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Accurate diagnosis of patent foramen ovale (PFO) and grading of right-to-left shunt severity by the standard method of transthoracic or transesophageal echocardiography (TEE) with bubble injection is often challenging. We proposed the novel Maximum Intensity T-Projection (MIP) Imaging method as a complementary or alternative approach for simplified diagnosis and grading of PFO. MIP Imaging represents the superimposition of all frames of an echocardiographic video onto one image. Thus, all bubbles passing from right to left atrium are represented in this single image. Diagnosis and quantification of PFO by MIP Images were compared to those obtained by standard echocardiographic methods, using the same echocardiography video loops. We applied the MIP Imaging approach to 122 echo examinations (75% of them TEE studies), performed to rule out PFOs. The average time needed to manually analyze video loops taken during bubble injection was 102 ± 52 s vs. less than 1 s using the MIP Imaging method. There was good concordance between the conventional echo method and MIP Imaging in the diagnosis and quantification of PFOs. MIP Imaging for diagnosis and quantification of PFOs was much less time consuming than the classical method and at least as accurate as the classical method. Thus MIP Imaging may be used initially as an adjunct method for PFO diagnosis and quantification and may eventually replace the classical method.

Dobutamine stress echocardiography is an alternative method to exercise stress echocardiography for the evaluation of ischemia. Recently, the novel speckle tracking imaging derived parameter, myocardial work index, was suggested for the evaluation of cardiac performance and was evaluated during exercise stress echocardiography. In this study, we analyzed the effect of dobutamine on myocardial work index variables during normal dobutamine stress echocardiography. Echocardiography examinations of patients with normal dobutamine stress echocardiography were collected and underwent off-line speckle tracking imaging analysis. Myocardial work index parameters were calculated at each dose of dobutamine and compared. 286 patients underwent dobutamine stress echocardiography during the study period. 102 patients were excluded due to pre-existed coronary artery disease or ischemia at dobutamine stress echocardiography. 65 patients were excluded due to suboptimal image quality unsuitable for speckle tracking imaging analysis. The remaining 119 patients with normal results were included. The global work index decreased from 2393.3 to 1864.7 mmHg%, p

Until recently, diagnosis of intramyocardial dissecting hematoma (IDH) was performed during necropsy or at surgery. During the recent years, echocardiography has permitted clinical suspicion, which usually needed confirmation with magnetic resonance imaging (MRI). In this study, we tried to define clinical and imaging features of IDH and predictors of mortality. We searched the literature for proven cases of IDH and analyzed them together with 2 of our cases. A total of 40 cases of IDH (2 our original and 38 literature cases) were included. Mean age was 60. In 32 cases, IDH was a complication of myocardial infarction (MI), in 66% anterior, a mean time from symptoms to diagnosis was 9 days. Thirty-eight % underwent surgery. In-hospital mortality was 23%. Multivariate analysis showed that the strongest independent predictor of mortality (42%) was EF 35%; in patients with age60, mortality risk was 44%; and in the presence of MI or late diagnosis (24 hours since symptoms started), mortality risk was 50%. In summary, IDH is a diagnostic challenge. A high level of suspicion is needed for prompt diagnosis. Management of these patients is based on individual clinical and imaging parameters. Low EF, age 60, and late diagnosis, all are predictors of in-hospital mortality.

The output settings of echocardiographic systems should be set to the full (original) frame rate and lossless compression (e.g., run-length encoding) in order to transmit echocardiographic videos so that they retain their original quality. In addition, monitors and display cards of echocardiography systems and workstations should be able to support an adaptive refresh rate for displaying video at an arbitrary frame rate, including a high frame rate (90+ fps) without dropping frames and preserving the original frame duration. Currently, the only available option for echocardiography monitors is 144-165 Hz (or higher) based on adaptive frame rate G-Sync or FreeSync technology monitors. These monitors should be accompanied by compatible display cards. Echocardiography systems and workstation video playback software should support G-Sync or FreeSync adaptive frame rate technology to display echocardiography videos at their original frame rates without the effects of jitter and frame drops. Echocardiography systems should support an online display of the videos on the workstations during acquisition with the original quality. The requirements for web-based workstations are the same as for desktops workstations. Hospital digital networks should provide transmission and long-term archiving of the echocardiographic videos in their original acquisition quality.

