Coronary flow reserve is the capacity of the coronary circulation to augment the blood flow in response an increase in myocardial metabolic demands and has a powerful prognostic significance in different clinical situations. It might assess with invasive and non-invasive technique. Transthoracic echocardiography Doppler is an emerging diagnostic technique, noninvasive, highly feasible, safe for patient and physician, without radiation, able to detect macrovascular and microvascular anomalies in the coronary circulation. This review aims to describe the benefit and limits of noninvasive assessment of coronary flow reserve, in particular his evaluation with echocardiography.

Abstract Background/aim: Two-dimensional speckle-tracking echocardiography (2D-STE) is a novel method that allows the assessment of regional myocardial function. The aim of our study was to use 2D-STE to assess left ventricular deformation in patients with coarctation of the aorta (CoA). Methods: In this prospective study, patients with CoA (n = 42) and healthy controls (n = 39) were recruited. Children with CoA who visited the outpatient clinic between 2013 and 2014 were included. The data were compared with those obtained from the sex- and age-matched controls. Results: The mean age of the patients was 5.8 ± 4.5 years. Global longitidinal strain based on all three apical views and total global strain values did not appear to be different between the patient and the control group (p = 0.59, p = 0.51, p = 0.15, p = 0.38). Hypertension was detected in 14 (33.3%) patients with CoA. There were significant differences between the global longitudinal strain values of the normotensive CoA subgroup and the hypertensive CoA subgroup (p < .05). Conclusions: In our study, we found that 2D-STE total strain analysis of patients with CoA was not different from comparative healthy controls. However, we determined that 2D-STE parameters were lower in the hypertensive CoA subgroup compared to the normotensive CoA subgroup.

