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Background: Restrictive cardiomyopathy (RCM) places patients at high risk for adverse events. In this study, we aim to evaluate the association between left atrial function and time to adverse events such as all-cause mortality and cardiovascular hospitalizations related to RCM. Material and Methods: In this single-center study, ninety-eight patients with a clinical diagnosis of RCM were recruited from our registry: 30 women (31%); age (mean ± standard deviation) 61 ± 13 years. These patients underwent cardiac magnetic resonance (CMR) imaging from May 2007 to September 2015. Left atrial (LA) function (reservoir, contractile, and conduit strain), LA diameter and area, and left ventricular function (global longitudinal strain, ejection fraction), and volume were quantified, and the presence of late gadolinium enhancement was visually assessed. The cutoff value of the LA reservoir strain was selected based on tertile. An adjusted Cox proportional regression analysis was used to assess time to adverse outcomes with a median follow up of 49 months. Results: In our cohort, all-cause mortality was 36% (35/98). Composite events (all-cause mortality and cardiovascular hospitalizations) occurred in 56% of patients (55/98). All-cause mortality and composite events were significantly associated with a decreased LA reservoir strain (adjusted hazard ratio (aHR) = 0.957, p = 0.002 and aHR = 0.969, p = 0.008) using a stepwise elimination of imaging variables, demographics, and comorbidities. All-cause mortality and composite events were six and almost four times higher, respectively, in patients with the LA reservoir strain <15% (aHR = 5.971, p = 0.005, and HR = 4.252, p = 0.001) compared to patients with the LA reservoir strain >34%. Survival was significantly reduced in patients with an LA reservoir strain <15% (p = 0.008). Conclusions: The decreased LA reservoir strain is independently associated with time to adverse events in patients with RCM.

Exercise Doppler echocardiography (EDE) is a well-validated tool in ischemic and valvular heart diseases. However, its use in the assessment of the right heart and pulmonary circulation unit (RH-PCU) is limited. The aim of this study is to assess the semi-recumbent bicycle EDE feasibility for the evaluation of RH-PCU in a large multi-center population, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension (PH). From January 2019 to July 2019, 954 subjects [mean age 54.2 ± 16.4 years, range 16-96, 430 women] underwent standardized semi-recumbent bicycle EDE with an incremental workload of 25 watts every 2 min, were prospectively enrolled among 7 centers participating to the RIGHT Heart International NETwork (RIGHT-NET). EDE parameters of right heart structure, function and pressures were obtained according to current recommendations. Right ventricular (RV) function at peak exercise was feasible in 903/940 (96%) by tricuspid annular plane systolic excursion (TAPSE), 667/751 (89%) by tissue Doppler-derived tricuspid lateral annular systolic velocity (S') and 445/672 (66.2%) by right ventricular fractional area change (RVFAC). RV-right atrial pressure gradient [RV-RA gradient = 4 × tricuspid regurgitation velocity 2 (TRV)] was feasible in 894/954 patients (93.7%) at rest and in 816/954 (85.5%) at peak exercise. The feasibility rate in estimating pulmonary artery pressure improved to more than 95%, if both TRV and/or right ventricular outflow tract acceleration time (RVOT AcT) were considered. In high specialized echocardiography laboratories semi-recumbent bicycle EDE is a feasible tool for the assessment of the RH-PCU pressure and function., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders., Methods: This prospective observational study was performed at the Veterans Affairs Ann Arbor Healthcare System. From October to December 2016 (preintervention), consecutive TTEs ordered in the inpatient, outpatient, and emergency department settings were included. In May 2017, a decision-support algorithm was incorporated into the EMR, giving immediate feedback to providers. Chart review was performed for TTEs ordered from June to August 2017 (early intervention) and from June to August 2018 (late intervention). Appropriateness was determined based on the 2011 appropriate use criteria for echocardiography., Results: Appropriate TTE orders increased from 87.6% preintervention to 94.5% at early intervention (z = 0.00018) but decreased to 90.0% at late intervention (z = 0.51, compared with preintervention). Among patients with no previous TTEs in our system, 95.3% of TTEs were appropriate, compared with 87.7% of TTEs for patients with prior TTEs within 30 days prior (odds ratio = 2.85; 95% CI, 1.18-6.31; P = .005)., Conclusions: The EMR algorithm initially increased the percentage of appropriate TTEs, but this effect decayed over time. Further study is needed to develop EMR-based interventions that will have lasting impacts on provider ordering patterns., (Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Purpose: This study was a quality-control study of resting and exercise Doppler echocardiography (EDE) variables measured by 19 echocardiography laboratories with proven experience participating in the RIGHT Heart International NETwork., Methods: All participating investigators reported the requested variables from ten randomly selected exercise stress tests. Intraclass correlation coefficients (ICC) were calculated to evaluate the inter-observer agreement with the core laboratory. Inter-observer variability of resting and peak exercise tricuspid regurgitation velocity (TRV), right ventricular outflow tract acceleration time (RVOT Act), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler tricuspid lateral annular systolic velocity (S'), right ventricular fractional area change (RV FAC), left ventricular outflow tract velocity time integral (LVOT VTI), mitral inflow pulsed wave Doppler velocity (E), diastolic mitral annular velocity by TDI (e') and left ventricular ejection fraction (LVEF) were measured., Results: The accuracy of 19 investigators for all variables ranged from 99.7 to 100%. ICC was > 0.90 for all observers. Inter-observer variability for resting and exercise variables was for TRV = 3.8 to 2.4%, E = 5.7 to 8.3%, e' = 6 to 6.5%, RVOT Act = 9.7 to 12, LVOT VTI = 7.4 to 9.6%, S' = 2.9 to 2.9% and TAPSE = 5.3 to 8%. Moderate inter-observer variability was found for resting and peak exercise RV FAC (15 to 16%). LVEF revealed lower resting and peak exercise variability of 7.6 and 9%., Conclusions: When performed in expert centers EDE is a reproducible tool for the assessment of the right heart and the pulmonary circulation.

Dyspnea in the postpartum period can be a symptom of a wide range of causes spanning normal pregnancy to life-threatening pathology. We describe a case of acute postpartum heart failure with preserved systolic function in the absence of pre-eclampsia or prior cardiovascular disease. ( Level of Difficulty: Beginner. ).

The relations between race and cardiac structure and function are incompletely understood. We hypothesized that race-specific differences in echocardiography measurements exist. We compared the relation between echocardiography measurements and race among 12,429 nonobese adults without known cardiovascular disease who underwent echocardiography. We compared measurements between whites (n = 10,508), blacks (n = 792), Asians (n = 628), Hispanics (n = 315), Native Americans (n = 34), and multiracial/other (n = 152) cohorts. Multivariate analysis compared measurements indexed to body surface area (BSA) between races and adjusted for variables including age, gender, and mean blood pressure. Mean age was 46.9 ± 17.4 years and 60.5% were women. After multivariable adjustment and using whites as a baseline, there were significant differences (p <0.05) in left ventricular end-diastolic diameter/BSA for blacks (-0.5 mm/m 2 ), Asians (0.4 mm/m 2 ), Hispanics (0.2 mm/m 2 ), and multiracial/others (0.1 mm/m 2 ); septal wall thickness/BSA for blacks (0.4 mm/m 2 ) and Asians (0.1 mm/m 2 ); posterior wall thickness/BSA for blacks (0.4 mm/m 2 ), Asians (0.1 mm/m 2 ), Hispanics (0.04 mm/m 2 ), and multiracial/others (0.03 mm/m 2 ); left atrial diameter/BSA for Asians (0.2 mm/m 2 ), Hispanics (0.3 mm/m 2 ), and multiracial/others (0.1 mm/m 2 ); septal and lateral e' for blacks (-0.7 cm/s; -0.9 cm/s); and peak tricuspid regurgitation gradient for blacks (4.3 mm Hg) and Asians (-0.9 mm Hg). Race is associated with significant differences in left ventricular size, left atrial size, mitral annular velocity, and tricuspid regurgitation gradient. Normal reference ranges for echocardiography measurements should utilize racially diverse cohorts to prevent misclassification of echocardiography findings based on race., (Copyright © 2019 Elsevier Inc. All rights reserved.)

