Prognostic value of dual imaging stress echocardiography following coronary bypass surgery.

AIMS: To assess the prognostic value of dual imaging stress echocardiography after coronary artery bypass grafting (CABG). Dual imaging stress echocardiography, combining the evaluation of regional wall motion and Doppler echocardiographic derived coronary flow velocity reserve (CFVR) of the left anterior descending artery (LAD), is the state-of-the-art methodology during vasodilatory stress. METHODS AND RESULTS: In a prospective, multicenter, observational study, 349 patients (270 men; 69 ±â€¯9 years; 262 symptomatic) with history of CABG underwent high-dose dipyridamole (0.84 mg/kg over 6 min) stress echocardiography with CFVR evaluation of LAD by Doppler. The composite endpoint of death and myocardial infarction was considered in the survival analysis. Positivity rate with either criteria was 13% in the 262 symptomatic patients with appropriate and 6% in the 87 asymptomatic patients with maybe/rarely appropriate indications on the basis of 2014 American College of Cardiology Foundation guidelines. During a median follow-up of 22 months (1st quartile 8, 3rd quartile 44), there were 56 (16%) events: 21 deaths, and 35 nonfatal myocardial infarctions. At Cox analysis, ischemia at stress echo (HR 4.80, 95% CI 2.69-8.55; p < 0.0001), and CFVR of LAD ≤2 (HR 2.28, 95% CI 1.32-3.95; p = 0.003) were multivariable prognostic predictors. Considering the group with no ischemia, patients with CFVR ≤2 showed 2.5 fold higher yearly hard events as compared to those with CFVR >2 (7.5 vs 2.9%; p = 0.002). CONCLUSIONS: Dual imaging stress echocardiography provides useful prognostic information following CABG. Inducible ischemia and abnormal CFVR are strong and independent prognostic indicators in patients with appropriate and rarely/maybe appropriate indications.

Preoperative Cardiac Stress Testing in the Southern California Vascular Outcomes Improvement Collaborative.

BACKGROUND: The objective of this study was to examine the use of preoperative cardiac stress testing (PCST) in the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe). METHODS: A retrospective review was performed on data in all modules of the So Cal VOICe from September 2012 through May 2016. PCST was defined as stress echocardiogram or nuclear stress test. A new postoperative myocardial infarction (MI) was defined as troponin elevation and/or electrocardiogram/imaging changes with or without ischemic symptoms. Only elective cases in patients with asymptomatic cardiac status were included in the study. RESULTS: During the study period, 3,063 procedures meeting the inclusion criteria were performed in 7 registries: carotid endarterectomy (CEA), carotid artery stent, thoracic endovascular aneurysm repair, infrainguinal bypass (Infra), endovascular aneurysm repair (EVAR), suprainguinal bypass (Supra), and open abdominal aortic aneurysm repair (OAAA). PCST varied across registries from 17% in PVI to 62% in OAAA. PCST in CEA varied across 9 institutions from 10% to 79%. PCST in EVAR varied across 7 institutions from 14% to 83%. PCST in Infra varied across 4 institutions from 10% to 57%. Of the 12 patients across all registries who had a new MI, 6 had PCST, one of which was abnormal. CONCLUSIONS: The incidence of PCST varies widely across registries and institutions in the So Cal VOICe. Despite the wide variation, the incidence of new postoperative MI is exceptionally low. Further studies should evaluate the cost-effectiveness of the PCST practices and future quality improvement efforts should focus on standardization of indications for PCST.

Variation in Management of Patients With Obstructive Coronary Artery Disease: Insights From the Veterans Affairs Clinical Assessment and Reporting Tool (VA CART) Program.

BACKGROUND: Little is known about facility-level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures. METHODS AND RESULTS: We evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk-adjusted facility-level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility-level rates of revascularization and post-PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%-66.7%). Across all facilities, risk-adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%-47.1%). There was no evidence of correlation between facility-level rate of revascularization and follow-up stress testing. CONCLUSIONS: Within the Veterans Affairs system, we observed large facility-level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility-level use of revascularization and follow-up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility-level use.

The declining frequency of inducible myocardial ischemia during stress echocardiography over 27 consecutive years (1983-2009).