Objectives Exercise stress echocardiography is a widely used modality for the diagnosis and follow-up of patients with coronary artery disease. During the last decade, speckle tracking imaging has been used increasingly for accurate evaluation of cardiac function. This work aimed to assess speckle-tracking imaging parameters during nonischemic exercise stress echocardiography. Methods During 2011 to 2014 we studied 46 patients without history of coronary artery disease, who completed exercise stress echocardiography protocol, had normal left ventricular function, a nonischemic response, and satisfactory image quality. These exams were analyzed with speckle-tracking imaging software at rest and at peak exercise. Peak strain and time-to-peak strain were measured at rest and after exercise. Clinical follow-up included a telephone contact 1 to 3 years after stress echo exam, confirming freedom from coronary events during this time. Results Global and regional peak strain increased following exercise. Time-to-peak global and regional strain and time-to-peak strain adjusted to the heart rate were significantly shorter in all segments after exercise. Rest-to-stress ratio of time-to-peak strain adjusted to the heart rate was 2.0 to 2.8. Conclusions Global and regional peak strain rise during normal exercise echocardiography. Peak global and regional strain occur before or shortly after aortic valve closure at rest and after exercise, and the delay is more apparent at the basal segments. Time-to-peak strain normally shortens significantly during exercise; after adjustment to heart rate it shortens by a ratio of 2.0 to 2.8. These data may be useful for interpretation of future exercise stress speckle-tracking echocardiography studies.

A cardiac restrictive filling patterns are associated with unfavorable prognoses. Cardiac interventions may change the natural history of patients.To investigate the prevalence of restrictive filling pattern in routine echocardiographic examinations and their association with morbidity and mortality.The clinical and echocardiographic data of patients with newly diagnosed restrictive filling pattern were analyzed and summarized.Among 8000 patients who underwent an echocardiographic examination in our hospital in 2013, a restrictive filling pattern was identified in 256. Of these, 134 showed a restrictive filling pattern that was newly diagnosed. Mean age was 69 years. Hypertension, diabetes, and ischemic heart disease were found in 81%, 60%, and 53%, respectively. Left ventricular ejection fraction was 42% ± 16%. Severe valvular abnormalities were found in 18%. During follow-up (29 ± 15 months), 40% of patients died. The strongest predictor of mortality (73%) was moderate or more advanced aortic stenosis, P = 0.005. Renal failure was an important independent predictor of mortality (53%, P0.05). A very high E/E' ratio ≥ 20, was another independent mortality predictor (50%, P0.03). Patients who died were less likely to have undergone cardiac interventions than those who survived (26% vs. 45%, P0.03).Prevalence of restrictive filling among echocardiographic studies is 3.2%. In a half of these, the restrictive filling pattern is a new diagnosis. Patients who are diagnosed with a new restrictive filling pattern have higher mortality rates. Patients with restrictive filling should be evaluated thoroughly for possible coronary artery or valvular heart disease.

Accurate diagnosis of acute myocarditis is important for the prognosis and risk stratification of these patients. Cardiac magnetic resonance (CMR) has become a major modality for diagnosis of myocarditis, but not widely available. In this study, we tried to evaluate regional and global longitudinal strain by speckle tracking echocardiography in patients with acute inflammatory myocardial diseases in correlation with CMR. Patients with suspected acute myocarditis were recruited prospectively. Clinical diagnosis was established based on clinical, electrocardiographic, laboratory and conventional echocardiographic data. All patients underwent CMR and repeat echocardiographic examination within 24 h of CMR. Echocardiographic examinations were analyzed offline with speckle tracking imaging software. Thirty-two patients with acute perimyocarditis and myopericarditis were included. Mean age was 29 ± 8, 30 males. All patients presented with chest pain and an abnormal electrocardiogram, in 28 ST elevation was found. Troponin was elevated in 30 and was 0.7 ± 0.5 ng/ml. Creatine kinase was 487 ± 319 U. LVEF was 56 ± 5%. Wall motion abnormalities were present in postero-lateral (53%), and inferior wall (21%). Delayed enhancement on CMR was found in 29 patients. Echocardiographic EF based on speckle tracking imaging correlated with CMR calculated EF. There was a positive correlation between the amplitude of regional strain and delayed enhancement, r = 0.52. Sensitivity and specificity of regional strain for prediction of delayed enhancement was 85 and 73% respectively. Speckle tracking imaging can help in the diagnosis of acute myocarditis when CMR is not readily available. Speckle tracking imaging based EF correlates with CMR calculated LVEF and with global strain.