It is not clear whether there are differences in aortic dimensions by race. Our hypothesis was that race-specific differences in aortic size exist. We compared the relation between race and aortic dimensions among 15,295 adults without known risk factors for cardiovascular disease or aortic dilatation, who underwent clinically indicated transthoracic echocardiography. We compared inner edge-to-inner edge measurements between whites (n = 12,932), blacks (n = 958), Asians (n = 827), Hispanics (n = 366), Native Americans (n = 38), and others (n = 174). Multivariate analysis compared measurements indexed with body surface area (BSA) between races and adjusted for variables including age, gender, and mean blood pressure. Mean age was 49.9 ± 17.6 years, and 58.7% were female. On gender-specific comparisons, there were significant differences in aortic size between races (p <0.001 for each). Using whites as a baseline, multivariable analysis demonstrated that blacks had smaller BSA-indexed aortic sinus (-0.34 mm/m 2 , p <0.001) and ascending aorta (-0.43 mm/m 2 , p <0.001) dimensions; Asians had larger BSA-indexed aortic sinus (0.36 mm/m 2 , p <0.001), ascending aorta (0.41 mm/m 2 , p <0.001), and aortic arch (0.20 mm/m 2 , p = 0.002) dimensions; Hispanics had larger BSA-indexed aortic arch dimensions (0.15 mm/m 2 , p = 0.01); Native Americans had increased BSA-indexed aortic arch dimensions (0.32 mm/m 2 , p = 0.01); and other races had increased BSA-indexed aortic arch dimensions (0.11 mm/m 2 , p = 0.03). In a cohort without known risk factors for aortic dilatation, race is associated with significant differences in aortic dimensions. In conclusion, these findings suggest that reference ranges for aortic size should be established using racially diverse cohorts to prevent misdiagnosis of aortic dilatation based on race., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Guidelines provide normal ranges of left ventricular (LV) wall thicknesses (WT) without indexing. We hypothesized that indexing WT to body surface area (BSA) improves prognostic value., Methods: We examined the relationship between WT and BSA in 9737 patients undergoing echocardiography without risk factors for LV hypertrophy other than obesity. We compared WT to BSA and examined the relationship of WT and LV mass index (LVMI) to mortality., Results: There is a linear relationship between BSA and septal and posterior WT (r = 0.38, P < 0.001 for each). Higher quartiles of BSA were associated with increased WT (P < 0.001). After adjusting for age and gender, greater mean WT (MWT) (Hazards Ratio [HR] 1.10 per mm, 95% Confidence Interval [CI] 1.04-1.16, P = 0.001, C-statistic 0.66), LVMI (HR 1.01, 95% CI 1.001-1.01, P = 0.01, C-statistic 0.66), and indexed MWT (HR 1.34 per mm/m 2 , 95% CI 1.23-1.47, P < 0.001, C-statistic 0.67) are each associated with increased mortality, with indexed MWT having the highest prognostic value. Each decile of indexed MWT ≥8th decile was associated with increased mortality compared to the 1st decile (P < 0.01 for each). Individuals with indexed MWT ≥8th decile (≥5.0 mm/m 2 ) had increased adjusted mortality (HR 1.67, 95% CI 1.43-1.94, P < 0.001, C-statistic 0.67); this had improved prognostic value over guideline definitions of increased MWT (C-statistic 0.66) or LVMI (P = NS)., Conclusions: We observe a linear relationship between BSA and WT. Indexing WT improves mortality prediction over LVMI and nonindexed WT. These findings support indexing WT to BSA., (© 2019 Wiley Periodicals, Inc.)

