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Exercise intolerance is the primary symptom of patients with heart failure with preserved ejection fraction (HFpEF). Chronotropic incompetence has been considered to be common and contribute to poor exercise capacity in HFpEF. However, clinical characteristics, pathophysiology, and outcomes of chronotropic incompetence in HFpEF remain poorly understood. Patients with HFpEF (n = 246) underwent ergometry exercise stress echocardiography with simultaneous expired gas analysis. The patients were divided into two groups based on the presence of chronotropic incompetence, which was defined by heart rate reserve <0.80. Chronotropic incompetence was common in HFpEF (n = 112, 41 %). Compared to HFpEF patients with a normal chronotropic response (n = 134), those with chronotropic incompetence had higher body mass index, a higher prevalence of diabetes, more frequent β-blocker use, and worse New York Heart Association class. During peak exercise, patients with chronotropic incompetence demonstrated less increase in cardiac output and arterial oxygen delivery (cardiac output × saturation × hemoglobin × 1.34 × 10), higher metabolic work (peak oxygen consumption [VO 2 ]/watt), an inability to increase arteriovenous oxygen difference, and poorer exercise capacity (lower peak VO 2) than those without. Chronotropic incompetence was associated with higher rates of a composite of all-cause mortality or worsening HF events (hazard ratio, 2.66, 95 % confidence intervals, 1.16–6.09, p = 0.02). Chronotropic incompetence is common in HFpEF, and is associated with unique pathophysiologic characteristics during exercise and clinical outcomes. [Display omitted] • Chronotropic incompetence, defined by heart rate reserve <0.80, was common in HFpEF. • Chronotropic incompetence was related to higher body mass index, diabetes, and β-blocker use. • Chronotropic incompetence was related to poor cardiac output reserve and exercise capacity. • Chronotropic incompetence was associated with higher rates of clinical events. [ABSTRACT FROM AUTHOR]

E/e′ ratio during exercise is the key parameter in identifying elevated pulmonary capillary wedge pressure (PCWP), and thus heart failure with preserved ejection fraction (HFpEF). However, its diagnostic value is limited when mitral inflow or tissue velocities are fused during elevated heart rate. The authors hypothesized that E/e' ratio during low-level (20 W) exercise (E/e′ 20W) can help diagnose HFpEF. Ergometric exercise stress echocardiography was performed in 215 dyspneic patients with an EF ≥50%. The authors determined the feasibility of E/e′ ratio at each stage (frequency of patients who had measurable E/e′ without E-A fusion among 215 participants) and examined whether E/e′ 20W could predict normal E/e′ ratio during peak exercise (E/e′ peak ≤15). The authors also evaluated whether E/e′ 20W could predict normal PCWP during exercise (PCWP <25 mm Hg) in a subset of participants (n = 45) who underwent exercise right heart catheterization. The feasibility of the E/e′ ratio decreased from 100% at rest to 96.3% during 20-W exercise and 74.9% during peak exercise caused by E-A fusion. In patients with E/e′ peak >15, there was an increase in E/e′ ratio from rest to 20-W exercise (11.2 ± 2.1 to 16.3 ± 3.5; P < 0.0001), but it did not change significantly from 20-W exercise to peak exercise (P = 0.12). E/e′ 20W predicted E/e′ peak ≤15 (AUC: 0.91; P < 0.0001) with the cutoff value of ≤12.4 showing high specificity (94%) and positive predictive value (98%). During 20-W exercise, 93% of the HFpEF patients developed PCWP ≥25 mm Hg. E/e′ 20W predicted normal PCWP during exercise (AUC: 0.77; P = 0.01) with the cutoff value of ≤12.4 showing high specificity (83%). E/e′ ratio during low-level exercise is highly feasible and predicts normal E/e′ ratio or PCWP during peak exercise with high specificity. These data suggest that E/e′ 20W could be used as an alternative to the peak exercise value to rule out HFpEF in patients with dyspnea. [Display omitted] [ABSTRACT FROM AUTHOR]

