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Background: The aim of this study was to evaluate enoximone echocardiography (EE) for the identification of residual myocardial viability in postinfarction patients. Findings obtained during EE were compared with those acquired by myocardial uptake of fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) and functional follow-up results. Methods: Twenty-five patients underwent EE and PET 18F-FDG studies. An asynergic segment was considered as having contractile enhancement when the wall motion score decreased by >= 1 grade during EE and was defined as viable if 18F-FDG uptake score was >= 2 grade on PET. Results: Of 293 dysfunctional segments at baseline, 139 (47%) were viable by PET criteria; 117 (40%) had contractile enhancement induced by enoximone (P = 0.07). Agreement between EE and PET was found in 75% of involved segments (K = 0.46, P < 0.001). The majority of discrepancies (65%, P < 0.01) were mainly due to discordant segments in which PET revealed evidence of 18F-FDG uptake but EE showed no change in wall motion. In 179 revascularized segments, negative predictive value for functional recovery of both tests reached the same value (89% for both), whereas positive predictive value was 82% for EE and 68% for PET, respectively (P < 0.05). Sensitivity was 85% for EE and 88% for PET (P = ns); specificity was 87% and 70%, respectively (P < 0.01). Conclusions: EE yields a fair concordance with PET study. Compared with PET, despite a similar negative accuracy, EE shows a greater specificity for prediction of function recovery after revascularization. (Echocardiography 2010;27:544-551). RI Balbarini, Alberto/G-8753-2011

The aims of this study were to evaluate through Color Doppler Myocardial Imaging (CDMI) echocardiography if atrial or ventricular myocardial alterations could be detectable in patients with thalassemia major (THAL) and if these alterations could be considered as predictive elements for supra-ventricular arrhythmic events. Twenty-three patients with THAL underwent clinical and electrocardiographic evaluation; patients were grouped in THAL1 (9 with supra-ventricular arrhythmias) and THAL2 (14 without arrhythmias); 12 healthy subjects were considered as control group (C). We examined through conventional 2D Color Doppler echocardiography some morphological and functional parameters regarding left ventricular (LV) systolic and diastolic function, and through CDMI the velocities at mitral annulus level, the regional LV and left atrial (LA) strain and strain rate. All THAL patients had LV dimension (pless than 0.05), LA area (p less than 0.01) and E/Em ratio (pless than 0.001) to be significantly higher than controls. The mitral annulus longitudinal velocities were significantly lower in THAL1 than in THAL2 (pless than 0.001); the E/Em ratio was higher in THAL1 than THAL2 (pless than 0.001). The THAL1 showed a lower systolic strain rate of atrial wall than THAL2 and C (pless than 0.05). The multiple regression highlighted a significantly inverse correlation among E/Em and atrial strain (pless than 0.02). CDMI showed both THAL subgroups had subtle systolic and diastolic left ventricular myocardial alterations, which could represent the onset of developing “iron cardiomyopathy” and are related to supra-ventricular arrhythmia. Monitoring these parameters in the THAL patients could contribute to decisions about follow-up and therapy.

The objective of this review was to explore the clinical relevance of Doppler echocardiographic techniques in the evaluation of right and left ventricular function. It is well known that echocardiographic and Doppler analysis are able to provide information about several hemodynamic parameters, such as cardiac output, diastolic filling pressure, vascular resistances and pulmonary arterial pressures. This integrated approach, completely reliable and non-invasive, could allow to obtain useful information not only from a diagnostic and prognostic point of view but also for a potential therapeutic management, either pharmacological or surgical. This review summarizes the current knowledge and the emerging applications of echocardiographic and Doppler techniques focusing on the close correlation between Doppler-derived data and those coming from invasive techniques. On the basis of these evidences, the importance, even in daily clinical practice, of a non-invasive catheterization laboratory is clear and able to supply key information about ventricular function and, at the same time, to avoid expensive and unpleasant invasive procedures for patients.

Ultrasonic myocardial tissue characterization represents a relatively new diagnostic tool which allows integration of the conventional echocardiographic evaluation, in order to obtain specific textural parameters which reflect the myocardial ultrastructural texture. In particular, through this approach it is possible to obtain two different types of information: the first is static and consists of the absolute myocardial echo intensity that reflects the ultrastructural myocardial changes in different diseases; the second is dynamic and is related to the variations of echo intensity during the cardiac cycle which seem to be linked, even though not linearly, to the intrinsic myocardial contractility. Our research group has extensively applied this methodological approach to different pathophysiological models, in particular to essential hypertension. In the present review the technological evolution of the method and comparison with other research groups' experience with the specific pathophysiological models, are shown and discussed.