The Right Heart International Network is a multicenter international study aiming to prospectively collect exercise Doppler echocardiography tests of the right heart pulmonary circulation unit (RHPCU) in large cohorts of healthy subjects, elite athletes, and individuals at risk of or with overt pulmonary hypertension. It is going to provide standardization of exercise stress echocardiography of RHPCU and explore the full physiopathologic response., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The EACVI/ASE/Industry Task Force to standardize deformation imaging prepared this consensus document to standardize definitions and techniques for using two-dimensional (2D) speckle tracking echocardiography (STE) to assess left atrial, right ventricular, and right atrial myocardial deformation. This document is intended for both the technical engineering community and the clinical community at large to provide guidance on selecting the functional parameters to measure and how to measure them using 2D STE.This document aims to represent a significant step forward in the collaboration between the scientific societies and the industry since technical specifications of the software packages designed to post-process echocardiographic datasets have been agreed and shared before their actual development. Hopefully, this will lead to more clinically oriented software packages which will be better tailored to clinical needs and will allow industry to save time and resources in their development.

Introduction: Coronary microvascular dysfunction (MVD) may contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Using myocardial flow reserve (MFR) measured by positron emission tomography (PET) as an assessment of microvascular function, we hypothesized that abnormal MFR is associated with LV diastolic dysfunction (DD) and reduced LV and LA strain in patients with risk factors for HFpEF and normal epicardial perfusion on cardiac PET., Methods and Results: Retrospective study of patients without heart failure who underwent cardiac rubidium-82 PET and echocardiography. Global MFR was calculated as the ratio of global stress to rest myocardial blood flow. Echocardiographic measures of diastolic function were recorded. Global longitudinal LA and LV strain were measured with a 2-dimensional speckle-tracking technique. Relationships among MFR and echocardiographic measures were assessed with linear regression, analysis of variance, and test for trend. Seventy-three patients (age 64 ± 11 years, 52% male) were identified with no epicardial perfusion defect on cardiac PET and an ejection fraction ≥50%. Decreased MFR was associated with LV DD (P = .02) and increased E/e', an estimation of LV filling pressure (low E/e' [<8] vs. high E/e' [>15], P < .001). MFR was associated with LA strain independent of age, gender, and common comorbidities (adjusted β = 2.6% per unit MFR, P = 0.046); however, MFR was only marginally related to LV strain., Conclusions: In patients with risk factors for HFpEF, MVD assessed with MFR was associated with DD, increased estimated LV filling pressure, and abnormal LA strain., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Transthoracic echocardiography (TTE) is a practical and widely used tool for risk stratification in pulmonary arterial hypertension (PAH). We hypothesized that right atrial (RA) reservoir function, represented by peak RA systolic strain, correlates with invasive hemodynamic measurements and clinical outcomes in PAH. Patients with group 1 PAH who had TTE within 6 months of index PAH clinic visit and right heart catheterization were included in this retrospective study. Peak RA strain in the 2D apical 4-chamber view was measured with speckle-tracking software. The primary endpoint was a composite of prostacyclin initiation, lung transplantation, and death. RA strain was also measured in healthy control subjects. Among the 37 patients studied, 25 (68%) met the primary endpoint. RA strain was significantly lower among patients who met the primary endpoint than among those who did not (mean 20% vs. 33%, P = 0.002). Strain was lower in PAH patients than in controls (mean 24% vs. 35%, P = 0.0001). RA strain correlated negatively with hemodynamic data including RA pressure (R = -0.31), mean pulmonary arterial pressure (R = -0.33), and pulmonary vascular resistance (R = -0.39), and positively with cardiac index (R = 0.44). In receiver operating characteristic analysis to distinguish between patients meeting the primary endpoint and event-free survivors, RA strain was not significantly different from RA volume, right ventricular (RV) fractional area change, RV basal diameter, or right ventricular systolic pressure (area under the curve 0.82, 0.81, 0.83, 0.86, and 0.97, respectively). Our results demonstrate that RA strain is predictive of clinical outcomes in PAH. Further research is needed to determine if RA strain is independently associated with outcomes in this population.

