[Features of echocardiographic examination in patients with COVID-19].

Novel coronavirus infection has become one of urgent health problems of the 21st century. The associated disorders often result in the development of cardiopulmonary pathology, which requires creation of a new paradigm in diagnosis and treatment. Studies performed during the pandemic have demonstrated an important role of echocardiography (EchoCG) in diagnosis of right ventricular (RV) dysfunction in patients with respiratory insufficiency in COVID-19. The analysis of EchoCG parameters with a high prognostic value showed that in EchoCG, a special attention should be paid to right heart dimensions, RV contractility, and pulmonary artery (PA) systolic pressure, which are the most sensitive indexes of RV afterload and indirect markers of pulmonary disease severity. RV FAC can be recommended for evaluation of the RV systolic function as the most informative variable. Also, it was demonstrated that the RV longitudinal strain has an additional significance for early identification of signs of systolic dysfunction and risk stratification in patients with COVID-19. In addition to the effectiveness and reproducibility of this method, an important advantage of EchoCG is its availability, possibility of saving images for remote interpretation by other specialists, and tracking changes in morphological and functional parameters of the heart. Thus, the analysis of international literature suggests that EchoCG plays an important role in prediction of severe cardiopulmonary disorders and timely selection of the treatment for patients with COVID-19. For these reasons, EchoCG should serve as an additional method of clinical evaluation, particularly in persons with moderate or severe disease.

Diagnostic value of postsystolic shortening of the left ventricular myocardium assessed during speckle tracking stress echocardiography on the treadmill in patients with coronary artery disease.

Aim      To evaluate the diagnostic capacity of left ventricular (LV) postsystolic shortening (PSS) values obtained by speckle-tracking stress-echocardiography (stress-EchoCG) using a treadmill test in determining the functional significance of the degree of coronary artery (CA) stenosis.Material and methods  The study included 132 patients (80 men aged 65.0±9.3 years) with suspected or previously verified diagnosis of ischemic heart disease. Stress-EchoCG with the treadmill test was performed for all patients. Strain parameters were determined by two-dimensional speckle-tracking on gray-scale images before and after the exercise. Values of LV postsystolic index (PSI) and LV mean postsystolic time (PST) were calculated. Coronary angiography was performed for all patients. Patients were divided into 3 groups based on the severity of CA stenosis according to the G. G. Gensini score.Results LV PSS values at rest did not significantly differ between the patient groups. After completion of the exercise, the mean LV PSI was significantly higher for patients with pronounced CA stenosis than in the group without CA stenosis or with moderate CA stenosis: 8.9 %  [3.8; 10.7 %] vs. 3.8 % [2.2; 6.8 %] (p=0.012) and 3.4 %  [2.2; 6.2 %] (p=0.012), respectively. The mean LV PSI after completion of the exercise indicated the presence of pronounced CA stenosis with a sensitivity of 75 % and a specificity of 61 % (area under the curve, AUC, 0.74±0.06; р<0.001). After completion of the exercise, the mean LV PST was significantly greater for patients with pronounced CA stenosis than in the group without CA stenosis or with moderate CA stenosis: 27.4 [18.7; 34.7] ms vs. 18.4 [10.8; 26.5] ms (p=0.036) and 20.9 [14.2; 29.5] ms (p=0.036), respectively. The mean LV PST after completion of the exercise exceeding 23.5 ms suggests pronounced CA stenosis with a sensitivity of 71 % and a specificity of 65 % (AUC 0.69±0.06; p=0.004). A complex evaluation of the LV PSI, the LV local contractility disorder (LCD) index, the LV PST, and LV LCD index allows enhancement of the test sensitivity in diagnozing pronounced CA stenosis.Conclusion      Determination of LV PSS in speckle-tracking stress-EchoCG may be useful for evaluating the functional significance of the degree of CA stenosis to enhance the sensitivity of stress-EchoCG in patients with pronounced CA stenosis.

[Focus ultrasound for cardiology practice. Russian consensus document].

This document is a consensus document of Russian Specialists in Heart Failure, Russian Society of Cardiology, Russian Association of Specialists in Ultrasound Diagnostics in Medicine and Russian Society for the Prevention of Noncommunicable Diseases. In the document a definition of focus ultrasound is stated and discussed when it can be used in cardiology practice in Russian Federation.

[Left ventricular global function index as a predictor of adverse cardiovascular events in patients with acute coronary syndrome].