Utility of the E/e’ index in ventilated patients and those with sepsisImran Sunderji 1, Alan G Fraser 2(Reply to the letter from Filippo Sanfilippo and colleagues, ECHO-2020-0930)1 Department of Cardiology, Castle Hill Hospital, Hull, U.K.2 Department of Cardiology, University Hospital of Wales, Cardiff, U.K.Address for correspondence :Professor Alan G. Fraser,University Hospital of Wales,Heath Park,Cardiff, CF14 4XW,Wales, [email protected]: +44 (0)29 2074 5366Fax: +44 (0)29 2074 4473915 wordsWe thank Sanfilippo and his colleagues for their interest in our paper, and for the opportunity thus afforded to comment on the E/e’ index in critically ill patients and in those who have severe sepsis.We agree that the E/e’ index has some utility in predicting successful weaning from mechanical ventilation, as they have shown in their most recent meta-analysis,1 but published studies show high heterogeneity, there are often only small initial differences in mean E/e’ between patients who will remain off ventilation and those who will not, and average E/e’ values in both groups are sometimes within normal or intermediate ranges. Earlier systematic reviews also concluded that a higher E/e′ ratio is associated with weaning failure in ventilated patients2 and that E/e′ (as well as other markers of diastolic dysfunction) predicts mortality in critically ill patients.3 In a large study of 161 patients, however, neither E/e’ at the lateral mitral annulus nor any other echocardiographic index predicted success in weaning.4The heterogeneity of criteria for diastolic dysfunction in these studies is illustrated by cut-points for abnormal E/e’ varying between 8 and 12 at the lateral mitral annulus and 8 and 9.6 at the medial (septal) annulus.3In ventilated as in other patients, both E and e’ are preload-dependent.5 Positive end-expiratory pressure (PEEP) reduces both; for example PEEP of 12 cm H2O decreased lateral e’ by 19.7% and E by 13.7%, so E/e’ was unchanged.6 An increase in e’ when a patient is taken off a ventilator could indicate a response to changed loading rather than an improvement in intrinsic diastolic function. Before concluding that observed changes in E/e’ imply corresponding changes in left ventricular (LV) filling pressures, we should consider if E/e’ has been validated by correlation with pulmonary capilllary wedge pressure (PCW) measured with Swan Ganz catheters, specifically in ventilated and critically ill patients.In 39 patients there was no difference in E/e’ before a trial of spontaneous breathing, between those subjects in whom it was successful (defined as PCW remaining <18 mmHg after 60 minutes; mean baseline E/e’ 8.0) and those in whom it was not (PCW increasing to >18 mmHg; baseline E/e’ 7.6).7 The area under the receiver operating characteristic curve (AUC) for E/e’ as a guide to PCW at the end of the trial of spontaneous breathing was 0.8. In an earlier study of patients in intensive care who were also breathing spontaneously, E/e’ had a modest correlation with PCW (r=0.69); a patient with E/e’ of around 10 could have a PCW ranging from <10 to >20 mmHg.8 In other studies of ventilated patients, the correlation of lateral E/e’ with PCW was 0.849 and its AUC was 0.91.10Recently, Brault et al reported that the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines for diastolic dysfunction did not accurately assess PCW in 98 ventilated and critically ill patients, of whom 54% experienced septic shock. The diagnostic score was indeterminate in 49% of patients, sensitivity and specificity were both 74%, and agreement between echocardiography and PCW was moderate (Cohen’s Kappa, 0.48). The best echocardiographic predictor of a normal PCW was not the E/e’ ratio but a lateral e′ >8.11From experimental and clinical observations it is clear that severe sepsis can depress myocardial contractile function, probably through multiple mechanisms.12 In 40 patients with sepsis, however, there were no significant correlations between serum concentrations of inflammatory cytokines and measurements of e’ or calculated E/e’.13 In another study, mortality was predicted by the APACHE II score and mitral annular systolic excursion (MAPSE) with an AUC of 0.88, while the E/e’ index was not selected as a predictor in a logistic regression analysis.14Reproducibility of echocardiographic measurements in patients with septic shock is moderate to good15 but it is difficult to rely on single observations to guide clinical decisions.In patients with sepsis and severe diastolic dysfunction, failure to respond to volume replacement may be caused by impaired early diastolic relaxation and LV suction, which cannot be detected by the E/e’ index. In a randomised trial, an intravenous infusion of esmolol to slow the heart rate prolonged LV filling and increased stroke volume, with a subsequent reduction in mortality.16 In a prospective observational study, levosimendan increased the probability of successful weaning from ventilation, and averted any increase in E/e’;17 that could also be explained by improved early diastolic relaxation and filling, since levosimendan is positively lusitropic.18 Detailed echocardiographic assessment of ventilated patients after cardiac surgery showed that levosimendan increased early diastolic strain rate by 30%.19 Thus changes in E/e’ as a marker of mean PCW do not necessarily confirm a causal relationship with any particular aspect of LV diastolic function, while more comprehensive echocardiographic analysis of pathophysiological mechanisms may be more informative.These thoughts reinforce some of the conclusions that we drew in our review. Many studies are difficult to interpret because the E/e’ index is reported without information on changes in its individual components, and because dichotomising patients into normal or diastolic dysfunction (grades) loses information from multiple continuous variables that are inter-related but may change with differing patterns according to particular circumstances. It is unwise to use discrete cut-points especially if they are unadjusted for age and gender, and mistaken to conclude that LV diastolic function has changed when there are significant differences in the E/e’ index but its mean values remain within the normal range. The optimal assessment of diastolic dysfunction in septic and ventilated patients requires a multiparametric approach and we caution against over-reliance on E/e’.

Objective: The aim of this research was to compare the sensitivity and positive predictive value of contrast transcranial Doppler (c-TCD), contrast- transthoracic echocardiography (c-TTE) and contrast- transesophageal echocardiography (c-TEE), to determine the best method for diagnosing patent foramen ovale (PFO) and to provide a reference for the further improvement of clinical practice. Methods: We investigated 161 patients who suffered from migraines, cryptogenic stroke, TIA, and cerebral infarction of unknown cause. All patients underwent transcatheter examination, and the results of the right heart catheterization (RHC) were considered the gold standard for PFO diagnosis. Results: The present study revealed that c-TTE with the Valsalva maneuver had a higher sensitivity in detecting PFO related right-to-left shunt (PFO-RLS), but it might have a higher rate of misdetection than c-TCD. Conclusion: Patients with suspected PFO can be examined with c-TCD first, and if positive results are obtained, then c-TTE and c-TEE should be performed for further confirmation.