Objectives: The purpose of this study was to compare haemodynamics at rest and during exercise after clinically indicated aortic valve replacement (AVR) for aortic stenosis among patients randomly assigned to one of three haemodynamically excellent bioprostheses., Methods: In a single-centre, prospective trial, 60 patients undergoing clinically indicated AVR were randomly assigned to Freestyle, Magna Ease or Trifecta bioprostheses. Six months after surgery, patients underwent supine bicycle stress echocardiography for the assessment of aortic valve haemodynamics., Results: There were 5 protocol deviations from random valve assignments, and 4 patients did not return for follow-up stress echo, yielding a study group of 56 patients {17 Freestyle, 21 Magna Ease, 18 Trifecta; median age 70 [interquartile range (IQR) 63-78 years], 37 (66%) men}. There were no statistically significant differences between groups in valve size, concomitant procedures or exercise variables. Resting haemodynamics revealed significant differences between groups in mean gradient [Freestyle 7 (IQR 5-9) mmHg, Magna Ease 9 (IQR 7-11) mmHg, Trifecta 5 (IQR 4-8) mmHg; P = 0.04], effective orifice area (EOA) [2.5 (IQR 2.2-2.7), 2.1 (IQR 1.7-2.3) and 2.6 (IQR 2.3-2.8), respectively; P = 0.02] and EOA index [1.22 (IQR 1.11-1.32), 1.02 (IQR 0.89-1.14) and 1.31 (IQR 1.00-1.42), respectively; P = 0.03]; in each case, Trifecta had better haemodynamics compared with Magna Ease. With exercise, significant differences between groups were evident in peak velocity at 50 watts and peak exercise; mean gradient at 25 watts, 50 watts and maximal exercise; and EOA at 25 watts and at peak exercise; all with haemodynamic superiority of Trifecta compared with Magna Ease. There were no statistically significant differences between Trifecta and Freestyle haemodynamics at rest or with exercise., Conclusions: In a prospective, randomized study comparing haemodynamics after Freestyle, Magna Ease and Trifecta, all three valves exhibited good haemodynamics at rest and with exercise. There were small but significant differences between groups, with favourable haemodynamics associated with Trifecta compared to Magna Ease, and no significant differences between Trifecta and Freestyle. The Trifecta valve appears to offer haemodynamics similar to a stentless valve without the technical complexity of stentless valve implantation., Clinicaltrialsgov Identifier: NCT01635244., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Takotsubo cardiomyopathy (TC) is believed to be an increasingly diagnosed syndrome; however, data on its incidence are limited. The purpose of this study was to determine the reported incidence of TC in the United States and to examine its trend over several years. Data was obtained from the Nationwide Inpatient Sample, created by the Agency for Healthcare Research and Quality, for each of the years from 2006 to 2012. Hospital discharges with principal diagnosis of TC, identified using Internal Classification of Diseases, Ninth Revision, code 429.83, were included. We tabulated estimated total numbers of discharges, incidence per 100,000 persons, mean length of stay, inhospital death rates, and diagnoses stratified by age group and gender. The reported incidence of TC based on principal diagnosis at hospital discharge increased significantly over the study period, with 315 cases ± 43 (standard error) in 2006 and 6,230 cases ± 232 (standard error) in 2012 (p <0.001 for trend). Mean length of hospital stay was stable over the study period (3.4 days in 2006 vs 3.6 days in 2012; p = 0.74 for trend). The diagnosis was most frequent in patients aged 65 to 84 years (50% of all diagnoses in 2012), followed by those aged 45 to 64 years (39% of all diagnoses in 2012). Women accounted for >90% of diagnoses throughout the study period. In conclusion, the reported incidence of TC has increased significantly from 2006 to 2012, most likely because of increasing recognition of the syndrome., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Recognizing the critical need for standardization in strain imaging, in 2010, the European Association of Echocardiography (now the European Association of Cardiovascular Imaging, EACVI) and the American Society of Echocardiography (ASE) invited technical representatives from all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. As an initial product of the work of the EACVI/ASE/Industry initiative to standardize deformation imaging, we prepared this technical document which is intended to provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocardiography and thus create a common standard., (Copyright © 2015 American Society of Echocardiography. All rights reserved.)