Aim      To evaluate the prognostic significance of the left ventricular global function index (LV GFI) in patients with acute coronary syndrome (ACS) using echocardiography (EchoCG).Material and methods             The LV GFI is an index that integrates LV cavity volumes, stroke volume, and myocardial volume. This study included 2169 patients with ACS (1340 (61.8%) men) aged 64.1±12.6 years from two observational multicenter studies, ORACLE I and ORACLE II. 1800 (83 %) cases were associated with increased concentrations of myocardial injury markers, including 826 (38.1 %) cases of ST segment elevation myocardial infarction (MI). The observation was started on the 10th day of clinical condition stabilization and lasted for one year. EchoCG was performed with evaluation of LV GFI, which was calculated as a ratio of LV stroke volume to LV global volume. The LV global volume was calculated as a sum of mean LV cavity volume (LV end-diastolic volume + LV end-systolic volume / 2) and LV myocardial volume.Results The main outcome of the study was all-cause death (n=193); recurrent coronary complications (n=253) were analyzed separately. The only EchoCG parameter indicating an adverse outcome during the one-year follow-up was a LV GFI decrease to below 22.6 % with a sensitivity of 72 % and a specificity of 60% (area under the curve, AUC=0.63). A LV GFI <22.6 % was an independent predictor of all-cause death (p=0.019) along with age (p=0.0001), history of MI (p=0.034), and presence of heart failure (HF) (p=0.044), diabetes mellitus (p=0.012), and peripheral atherosclerosis (p=0.001). The LV GFI <22.6 %, (p=0.044), heart rate upon discharge from the hospital (p=0.050), history of MI (p=0.006), presence of HF (p=0.014), and peripheral atherosclerosis (p=0.001) were also independent predictors for recurrent coronary complications. Decreased LV GFI was associated with the risk of fatal outcomes independent of the LV ejection fraction at baseline.Conclusion      In patients with ACS, the left ventricular global function index is an independent predictor for all-cause death and recurrent coronary complications and may be used for risk stratification.

Speckle Tracking Stress Echocardiography on Treadmill in Assessment of the Functional Significance of the Degree of Coronary Artery Disease.

Aim        To determine diagnostic capabilities of left ventricular (LV) global longitudinal systolic strain (GLSS) in stress echocardiography (stress-EchoCG) with a treadmill test for diagnosing the functional significance of the degree of coronary stenosis.Material and methods        The study included 121 patients (73 men aged 68.3±7.7 years) with suspected or previously diagnosed ischemic heart disease (IHD). Speckle-tracking stress-EchCG (method of tracking speckles on two-dimensional gray-scale ultrasonic images) with a treadmill test and coronarography was performed for all patients. The patients were divided into 3 groups based on the severity of coronary artery (CA) stenosis according to the Gensini scale.Results   LV GLSS at rest did not significantly differ between the study groups. After the exercise, LV GLSS was significantly lower in patients with pronounced CA stenosis than in patients without or with moderate CA stenosis (15.9±4.6 % vs. 20.6±3.7 % (p<0.001) and 19.6±3.0 % (p=0.003), respectively). Postexercise LV GLSS <16.9% suggested a pronounced CA stenosis with a sensitivity of 80% and a specificity of 70% (area under the curve, AUC, 0.76±0.06 at 95 % confidence interval, CI, 0.63-0.89; р<0.001). In the patient group without CA stenosis, LV GLSS showed a significant increase after completion of the exercise (from 19.1±3.1 to 20.6±3.7; p=0.04).Conclusion            Evaluation of LV GLSS and its dynamics in stress-EchoCG with a treadmill test may be promising in patients with IHD, since in most patients with pronounced CA stenosis, LV GLSS is reduced at baseline and further reduces in response to exercise. In patients without CA stenosis, LV GLSS increases after completing the exercise.

[Classification of stages of severe aortic stenosis based on the prevalence of extravalvular heart damage].

This thematic review focuses on recently proposed classification of stages in pronounced aortic stenosis based on the prevalence of extravalvular cardiac damage and its modified variant designed for asymptomatic patients. The review presents studies, which analyzed the predictive significance of the proposed classification. The use of this classification allows predicting the course of disease in patients with pronounced aortic stenosis in valve replacement. The classification is based on routinely used structural and functional echocardiographic signs with already proven predictive values with respect of adverse events in patients after aortic valve replacement. The review discusses limitations of the classification for pronounced aortic stenosis stages based on the prevalence of extravalvular cardiac damage.

[The role of diastolic transthoracic stress echocardiography with incremental workload in the evaluation of heart failure with preserved ejection fraction: indications, methodology, interpretation. Expert consensus developed under the auspices of the National Medical Research Center of Cardiology, Society of Experts in Heart Failure (SEHF), and Russian Association of Experts in Ultrasound Diagnosis in Medicine (REUDM)].