Inadvertent endocardial lead malposition is recognised as a rare incident which is usually underreported and if recognised during implantation can be easily corrected. This phenomenon is caused by the ventricular lead unintentionally crossing a pre-existing patent foremen ovale, septal defects (atrial or ventricular) or directly from the aorta via an accidental subclavian puncture resulting in the lead implanting into the left ventricle. While this is a rare occurrence we report the incidental finding of pacemaker lead malposition during a routine follow-up transthoracic echocardiogram and the benefits of three dimensional transoesophageal echocardiography in this patient prior to lead extraction.

A document by Roman Komorovsky. Click on the document to view its contents.

Background: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a major cause of postoperative morbidity and mortality. Despite the availability of multiple imaging parameters, none of these parameters had adequate predictive accuracy for post-LVAD RVF. Aim: To study whether right ventricular pressure-dimension index (PDI), which is a novel echocardiographic index that combines both morphologic and functional aspects of the right ventricle, is predictive of post-LVAD RVF and survival. Methods: 49 cases that underwent elective LVAD implantation were retrospectively analyzed using data from an institutional registry. PDI was calculated by dividing systolic pulmonary artery pressure to the square of the right ventricular minor diameter. Cases were categorized according to tertiles. Results: Patients within the highest PDI tertile (PDI>3.62 mmHg/cm2) had significantly higher short-term mortality (42.8%) and combined short-term mortality and definitive RVF (50%) compared to other tertiles (p<0.05 for both, log-rank p for survival to 15th day 0.014), but mortality was similar across tertiles in the long-term follow up. PDI was an independent predictor of short-term mortality (HR:1.05–26.49, p=0.031) and short-term composite of mortality and definitive RVF (HR:1.37–38.87, p=0.027). Conclusions: Increased PDI is a marker of an overburdened right ventricle. Heart failure patients with a high PDI is at risk for short-term mortality following LVAD implantation.

Prosthetic valve endocarditis is a rare but serious complication of cardiac valve replacement, and echocardiography plays a fundamental role in its diagnosis and management. However, there is not much information about the use of the 3D transillumination rendering in this context. In this report we present an unusual case of prosthetic valve endocarditis that exemplifies the utility of this new tool.

Volume ultrasound has been shown to provide valid complementary information on fetal anatomy. Three-dimensional assessment of the fetal cardiovascular system using spatial-temporal image correlation (STIC) allows for detailed examination of a highly complex organ from the early second trimester onwards. There is compelling evidence that this technique harbors quite a number of diagnostic opportunities, but manual navigation through STIC volume datasets is highly operator dependent. In fact, STIC is not incorporated yet into daily practice. Application of the novel fetal intelligent navigation echocardiography (FINE) considerably simplifies fetal cardiac volumetric examinations. This semiautomatic technique reportedly has both high sensitivity and specificity for the detection of congenital heart defects (CHDs). Part I reviewed current data regarding detection rates of CHDs and illustrated the additional value of a semiautomatic approach in delineating cardiac anatomy exemplified by congenital lesions of the right heart. In part II of this pictorial essay, we focused on left heart anomalies and aimed to tabulate recent findings on the quantification of normal and abnormal cardiac anatomy.