An 81-year-old man was admitted to the hospital because of decreased level of consciousness. He had bradycardia (27 beats/min). Electrocardiography showed ST-segment elevation in leads II, III, and aVF and ST-segment depression in leads aVL, V1. Transthoracic echocardiography (TTE) visualized reduced motion of the left ventricular (LV) inferior wall and right ventricular (RV) free wall. Coronary angiography revealed occlusion of the right coronary artery. A primary percutaneous coronary intervention was successfully performed with temporary pacemaker backup. On the third day, the sinus rhythm recovered, and the temporary pacemaker was removed. On the fifth day, a sudden cardiac arrest occurred. Extracorporeal cardiopulmonary resuscitation was performed. TTE showed a high-echoic effusion around the right ventricle, indicating a hematoma. The drainage was ineffective. He died on the eighth day. An autopsy showed the infarcted lesion and an intramural hematoma in the RV. However, no definite perforation of the myocardium was detected. The hematoma extended to the epicardium surface, indicative of oozing-type RV rupture induced by RV infarction. The oozing-type rupture induced by RV infarction might develop asymptomatically without influence on the vital signs of the patient. Frequent echocardiographic evaluation is essential in cases of RV infarction taking care of silent oozing-type rupture. Inferior left ventricular infarction sometimes complicates right ventricular (RV) infarction. The typical manifestations of RV infarction include low blood pressure, low cardiac output, and elevated right atrium pressure. Although the frequency is low, fatal complications of oozing-type RV rupture might progress asymptomatically. Frequent echocardiographic screening is necessary to detect them. [ABSTRACT FROM AUTHOR]

• The demonstration of elevated left ventricular (LV) filling pressure, in which echocardiography plays a central role, is crucial in diagnosing heart failure with preserved ejection fraction (HFpEF) in euvolemic patients with dyspnea. • Exercise stress echocardiography may enhance the diagnosis of HFpEF by detecting elevation in LV filling pressures that develop only during exercise. • Echocardiography also provides valuable insight into the pathophysiology and underlying phenotypes of HFpEF. • Exercise stress echocardiography may allow for a better pathophysiological characterization in HFpEF. Heart failure with preserved ejection fraction (HFpEF) represents one of the greatest unmet needs in modern cardiology given its diagnostic difficulty and limited therapeutic options. Echocardiography provides valuable information on cardiac structure, function, and hemodynamics and plays a central role in the evaluation of HFpEF. Echocardiography is crucial in identifying HFpEF among patients with dyspnea, especially when overt congestion is absent. The combination of echocardiographic indices of diastolic function, clinical characteristics, and natriuretic peptide tests has been proposed in the diagnostic evaluation of patients with suspected HFpEF. Echocardiography also provides valuable insight into the pathophysiology and underlying phenotypes of HFpEF. Exercise stress echocardiography can also detect abnormalities that develop only during exercise. This may enhance the diagnosis of HFpEF by demonstrating elevation in the left ventricular filling pressure and may have potential for better pathophysiological characterization. This review focuses on the role of echocardiography in the diagnostic evaluation and phenotyping of HFpEF. We also discuss the potential role of exercise stress echocardiography for the diagnosis and disease phenotyping of HFpEF. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Few studies have investigated right atrial (RA) remodeling in heart failure (HF) with preserved ejection fraction (HFpEF). This study sought to characterize the RA remodeling in HFpEF and to determine its prognostic significance.Methods and Results: Patients with HFpEF were classified based on the presence of RA enlargement (RA volume index >39 mL/m2 in men and >33 mL/m2 in women). Compared with patients with normal RA size (n = 234), patients with RA dilation (n = 67) showed a higher prevalence of atrial fibrillation (AF), worse right ventricular systolic function, more severe pulmonary hypertension, and a greater prevalence of mild tricuspid regurgitation, as well as impaired RA reservoir function, with increased hepatobiliary enzyme levels. AF was strongly associated with the presence of RA dilation (odds ratio [OR] 10.2, 95% confidence interval [CI] 4.00-26.1 in current AF vs no AF and odds ratio 3.38, 95% CI 1.26-9.07, earlier AF vs no AF). Patients with RA dilation had more than a two-fold increased risk of composite outcomes of all-cause mortality or HF hospitalization (adjusted hazard ratio 2.01, 95% CI 1.09-3.70, P = .02). The presence of RA dilation also displayed an additive prognostic value over left atrial dilation alone.Conclusions: These data demonstrate that HFpEF with RA remodeling is associated with distinct echocardiographic features characterizing advanced right heart dysfunction with an increased risk of adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vascular disease may play an important role in the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). However, no study has demonstrated noninvasive quantification of pulmonary vascular alterations in HFpEF. This study sought to determine the association between pulmonary vascular alterations quantified by chest computed tomography scan and clinical outcomes in HFpEF.Methods and Results: Pulmonary vascular alterations were quantified in 151 patients with HFpEF who underwent noncontrast chest computed tomography scan by measuring the percentage of total cross-sectional area (CSA) of pulmonary vessels less than 5 mm2 to the total lung area (%CSA<5). We divided the patients by the median value of %CSA<5 (=1.45%) and examined the association between %CSA<5 and a composite outcome of all-cause mortality or HF hospitalization. During a median follow-up of 17.3 months, there were 44 (29%) composite outcomes. Event rates were significantly higher in patients with higher %CSA<5 than those with lower %CSA<5 (log-rank P = .02). %CSA<5 was associated with an increased risk of the outcome (hazard ratio per 1.0% increment, 1.46; 95% confidence interval 1.06-1.98; P = .02) in an unadjusted Cox model, and was independently and incrementally associated with the outcome over age, the presence of atrial fibrillation, E/e' ratio, and estimated pulmonary artery systolic pressure (global χ2 17.3 vs 11.5, P = .02).Conclusions: A higher %CSA<5 was associated with an increased risk of all-cause mortality or HF hospitalization in patients with HFpEF, with an incremental prognostic value over age, atrial fibrillation, E/e' ratio, and pulmonary artery systolic pressure. [ABSTRACT FROM AUTHOR]