Diagnosis of heart failure with preserved ejection fraction (HFpEF) is associated with certain difficulties since many patients with HFpEF have a slight left ventricular diastolic dysfunction and normal filling pressure at rest. Diagnosis of HFpEF is improved by using diastolic transthoracic stress-echocardiography with dosed exercise (or diastolic stress test), which allows detection of increased filling pressure during the exercise. The present expert consensus explains the requirement for using the diastolic stress test in diagnosing HFpEF from clinical and pathophysiological standpoints; defines indications for the test with a description of its methodological aspects; and addresses issues of using the test in special patient groups.

[Echocardiography in the Assessment of Postsystolic Shortening of the Left Ventricle Myocardium of the Heart].

Echocardiography allows evaluating left ventricular (LV) myocardial contractility; however, the visual assessment of contractility is subjective and requires considerable experience. Modern technologies for assessment of LV myocardial contractility, such as tissue Doppler and speckle-tracking echocardiography, provide quantitative estimation of various parameters of myocardial strain, including the LV postsystolic shortening. Several studies have demonstrated the value of postsystolic shortening for evaluation of myocardial ischemia and "ischemic memory" in patients with cardiovascular diseases. This review analyzes experimental and clinical studies that addressed LV postsystolic shortening.

[Myocardial work in assessment of left ventricular systolic function].

This review focuses on a new method for noninvasive, complex evaluation of left ventricular (LV) systolic function using an echocardiography-based technology of computing indexes of myocardial performance by construction of pressure-deformation curves. Since this new method accounts for the effect of afterload on myocardial contractility, the article presents data demonstrating advantages of the evaluation of LV myocardial performance over the speckle-tracking echocardiography and other methods in diagnostics of several diseases. The review provides a description of this method and its advantages and limitations. The authors analyzed results of major studies on evaluation of LV performance. Prospects of implementation and practical use of the method are discussed in the aspects of diagnostics of cardiovascular diseases and risk stratification for different groups of patients.

[Contrast Echocardiography with a Quantitative Assessment of Myocardial Perfusion in Patients with Previous Q-Wave Myocardial Infarction].

OBJECTIVE:  To assess possibilities of contrast echocardiography with quantitative evaluation of myocardial perfusion in patients with previous Q-wave myocardial infarction. MATERIALS AND METHODS:  We examined 15 men (42-72 years) with coronary artery disease and previous myocardial infarction, and pathological Q-wave in 2 or more ECG leads. Quantification of left ventricular (LV) myocardial perfusion was performed by calculating of the ultrasound signal tissue intensity from the LV myocardial segments during intravenous administration of the ultrasound contrast agent (SonoVue). The Tissue intensive curve (TIC) analysis was done in the end-diastolic period before and on the fourth cardiac cycle after applying the "flash". Changes in the intensity of myocardial perfusion (A4, dB) was estimated as the difference between the intensity values of the ultrasound signal in the myocardial segment during the period of filling the contrast bubbles on 4-th cardiac cycle and before applying the «flash¼. Measurements were performed in 16 segments of the LV. A contrast cardiac magnetic resonance imaging (contrast MRI) was performed in order to verify the LV scar. Fibrotic changes of 50% of myocardial wall or more were considered as signs of post-infarction scar. RESULTS: The dynamics of perfusion and scar presence in 240 myocardial segments were evaluated. The median A4 was 1 dB (range, -20 to 10 dB). MRI revealed 82 of 240 segments with the large-focal scar. The effectiveness of the diagnostic test (quantitative contrast perfusion echocardiography with A4 assessment) to detect myocardial scar was investigated. ROC curve analysis showed good model quality, AUC=0,787 (0,730-0,837); sensitivity 82.9%; specificity 75.3%; p<0.01. The cut-off point for A4 was -1. CONCLUSION:  A new approach to quantitative contrast assessment of perfusion allows to identify perfusion disorders with high efficiency in patients with previous Q-wave myocardial infarction.

[Phenomenon of unstable tcpO2 level in transcutaneous oximetry in patients with diabetes mellitus]. / Fenomen nestabil'nogo urovnia tcpO2 pri transkutannoi oksimetrii u bol'nykh sakharnym diabetom.