Attempting a comprehensive examination of the fetal heart remains challenging for unexperienced operators as it emphasizes the acquisition and documentation of sequential cross-sectional and sagittal views and inevitably results in diminished detection rates of fetuses affected by congenital heart disease. The introduction of three-/four-dimensional spatial-temporal image correlation 3D/4D STIC technology facilitated a volumetric approach for thorough cardiac anatomic evaluation by the acquisition of cardiac 4D datasets by analyzing and correlating numerous images from different heart cycles obtained during an automated sweep and subsequently displaying them in an endless cine loop sequence. However, postanalysis with manipulation and repeated slicing of the volume usually requires experience and in-depth anatomic knowledge, which limits the widespread application of this advanced technique in clinical care and unfortunately leads to the underestimation of its diagnostic value to date. Fetal intelligent navigation echocardiography (FINE), a novel method that automatically generates and displays 9 standard fetal echocardiographic views in normal hearts, has shown to be able to overcome these limitations. Very recent data on the detection of congenital heart defects (CHDs) revealed a sensitivity and specificity of 98 % and 93 %, respectively. In this two-part manuscript, we focused on the performance of FINE in delineating abnormal anatomy of typical right and left heart lesions and thereby emphasized the educational potential of this technology for more than just teaching purposes. We further discussed recent findings regarding these morphological changes seen in a pathophysiological and/or functional context.

Congenital left atrial appendage aneurysm is an extremely rare anomaly. It is seen at any time ranging from fetal to ninth decade of life. Patients with left atrial appendage aneurysm may be asymptomatic, or present with dyspnea, arrhythmias, thromboembolic phenomenon. We report a case of prenatal diagnosis at 26 weeks of gestation , postnatal management and outcome of left atrial appendage aneurysm.

Aortic atresia is uncommonly associated with atrioventricular and ventriculoarterial discordance.(1) Presence of severe regurgitation of Ebsteinoid malformation of the tricuspid valve in this subset results in reduced aortic blood flow in-utero. The hemodynamic explanation of this anomaly was reported by Celermajer and colleagues.(2) We report here a term neonate with this anomaly detect antenatally.

Background: Ibrutinib is associated with atrial fibrillation (AF), though echocardiographic predictors of AF have not been studied in this population. We sought to determine whether left atrial (LA) strain on transthoracic echocardiography could identify patients at risk for developing ibrutinib-related atrial fibrillation (IRAF). Methods: We performed a retrospective review of 66 patients who had an echocardiogram prior to ibrutinib treatment. LA strain was measured with TOMTEC Imaging Systems, obtaining peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) on 4-chamber and 2-chamber views. Statistical analysis was performed with Chi-square analysis, T-test, or binomial regression analysis, with a p-value < 0.05 considered statistically significant. Results: Twenty-two patients developed IRAF (33%). Age at initiation of ibrutinib was significantly associated with IRAF (65.1 years vs. 74.1 years, p = 0.002). Mean ibrutinib dose was lower among patients who developed IRAF (388.2 ± 121.7 vs. 448.6 ± 88.4, p = 0.025). E/e’ was significantly higher among patients who developed IRAF (11.5 vs. 9.3, p = 0.04). PALS was significantly lower in patients who developed AF (30.3% vs. 36.3%, p = 0.01). On multivariate regression analysis, age, PALS and PACS were significantly associated with IRAF. On multivariate regression analysis, only PACS remained significantly associated with IRAF while accounting for age. Conclusions: Age, ibrutinib dose, E/e’, and PALS on pre-treatment echocardiogram were significantly associated with development of IRAF. On multivariate regression analyses, age, PALS and PACS remained significantly associated with IRAF. Impaired LA mechanics add to the assessment of patients at risk for IRAF

Introduction: Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis. Objective: To better delineate the course of coronary artery fistula using an intracoronary injection of SonoVue contrast agent, whilst performing transthoracic echocardiography. Method and results: A referred 46-year-old male, with a history of exertional dyspnea for almost three months, was admitted to the hospital with progressive dyspnea, and assessed under suspicion of CAF. CAF was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined. CT angiography also failed to establish the drainage site , so CAG (coronary angiography) was repeated with the SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) and passing through the fistula to LV. Conclusion: Contrast-Enhanced Echocardiography by direct intracoronary injection of SonoVue contrast agent, is safe and can aid in the delineation of fistula drainage.

