Upright treadmill vs. semi-supine bicycle exercise echocardiography to provoke obstruction in symptomatic hypertrophic cardiomyopathy: a pilot study.

Aims: Recent findings regarding hypertrophic cardiomyopathy (HCM) haemodynamics emphasized the relationship between symptoms, left ventricular outflow tract obstruction (LVOTO), and the preload condition as the venous return level. As various types of exercises have different effects on peripheral vascular beds, this study sought to compare upright treadmill exercise echocardiography (EE) to semi-supine bicycle EE in maximum provoked LVOTO in HCM patients. Methods and results: Semi-supine bicycle and upright treadmill EE were prospectively performed in HCM patients with New York Heart Association functional Class II. Maximal LVOT gradient at rest in the supine and standing position, and during Valsalva manoeuvre, LVOT gradients of both semi-supine bicycle and treadmill exercise at peak and post-exercise, maximal exercise levels, and blood pressure adaptation were recorded. One patient was excluded for not sufficient image quality during treadmill. We studied 22/23 patients (mean age: 54.9 ± 12.3 yrs; 55% male). The supine position at rest displayed a mean maximal LVOT gradient of 46.1 ± 44.8 mmHg, which increased to 51.6 ± 41.2 mmHg during Valsalva (P = 0.066), and to 55.1 ± 37.8 mmHg in the standing position (P = 0.053). Mean maximal peak exercise LVOT gradient with semi-supine bicycle was significantly lower than in treadmill EE (54.6 ± 38.2 mmHg vs. 87.5 ± 42.1 mmHg, respectively, P < 0.01). Among these patients, 41% exhibited LVOT gradient ≥ 30 mmHg at rest. Moreover, 41% exhibited LVOT gradient ≥ 50 mmHg during Valsalva, 55% in resting standing position, 41% at peak semi-supine bicycle exercise, 91% at peak treadmill exercise, and 95% in standing position during treadmill recovery period. Conclusion: This pilot study may suggest treadmill's greater value compared to semi-supine bicycle EE for determining maximum LVOT gradient in HCM.

Impact of Afterload Increase on Left Ventricular Myocardial Deformation Indices.

BACKGROUND: Left ventricular (LV) afterload could be associated with reduced myocardial contractility. The aim of this study was to evaluate the relative impact of increased afterload on LV myocardial deformation indices in chronic aortic constriction, with regard to hypertrophy, myocardial fibrosis, and mitochondrial function, and to differentiate acute versus chronic afterload effect. METHODS: Young pigs underwent aortic banding (n = 11) or sham (n = 7) operations. Nineteen weeks later, LV morphology and systolic function, including myocardial deformation, were assessed by echocardiography before and after banding release or acute aortic constriction (in the sham group). After the animals were euthanized, mitochondrial function and LV interstitial fibrosis were assessed. RESULTS: The chronic banding group (n = 8) presented with significant LV hypertrophy compared with the sham group (n = 7), and longitudinal strain (LS) was significantly altered (16.9 ± 0.7% vs 20.3 ± 0.7%, P = .001) while circumferential, radial strain, and ejection fraction were not. LS abnormalities were situated mostly on the basal and mid segments and on the septal wall. There was also significantly more myocardial fibrosis in the chronic banding group compared with the sham group, while mitochondrial function was preserved. The relative contributions of hypertrophic and fibrotic remodeling and of afterload to alter global LS were 62%, and 38%, respectively. Acute aortic banding also significantly altered LS. The ratio of LS to septal wall thickness enabled differentiation between chronic and acute afterload increase (1.9 ± 0.2 in the chronic group vs 2.9 ± 0.3 in the acute group, P = .001). CONCLUSIONS: LS is susceptible to both hypertrophic and fibrotic remodeling and afterload increase, particularly on the basal and mid LV segments of the septum. The ratio of LS to septal wall thickness enables differentiation of acute from chronic afterload LS alteration.

