ischemic from nonischemic PSM and appears the best quantitative parameter to identify ischemia during dobutamine stress. A method to detect LV wall asynchrony and immediate benefit of cardiac resynchronization therapy has been developed combining the assessment of tissue-tracking (TT) derived delayed longitudinal contraction and of SR-derived PSM. (ECHOCARDIOGRAPHY, Volume 22, July 2005) [ABSTRACT FROM AUTHOR]

Transthoracic Doppler echocardiographic-derived coronary flow reserve is an useful hemodynamic index to assess dysfunction of coronary microcirculation. Isolated coronary microvascular abnormalities are overt by reduced coronary flow reserve despite normal epicardial coronary arteries. These abnormalities may occur in several diseases (arterial hypertension, diabetes mellitus, hypercholesterolemia, syndrome X, aortic valve disease, hypertrophic cardiomyopathy and idiopathic dilated cardiomyopathy). The prognostic role of impaired microvascular coronary flow reserve has been shown unfavourable especially in hypertrophic or idiopathic dilated cardiomyopathies. Coronary flow reserve reduction may be reversible, for instance after regression of left ventricular hypertrophy subsequent to valve replacement in patients with aortic stenosis, after anti-hypertensive treatment or using cholesterol lowering drugs. Coronary flow reserve may increase by 30% or more after pharmacological therapy and achieve normal level >3.0. In contrast to other non invasive tools as positron emission tomography, very expensive and associated with radiation exposure, transthoracic Doppler-derived coronary flow reserve is equally non invasive but cheaper, very accessible and prone to a reliable exploration of coronary microvascular territories, otherwise not detectable by invasive coronary angiography, able to visualize only large epicardial arteries. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) diastolic dysfunction (DD) and diastolic heart failure (HF), that is symptomatic DD, are due to alterations of myocardial diastolic properties. These alterations involve relaxation and/or filling and/or distensibility. Arterial hypertension associated to LV concentric remodelling is the main determinant of DD but several other cardiac diseases, including myocardial ischemia, and extra-cardiac pathologies involving the heart are other possible causes. In the majority of the studies, isolated diastolic HF has been made equal to HF with preserved systolic function (= normal ejection fraction) but the true definition of this condition needs a quantitative estimation of LV diastolic properties. According to the position of the European Society of Cardiology and subsequent research refinements the use of Doppler echocardiography (transmitral inflow and pulmonary venous flow) and the new ultrasound tools has to be encouraged for diagnosis of DD. In relation to uncertain definitions, both prevalence and prognosis of diastolic heart failure are very variable. Despite an apparent lower death rate in comparison with LV systolic HF, long-term follow-up (more than 5 years) show similar mortality between the two kinds of HF. Recent studies performed by Doppler diastolic indexes have identified the prognostic power of both transmitral E/A ratio < 1 (pattern of abnormal relaxation) and > 1.5 (restrictive patterns). The therapy of LV DD and HF is not well established but ACE-inhibitors, angiotensin inhibitors, aldosterone antagonists and β-blockers show potential beneficial effect on diastolic properties. Several trials,c ompleted or ongoing, have been planned to treat DD and diastolic HF. [ABSTRACT FROM AUTHOR]

Left ventricular hypertrophy (LVH) is the most common cardiac abnormality in acromegaly. Left ventricular mass (LVM) is an important parameter measured to detect LVH, but the relationship with body size should be considered by correcting LVM to body surface area (BSA), height or height2·7. All trials concerning acromegaly have detected LVH on the basis of LVM indexed for BSA, but have been criticized for disregarding the effects of obesity. 97 patients with active acromegaly and a control group of 97 nonacromegalic subjects, were compared for the prevalence of LVH, calculated with different corrections of LVM for BSA, height and height2·7. In addition, we evaluated determinants of LVH in acromegalic group. In controls, the prevalence of LVH, determined by correcting LVM for BSA (10·3%) was significantly lower than correcting by LVM/height (21·6%, P = 0·05) and LVM/height2·7 (33%, P < 0·0001). Similarly, in the acromegalic population the prevalence of LVH was significantly higher when measured by LVM/height (86·6%) or LVM/height2·7 (89·7%), than by LVM/BSA (67%) ( P = 0·002 and P < 0·0001, respectively). A lower prevalence of LVH detected by LVM/BSA than LVM/height and LVM/height2·7 has been observed in an acromegalic overweight group, while in patients with normal weight there was no significant differences using different corrections. In acromegalic patients with disease duration of ≤ 10 years the prevalence of LVH by correcting LVM for height2·7 was higher than when correcting for BSA. No difference in the prevalence of LVH determined by different corrections was observed in patients with disease duration > 10 years. By separate multiple regression analyses systolic blood pressure was the only independent determinant of LVM/BSA or LVM/height, while systolic blood pressure and GH levels were both predictors of LVM/height2·7. LVM indexed for height2·7 appears to be the most appropriate method to identify LVH in acromegaly, particularly in overweight patients and those with shorter disease duration. [ABSTRACT FROM AUTHOR]