The back of the foot is a standard region for measuring transcutaneous oxygen tension (tcpO2) with a reliably determined threshold of ischaemia, but such measurement reflects blood supply of only a portion of angiosomes of the foot. Determining the reference values of tcpO2 in other regions of the lower extremity is of current importance. However, measuring the tcpO2 level on the plantar surface and in some other regions not uncommonly reveal a phenomenon of its steady decrease instead of formation of a plateau. The purpose of the present study was to analyse the frequency of the phenomenon of a steady decrease in ptcO2 level while performing transcutaneous oximetry in various zones of the lower extremity. We retrospectively analysed the results of a total of 160 measurements of tcpO2 in 35 patients with diabetes mellitus. The patients' mean age amounted to 68 (47-87) years, with the duration of diabetes mellitus averaging 14 (1-24) years. The male-to-female ratio was 60:40. Seventy-seven percent of patients had foot ulcers/wounds, 34% of patients had a history of previously endured revascularization. The examination was carried out in the dorsal, plantar, medial plantar regions of the foot, on the medial surface of the crus and in the subclavian region, using the TCM 400 monitoring device (Radiometer, Denmark). The measurements were performed by an experienced operator in strict accordance with the manufacturer's recommendations. We evaluated the average value of tcpO2 between the 15th and 19th minutes of measurement and the peculiarities of the tpcO2 curve (plateau/increase/decrease of the value) within this time interval. The mean tcpO2 value in the medial plantar region was significantly higher than that on the back of the foot: 34 (3-70) versus 22 (1-59) mm Hg, p=0.003. A portion of measurements demonstrated a steady decrease in the tpcO2 during the measurement up to the 40th minute. Complying with the stable plateau phase criteria we had developed were 92% of measurements in the subclavian region, 100% - in the middle third of the crus, 76% - on the back of the foot, 77% - in the medial plantar region and 43% - on the plantar surface of the foot. CONCLUSIONS: 1) the revealed phenomenon of a steady decrease of tcpO2 in some patients needs to be taken into consideration in clinical practice and deserves further study; 2) the nature of this phenomenon is unclear, with a possible effect of skin creams on the results of the measurements; 3) it is advisable to include into the functions of the devices for transcutaneous oximetry an algorithm for confirmation of the true phase of the plateau and calculation of the mean tcpO2 value for a chosen period; 4) despite the need for measurement of tcpO2 in the 'alternative zones' it is necessary to thoroughly study the reliability of the data in these zones and to determine the normal values of the parameter separately for each of them.

[Intracardiac and Pulmonary Cement Embolism after Percutaneous Vertebroplasty].

The article presents a clinical case of embolism with bone cement of the right ventricle of the heart and pulmonary artery after percutaneous vertebroplasty in a patient aged 63 years. According to the results of a comprehensive examination using ultrasound and x-ray methods, three foreign bodies were found: in the right ventricle cavity, in the trunk of the pulmonary artery, in the branches of the left pulmonary artery. Considering the stable condition, normal blood oxygen saturation, the lack of influence of formations on intracardiac hemodynamics, it was decided to refrain from surgery, since the risk of intervention exceeded the possible benefit. Conservative treatment tactics and dynamic observation were chosen. The literature data on the frequency of such events and tactics of management of these patients are presented.

[Significance of Electrocardiography in Patients With Arterial Hypertension].

The article is devoted to the analysis of significance of electrocardiography for assessment of anatomical-functional measurements of the heart in patients with arterial hypertension. Modern methods of calculation of the left ventricular myocardial mass are presented with corresponding recommended normal ranges values. The article contains discussion of variants of left ventricular remodeling, significance of functional indexes characterizing the state of systolic and diastolic function of the heart, parameters of deformation of the left ventricle for diagnosis of causes of left ventricular hypertrophy, as well as for assessment of prognosis.

Value of Contrast-Enhanced Echocardiography of Left Cardiac Chambers for Clinical Practice.

This literature review in devoted to the potential of application of contrast-enhanced echocardiography (CEE) for assessment of structure and function of left cardiac chambers. It contains based on current recommendations discussion of main indications for CEE and analysis of its possibilities in evaluation of perfusion of the left ventricular myocardium, detection of myocardial ischemia, and assessment of myocardial viability. Data on CEE safety and possible side effects associated with the use of ultrasound contrasts are also presented.

Current Echocardiographic Techniques for Evaluation of the Right Ventricle.

The review is dedicated to the new echocardiographic techniques in the assessment of right ventricular (RV) function, such as twodimensional speckle tracking and determining the RV volume by a three-dimensional model. Subclinical changes in RV function are of great importance for the diagnosis and assessment of prognosis of multiple cardiovascular as well as non-cardiac pathologies. Two-dimensional speckle tracking allows to assess longitudinal strain of the RV myocardium and to detect pathological changes before their clinical manifestations. Three-dimensional echocardiography enables calculation of the RV ejection fraction, what was not possible before with the use of ultrasound. Currently, both methods are promising for a comprehensive assessment of RV function.