Drug-induced aortic valve stenosis: An under recognized entity.

BACKGROUND: We have been intrigued by the observation that aortic stenosis (AS) may be associated with characteristic features of mitral drug-induced valvular heart disease (DI-VHD) in patients exposed to valvulopathic drugs, thus suggesting that beyond restrictive heart valve regurgitation, valvulopathic drugs may be involved in the pathogenesis of AS. METHODS: Herein are reported echocardiographic features, and pathological findings encountered in a series of patients suffering from both AS (mean gradient >15mmHg) and mitral DI-VHD after valvulopathic drugs exposure. History of rheumatic fever, chest radiation therapy, systemic disease or bicuspid aortic valve disease were exclusion criteria. RESULTS: Twenty-five (19 females, mean age 62years) patients having both AS and typical features of mitral DI-VHD were identified. Mean transaortic pressure gradient was 32+/-13mmHg. Aortic regurgitation was ≥ mild in 24 (96%) but trivial in one. Known history of aortic valve regurgitation following drug initiation prior the development of AS was previously diagnosed in 17 patients (68%). Six patients underwent aortic valve replacement and 3 both aortic and mitral valve replacement. In the 9 patients with pathology analysis, aortic valvular endocardium was markedly thickened by dense non-inflammatory fibrosis, a characteristic feature of DI-VHD. CONCLUSION: The association between AS and typical mitral DI-VHD after valvulopathic drug exposure may not be fortuitous. Aortic regurgitation was usually associated to AS and preceded AS in most cases but may be lacking. Pathology demonstrated the potential role of valvulopathic drugs in the development of AS.

Morphological and functional abnormalities pattern in hypertrophy-free HCM mutation carriers detected with echocardiography.

To evaluate if morphological or functional abnormalities could be detected with echocardiography in hypertrophic myocardiopathy (HCM) mutation carriers without left ventricle (LV) hypertrophy has developed. HCM is caused by extensive genes mutations found in two-third of patients. Because screening for carriership of a large population is unreasonable, identification of asymptomatic subjects is confined to the use of imaging such as echocardiography, by which subtle abnormalities can be detected. Comprehensive echocardiographic studies including morphological and functional assessment were performed. Asymptomatic HCM mutation carriers without hypertrophy (Phe-/Gen+, n = 14), and HCM patients (Phe+/Gen+, n = 17) were compared with healthy control subjects (n = 32) in a prospective design. Compared to controls, septum thickness was significantly higher with an elongated mitral valve in both groups. Thickened LV muscular band (LVMB) are more likely found in Phe-/Gen+ and Phe+/Gen+. The thickness of LVMB was higher in the Phe-/Gen+ versus controls. A LVMB thickness ≥3.6 mm was associated with HCM mutation carriership (sensitivity: 76.9 %, specificity: 94.1 %). The regional strain was significantly impaired in the basal segments of the septum in the Phe-/Gen+. The GLS was significantly impaired in the Phe+/Gen+ (-16.4 % ± 2.9 vs. -21.4 % ± 2.3 in control subjects, p = 0.01). Mitral A wave velocity, septal E/e', averaged E/e' were increased in both groups. E/A ratio was significantly lower in Phe+/Gen+. Morphological and functional abnormalities in hypertrophy-free HCM mutation carriers could be detected with echocardiography. Anomalous thickened LVMB could be representing a morphological marker for the HCM disease without overt hypertrophy has developed or in patients with an ambiguous diagnosis.

close: Closure of patent foramen ovale, oral anticoagulants or antiplatelet therapy to prevent stroke recurrence: Study design.