Background: We have developed new universal strain software (USS) that can be used to perform speckle tracking of any Digital Imaging and Communications in Medicine (DICOM) image, regardless of the ultrasound system used to obtain it., Methods: Fifty patients prospectively underwent echocardiography immediately prior to cardiac catheterization. Biplane peak global longitudinal strain (GLS), peak systolic longitudinal strain rate (SSR), peak early diastolic longitudinal strain rate (DSR), and peak early diastolic circumferential strain rate (DCSR) were determined using conventional strain software (CSS) that uses raw data, and using the new USS applied to DICOM images., Results: Universal strain software correlated with CSS for GLS (r = 0.78, P < 0.001), SSR (r = 0.78, P < 0.001), DSR (r = 0.54, P < 0.001), and DCSR (r = 0.43, P = 0.019). GLS and SSR using USS correlated with left ventricular ejection fraction (LVEF) (r = -0.67 and -0.71, respectively) as well as using CSS (r = -0.66 and -0.71). Patients with diastolic dysfunction had significantly lower DSR (0.61 vs. 0.87/sec, P = 0.02) and DCSR (0.89 vs. 1.23/sec, P = 0.03), and less negative GLS (-10.8 vs. -16.1%, P = 0.002) using USS in all patients, as well as among those with LVEF ≥ 50%. Receiver-operating characteristic (ROC) analysis for detection of diastolic dysfunction revealed a sensitivity and specificity of 82% and 83% for DCSR < 1.09/sec (area under the curve [AUC = 0.80]) and 85% and 83% for GLS > -13.7% (AUC = 0.84) using USS., Conclusion: Universal strain software can be used to accurately assess LV systolic and diastolic function using speckle tracking echocardiography., (© 2014, Wiley Periodicals, Inc.)

Background: Heart failure with preserved ejection fraction (HFPEF) involves failure of cardiovascular reserve in multiple domains. In HFPEF animal models, dietary sodium restriction improves ventricular and vascular stiffness and function. We hypothesized that the sodium-restricted dietary approaches to stop hypertension diet (DASH/SRD) would improve left ventricular diastolic function, arterial elastance, and ventricular-arterial coupling in hypertensive HFPEF., Methods and Results: Thirteen patients with treated hypertension and compensated HFPEF consumed the DASH/SRD (target sodium, 50 mmol/2100 kcal) for 21 days. We measured baseline and post-DASH/SRD brachial and central blood pressure (via radial arterial tonometry) and cardiovascular function with echocardiographic measures (all previously invasively validated). Diastolic function was quantified via the parametrized diastolic filling formalism that yields relaxation/viscoelastic (c) and passive/stiffness (k) constants through the analysis of Doppler mitral inflow velocity (E-wave) contours. Effective arterial elastance (Ea) end-systolic elastance (Ees) and ventricular-arterial coupling (defined as the ratio Ees:Ea) were determined using previously published techniques. Wilcoxon matched-pairs signed-rank tests were used for pre-post comparisons. The DASH/SRD reduced clinic and 24-hour brachial systolic pressure (155 ± 35 to 138 ± 30 and 130 ± 16 to 123 ± 18 mm Hg; both P=0.02), and central end-systolic pressure trended lower (116 ± 18 to 111 ± 16 mm Hg; P=0.12). In conjunction, diastolic function improved (c=24.3 ± 5.3 to 22.7 ± 8.1 g/s; P=0.03; k=252 ± 115 to 170 ± 37 g/s(2); P=0.03), Ea decreased (2.0 ± 0.4 to 1.7 ± 0.4 mm Hg/mL; P=0.007), and ventricular-arterial coupling improved (Ees:Ea=1.5 ± 0.3 to 1.7 ± 0.4; P=0.04)., Conclusions: In patients with hypertensive HFPEF, the sodium-restricted DASH diet was associated with favorable changes in ventricular diastolic function, arterial elastance, and ventricular-arterial coupling., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00939640.