After percutaneous transluminal coronary angioplasty (PTCA), stress-echocardiography and gated single photon emission computerized tomography (g-SPECT) are usually performed but both tools have technical limitations. The present study evaluated results of PTCA of left anterior descending artery (LAD) six months after PTCA, by combining transthoracic Doppler coronary flow reserve (CFR) and color Tissue Doppler (C-TD) dobutamine stress. Six months after PTCA of LAD, 24 men, free of angiographic evidence of restenosis, underwent standard Doppler-echocardiography, transthoracic CFR of distal LAD (hyperemic to basal diastolic coronary flow ratio) and C-TD at rest and during dobutamine stress to quantify myocardial systolic (Sm) and diastolic (Em and Am, Em/Am ratio) peak velocities in middle posterior septum. Patients with myocardial infarction, coronary stenosis of non-LAD territory and heart failure were excluded. According to dipyridamole g-SPECT, 13 patients had normal perfusion and 11 with perfusion defects. The 2 groups were comparable for age, wall motion score index (WMSI) and C-TD at rest. However, patients with perfusion defects had lower CFR (2.11 ± 0.4 versus 2.87 ± 0.6, p < 0.002) and septal Sm at high-dose dobutamine (p < 0.01), with higher WMSI (p < 0.05) and stress-echo positivity of LAD territory in 5/11 patients. In the overall population, CFR was related negatively to high-dobutamine WMSI (r = -0.50, p < 0.01) and positively to high-dobutamine Sm of middle septum (r = 0.55, p < 0.005). In conclusion, even in absence of epicardial coronary restenosis, stress perfusion imaging reflects a physiologic impairment in coronary microcirculation function whose magnitude is associated with the degree of regional functional impairment detectable by C-TD. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the relation between coronary blood flow and left ventricular (LV) myocardial diastolic dysfunction in arterial hypertension. The study population included 30 hypertensive patients who were free of coronary artery disease and pharmacologic therapies. They underwent standard Doppler echocardiography and color tissue Doppler of the middle posterior septum at baseline and with high-dose dobutamine, and second-harmonic Doppler flow analysis of the distal left anterior descending coronary artery at baseline and after vasodilation by dipyridamole (0.56 mg/kg IV in 4’). Coronary flow reserve (CFR) was estimated as the ratio of hyperemic and baseline diastolic flow velocities. According to CFR, hypertensives were divided into 2 groups: 15 patients with normal CFR (≥2) and 15 patients with reduced CFR (<2). The 2 groups were comparable for sex, age, body mass index, baseline heart rate, and blood pressure. LV mass index was greater in hypertensives with reduced CFR (p <0.01). By color tissue Doppler, baseline and high-dose dobutamine septal systolic velocities did not differ between the 2 groups. The ratio between myocardial velocities in early diastole and at atrial contraction (Em/Am ratio) was lower in patients with reduced CFR, both at baseline (p <0.05) and with high-dose dobutamine (p <0.00001). After adjusting for age, body mass index, LV mass index, and both high-dose dobutamine diastolic blood rate and heart rate by a multiple linear regression analysis, Em/Am ratio at high-dose dobutamine was independently associated with CFR in the overall population (β 0.62, p <0.0005) (cumulative R2 0.38, p <0.0005). In conclusion, this study provides evidence of an independent association between CFR and myocardial diastolic function. In hypertensive patients without coronary artery stenosis, CFR alteration may be a determinant of myocardial diastolic dysfunction or diastolic impairment that should be taken into account as possibly contributing to coronary flow reduction. [Copyright &y& Elsevier]