BACKGROUND: Previous studies have suggested a decline in positivity of stress cardiac imaging, suggesting the need for developing better strategies for test selection to achieve acceptable cost-effectiveness balance. The aim of this retrospective study was to assess the rate of positivity of stress echocardiography (SE) over 27 consecutive years. METHODS: We assessed the rate of SE positivity in 2007 patients without previous myocardial infarction or coronary revascularization who performed SE in a tertiary care referral center from 1983 to 2009. SE was performed with dipyridamole (1427), dobutamine (136) or exercise (444). RESULTS: There was a progressive decline over time in the rate of SE positivity from 42% (1983-1991) to 22% (2001-2009), with a relative increase of patients with low pre-test probability of disease (from 5% to 27%). The percentage of patients studied with SE under anti-ischemic therapy increased markedly (from 8% in the first to 61% in the last nine years). CONCLUSION: Over 27 consecutive years, we observed a steady decline in SE positivity rate (with >5-fold increase of low probability patients), with almost 8-fold increase in anti-ischemic therapy at testing. We probably need refined criteria of referral for testing and/or better ways to titrate the negative response beyond wall motion abnormalities during SE.

Novel techniques in stress echocardiography: a focus on the advantages and disadvantages.

Stress echocardiography (SE) is an established tool not only for the assessment of coronary artery disease (CAD), but also for the evaluation of valvular disease and cardiomyopathy. New techniques, namely contrast echocardiography for function and perfusion including assessment of coronary flow reserve, strain imaging, 3-dimensional echocardiography, Doppler-derived coronary flow reserve and multimodality echocardiography, have been incorporated into stress protocols for improving assessment of cardiac disease. In this review, the advantages and disadvantages of these novel SE techniques are examined in terms of feasibility, accuracy, reproducibility and applications.

Growth and geographical variation in the use of cardiac imaging in Australia.

BACKGROUND AND AIM: Growth rates and regional differences in the use of cardiac imaging are potential metrics of quality of care. This study sought to define growth and regional variation in outpatient cardiac imaging in Australia. METHODS: Analyses are based on the rate of outpatient transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE) and stress echocardiography (SE) and single-photon emission computed tomography (SPECT) per 100 000 people in each geographic insurance region in Australia (Medicare local, ML). Numbers of tests from 2002 to 2013 were obtained from Medicare Australia Statistics, and the number of doctors was obtained from the Health Workforce data. Demographic data (total population, rural areas and quintiles of disadvantage) were obtained from census data. RESULTS: Over the past 11 years, TTE reimbursements/100 000 people increased from 1780 to 3497 (8.8% annualised growth), TOE from 33 to 61, SE from 181 to 947 and SPECT from 287 to 337. SE had the biggest increment, an average growth rate of 38.5%/year. The relationships between the use of each cardiac imaging techniques and demographic, medical and illness factors were analysed in outpatient tests reimbursed in 2012. For each additional medical practitioner per 1000 people, there was an increase in the rate of TTE (ß = 1.25 (95% confidence interval CI: 1.17-1.33), P < 0.001), and TOE use (ß = 1.13 (1.04-1.24), P = 0.005), independent of regional burden of cardiovascular disease and social determinants. For SPECT the largest independent correlate for testing was the percentage of women within the ML; each additional percentage increase resulted in doubling of the rate of testing (ß = 2.25 (1.72-2.94), P < 0.001). CONCLUSION: Variation in the use of TTE in Australia does not appear illness related and may be evidence of under- and overutilisation. An appropriate use process may contain this variation.

Resonancia magnética para la detección no invasiva de la enfermedad microcirculatoria asociada a la vasculopatía de alotrasplante: validación de la determinación intracoronaria / Magnetic resonance for noninvasive detection of microcirculatory disease associated with allograft vasculopathy: intracoronary measurement validation