Background: Identification of elevated pulmonary artery (PA) pressures during exercise may provide diagnostic, prognostic, and therapeutic implications in heart failure with preserved ejection fraction. Although widely performed, exercise stress echocardiography may underestimate true PA pressures due to the difficulty in estimating right atrial pressure (RAP) during exercise. We hypothesized that peripheral venous pressure (PVP) could allow for reliable estimation of RAP, and thus PA pressures during exercise stress echocardiography. Methods: In protocol 1, we investigated the accuracy of PVP compared with simultaneously measured RAP at rest and during exercise right heart catheterization in 19 subjects. In protocol 2, we examined whether the addition of PVP to Doppler exercise echocardiography (tricuspid regurgitant velocity) would increase the ability to identify exercise-induced pulmonary hypertension compared with inferior vena cava-based RAP estimation in 60 patients with dyspnea. Results: In protocol 1, PVP was strongly correlated with simultaneously measured RAP at rest and during exercise (r =0.77 and 0.90), with little overestimation of invasively measured RAP (bias 3.4 mm Hg at rest and 1.7 mm Hg during exercise). In protocol 2, PVP increased dramatically during exercise echocardiography (14+/-5 mm Hg) while an increase in inferior vena cava-based RAP was modest (6+/-4 mm Hg). Exercise PA pressures calculated from PVP and tricuspid regurgitant velocity were significantly higher than those estimated from inferior vena cava and the use of PVP increased the proportion of patients with exercise-induced pulmonary hypertension from 40% to 68%. Conclusions: PVP may prevent underestimation of PA pressures during exercise echocardiography and could be a preferred approach to identify exercise-induced pulmonary hypertension in patients with suspected heart failure with preserved ejection fraction. * Peripheral venous pressure (PVP) was strongly correlated with invasively measured right atrial pressure (RAP) at rest and during exercise, with little bias. * We found that, in contrast to modest increases in RAP estimated from the inferior vena cava (eRAP), PVP substantially increased during exercise stress echocardiography. * Compared with eRAP, the addition of PVP to Doppler exercise echocardiography increased the proportion of patients with exercise-induced pulmonary hypertension. * PVP may serve as a reliable alternative to RAP during exercise stress echocardiography. * The addition of PVP measurements to the standard exercise echocardiography might allow accurate estimation of pulmonary artery pressures during exercise. * This technique may help clinical decision-making in patients with dyspnea. [ABSTRACT FROM AUTHOR]