In this study, regional diastolic patterns and their relations with transmitral Doppler inflow were investigated in hypertrophic cardiomyopathy (HC) by pulsed Doppler tissue imaging (DTI). Doppler echocardiography and DTI of basal septum and lateral wall (apical 4-chamber view) were performed in 20 patients (15 men and 5 women) with HC and in 10 healthy subjects (7 men and 3 women). Diabetes, hypertension, coronary artery and valvular disease, mitral regurgitation, New York Heart Association functional classes III to IV, sinus tachycardia, atrial fibrillation, and inadequate echocardiograms were exclusion criteria. Peak velocity and time-velocity integral of early and late waves and their ratios, and deceleration and isovolumic relaxation times were determined by standard Doppler and by DTI at the septal and lateral wall levels. The 2 groups were comparable for age, heart rate, blood pressure, and ejection fraction. Transmitral peak velocity and time-velocity integral E/A ratios were reduced (both p <0.05) and deceleration and isovolumic relaxation times prolonged (both p <0.00001) in HC. Septal DTI showed lower peak velocity and time-velocity integral e/a ratios (p <0.00001 and p <0.001, respectively) and lengthened regional deceleration (p <0.01) and isovolumic (p <0.001) relaxation times. DTI of the lateral wall showed a prolongation of deceleration and isovolumic relaxation times (both p <0.01). By dividing HC according to transmitral E/A, 8 patients with E/A <1 had lower DTI septal e/a ratio (p <0.01) and prolonged septal deceleration and isovolumic relaxation times (both p <0.01) but no changes in DTI pattern of lateral wall than 12 patients with E/A > 1. In conclusion, DTI is useful and complementary to standard Doppler imaging to characterize diastolic properties in HC, reflecting a typical pattern of intramyocardial impaired relaxation at the level of hypertrophied septum and also providing information about the degree of this regional impairment. The lateral wall presents minor changes in diastolic times, which indicate how diastolic asynchrony is not confined to the hypertrophied segment in HC. [ABSTRACT FROM AUTHOR]

We examined the effect of left ventricular filling on different combinations of programmable heart rate and atrioventricular delay in patients with dual-chamber pacemakers. Pacing mode with heart rates of 60 beats/min and 156 ms of atrioventricular delay induced a diastolic pattern that resembles more than others the one observed in healthy subjects in sinus rhythm. [ABSTRACT FROM AUTHOR]

Background: The search for reliable cardiac functional parameters is crucial in patients with mitral regurgitation (MR). In the Italian arm of the European Registry of MR, we compared the ability of global longitudinal strain (GLS) and left ventricular (LV) ejection fraction (LVEF) to detect cardiac damage in MR.Methods: Five hundred four consecutive patients with MR underwent a complete echo-Doppler exam. A total of 431, 53 and 20 patients had degenerative, secondary and mixed MR, respectively. The main echocardiographic parameters, including LV and left atrial (LA) size measurements, pulmonary artery systolic pressure (PASP) and GLS were compared between patients with mild MR (n = 392) vs. moderate to severe MR (n = 112).Results: LVEF and GLS were related one another in the pooled population, and separately in patients with mild and moderate/severe MR (all p < 0.0001). However, a certain number of patients were above the upper or below the lower limits of the 95% confidence interval (CI) of the normal relation in the pooled population and in patients with mild MR. Only 2 patients were below the 95% CI in moderate to severe MR. After adjusting for confounders by separate multivariate models, LVEF and GLS were independently associated with LV and left atrial size in the pooled population and in mild and moderate/severe MR. GLS, but not LVEF, was also independently associated with PASP in patients with mild and moderate to severe MR.Conclusions: Both LVEF and GLS are independently associated with LV and LA size, but only GLS is related to pulmonary arterial pressure. GLS is a powerful hallmark of cardiac damage in MR. [ABSTRACT FROM AUTHOR]