Based on various epidemiological observations, it has been hypothesized that there is a "diabetic cardiomyopathy" strictly related to diabetes per se and probably due to an increase in the collagen content at the myocardial level, to microangiopathy or to complex alteration of myocardial metabolic pattern. Ultrasonic tissue characterization has recently been applied with different methodological approaches in order to identify early structural alterations of the myocardium.We used two different methods of myocardial tissue characterization, i.e. integrated backscatter and videodensitometry, to analyze 26 type I diabetics without clinical symptoms, without hypertension or coronary artery disease, which were excluded on the basis of a negative exercise ECG, and in whom conventional echocardiographic parameters were normal. Seventeen healthy age- and sex-matched subjects were evaluated as the control group.Of the common left ventricular functional indexes, only E/A ratio (expression of global diastolic function) was lower in diabetics compared with controls (p0.01). The integrated backscatter index (IBI%) at the septum and posterior wall was significantly higher in diabetics as compared to controls, expressing an increased collagen content on a myocardial level. The cyclic variation index (%) of the mean gray level (videodensitometry) was significantly lower in diabetics in comparison with controls, both for the septum (p0.0001) and posterior wall (p0.002). This probably expresses an altered intrinsic myocardial contractility, due to an increase in myocardial collagen content and/or impairment of micro-circulatory function.In agreement with previous studies, we found an altered behavior in myocardial tissue reflectivity in type I diabetics. The real significance of this finding in the "normal" heart is the subject of intense debate. One hypothesis is that these findings could be considered a very early index of a "diabetic cardiomyopathy".

Functional mitral regurgitation (FMR) is a common finding in patients with ischemic or nonischemic dilated cardiomyopathy as a complication of left ventricular (LV) dysfunction and remodeling associated with a fibrotic remodeling response of mitral leaflets to abnormal valvular loading. Although mitral valve tenting is the main determinant of FMR, clinical and experimental observations suggest that intraventricular delay could be a potential co-determinant of FMR. LV dyssynchrony can potentially contribute to FMR by several mechanisms, such as creating an uncoordinated regional LV mechanical activation in segments supporting the papillary muscles, determining diastolic mitral regurgitation, reducing the sphincteric function of the mitral annulus, and decreasing the efficiency of LV contraction and closing forces. Cardiac resynchronization therapy has been demonstrated to reduce FMR with correction of some of the underlying pathophysiological mechanisms. The present review article focuses on the role of mechanical dyssynchrony as a pathophysiological determinant of FMR, and on the potential role of cardiac resynchronization therapy as a therapeutic option for treatment of FMR in patients with severe heart failure and advanced LV dysfunction.

The percutaneous mitral valve (MV) repair procedure performed with the MitraClip (R) delivery system is increasingly used to treat severe mitral regurgitation in high-risk patients. The treatment involves percutaneous insertion and positioning of a clip between the MV leaflets. Transesophageal echocardiography (TEE) plays a key role in the procedure by providing information regarding clip navigation, clip alignment to the MV coaptation line, transmitral advancement of the system, leaflet grasping, confirmation of valve tissue catching, and assessment of the final result. Real-time 3-dimensional TEE has increasing value in percutaneous MV repair providing high-quality visualization of both the heart and the intravascular devices. Optimal visualization by 3-dimensional TEE is obtained through both the atrial and ventricular aspects. In contrast to MV surgery, where TEE is involved in the prebypass assessment phase and in evaluation of the final repair, TEE is mandatory to guide management during MitraClip repair. Cardiac anesthesiologists may provide assistance to interventional cardiologists during the procedure itself in addition to their anesthetic-related tasks. OI Guarracino, Fabio/0000-0002-2562-0199 The percutaneous mitral valve (MV) repair procedure performed with the MitraClip (R) delivery system is increasingly used to treat severe mitral regurgitation in high-risk patients. The treatment involves percutaneous insertion and positioning of a clip between the MV leaflets. Transesophageal echocardiography (TEE) plays a key role in the procedure by providing information regarding clip navigation, clip alignment to the MV coaptation line, transmitral advancement of the system, leaflet grasping, confirmation of valve tissue catching, and assessment of the final result. Real-time 3-dimensional TEE has increasing value in percutaneous MV repair providing high-quality visualization of both the heart and the intravascular devices. Optimal visualization by 3-dimensional TEE is obtained through both the atrial and ventricular aspects. In contrast to MV surgery, where TEE is involved in the prebypass assessment phase and in evaluation of the final repair, TEE is mandatory to guide management during MitraClip repair. Cardiac anesthesiologists may provide assistance to interventional cardiologists during the procedure itself in addition to their anesthetic-related tasks.