RATIONALE: Currently available data do not provide definitive evidence on the comparative benefits of closure of patent foramen ovale, oral anticoagulants and antiplatelet therapy in patients with patent foramen ovale-associated cryptogenic stroke AIM: To assess whether transcatheter patent foramen ovale closure plus antiplatelet therapy is superior to antiplatelet therapy alone and whether oral anticoagulant therapy is superior to antiplatelet therapy, for secondary stroke prevention in patients aged 16 to 60 years with a large patent foramen ovale or a patent foramen ovale associated with an atrial septal aneurysm, and an otherwise unexplained ischaemic stroke or retinal ischaemia. SAMPLE SIZE: Six hundred and sixty-four patients were included in the study. METHODS AND DESIGN: CLOSE is an academic-driven, multicentre, randomized, open-label, three-group, superiority trial with blinded adjudication of outcome events. The trial has been registered with Clinical Trials Register (Clinicaltrials.gov, NCT00562289). Patient recruitment started in December 2007. Patient follow-up will continue until December 2016. Expected mean follow-up = 5.6 years. STUDY OUTCOMES: The primary efficacy outcome is the occurrence of fatal or nonfatal stroke. Safety outcomes include fatal, life-threatening or major procedure- or device-related complications and fatal, life-threatening or major haemorrhagic complications. DISCUSSION: CLOSE is the first specifically designed trial to assess the superiority of patent foramen ovale closure over antiplatelet therapy alone and the superiority of oral anticoagulants over antiplatelet therapy to prevent stroke recurrence in patients with patent foramen ovale-associated cryptogenic stroke.

Efficacy and follow-up of transcatheter aortic valve implantation in patients with radiation-induced aortic stenosis.

OBJECTIVE: To investigate transcatheter aortic valve implantation (TAVI) feasibility, effectiveness and safety in radiation-induced aortic valve stenosis cases. METHODS: 198 consecutive patients referred for TAVI were prospectively enrolled. They were divided into two groups: patients with a history of chest radiation therapy with suspected radiation-induced valvular disease (RXT) and others with suspected degenerative aortic valve stenosis (NRXT). Procedural, early and mid-term clinical outcomes were compared. RESULTS: Of the 198 patients enrolled in our study, 9.6% qualified for inclusion in the RXT group. A comparison of baseline characteristics revealed that patients with RXT were younger than patients with NRXT (68.3 vs 82.5 years; p<0.05) and exhibited a lower surgical risk score (Euroscore: 7.1% vs 21.8%; p<0.05) and a higher frequency of hostile thorax and porcelain aorta (52.6% vs 28.5%; p<0.05; 63.2% vs 10.6%; p<0.05, respectively). In both groups, the implantation success rate was high and the 30-day safety end point acceptable (RXT: 94.7% and 83.3%; NRXT: 93.9% and 75.6%, respectively). At 6 months, overall mortality was significantly lower in the RXT group (0% vs 18%; p=0.048). CONCLUSIONS: In patients suffering from radiation-induced aortic valve stenosis and contraindicated for surgery, TAVI is a promising approach, with high feasibility, acceptable risk, low mortality and high clinical effectiveness at mid-term follow-up.

Eosinophilic cardiac disease: Molecular, clinical and imaging aspects.

Eosinophilia may be responsible for cardiac injuries of widely varying severity, from acute myocarditis to endomyocardial fibrosis. In this review, we present both the molecular mechanisms that are responsible for these lesions and their clinical and paraclinical aspects. Numerous aetiologies can lead to severe eosinophilia, but these are mainly represented by hypersensitivity reactions, rheumatological diseases and hypereosinophilic syndrome. Because cardiac involvement may be extremely severe, echocardiography should be always performed in the context of eosinophilia and appropriate therapeutics should be started rapidly in order to limit the progression of the disease.

Comparison of resting and exercise echocardiographic parameters as indicators of outcomes in hypertrophic cardiomyopathy.