[The Evaluation of Left Ventricular Diastolic Function by Echocardiography in Patients With Preserved Ejection Fraction].

OBJECTIVE: to compare non-invasive evaluation of left ventricular (LV) diastolic function (DF) by echocardiography using algorithms of the 2009 and 2016 American Society of Echocardiography (ASE)/European Association of Echocardiography (EAE, now European Association of Cardiovascular Imaging [EACVI]) Recommendations. MATERIAL AND METHODS: The study included 100 patients with sinus rhythm and preserved left ventricular (LV) ejection fraction (EF). In all patients LV DF was assessed using both algorithms. In accordance with the ASE/EAE 2009 algorithm pulsed-wave tissue Doppler early diastolic velocity (e velocity) at lateral and septal basal regions of mitral annulus, as well as left atrial maximum volume index were evaluated. In accordance with the ASE/EACVI 2016 algorithm for judging the presence of LV diastolic dysfunction (DD), in addition to the two above-described criteria, E/e ratio and peak velocity of tricuspid regurgitation were analyzed. In the presence of 1 and more or equal 3 criteria LVDF was classified as normal and DD, respectively. If 2 criteria were detected result was considered as indeterminate. RESULTS: In 70% of patients in accordance with the ASE/EACVI 2016 algorithm DF was evaluated with 4 and in 100% - with 3 proposed criteria. The reason for using only 3 criteria was inadequate imaging of tricuspid regurgitation flow by continuous wave Doppler. Use of ASE/EACVI 2016 compared with the ASE/EAE 2009 algorithm in patients with normal LV EF led to a significant decrease of the number of patients with LV DD (13 vs. 27%, respectively; <0.05). The main reason for this redistribution was lowering of the cutoff value of annular e septal velocity from 8 (2009 algorithm) to 7 cm/sec (2016 algorithm). Frequency of indeterminate results with the use of 2016 algorithm was 2 times less than with the use of 2009 algorithm (15 vs. 36%, respectively; p<0.001). CONCLUSION: In patients with preserved LVEF the use of ASE/EACVI 2016 algorithm led to redistribution of data of evaluation of LVDF by echocardiography towards reduction of the number of patients with LV DD and with indeterminate results.

[Problems and Perspectives of Echocardiographic Evaluation of the Left Ventricular Diastolic Function].

This literature review is devoted to noninvasive evaluation of the left ventricular (LV) diastolic function by echocardiography with special stress on existing problems of detection of LV dysfunction by Doppler echocardiography of transmitral blood flow. Basing on existent algorithms one often cannot clearly judge whether LV dysfunction is present even when such methods are used as assessment of blood flow in pulmonary veins, transmitral blood flow during the Valsalva maneuver, etc. The review also contains discussion and analysis of newly suggested Doppler echocardiography based algorithms of detection of LV diastolic dysfunction and estimation of its severity (two-dimensional deformation of left atrial walls, three-dimensional echocardiography and three-dimensional deformation of the left ventricle).

[Current Echocardiographic Techniques for Evaluation of the Right Ventricle].

The review is dedicated to the new echocardiographic techniques in the assessment of right ventricular (RV) function, such as two-dimensional speckle tracking and determining the RV volume by a three-dimensional model. Subclinical changes in RV function are of great importance for the diagnosis and assessment of prognosis of multiple cardiovascular as well as non-cardiac pathologies. Two-dimensional speckle tracking allows to assess longitudinal strain of the RV myocardium and to detect pathological changes before their clinical manifestations. Three-dimensional echocardiography enables calculation of the RV ejection fraction, what was not possible before with the use of ultrasound. Currently, both methods are promising for a comprehensive assessment of RV function.

[Diagnostic Possibilities of Speckle-Tracking Echocardiography].

The review is devoted to merits and demerits of a new method of assessment of condition of the heart - speckle-tracking echocardiography. Speckle-tracking echocardiography is a perspective method allowing to register disorders of both global and regional contractile motion.

[Chiari network and pulmonary embolism].

We present the case of a patient with acute pulmonary embolism, Chiari network thrombus, and deep vein thrombosis in lower extremities. Chiari networks are present in the right atrium in a minority of population and are usually of no clinical significance. On the other hand it may be associated with such pathological changes as patent foramen ovale, intraatrial thrombus, or atrial arrhythmias. In our case thrombus was trapped by a Chiari's network.