Progress in the treatment of cancer has significantly improved survival of oncologic patients in recent decades. However, anticancer therapies, particularly some new, more potent and targeted agents, are potentially cardiotoxic. As a consequence, cardiovascular complications, including heart failure, arterial hypertension, coronary artery disease, venous thromboembolism, peripheral vascular disease, arrhythmias, pericardial disease, and pulmonary hypertension, as related to cancer itself or to anticancer treatments, are increasingly observed and may adversely affect prognosis in oncologic patients. Cardiovascular oncology is an emerging field in cardiology and internal medicine, which is rapidly growing, dealing with the prevention, the early detection, and the management of cardiovascular disease, in all stages of anticancer therapy and during the survivorship period, now crucial for reducing cardiovascular morbidity and mortality in cancer patients. In this narrative review, the existing literature regarding the epidemiology of cardiovascular oncology, the mechanisms of cardiovascular complications in cancer, and the pathophysiology of cardiotoxicity related to chemotherapeutic agents, targeted therapies, immunotherapies, and radiotherapy will be analyzed and summarized. [ABSTRACT FROM AUTHOR]

Abstract: Our experience underscores the ability of hand-held echocardiography to identify the association between aortic root dilation and left ventricular mass in a population-based screening among normotensive and hypertensive participants of “The Heart in the City”, a project designed to detect pre-clinical echocardiographic markers of heart failure by hand-held echocardiography. [Copyright &y& Elsevier]

Abstract: Our retrospective experience underscores the ability of Doppler echocardiography to detect the cardiotoxicity of chemotherapy (functional and pericardial abnormalities, heart involvement) and points out the need for an accurate echocardiographic follow-up of hematologic patients. [Copyright &y& Elsevier]

Purpose: The effect of Transcatheter Aortic Valve Implantation (TAVI) on left ventricular (LV) geometry and function was compared to traditional aortic replacement (AVR) by major surgery.Methods: 45 patients with aortic stenosis (AS) undergoing TAVI and 33 AVR were assessed by standard echo Doppler the day before and 2 months after the implantation. 2D echocardiograms were performed to measure left ventricular (LV) mass index (LVMi), relative wall thickness (RWT), ejection fraction (EF) and the ratio between transmitral E velocity and early diastolic velocity of mitral annulus (E/e' ratio). Valvular-arterial impedance (Zva) was also calculated.Results: At baseline, the 2 groups were comparable for blood pressure, heart rate, body mass index mean transvalvular gradient and aortic valve area. TAVI patients were older (p<0.0001) and had greater LVMi (p<0.005) than AVR group. After 2 months, both the procedures induced a significant reduction of transvalvular gradient and Zva but the decrease of LVMi and RWT was significant greater after TAVI (both p<0.0001). E/e' ratio and EF were significantly improved after both the procedure but E/e' reduction was greater after TAVI (p<0.0001). TAVI exhibited greater percent reduction in mean transvalvular gradient (p<0.05), Zva (p<0.02), LVMi (p<0.0001), RWT (p<0.0001) and E/e' ratio (p<0.0001) than AVR patients. Reduction of E/e' ratio was positively related with reduction of RWT (r = 0.46, p<0.002) only in TAVI group, even after adjusting for age and percent reduction of Zva (r =0.43, p<0.005).Conclusions: TAVI induces a greater improvement of estimated LV filling pressure in comparison with major prosthetic surgery, due to more pronounced recovery of LV geometry, independent on age and changes of hemodynamic load. [ABSTRACT FROM AUTHOR]