BACKGROUND: Both resting echocardiography and exercise echocardiography produce variables predictive of outcomes in patients with hypertrophic cardiomyopathy (HCM). The aim of the present study was to compare the respective value of resting and exercise echocardiographic parameters as indicators of clinical outcomes in patients with HCM. METHODS: Resting and exercise echocardiography was performed prospectively in patients with HCM evaluated at the HCM Competence Center of Bordeaux and followed up every 6 months. A composite cardiac event was defined. RESULTS: One hundred fifteen patients (mean age, 51.9 ± 15.2 years; 66% men) were evaluated by echocardiography and followed for a mean period of 19 ± 11 months. Eighteen patients (16%) reached the composite end point, including 10 progressions to New York Heart Association functional class III or IV. On rest echocardiography, in patients with cardiac events during follow-up, left atrial volume index was significantly more increased, as were lateral E/E' ratio and left ventricular outflow tract (LVOT) gradient, whereas mean global longitudinal strain (GLS) expressed in magnitude (14.0 ± 2.6% vs 17.0 ± 3.6%, P < .001) and peak velocities at the lateral annulus by Doppler tissue imaging were significantly reduced compared with patients without events. At peak exercise, patients who developed cardiac events were characterized by lower ejection fractions and greater LVOT gradients (76 ± 55 mm Hg vs 40 ± 40 mm Hg, P < .002). A Cox backward-entry selection model revealed that GLS ≤ 15% at rest and LVOT gradient ≥ 50 mm Hg at peak exercise were independently associated with an increased risk for poor outcomes in patients with HCM (hazard ratios, 3.8 [P = .017] and 3.3 [P = .028], respectively). On Kaplan-Meier survival analyses, peak exercise LVOT gradient evaluation showed additive value to predict outcomes, particularly in patients with rest GLS > 15% (log-rank P = .001) and despite a resting LVOT gradient ≥ 30 mm Hg (log-rank P = .001). CONCLUSION: This study supports the value of resting GLS and of peak LVOT gradient, measured during exercise echocardiography, in identifying patients with HCM at increased risk for adverse events during follow-up.

Clinical and imaging description of the Maron subtypes of hypertrophic cardiomyopathy.

Longitudinal strain analysis enables early detection of left ventricular (LV) contraction abnormalities in patients with preserved ejection fraction. Hypertrophic cardiomyopathy (HCM) is associated with low values of regional and global longitudinal myocardial deformations. In addition to contraction abnormalities, LV regional strain abnormalities are partially related to the degree of hypertrophy. This study sought to describe global longitudinal strain (GLS) in HCM patients as categorized using the Maron's classification. Complete echocardiography examinations, including GLS analysis, were performed in consecutive HCM patients followed up in two French HCM-clinics. A total of 271 patients (mean age 49 ± 16yrs; 71 % male) were evaluated. In this population, the most frequently classified hypertrophy pattern was Type II (47 %), following the Maron's classification. Type III was characterized by a higher degree of LV hypertrophy in terms of mass and maximal wall thickness, and was more frequently obstructive at rest, with lower GLS values (-15.3 ± 3.9 %, p = 0.016), higher E/E' ratio (13.4 ± 6.7, p < 0.001), and a more frequently inadequate blood pressure response to exercise (30 %, p = 0.04) compared to other patterns. The variable that correlated best with GLS was LV mass index (r = 0.49, p < 0.01), while GLS did not significantly correlate with left ventricular outflow tract obstruction. This study demonstrated that the Type III HCM pattern presented with lower GLS, which was partially related to higher LV mass index, more elevated LV filling pressures, and a more frequently inadequate blood pressure response to exercise, in comparison with other patterns categorized using the Maron's classification.

Paradoxical response to exercise in asymptomatic hypertrophic cardiomyopathy: a new description of outflow tract obstruction dynamics.