Acute severe mitral regurgitation (MR) is a serious medical condition. Whilst clear guidelines exist regarding the management of chronic MR, acute severe MR is usually treated on an individual basis. Currently, few data exist regarding acute MR in the era of primary coronary interventions (PCI). The present study included patients admitted to the Department of Cardiology during recent years with acute severe MR of different etiologies, and an analysis of these data in the light of previous investigations.The digital database of the present authors' hospital was searched for patients diagnosed with severe MR between 2008 and 2015. From a total of 228 patients identified, 19 with primary MR and 17 with secondary (functional) MR were admitted to the Department of Cardiology. The clinical data and outcome of these patients were analyzed.Among patients with MR due to acute myocardial infarction (MI), 13 had functional MR and six had MR due to mechanical complications, namely rupture of the papillary muscle or chordae tendineae. Among patients with MR not in the setting of MI, 13 had primary MR and four had functional MR. Patients with MR due to acute MI were more often in cardiogenic shock or had pulmonary edema and had a higher mortality. The strongest predictor of mortality was the presence of shock, followed by female gender, hypertension, age ≥68 years; previous MI and pulmonary edema were also predictors of mortality. In patients with acute MI and secondary MR, PCI to the culprit coronary artery was associated with a lesser degree of MR on follow up.Patients with severe MR are at high risk of in-hospital death. Patients with functional MR are likely to benefit from prompt PCI to the culprit artery, and for those with primary MR urgent surgery is life-saving.

In recent years cardioversion of atrial fibrillation has become a routine procedure, enabling symptomatic functional improvement in most cases. However, some patients develop complications after cardioversion. Identifying these individuals is an important step toward improving patient outcome.To characterize those patients who may not benefit from cardioversion or who may develop complications following cardioversion.We retrospectively analyzed 186 episodes of cardioversion in 163 patients with atrial fibrillation who were admitted to our cardiology department between 2008 and 2013 based on their clinical and echocardiographic data. Patients were divided into two groups: those with uncomplicated cardioversion, and those who developed complications after cardioversion.Of the 186 episodes, cardioversion was done in 112 men (60%) and 74 women (40%), P0.00001. Complications after cardioversion occurred in 25 patients (13%). These patients were generally older (72 vs. 65 years, P0.01), were more often diabetic (52% vs. 27%, P = 0.005), had undergone emergency cardioversion (64% vs. 40%, P = 0.01), had left ventricular hypertrophy (left ventricular mass 260 vs. 218 g, P = 0.01), had larger left atrium (left atrial volume 128 vs. 102 ml, P0.009), and more often died from complications of cardioversion (48% vs. 16%). They had significant mitral regurgitation (20% vs. 4%, P = 0.03) and higher pulmonary artery pressure (50 vs. 42 mm Hg, P0.02).People with complications after cardioversion tend to be older, are more often diabetic and more often have severe mitral regurgitation. In these patients, the decision to perform cardioversion should consider the possibility of complications.

Aims Lambl's excrescences (valvular strands) have been associated with an increased embolic risk. In previous studies, valvular strands have mostly been detected by transoesophageal echo (TEE). The current high-resolution echo systems allow better detection of valvular strands often even by transthoracic echocardiography (TTE). We attempted to determine the incidence of valvular strands during routine echo exams, TTE and/or TEE, and their relation to the cardiovascular risk factor, co-morbidities, and outcome. Methods and results Over 21 000 echo exams were performed at our hospital during 2008–12 and were searched for reporting of valvular strands. One hundred and fifty such studies were identified and the presence of valvular strands was confirmed. These patients were then evaluated for clinical characteristics, co-morbidities, and outcome, and compared with 150 age- and gender-matched patients without valvular strands. Incidence of valvular strands was maximal at age 61–70 (0.94%), and they were found more commonly in men than in women, 92 vs. 58, P < 0.00001. Valvular strands occurred more often on the aortic than on the mitral valve, 125 vs. 36, respectively, P < 0.00001, were more often associated with thickened or calcified aortic or mitral valve, and occupied the ventricular side of the aortic valve and the atrial side of the mitral valve, P < 0.00001. Embolic events occurred in 40 of the 150 patients with strands (27%). Valvular strands were not associated with increased mortality. Conclusion Valvular strands (Lambl's excrescences) appear not to affect life expectancy, but are often associated with embolic/cerebrovascular events, are more common in older patients, in men than in women, and are more commonly located on the aortic than on the mitral valve.

Exercise stress echocardiography is a widely used modality for the diagnosis and follow-up of patients with coronary artery disease. During the last decade, speckle tracking imaging has been used increasingly for accurate evaluation of cardiac function. This work aimed to assess speckle-tracking imaging parameters during nonischemic exercise stress echocardiography.During 2011 to 2014 we studied 46 patients without history of coronary artery disease, who completed exercise stress echocardiography protocol, had normal left ventricular function, a nonischemic response, and satisfactory image quality. These exams were analyzed with speckle-tracking imaging software at rest and at peak exercise. Peak strain and time-to-peak strain were measured at rest and after exercise. Clinical follow-up included a telephone contact 1 to 3 years after stress echo exam, confirming freedom from coronary events during this time.Global and regional peak strain increased following exercise. Time-to-peak global and regional strain and time-to-peak strain adjusted to the heart rate were significantly shorter in all segments after exercise. Rest-to-stress ratio of time-to-peak strain adjusted to the heart rate was 2.0 to 2.8.Global and regional peak strain rise during normal exercise echocardiography. Peak global and regional strain occur before or shortly after aortic valve closure at rest and after exercise, and the delay is more apparent at the basal segments. Time-to-peak strain normally shortens significantly during exercise; after adjustment to heart rate it shortens by a ratio of 2.0 to 2.8. These data may be useful for interpretation of future exercise stress speckle-tracking echocardiography studies.