Background: Cardiac power output is a measure of cardiac performance, and its prognostic significance has been shown in heart failure (HF) with reduced ejection fraction. Patients with HF with preserved ejection fraction may have altered cardiac performance, but the prognostic relevance of cardiac power output is unknown. This study sought to determine the association between cardiac power output and clinical outcomes in HF with preserved ejection fraction and to compare its prognostic effect to other measures of cardiac performance including ventricular-arterial coupling and mechanical efficiency. Methods: Cardiac power output normalized to left ventricular mass was assessed by echocardiography in 408 patients with HF with preserved ejection fraction. Load-independent contractility (end-systolic elastance), arterial elastance, its coupling (arterial elastance/end-systolic elastance), left ventricular global longitudinal strain, and mechanical efficiency (stroke work/pressure-volume area) were also estimated noninvasively. The primary end point was a composite of cardiovascular mortality or HF hospitalization. Results: The primary composite outcome occurred in 84 patients during a median follow-up of 19.4 months. There was a dose-dependent association between cardiac power output and the composite outcomes, in which patients with the lowest tertile of cardiac power output had >3-fold risk than those with the highest tertile (hazard ratio, 3.04 [95% CI, 1.66-5.57]; P =0.0003). In a multivariable model, lower cardiac power output was independently associated with adverse outcomes (hazard ratio, 0.70 per 1 SD [95% CI, 0.49-0.97]; P =0.03). In contrast, left ventricular size, end-systolic elastance, arterial elastance, arterial elastance/end-systolic elastance ratio, and left ventricular mechanical efficiency were not associated with outcomes. Cardiac power output provided an incremental prognostic effect over the model based on clinical (age, gender, diastolic blood pressure, and atrial fibrillation) and echocardiographic markers (left atrial size, pulmonary pressures, global longitudinal strain, and the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular tissue velocity; P =0.03). Conclusions: In patients with HF with preserved ejection fraction, cardiac power output was independently and incrementally associated with adverse outcomes whereas other markers of cardiac performance were not. [ABSTRACT FROM AUTHOR]

Abstract: A 65-year-old man with a history of refractory paroxysmal atrial fibrillation (AF) underwent catheter ablation for persistent AF lasting 2 months. AF was not terminated after complete isolation of the 4 pulmonary veins (PV). Instead, it was transformed to a sustained atrial tachyarrhythmia with beat-to-beat variability in the atrial cycle length. A 12-lead electrocardiogram during tachycardia showed negative flutter-like waves in the inferior leads. Entrainment pacing along the tricuspid annulus confirmed the diagnosis of irregular cavotricuspid isthmus (CTI)-dependent typical atrial flutter (AFL). Linear ablation of the CTI terminated AFL and restored sinus rhythm. [Copyright &y& Elsevier]

Focal pseudo-atrial fibrillation (AF) developed in a 30-year-old woman after radiofrequency (RF) ablation of focal atrial tachycardia (AT) originating from the coronary sinus ostium. Programmed atrial stimulation occasionally induced, accelerated or terminated AT, and a spiky prepotential preceded the earliest atrial electrogram at the AT focus. After the first RF application, repetitive bursts of accelerated tachycardia developed, mimicking AF on the surface ECG. An additional RF application where the spiky prepotential was observed, eliminated the focal pseudo-AF. [Copyright &y& Elsevier]

Introduction: Fasciculoventricular (FV) accessory pathways are rare variants of preexcitation syndrome and published data on the ECG of FV pathways are limited. The purpose of this study was to analyze the electrocardiographic characteristics of FV pathways. Methods: We enrolled 5 patients (mean age, 26.8 ± 15.1 years; range 15–49 years, 2 male) with FV pathways which were diagnosed based on the standard electrophysiologic criteria. According to the standard criteria for the ECG classification of manifest Wolff-Parkinson-White (WPW) syndrome, the ECGs were classified as type A, B or C. The polarity of delta wave in each lead of each patient was divided into positive, flat or negative and was applied to the stepwise ECG algorithms of atrioventricular accessory pathway previously published by Fitzpatrick, Arruda and Iturralde. Results: Type A was found in one patient (Case No 4), type B in one patient (Case No 5) and type C in three patients (Case No 1, 2 and 3). Based on stepwise ECG algorithm, all cases corresponded to the polarity of the delta wave in patients with right anteroseptal, posteroseptal, right anterolateral or left anterolateral AP. In all three cases exhibiting type C, the polarity of delta wave in lead V2 was flat. Conclusions: ECGs of FV pathways may be misidentified as ECG of WPW syndrome, and may present with any preexcitation pattern of type A, B or C. [Copyright &y& Elsevier]

Summary: A 59-year-old man during chemotherapy for squamous cell carcinoma of the lung, underwent catheter ablation of drug-refractory atrial tachycardia. Pulmonary venography and chest computed tomography revealed presence of stenotic, carcinomatous lesion of the left superior pulmonary vein. Excellent pace map and elimination of inducibility of atrial tachyarrhythmias after left pulmonary isolation suggested that the atrial tachycardia originated from the metastatic region. [Copyright &y& Elsevier]