OBJECTIVES: The purpose of this study was to analyze left ventricular obstruction in patients with hypertrophic cardiomyopathy (HCM) during exercise echocardiography. BACKGROUND: Despite the association of symptoms with left ventricular outflow tract obstruction in HCM, there exist paradoxical situations in which significant intraventricular gradients (>50 mm Hg) at rest occur in conjunction with excellent exercise tolerance. METHODS: To examine this phenomenon, we performed exercise echocardiography and analyzed the clinical status of 107 HCM patients with and without resting obstruction. RESULTS: At rest, 69 patients had no obstruction and 38 exhibited an intraventricular gradient, 9 of whom exhibited a decrease in gradient of at least 30 mm Hg (99.4 ± 35.5 mm Hg to 30.2 ± 14.3 mm Hg, p < 0.001) during exercise (paradoxical response to exercise [PRE]). The PRE patients presented with a significantly lower New York Heart Association clinical class and higher left ventricular volumes and arterial pressure both at rest and during exercise than HCM patients in whom the gradient increased or did not change during stress echocardiography. Finally, PRE patients exhibited a trend toward a reduced rate of cardiac events. CONCLUSIONS: Our study reports a subgroup of HCM patients, designated PRE based on a decreased intraventricular gradient during exercise. The reduced exertional obstruction may account for the better functional class and trend toward fewer clinical events in PRE patients.

Estimation of pulmonary pressures and diagnosis of pulmonary hypertension by Doppler echocardiography: a retrospective comparison of routine echocardiography and invasive hemodynamics.

BACKGROUND: To date, Doppler echocardiography is the most widespread and well-recognized technique for the noninvasive evaluation of systolic pulmonary artery pressure (sPAP). However, recent studies have reported reservations about the relevance of Doppler echocardiography or the tool's reliability in the diagnosis and follow-up of patients with pulmonary hypertension (PH). Thus, the aim of this dedicated retrospective study was to address the questions of Doppler echocardiography's relevance and accuracy for PH diagnosis in the routine activity of a conventional echocardiography department. METHODS: Institutional databases were used to extract and analyze the records of 310 patients who underwent both hemodynamic and echocardiographic investigations within a single hospitalization period. RESULTS: Despite an underestimation of absolute Doppler sPAP values compared with measurements on right heart catheterization, data analysis revealed a strong correlation (r = 0.80, P < .00001, n = 310). Targeting a mean pulmonary pressure on right heart catheterization of 25 mm Hg for the definition of PH, receiver operating characteristic curve analysis demonstrated a strong association between sPAP and PH diagnosis (area under the curve, 0.82; n = 155). The cutoff obtained for sPAP was 38 mm Hg, and when applied on a second-test subgroup population (n = 155), sensitivity, specificity, and accuracy were 88%, 83%, and 86%, respectively. When patients with examination intervals of <2 days were selected (n = 115), sensitivity and specificity reached 89% and 89%, respectively. No combination of parameters produced an improvement on the initial results. CONCLUSIONS: In the real-world practice of a conventional echocardiography department, Doppler echocardiography is associated with high accuracy, sensitivity, and specificity for PH evaluation, thus confirming its major position as a primary noninvasive tool.

Early detection of left ventricular systolic dysfunction using two-dimensional speckle tracking strain evaluation in healthy subjects after acute alcohol intoxication.