Introducción y objetivos. La vasculopatía del aloinjerto cardiaco afecta tanto al compartimento coronario epicárdico como al de la microcirculación. Se ha propuesto el uso de las técnicas de imagen de perfusión de la resonancia magnética como instrumento útil para la evaluación de la microcirculación, principalmente fuera del contexto del trasplante de corazón. La pendiente de velocidad del flujo-presión diastólica hiperémica instantánea, que es un índice de la fisiología intracoronaria, ha mostrado mejor correlación con el remodelado microcirculatorio en la vasculopatía del aloinjerto cardiaco que la de otros índices como la reserva de velocidad del flujo coronario. Con objeto de investigar el potencial de las técnicas de imagen de perfusión de resonancia magnética para detectar la presencia de remodelado microcirculatorio en la vasculopatía de aloinjerto cardiaco, se ha comparado los datos de perfusión de resonancia magnética con los índices fisiológicos intracoronarios invasivos, para estudiar la microcirculación en una población de pacientes con trasplante de corazón que presentaban una enfermedad macrovascular no obstructiva demostrada por la ecografía intravascular. Métodos. Se estudió a 8 pacientes con trasplante de corazón (media de edad, 61 ± 12 años; el 100% varones) que presentaban una vasculopatía del aloinjerto epicárdica definida por ecografía intravascular, estenosis coronarias no significativas y una resonancia magnética de estrés con dobutamina con evaluación visual del movimiento de la pared/perfusión negativa. Se determinaron los datos de perfusión de resonancia magnética cuantitativa en estrés y en reposo para establecer el índice de reserva de perfusión miocárdica, de manera no invasiva, y se determinaron cuatro índices fisiológicos intracoronarios evaluados de manera invasiva. Resultados. Los datos posprocesados mostraron una media del índice de reserva de perfusión miocárdica de 1,22 ± 0,27, mientras que la reserva de flujo fraccional, la reserva de velocidad del flujo coronario, la resistencia microvascular hiperémica y la pendiente de velocidad del flujo-presión diastólica hiperémica instantánea fueron de 0,98 ± 0,02, 2,34 ± 0,55, 2,00 ± 0,69 y 0,91 ± 0,65 cm/s/mmHg respectivamente. El índice de reserva de perfusión miocárdica presentó una correlación intensa tan solo con la pendiente de velocidad del flujo-presión diastólica hiperémica instantánea (r = 0,75; p = 0,033). Conclusiones. El índice de reserva de perfusión miocárdica obtenido a partir de la resonancia magnética de estrés con dobutamina completa resulta una técnica fiable para la detección no invasiva de la enfermedad coronaria microcirculatoria asociada a la vasculopatía de aloinjerto cardiaco (AU)

Introduction and objectives. Cardiac allograft vasculopathy affects both epicardial and microcirculatory coronary compartments. Magnetic resonance perfusion imaging has been proposed as a useful tool to assess microcirculation mostly outside the heart transplantation setting. Instantaneous hyperemic diastolic flow velocity-pressure slope, an intracoronary physiology index, has demonstrated a better correlation with microcirculatory remodelling in cardiac allograft vasculopathy than other indices such as coronary flow velocity reserve. To investigate the potential of magnetic resonance perfusion imaging to detect the presence of microcirculatory remodeling in cardiac allograft vasculopathy, we compared magnetic resonance perfusion data with invasive intracoronary physiological indices to study microcirculation in a population of heart transplantation recipients with macrovascular nonobstructive disease demonstrated with intravascular ultrasound. Methods. We studied 8 heart transplantation recipients (mean age, 61 [12] years, 100% male) with epicardial allograft vasculopathy defined by intravascular ultrasound, nonsignificant coronary stenoses and negative visually-assessed wall-motion/perfusion dobutamine stress magnetic resonance. Quantitative stress and rest magnetic resonance perfusion data to build myocardial perfusion reserve index, noninvasively, and 4 invasive intracoronary physiological indices were determined. Results. Postprocessed data showed a mean (standard deviation) myocardial perfusion reserve index of 1.22 (0.27), while fractional flow reserve, coronary flow velocity reserve, hyperemic microvascular resistance and instantaneous hyperemic diastolic flow velocity-pressure slope were 0.98 (0.02), cm/s/mmHg, 2.34 (0.55) cm/s/mmHg, 2.00 (0.69) cm/s/mmHg and 0.91 (0.65) cm/s/mmHg, respectively. The myocardial perfusion reserve index correlated strongly only with the instantaneous hyperemic diastolic flow velocity-pressure slope (r = 0.75; P = .033). Conclusions. Myocardial perfusion reserve index derived from a comprehensive dobutamine stress magnetic resonance appears to be a reliable technique for noninvasive detection of microcirculatory coronary disease associated with cardiac allograft vasculopathy (AU)

Contrast echocardiography: latest developments and clinical utility.