Cardiac imaging is the cornerstone of defining the etiology, quantification and management of mitral regurgitation (MR). This continues to be even more so the case with emerging trans-catheter techniques to manage MR. Transthoracic echocardiography remains the first line imaging modality to assess MR but has limitations. Cardiac MRI(CMR) provides the advantages of quantitative non-visual estimation, 3D volumetric data, late gadolinium, T1 and extracellular volume measurements to comprehensively assess mitral valvular pathology, cardiac remodeling and the prognostic impact of therapies. This review describes the superiority, technical aspects and growing evidence behind CMR, and lays the roadmap for the future of CMR in MR.

Purpose: Degenerative mitral stenosis (DMS) is an increasingly recognized cause of mitral stenosis. The goal of this study was to compare echocardiographic differences between DMS and rheumatic mitral stenosis (RMS), identify echocardiographic variables reflective of DMS severity, and propose a dimensionless mitral stenosis index (DMSI) for assessment of DMS severity. Methods: This is a single-center, retrospective cohort study. We included patients with at least mild MS and a mean transmitral pressure gradient (TMPG) ≥ 4 mmHg. Mitral valve area by the continuity equation (MVACEQ) was used as an independent reference. The DMSI was calculated as follows: DMSI = VTILVOT / VTIMV. All-cause mortality data were collected retrospectively. Results: A total of 64 patients with DMS and 24 patients with RMS were identified. MVACEQ was larger in patients with DMS (1.43  0.4 cm2) than RMS (0.9  0.3 cm2) by ~0.5 cm2 (p = <0.001) and mean TMPG was lower in the DMS group (6.0 2 vs. 7.93 mmHg, p=0.003). A DMSI of  0.50 and ≤ 0.351 were associated with MVACEQ ≤ 1.5 and MVACEQ ≤ 1.0 cm2 (p<0.001), respectively. With the progression of DMS from severe to very severe, there was a significant drop in DMSI. There was a non-significant trend towards worse survival in patients with MVACEQ ≤ 1.0 cm2 and DMSI ≤ 0.35, suggesting severe stenosis severity. Conclusion: Our results show that TMPG correlates poorly with MVA in patients with DMS. Proposed DMSI may serve as a simple echocardiographic indicator of hemodynamically significant DMS.

Abstract Background: Transthoracic echocardiography (TTE) in prone position is challenging. Innovative use of transesophageal echocardiography (TEE) probe to perform TTE for such patients was described; but reproducibility and correlation of the TTE measurements by this technique with those obtained by the standard supine TTE study are still unknown. Methods: We enrolled 30 non-COVID-19 individuals, with a mean (SD) age 35 (10.9) years and 11 females, to study the agreement between the transthoracic measurements of the left ventricular (LV), left atrial (LA) and aortic dimensions obtained in prone position using an external TEE probe versus the standard supine position using the conventional TTE probe. Results: There were no significant differences between LV end-diastolic and end-systolic diameters, septal wall thickness, posterior wall thickness and aortic root dimensions in the prone versus the supine positions. While the mean ejection fraction (EF) (60.3% vs. 63.1%, P = 0.014) and mean LA dimensions (1.8 vs. 1.9 cm/m2, P < 0.001) were significantly lower in the prone position. The mean time of scans was significantly longer in the prone as compared to the supine (12.5 vs 4.5 minutes, P < 0.001). All supine studies had good quality while in the prone position 4 studies were of poor quality, and one was non-diagnostic. Conclusions: Assessment of cardiac dimensions and systolic function in the prone position using transthoracic TEE probe was feasible. LV and aortic dimensions agreed well with the standard TTE in supine position, however, LA dimensions and EF were lower in the prone position.

A patient with heart failure due to dilated ischemic cardiomyopathy presented in cardiogenic shock for institution of veno-arterial extracorporeal membrane oxygenation as a bridge to cardiac transplantation. To provide adequate venous drainage and simultaneous decompression of the left atrium (indirect left ventricular venting) a single venous cannula was placed across the interatrial septum so the distal orifice and side ports were located within the left atrium and the proximal set of side ports at the cavoatrial junction. Three-dimensional transesophageal echocardiography demonstrated utility in guiding cannula placement and appropriate positioning within the left atrium.