When applying echo-Doppler imaging for either clinical or research purposes it is very important to select the most adequate modality/technology and choose the most reliable and reproducible measurements. Quality control is a mainstay to reduce variability among institutions and operators and must be obtained by using appropriate procedures for data acquisition, storage and interpretation of echo-Doppler data. This goal can be achieved by employing an echo core laboratory (ECL), with the responsibility for standardizing image acquisition processes (performed at the peripheral echo-labs) and analysis (by monitoring and optimizing the internal intra- and inter-reader variability of measurements). Accordingly, the Working Group of Echocardiography of the Italian Society of Cardiology decided to design standardized procedures for imaging acquisition in peripheral laboratories and reading procedures and to propose a methodological approach to assess the reproducibility of echo-Doppler parameters of cardiac structure and function by using both standard and advanced technologies. A number of cardiologists experienced in cardiac ultrasound was involved to set up an ECL available for future studies involving complex imaging or including echo-Doppler measures as primary or secondary efficacy or safety end-points. The present manuscript describes the methodology of the procedures (imaging acquisition and measurement reading) and provides the documentation of the work done so far to test the reproducibility of the different echo-Doppler modalities (standard and advanced). These procedures can be suggested for utilization also in non referall echocardiographic laboratories as an "inside" quality check, with the aim at optimizing clinical consistency of echo-Doppler data. [ABSTRACT FROM AUTHOR]

Background Vasodilator stress echocardiography allows dual imaging of regional wall motion and coronary flow reserve (CFR) on left anterior descending (LAD) artery. Hypertension may affect CFR independently of obstructive coronary artery disease (CAD) through coronary microcirculatory damage. Aims The authors sought to determine the best value of Doppler-echocardiography-derived coronary flow reserve (CFR) for detecting ≥75% stenosis of the left anterior descending artery (LAD) and assessing the risk in patients with and without hypertension. Participants The study group was formed by 2089 patients (1411 hypertensive patients and 678 normotensive patients) with known or suspected coronary artery disease who underwent dipyridamole (up to 0.84 mg/kg over 6 min) stress echo with CFR assessment of LAD by Doppler and coronary angiography. Results Mean CFR was 2.2060.62 in hypertensive patients and 2.36±0.70 in normotensive patients (p<0.0001). A significant LAD stenosis was present in 376 (18%) cases. With a receiver operating characteristic analysis, a CFR ≤1.91 was the best value for diagnosing LAD stenosis in both hypertensive patients (area under curve 0.86 (95% CI 0.84 to 0.88), sensitivity 87% (95% CI 82% to 91%), specificity 76% (95% CI 73% to 78%)) and normotensive patients (area under curve 0.90 (95% CI 0.88 to 0.92), sensitivity 89% (95% CI 81% to 95%), specificity 80% (95% CI 77% to 83%)). During a median follow-up of 15 months, there were 348 events (58 deaths, 79 ST elevation myocardial infarctions and 211 non-ST elevation myocardial infarctions). Multivariable prognostic indicators were age (HR¼1.0; 95% CI 1.0 to 1.04), test positivity for wall motion criteria (HR=5.9; 95% CI 3.6 to 9.6) and CFR on LAD ≤1.91 (HR=3.4; CI 95% 2.0 to 5.6) in normotensive patients and previous myocardial infarction (HR=1.3; 95% CI 1.0 to 1.7), test positivity for wall motion criteria (HR=5.0; 95% CI 3.8 to 6.6) and CFR on LAD ≤1.91 (HR=3.1; CI 95% 2.4 to 4.1) in hypertensive patients. Conclusions CFR on LAD provides useful information for vessel stenosis and prognostic assessment in both hypertensive and normotensive patients. However, diagnostic specificity is reduced in hypertensive. [ABSTRACT FROM AUTHOR]