OBJECTIVES: We evaluated the ability of two-dimensional speckle tracking strain echocardiography to detect left ventricular (LV) systolic dysfunction as compared with LV ejection fraction (EF) in healthy subjects following acute alcohol intoxication. METHODS AND RESULTS: In total, 25 healthy subjects were investigated using echocardiography 4-6 hours after the onset of alcohol intoxication at a regional festive gathering, and then compared to 23 healthy control subjects without alcohol consumption. Heart rate, blood pressure, blood alcohol level, LV volumes, EF, shortening fraction, E/A ratio, as well as global longitudinal strain (LS) were recorded. Mean blood alcohol level was 1.3 ± 0.3 g.L(-1) . Mean systolic blood pressure and heart rate were slightly increased in the alcohol group compared to controls (147.5 ± 21.8 mmHg vs 127.0 ± 9.9 mmHg, P = 0.003, and 79.7 ± 10.7 bpm vs 70.6 ± 7.6 bpm, P < 0.001, respectively). While there was no significant difference in terms of LVEF (62.9 ± 4.4% vs 64.8 ± 5.9%, P = 0.18) or shortening fraction (34.7 ± 5.9% vs 36.0 ± 4.3%, P = 0.54), global LS was significantly impaired (-17.8 ± 2.0% vs -21.2 ± 1.8%, P < 0.001). In addition, subjects who consumed alcohol had increased LV end-diastolic (108.3 ± 20.1 mL vs 95.5 ± 14.6 mL, P = 0.037) and end-systolic volumes (41.6 ± 11.4 mL vs 33.7 ± 6.9 mL, P = 0.024), along with depressed aortic time-velocity integral (19.9 ± 3.2 mL vs 21.9 ± 2.5 mL, P = 0.034). According to multivariate linear regression analyses, blood alcohol level was the only factor significantly associated with global LS (ß=-3.6 ± 1.0, P = 0.005). CONCLUSION: Alcohol intoxication around festive days induces acute LV contraction abnormalities, which may be detected using global LS by speckle tracking at an earlier stage and more accurately than LVEF decreases.

Cardiac resynchronization therapy reduces metaboreflex contribution to the ventilatory response in heart failure population.

Background. Metaboreflex overactivation has been proprosed to explain exaggerated hyperventilation in heart failure population. We investigated the metaboreflex activation after cardiac resynchronization therapy (CRT). Methods. 10 heart failure patients (mean left ventricular ejection fraction (LVEF) 27 ± 4%) schedulded for CRT implantation were prospectively studied. At baseline and after 6 month follow up two maximal cardiopulmonary exercise tests with and without regional circulatory occlusion (RCO) during recovery were performed. RCO was achieved by inflation of bilateral upper thigh tourniquets 30 mmHg above peak systolic blood pressure during 3 minutes after peak exercise. Metaboreflex contribution to the ventilatory response was assessed as the difference in ventilatory data at the third minute during recovery between the two tests (Δ). Results. Patients had enhanced VE/VCO(2) slope (40 ± 9) and an evident metaboreflex contribution to the high ventilatory response (ΔVE: 3 ± 4 L/min; P = 0.05, ΔRR: 4.5 ± 4/min; P = 0.003 and ΔVE/VCO(2): 5.5 ± 4; P = 0.007). 6 months after CRT implantation, NYHA class, LVEF, peak VO(2) and VE/VCO(2) were significantly improved (1.4 ± 0.5; P < 0.001, 42 ± 7%; P < 0.001, 16.5 ± 3 mL/kg/min; P = 0.003; 33 ± 10; P = 0.01). Metaboreflex contribution to VE, RR, and VE/VCO(2) was reduced compared with baseline (P = 0.08, P = 0.01 and P = 0.4 resp.). Conclusion. 6 months after CRT metaboreflex contribution to the ventilatory response is reduced.

Microbiologic characteristics and in vitro susceptibility to antimicrobials in a large population of patients with cardiovascular implantable electronic device infection.

INTRODUCTION: The incidence of cardiovascular implantable electronic device (CIED) infection is steadily increasing. However, no consensus has been reached with respect to the type and duration of antimicrobial therapy in this specific population of patients. The role played by new anti-Staphylococcus agents has not been defined. The aims of this study were to describe the microbiological characteristics of a large population of patients with CIED infections and to test the in vitro susceptibility of the various strains to different antimicrobials. METHODS: Two hundred eighty-six patients with CIED infection were included. The minimal inhibitory concentrations of 9 antimicrobials, including linezolid, tigecycline, and daptomycin were measured against all strains of staphylococci isolated. RESULTS: Microbiologic confirmation was obtained in 252 (88%) patients, the vast majority were from Staphylococcus species (86%), 90% of these were coagulase negative strains and 10% were Staphylococcus aureus; 30.5% were methicillin-resistant. All strains were susceptible to vancomycin, nearly 15% of coagulase negative strains were nonsusceptible to teicoplanin, and nearly 100% of the strains were susceptible to the 3 new antimicrobials. CONCLUSIONS: In this large contemporary study, we show that Staphylococcus is by far the most common cause of CIED infections, with the majority due to coagulase negative strains. Methicillin-resistance is common in this population. Currently, we would recommend vancomycin as first-line empirical therapy. However, given that not all patients tolerate vancomycin, we believe that newer antimicrobial therapies should now be tested in clinical trials to establish their clinical effectiveness in treating patients with device infections.