Ultrasound enhancing agents (UEAs) are being utilized for a growing number of applications with real-time very low mechanical index (MI) techniques in clinical cardiology today. This article will review recent developments on the safety of UEAs and their effectiveness in myocardial perfusion imaging, three-dimensional quantification of left ventricular function, and vascular imaging. UEAs are now being utilized in all age groups, with new indications that add incremental value to the currently approved by the Food and Drug Administration. These include the incremental value in cardiac imaging, where the off-label analysis of myocardial perfusion observed with UEAs adds to the enhanced endocardial border delineation. In carotid artery imaging, UEAs improve the detection of plaque but also can examine plaque neovascularization. Vascular surgeons now utilize UEAs in the evaluation of endovascular repair to detect endoleaks without the need of ionizing radiation. Newer applications are emerging in the detection of left atrial appendage thrombi and quantification of myocardial blood flow and volume in transplant patients.

Stress echo applications beyond coronary artery disease.

Stress echocardiography is an established method for the diagnosis and prognostic stratification of coronary artery disease. In the last few years, the tremendous technological and conceptual versatility of this technique has been increasingly applied in challenging diagnostic fields. Today, in the echocardiography laboratory we can detect not only ischaemia from coronary artery stenosis, but can also recognize abnormalities of the coronary microvessels, myocardium, heart valves, pulmonary circulation, alveolar-capillary barrier, and right ventricle. Therefore, we evaluate coronary arteries as well as coronary microvascular disease (associated with diabetes and hypertension), suspected or overt dilated cardiomyopathy, systolic and diastolic heart failure, hypertrophic cardiomyopathy, athletes' hearts, valvular heart disease, congenital heart disease, incipient or overt pulmonary hypertension, and heart transplant patients for early detection of chronic or acute rejection as well as potential donors for better selection of suitable donor hearts. From a stress echo era with a one-fits-all approach (wall motion by 2D-echo in the patient with known or suspected coronary artery disease) now we have moved on to an omnivorous, next-generation laboratory employing a variety of technologies (from M-Mode to 2D and pulsed, continuous and colour Doppler, to lung ultrasound and real-time 3D echo, 2D speckle tracking and myocardial contrast echo) on patients covering the entire spectrum of severity (from elite athletes to patients with end-stage heart failure) and ages (from children with congenital heart disease to the elderly with low-flow, low-gradient aortic stenosis). For each patient, we can tailor a dedicated stress protocol with a specific method to address a particular diagnostic question. Provided that the acoustic window is acceptable and the necessary expertise available, stress echocardiography is useful and convenient in many situations, from valvular to congenital heart disease, and whenever there is a mismatch between symptoms during stress and findings at rest. Increasing societal concern regarding cost, environment and radiation risks of medical imaging will lead to a preferential application of ultrasound over competing techniques, due to its unsurpassed versatility, portability, absence of radiation, and low cost.

The risk of adverse events associated with atropine administration during dobutamine stress echocardiography in cardiac transplant patients: a 28-year single-center experience.

BACKGROUND: Although dobutamine stress echocardiography (DSE) is performed in heart transplant patients, the safety profile of atropine administration in DSE in this setting is unclear. METHODS AND RESULTS: We identified heart transplant patients who received atropine during DSE from January 1984 to August 2011 at our institution and compared them with a propensity-scored matched control group of heart transplant patients who underwent DSE without atropine. Adverse events were defined as significant arrhythmias (sinus arrest, Mobitz type II heart block, complete heart block, ventricular tachycardia, or ventricular fibrillation), hypotension requiring hospitalization, syncope or presyncope, myocardial infarction, and death. Forty-five heart transplant patients (median age 62 years, 82% male) received 0.2-1 mg atropine during DSE. Of these, 1 patient (2.2%) developed temporary complete heart block. No adverse events were identified in the control group of 154 patients who received dobutamine without atropine. CONCLUSIONS: Our findings suggest that complete heart block can occur infrequently with the administration of atropine in heart transplant patients undergoing DSE. Therefore, patients should be appropriately monitored for these adverse events during and after DSE.