Abstract: Background: Left ventricular (LV) diastolic function represents a complex performance that involves long axis displacement, myocardial lengthening velocities as well as cavity filling. The aim of this study was to assess the various diastolic event interrelations in a group of patients with different degrees of diastolic dysfunction. Methods: 128 consecutive subjects with various degrees of diastolic impairment were studied by Doppler echocardiography. The amplitude of early diastolic (E l) and late diastolic (A l) long axis lengthening was measured by M-mode and corresponding myocardial velocities (E a and A a) by Tissue Doppler. LV filling velocities were also acquired by spectral pulsed wave Doppler. Results: Early diastolic long axis amplitudes and velocities correlated (r =0.73, P <0.0001) as did late diastolic ones (r =0.67, P <0.0001). E l of ≤5.6 mm was 80.6% sensitive and 70.5% specific in predicting E a of <8.0 cm/s, a feature of LV impaired relaxation. E l/A l correlated with E a/A a (r =0.78, P <0.0001), as did E/E l with E/E a ratios (r =0.74, P <0.0001). An E/E l ratio >17.3 cm/s/mm had 94.1% sensitivity and 87.4% specificity for predicting an E/E a ratio >15, a marker for raised LV filling pressures. E l ≤6.8 mm, total amplitude of diastolic motion (E l + A l)≤11.5 mm, and E/E l >14.2 cm/s/mm were the best criteria to discriminate between normal diastolic function and pseudonormal/restrictive LV filling. Conclusion: Diastolic LV components of motion, amplitude and velocities are not independent, neither from each other nor from filling pressures. An integrated approach towards using them all in assessing diastolic function, particularly in patients with raised filling pressure should be of great clinical value. [Copyright &y& Elsevier]

Hypertrophic cardiomyopathy (HCM) is one of the most common inherited cardiomyopathy. The identification of patients with HCM is sometimes still a challenge. Moreover, the pathophysiology of the disease is complex because of left ventricular hyper-contractile state, diastolic dysfunction, ischemia and obstruction which can be coexistent in the same patient. In this review, we discuss the current and emerging echocardiographic methodology that can help physicians in the correct diagnostic and pathophysiological assessment of patients with HCM. [ABSTRACT FROM AUTHOR]

Transthoracic echocardiography is a primary non-invasive modality for investigation of heart transplant recipients. It is a versatile tool which provides comprehensive information about cardiac structure and function. Echocardiographic examinations can be easily performed at the bedside and serially repeated without any patient's discomfort. This review highlights the usefulness of Doppler echocardiography in the assessment of left ventricular and right ventricular systolic and diastolic function, of left ventricular mass, valvular heart disease, pulmonary arterial hypertension and pericardial effusion in heart transplant recipients. The main experiences performed by either standard Doppler echocardiography and new high-tech ultrasound technologies are summarised, pointing out advantages and limitations of the described techniques in diagnosing acute allograft rejection and cardiac graft vasculopathy. Despite the sustained efforts of echocardiographic technique in predicting the biopsy state, endocardial myocardial biopsies are still regarded as the gold standard for detection of acute allograft rejection. Conversely, stress echocardiography is able to identify accurately cardiac graft vasculopathy and has a recognised prognostic in this clinical setting. A normal stress-echo justifies postponement of invasive studies. Another use of transthoracic echocardiography is the monitorisation and the visualisation of the catheter during the performance of endomyocardial biopsy. Bedside stress echocardiography is even useful to select appropriately heart donors with brain death. The ultrasound monitoring is simple and effective for monitoring a safe performance of biopsy procedures. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the prognostic value of Doppler echocardiographically derived coronary flow reserve (CFR) in assessing inotropic response in patients with idiopathic dilated cardiomyopathy (IDC). One hundred thirty-two patients with IDC (90 men; mean age 62 ± 11 years) were evaluated by transthoracic dipyridamole (0.84 mg/kg in 10 minutes) stress echocardiography. All patients had ejection fractions <40% (mean 33 ± 7%) and angiographically normal coronary arteries, with New York Heart Association class ≤III. CFR was assessed in the left anterior descending coronary artery by pulsed Doppler as the ratio of maximal peak vasodilation (dipyridamole) to rest diastolic flow velocity. Inotropic reserve was identified as rest-stress variation in wall motion score index >0.25. All patients were followed for a median of 24 months. Mean CFR was 2.0 ± 0.5. On individual patient analysis, 48 patients had normal CFR (>2), and 84 had abnormal CFR. The mean wall motion score index at rest was 2.0 ± 0.33 and decreased to 1.8 ± 0.4 at peak dipyridamole dose (p <0.000). Forty-two patients (32%) had inotropic reserve. During follow-up, 19 patients died, and 34 showed worsening of New York Heart Association class. The worst outcomes were observed in those patients with abnormal CFR and no inotropic reserve with high-dose dipyridamole. In a Cox model, mitral insufficiency (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.1 to 2.8), New York Heart Association class (HR 2.0, 95% CI 1.1 to 3.7), abnormal CFR (HR 2.8, 95% CI 1.0 to 8.5), wall motion score index at rest (HR 3.5, 95% CI 1.3 to 9.8), and the absence of inotropic reserve with high-dose dipyridamole (HR 2.3, 95% CI 1.06 to 5.1) were independent predictors of survival. In conclusion, in patients with IDC, CFR is often impaired. Reduced CFR and the absence of an inotropic response during vasodilator stress are additive in predicting a worse prognosis. [Copyright &y& Elsevier]