Evaluation of global left ventricular systolic function using three-dimensional echocardiography speckle-tracking strain parameters.

BACKGROUND: The aim of this study was to evaluate the capacity and reproducibility of three-dimensional echocardiographic (3DE) strain parameters in the assessment of global left ventricular (LV) systolic function. METHODS: A total of 128 subjects with differing LV ejection fractions were investigated using two-dimensional echocardiographic (2DE) and 3DE strains. Three-dimensional echocardiographic strain allows obtaining longitudinal, circumferential, radial, and area strains. First, values of global longitudinal strain (GLS) by 2DE and 3DE speckle-tracking analyses were compared. Thereafter, 3DE strain parameters were correlated with LV ejection fraction and indexed output. Last, the variability of 3DE versus 2DE strain measurements as well as recorded time of analysis were assessed. RESULTS: After excluding 21 patients for insufficient image quality, four for arrhythmia, two for severe valvular disease, and one for severe dyspnea, the final population consisted of 100 patients. Comparison between 2DE and 3DE GLS revealed high correspondence (r = 0.91, y = 1.04x - 0.71) and mean error measurement of -1.3% (95% confidence interval, -5.7 to 3.2). Among strain parameters, global area strain exhibited the highest correlation with LV ejection fraction (y = -1.65 + 10.4, r = -0.92, P < .001). Intraobserver measurement variability proved acceptable: 8% for GLS (vs 6% on 2DE analysis), 7% for circumferential strain (vs 15% on 2DE analysis), 7% for radial strain (vs 33% on 2DE analysis), and 5% for global area strain. The mean error between two measurements was lower with 3DE than 2DE analysis for circumferential and radial strains but similar for GLS. The mean time of analysis was of 117 ± 16 sec for 3DE analysis, which was 25% less than for 2DE analysis (P < .001). CONCLUSIONS: Of all strain parameters, new 3DE area strain correlated best with common LV systolic function parameters and is thus the most promising approach, while all 3DE strain markers exhibited good reproducibility.

Fast track echo of abdominal aortic aneurysm using a real pocket-ultrasound device at bedside.

BACKGROUND: Ultraminiaturization of echographic systems extraordinarily provides the image "within" the clinical examination. Abdominal aorta aneurysm (AAA) diagnosis based on conventional evaluation with a dedicated operator and ultrasound machine is still controversial due to the lack of evidence of the proposed management and guidelines' cost-effectiveness. We hypothesized that less expensive ultraportable devices could identify AAA with the same level of accuracy as conventional approaches. METHODS: A first step of this study was to validate the VSCAN's image capabilities in patients referred to the vascular Doppler laboratory. Abdominal aorta measurements were performed by an experienced physician using conventional equipment followed by a second blinded physician using the ultraportable device VSCAN. Then, 204 patients hospitalized in our cardiology institute were prospectively included for a systematic screening of AAA at bedside using the VSCAN in order to determine the feasibility and impact of fast track evaluation compared to clinical examination. RESULTS: A strong correlation was obtained between measurements of abdominal aorta diameters using the two ultrasound systems (r = 0.98, CI: 0.97-0.99, P < 0.001) with 100% of agreement for AAA diagnosis. In the second part of the study, visualization and measurement of the transverse diameter of the abdominal aorta was obtained in 199 patients, resulting in a feasibility of 97.5%. Among these patients, 18 AAAs were detected, which corresponds to a prevalence of 9%, whereas clinical evaluation did not detect any of them. Patients with AAA were more likely men (77.77% vs. 57.45%, P < 0.05) and hypertensive (88.8% vs. 56.9%, P < 0.05) as compared to those without AAA. Two patients with large AAA were quickly referred to the surgery department. CONCLUSION: Considering its low cost, diagnostic accuracy, and widespread availability, screening for AAA using an ultraportable ultrasound device such as VSCAN by an experienced physician is promising and should be used as an extension of routine physical examination in vascular patients.