Eco-Doppler de ejercicio en pacientes con miocardiopatía hipertrófica. Factores determinantes de la limitación funcional / Exercise eco-doppler in hypertrophic cardiomyopathy patients. Determinant factors of exercise intolerance

Introducción y objetivos. En pacientes con miocardiopatía hipertrófica, los datos ecocardiográficos en reposo han mostrado una pobre correlación con la capacidad de ejercicio. Investigamos si la ecografía Doppler de esfuerzo podría explicar mejor la limitación funcional. Métodos. Estudiamos a 87 pacientes consecutivos, remitidos para test cardiopulmonar y ecografía de esfuerzo. Se realizó estudio basal y en el pico de ejercicio para evaluar el gradiente máximo, la regurgitación mitral y las velocidades diastólicas mitral y del Doppler tisular del anillo. Resultados. Desarrollaron obstrucción con el ejercicio 43 pacientes. Estos alcanzaron un menor consumo de oxígeno (21,3 ± 5,7 frente a 24,6 ± 6,1ml/kg/min; p = 0,012), presentaban mayor volumen auricular izquierdo (42,1 ± 14,5 frente a 31,1 ± 11,6ml/m2; p < 0,001) y desarrollaron más regurgitación mitral y mayor relación E/E’ con el ejercicio. Los datos de ejercicio mejoraron el poder predictivo de la capacidad funcional (R2 ajustada = 0,49 frente a R2 ajustada = 0,38 en reposo). La edad, el volumen auricular izquierdo, la relación E/E’ con el ejercicio y la obstrucción fueron los factores independientes asociados con la capacidad funcional. En los pacientes sin obstrucción, los volúmenes de las cavidades izquierdas fueron los factores determinantes. Conclusiones. En pacientes con miocardiopatía hipertrófica, la obstrucción con el esfuerzo y el volumen auricular izquierdo son los principales determinantes de la limitación funcional. Los parámetros diastólicos de esfuerzo mejoran la predicción de la capacidad funcional, aunque su poder predictivo no supera el 50%. En pacientes sin obstrucción, los volúmenes de las cavidades izquierdas son los factores determinantes (AU)

Introduction and objectives. At-rest echocardiography is a poor predictor of exercise capacity in patients with hypertrophic cardiomyopathy. We aimed to test the performance of treadmill exercise Doppler echocardiography in the prediction of functional limitations in these patients. Methods. Eighty-seven consecutive patients with hypertrophic cardiomyopathy underwent treadmill exercise echocardiography with direct measurement of oxygen consumption. Both at rest and at peak exercise, the mitral inflow, mitral regurgitation, left ventricular outflow tract obstruction and mitral annulus velocities were assessed. Results. Forty-three patients developed left ventricular outflow tract obstruction during exercise, which significantly decreased oxygen consumption (21.3 [5.7] mL/kg/min vs 24.6 [6.1] mL/kg/min; P=.012), and had greater left atrial volume (42.1 [14.5] mL/m2 vs 31.1 [11.6] mL/m2; P<.001) and a higher degree of mitral regurgitation and E/E’ ratio during exercise. Exercise variables improved the predictive value of functional capacity (adjusted R2 rose from 0.38 to 0.49). Independent predictors of oxygen consumption were age, left atrial volume, E/E’ ratio and the presence of left ventricular outflow tract obstruction. In a subset of patients without left ventricular outflow obstruction, only left ventricular and atrial volume indexes were independent predictors of exercise capacity. Conclusions. In patients with hypertrophic cardiomyopathy, left ventricular outflow tract obstruction and left atrial volume are the main predictors of exercise capacity. Exercise echocardiography is a better predictor of functional performance than at-rest echocardiography, although its predictive power is under 50%. In nonobstructed patients, left atrial and ventricular volumes were the independent factors (AU)

Comparison of the updated 2011 appropriate use criteria for echocardiography to the original criteria for transthoracic, transesophageal, and stress echocardiography.