Cardiac resynchronization therapy (CRT) should be administered only after determining the suitability of the patient to the therapy. A case study is presented which shows that Color tissue Doppler (TD), sonography, assist in clarifying the need for a CRT. Standard Doppler and TD together test the viability of CRT. The author concludes by suggesting that electrophysiologists should consider new ultrasound methods in making a correct choice of CRT.

Background: The ultrasonic industry has recently produced echocardiographic Hand Held Devices (miniaturized, compact and battery-equipped echocardiographic systems). Their potential usefulness has been successfully assessed in a wide range of clinical conditions. The aim of the study was to verify if the routine use of a basic model of echocardiographic Hand Held Device (HHD) could be an important diagnostic tool during outpatient cardiologic consulting or in non-cardiologic hospital sections. Methods: 87 consecutive patients were included in this study; they underwent routine physical examination, resting ECG and echocardiographic evaluation using a basic model of HHD performed by trained echocardiographists; the cardiologist, whenever possible, formulated a diagnosis. The percentage of subjects in whom the findings were judged reasonably adequate for final diagnostic and therapeutic conclusions was used to quantify the "conclusiveness" of HHD evaluation. Successively, all patients underwent a second echocardiographic evaluation, by an examiner with similar echocardiographic experience, performed using a Standard Echo Device (SED). The agreement between the first and the second echocardiographic exam was also assessed. Results: Mean examination time was 6.7 ± 1.5 min. using HHD vs. 13.6 ± 2.4 min. using SED. The echocardiographic examination performed using HHD was considered satisfactory in 74/87 patients (85.1% conclusiveness). Among the 74 patients for whom the examination was conclusive, the diagnosis was concordant with that obtained with the SED examination in 62 cases (83.8% agreement). Conclusion: HHD may generally allow a reliable cardiologic basic evaluation of outpatient or subjects admitted to non-cardiologic sections, more specifically in particular subgroups of patients, with a gain in terms of time, shortening patient waiting lists and reducing healthy costs. [ABSTRACT FROM AUTHOR]

Endomyocardial fibrosis (Loeffler's endocarditis) is the main cause of poor outcome in Hyper Eosinophilic Syndrome (HES) and Eosinophilic Leukemia (EL). Reversion of the cardiac damage has been seldom reported, and thrombi can superimpose on infiltrated walls, originating oembolic complications. The tyrosine kynase inhibitor imatinib has been recently employed in patients affected by HES or EL, with impressive results. We have treated with imatinib a young patient affected by Loeffler's endocarditis during EL. Loeffler's endocarditis was studied by transthoracic Doppler echocardiography with and without the contrast agent SonoVue. Cytogenetics, FISH and molecular analysis showed the presence of the FIP1L1/PDGFRA fusion gene, recently detected in a majority of HES patients. Standard echocardiography revealed a large infiltration of the apical region, with apparently pedunculate corpora floating in the LV chamber; after SonoVue injection, a thick endo-myocardial infiltration involving papillary muscles and tendinous chords appeared, which simulated mobile thrombi at standard echography. Treatment with low dose imatinib caused rapid regression of both eosinophilic proliferation and endomyocardiopathy. The fusion gene FIP1L1-PDGFRA was found significantly decreased after a few months of treatment. Using a contrast echocardiographic approach, we demonstrated the non-thrombotic origin of the "in plus" image in our patient and its rapid resolution following imatinib treatment. Imatinib is an excellent candidate for first line treatment of Loeffler's endocarditis, especially when the FIP1L1/PDGFA fusion gene is detected. [ABSTRACT FROM AUTHOR]