Robustness of a new three-dimensional echocardiographic algorithm for left ventricular volume and ejection fraction quantification: experts vs. novices.

AIMS: We evaluated the ability of a new simplified algorithm for three-dimensional echocardiography (3DE) left ventricular (LV) measurements with minimal operator interaction to be reproducible and robust, independently of the experience. METHODS AND RESULTS: A total of 163 subjects were investigated using two-dimensional echocardiography (2DE) and 3DE. The 3D data sets were blindly analysed offline by novice investigators and experts. A subgroup of 30 patients was assessed using cardiac magnetic resonance imaging (CMRI) to compare end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) obtained by 2DE, 3DE, and CMRI. Intra-observer and inter-observer variabilities of 2DE and 3DE measurements were evaluated according to level of experience. Mean time analysis of 3DE data was 23.2 ± 6.3s for the novice and 26.1 ± 4.1 s for the expert (P = ns). Correlations (r) and mean error measurements (MEM) between 3DE analysis by experts and novices were 0.91 and -3.5 mL for EDV, 0.97 and 4.3 mL for ESV, and 0.91 and -2.6% for EF, respectively. Correlations between 3DE and CMRI were good with low variability and greater agreement when compared with those between 2DE and CMRI. For the novice, MEM was -21.3 mL for EDV, -15.0 mL for ESV, and 2.3% for EF. MEM and 95% confidence intervals were wider for 2DE vs. CMRI than for 3DE vs. CMRI in relation to both expert and novice. CONCLUSION: This new semi-automated algorithm of LV endocardial border detection based on 3DE data appears suitable for clinical use by either expert or novice investigators with greater reproducibility and time of analysis than 2DE.

Assessing global and regional left ventricular myocardial function in elderly patients using the bidimensional strain method.

UNLABELLED: Biological and anatomical alterations in the elderly result in modifications of the myocardial deformation detected previously by magnetic resonance imaging (MRI) technology and could have consequences on speckle tracking's parameters in this patient population. AIM: To compare left ventricular (LV) 2D strain between elderly patients and young individuals without heart disease. POPULATION AND METHODS: Patients without history of cardiac disease were enrolled from the geriatric department. After echocardiographic examination, exclusion criteria were LV myocardial abnormality, valve disease, and atrial fibrillation. The control group consisted of healthy subjects from the medical staff. 2D strain values were obtained from 16 segments in four-, three-, and two-chamber apical views for longitudinal and transversal strains, and from six basal segments in short-axis view for circumferential strain. RESULTS: Forty-five elderly patients (35 females) with mean age of 83.4±5.0 years (75-95 years) and 45 young subjects (28 females) with mean age of 33.6±7.5 years (17-45 years) were assessed. There was no difference between the two groups considering LV ejection fraction (66±6% vs. 65±4%, P=ns). Feasibility of segmental 2D strain was 55.6% for circumferential strain, 63% for transversal strain, and 82% for longitudinal strain. Global longitudinal strain was significantly lower in elderly patients (-20.9±1.9% vs. -22.2±2.2%, P<0.01). There was no significant difference in global transversal and circumferential strain. CONCLUSION: Aging results in a decrease in global longitudinal strain. This should be taken into account in the assessment of pathological myocardial dysfunction.