Measurement of force-frequency relationship (FFR) is useful in the evaluation of heart rate-dependent contractile dysfunction. The purpose of this study was to evaluate a new Doppler-derived method for assessing FFR. Doppler velocity spectra at the left ventricular (LV) outflow tract was used to estimate mean blood flow velocity (mBFV), ejection time (ET) and velocity-time integral. LV ejection force (LVF) was then calculated ac- cording to the law of conservation of momentum: 1060 kg/m 3 3 (mBFV(m/sec)/ET (s)) 3 Stroke volume (mL). A symptom-limited, graded, bicycle semi-supine exercise test was performed in 56 patients with LV dysfunction (LVejection fraction 527 ± 6%). Measurements were obtained at baseline and serially during the test. The change in FFR was defined as up-sloping when the peak LVF was higher than the baseline value. The change was biphasic when the trendwas initially up-sloping, then down-sloping; it wasflat or negative when peak LVF was less than the baseline value. LVF was 30 ± 12 mN in patients with up-sloping FFR (n 5 39) and 15 ± 6 mN in those with biphasic or flat FFR (n 5 17; p , 0.0001). The ultrasound assessment of the FFR was highly concordant with a previously validated method based on pressure-end-systolic volume index ratio (k 5 0.75; 95% confidence interval, 0.55-94.0). The evaluation of the LVF using Doppler is an alternative method for the assessment of FFR during stress echocardiography in patients with LV dysfunction. (E-mail: f.dini@ao-pisa.toscana.it) � 2013 World Federation for Ultrasound in Medicine & Biology.

Objectives: Aortic valve implantation through peripheral vascular access is an option for high-risk patients with severe aortic valve stenosis. The authors aimed to compare the acute effect of endovascular and surgical aortic valve procedures on left ventricular diastolic function. Design: A case-matched, nonrandomized study. Setting: A university hospital. Participants: Patients with aortic stenosis. Interventions: B-natriuretic peptide was measured in 30 patients with a logistic EuroSCORE >= 20% undergoing endovascular aortic valve implantation. Patients were case matched (age, mitral flow propagation velocity, mitral annulus early diastolic velocity, and B-natriuretic peptide measurement) with 30 control patients undergoing surgical aortic valve replacement through sternotomy. Left ventricular diastole was evaluated initially and after valve procedures with echocardiography by mitral flow propagation velocity and mitral annulus early diastolic velocity. Measurements and Main Results: B-natriuretic peptide was similar preoperatively in the 2 groups (346 [188-438] v 367 [211-458] pg/mL) and higher (p = 0.006) in the surgical group postoperatively (389.5 [237-479] v 710.5 [389-822] pg/mL), with a postprocedural statistically significant increase only in the surgical group. Diastolic function was similar in the 2 groups preoperatively, improved postoperatively in the endovascular group, and worsened in the surgical group. Conclusions: B-natriuretic peptide increased after surgical but not after endovascular aortic valve replacement. Furthermore, endovascular aortic valve implantation acutely improved left ventricular diastolic function as documented by increases in mitral flow propagation velocity and mitral annulus early diastolic velocity. (C) 2010 Elsevier Inc. All rights reserved.

The aim of this study was to evaluate the relationship between insulin resistance and preclinical abnormalities of the left ventricular structure and function detected in severe obesity by Color Doppler Myocardial Imaging (CDMI). Forty-eight consecutive severely obese patients (Group O) (11 males, 37 females, mean age 32.8+/-7 years) were enrolled. Forty-eight sex- and age-matched non-obese healthy subjects were also recruited as controls (Group C). All subjects underwent conventional 2D-Color Doppler echocardiography and CDMI. The homeostasis model assessment insulin resistance index (HOMA-IR) was used to assess insulin resistance results. Obese subjects had a greater left ventricular mass index (by height) (58.8+/-14 g/m(2.7)) than controls (37+/-8 g/m(2.7)) (P0.0001), owing to compensation response to volume overload caused by a greater cardiac output (P0.02). Preload reserve was increased in obese subjects, as demonstrated by a significant increase in left atrial dimension (P0.0001). Obese patients had a slightly reduced LV diastolic function (transmitral E/A ratio: Group O, 1.1+/-0.8 vs Group C, 1.5 +/-0.5; P0.002). Cardiac deformation assessed by regional myocardial systolic strain and strain rate (SR) values was significantly lower (abnormal) in obese patients than in controls, both at the septum and lateral wall level. These strain and SR abnormalities were significantly related to body mass index. In addition, the early phase of diastolic function, evaluated using SR, was compromised in obese patients (P0.001). The HOMA-IR values in obese patients were significantly higher (3.09+/-1.6) than those determined in the control group (0.92+/-0.5) (P0.0001). The HOMA-IR values, in the obese group, were significantly related to systolic strain and SR values sampled at the septum level (P0.0001).In conclusion, this study has demonstrated that obese patients pointed out systolic structural and functional abnormalities at a preclinical stage, in particular through strain and SR analysis; on the other hand, those altered CDMI parameters well distinguish obese subjects as compared with the control group. Furthermore, another main finding of the study was that myocardial deformation (systolic strain) could have a correlation with insulin resistance level.