Background Until recently acute inflammatory peri-myocardial syndromes have been associated with global rather regional left ventricular (LV) dysfunction. Recent advances in cardiac imaging with echocardiographic techniques and magnetic resonance imaging (MRI) permit comprehensive evaluation of global and regional LV function. Our study was aimed to assess regional LV function in 100 patients with acute perimyocarditis, and correlate these findings with the clinical presentation. Methods We report on 100 patients with acute perimyocarditis admitted during 2008–2011, in whom LV function was assessed by semi-quantitative wall motion score analysis on conventional echo. Long-term mortality and recurrent hospitalization were also assessed. Results Wall motion score in 100 patients with acute perimyocarditis demonstrated a significant predominance of regional wall motion abnormalities in the infero-postero-lateral LV wall. These data correspond well with speckle tracking results of a subgroup of these patients published earlier. Recent MRI data show frequent late enhancement of contrast in the infero-lateral region of the LV in patients with perimyocarditis. These observations were useful in re-classification of our patients into one of the following groups: pure or predominant pericarditis, and pure or predominant myocarditis. Over a mean period of 37 months, there was no mortality. Though recurrent hospitalizations were rather frequent, no significant differences were observed among groups. Conclusions Regional wall motion abnormalities in the infero-postero-lateral segments of the LV are frequent in patients with acute perimyocarditis. Detailed echocardiographic examination early in the course of the disease should become a major factor in the clinical differentiation among the various clinical presentations of acute inflammatory peri-myocardial syndromes. The long-term outcome of these patients appears to be benign, though recurrent hospitalizations are not infrequent.

Infective endocarditis is a serious disease with diverse clinical manifestations. The aim of this work was to analyse vegetations' size in relation to the clinical presentation, course of the disease, and the type of the microorganism. Methods and results A total of 146 patients with definite diagnosis of infective endocarditis were identified at Assaf Harofeh Medical Center during the years 1998 to 2010. Of them in 102 patients accurate vegetations' size was available. The data of these patients were collected and analysed. Twenty-three per cent of patients died, embolic complications occurred in 20.6% of patients, 16% of patients underwent surgery. Large vegetations (≥1 cm) occurred in 46 patients. Older patients (.60 years) with large vegetations had significantly increased risk of mortality 38% (P , 0.05). The strongest independent predictor of mortality was MRSA endocarditis (45%, P ¼ 0.01), followed by staphylococcal endocarditis associated with large vegetations (43%, P ¼ 0.01), or with older age (41%, P ¼ 0.01). The combination of staphylococcal endocarditis with large vegetations in the older patients was associated with mortality risk of 50%, P ¼ 0.02. Large vegetations were associated with high incidence of abscess formation (17%, P , 0.001), especially in combination with MRSA (27%, P ¼ 0.01), diabetes (25%, P , 0.02), and older age (30%, P ¼ 0.01). Conclusion Our results indicate that in patients with infective endocarditis the strongest predictor of mortality is MRSA infection, followed by staphylococcal infection especially in association with older age or with large vegetations. Older patients with large vegetations are also in significant risk of mortality. In these groups of patients surgery should be considered early.

Background The left ventricle is not homogenous and is composed of 3 myocardial layers. Until recently, magnetic resonance imaging has been the only noninvasive technique for detailed evaluation of the left ventricular (LV) wall. The aim of this study was to analyze strain in 3 myocardial layers using speckle-tracking echocardiography. Methods Twenty normal subjects and 21 patients with LV dysfunction underwent echocardiography. Short-axis (for circumferential) and apical (for longitudinal strain) views were analyzed using modified speckle-tracking software enabling the analysis of strain in 3 myocardial layers. Results In normal subjects, longitudinal and circumferential strain was highest in the endocardium and lowest in the epicardium. Longitudinal endocardial and mid layer strain was highest in the apex and lowest in the base. Epicardial longitudinal strain was homogenous over the left ventricle. Circumferential 3-layer strain was highest in the apex and lowest in the base. In patients with LV dysfunction, strain was lower, with late diastolic or double peak. Conclusions Three-layer analysis of circumferential and longitudinal strain using speckle-tracking imaging can be performed on a clinical basis and may become an important method for the assessment of real-time, quantitative global and regional LV function.