BACKGROUND: The aim of this study was to compare appropriateness designations as determined by the updated 2011 appropriate use criteria (AUC) for echocardiography with prior versions of the AUC for transthoracic echocardiographic (TTE) imaging, transesophageal echocardiographic (TEE) imaging, and stress echocardiographic (SE) imaging. An additional goal was to define relationships between appropriateness determinations and echocardiographic findings for each modality. METHODS: Previously published data sets of TTE, TEE, and SE studies were reclassified according to the 2011 AUC, and indication representation, appropriateness designations, and echocardiographic findings were compared with prior classifications according to the 2007 AUC for TTE and TEE imaging and the 2008 AUC for SE imaging. RESULTS: Overall, 2,247 echocardiographic studies were analyzed. The 2011 AUC addressed the vast majority of studies (98%), a marked increase compared with prior versions of the AUC (89%) (P < .001). An increase in addressed studies was present in each echocardiographic modality (TTE imaging: n = 1,525, 98% vs 89%, P < .001; TEE imaging: n = 405, 99.7% vs 91%, P < .01; SE imaging: n = 289, 97% vs 88%, P < .01). Among all echocardiographic procedures, the 2011 AUC found a lower frequency of appropriate studies compared with prior AUC (82% vs 88%, P < .01), primarily because of new uncertain indications for TTE imaging. The frequency of inappropriate echocardiographic studies was unchanged (11%). Among all echocardiographic procedures, the 2011 AUC found appropriate studies to have more new abnormal echocardiographic findings compared with inappropriate studies (45% vs 13%, P < .001). Interestingly, 2011 AUC inappropriate TTE studies had fewer major new echocardiographic abnormalities than 2007 AUC inappropriate TTE studies (9% vs 17%, P = .04). CONCLUSIONS: The updated 2011 AUC for echocardiography encompass the vast majority of echocardiographic procedures in a university hospital practice, filling virtually all of the gaps identified in prior versions of the AUC for TTE, TEE, and SE imaging. The 2011 AUC also reasonably stratify the likelihood of finding an echocardiographic abnormality, demonstrating improvement compared with the prior AUC.

Real time three-dimensional stress echocardiography advantages and limitations.

The role of two-dimensional stress echocardiography (2D-SE) is well established for diagnosis and prognosis of patients with known or suspected coronary artery disease. 2D-SE has its limitations as multiple views of the left ventricle (LV) must be obtained within 90 seconds of peak stress from more than window to completely visualize all LV segments. 2D-SE is operator-dependent and requires advanced skills to match the same myocardial segments during stress. LV foreshortening is a frequently encountered problem in 2D-SE that may result in false negative studies. Real time three-dimensional SE (RT-3D-SE) can overcome many limitations of 2D-SE. In 3D-SE, overall wall motion of the entire LV is assessed simultaneously in different planes. 3D images can be displayed in multiplane or multislice views for ease of comparison with greater accuracy and interobserver agreement when compared to 2D. 3D-SE is quantitative, provides rapid image acquisition, requires lower level of operator skills, and avoids LV foreshortening by correct alignment of imaging planes. 3D-SE is easily applied during pharmacologic stress and is feasible during exercise-induced stress. Despite these advantages, 3D has lower temporal and spatial resolution than 2D and requires longer analysis time. With advances in transducer technology, smaller matrix footprints, and automated softwares, 3D full LV volume image acquisition can be obtained with a single beat that is less prone to artifacts. We will discuss the current application of RT-3D-SE, highlight the pros and cons of 3D-SE over conventional 2D-SE, and review major studies on 3D-SE and future implications.

Recent advances in stress echocardiography.

PURPOSE OF REVIEW: This article reviews the recent advances in stress echocardiography, with particular attention to articles published in 2010 and 2011. It summarizes the developments in the diagnostic and prognostic capabilities of stress echocardiography, discusses new data regarding the safety of stress echocardiography, and highlights emerging roles for stress echocardiography in the areas of left ventricular assist devices, cardiac transplantation, strain-rate echocardiography, and myocardial perfusion imaging. RECENT FINDINGS: Stress echocardiography represents a well validated tool in the diagnosis and assessment of patients with known or suspected coronary artery disease. Recently, data have emerged supporting the prognostic capabilities of stress echocardiography in patients with various levels of systolic dysfunction, diastolic abnormalities, and valvular heart disease. New studies continue to document the safety of stress echocardiography, particularly with regard to arrhythmias, neuropsychiatric symptoms, dosing of dobutamine, and intravenous contrast. Studies are now suggesting that stress echocardiography may play novel roles in the evaluation of patients with left ventricular assist devices or potential donors for cardiac transplantation. Technologic developments in myocardial contrast perfusion imaging, three-dimensional imaging, and strain-rate echocardiography will continue to advance the field. SUMMARY: Stress echocardiography represents a dynamic, versatile, and well validated tool for the noninvasive assessment of patients with a wide spectrum of cardiovascular diseases.