Background: Left ventricular Doppler-derived -dP/dt determined from the continuous-wave Doppler spectrum of the mitral regurgitation (MR) jet has been shown to be a valuable marker of diastolic function, but requires the presence of MR for its assessment. We sought to determine if a novel method of determining -dP/dt using the diastolic blood pressure and isovolumic relaxation time (DBP-IVRT method) correlates with Doppler-derived -dP/dt using the MR method (Doppler-MR method)., Methods: Thirty-three patients with less than severe MR were enrolled. -dP/dt was determined using the Doppler-MR method from the continuous-wave Doppler spectrum of the MR jet (32 mmHg/time from 3 to 1 m/sec). -dP/dt was also determined using the DBP-IVRT method using the following equation: -dP/dt = (DBP - LVEDP)/IVRT, where left ventricular end-diastolic pressure (LVEDP) was estimated based on tissue Doppler and mitral inflow patterns., Results: Twenty-five patients had adequate Doppler waveforms for analysis. The average amount of MR was mild-to-moderate severity. The mean -dP/dt was 680 ± 201 mmHg by the Doppler-MR method and 681 ± 237 mmHg by the DBP-IVRT method. There was a significant correlation between the 2 methods of determining -dP/dt (Pearson r = 0.574, P = 0.003). The Bland-Altman plot revealed almost no bias between the 2 methods; the difference in -dP/dt between the 2 techniques was noted to be greater for patients with higher -dP/dt, however., Conclusion: Diastolic blood pressure and isovolumic relaxation time may be used to noninvasively assess diastolic function in patients who do not have MR, especially in those with reduced diastolic function., (© 2012, Wiley Periodicals, Inc.)

Recent studies suggest that oxidative stress and vascular dysfunction contribute to heart failure with preserved ejection fraction (HFPEF). In salt-sensitive HFPEF animal models, diets low in sodium and high in potassium, calcium, magnesium, and antioxidants attenuate oxidative stress and cardiovascular damage. We hypothesized that the sodium-restricted Dietary Approaches to Stop Hypertension diet (DASH/SRD) would have similar effects in human hypertensive HFPEF. Thirteen patients with treated hypertension and compensated HFPEF consumed the DASH/SRD for 21 days (all food/most beverages provided). The DASH/SRD reduced clinic systolic (155-138 mm Hg; P=0.02) and diastolic blood pressure (79-72 mm Hg; P=0.04), 24-hour ambulatory systolic (130-123 mm Hg; P=0.02) and diastolic blood pressure (67-62 mm Hg; P=0.02), and carotid-femoral pulse wave velocity (12.4-11.0 m/s; P=0.03). Urinary F2-isoprostanes decreased by 31% (209-144 pmol/mmol Cr; P=0.02) despite increased urinary aldosterone excretion. The reduction in urinary F2-isoprostanes closely correlated with the reduction in urinary sodium excretion on the DASH/SRD. In this cohort of HFPEF patients with treated hypertension, the DASH/SRD reduced systemic blood pressure, arterial stiffness, and oxidative stress. These findings are characteristic of salt-sensitive hypertension, a phenotype present in many HFPEF animal models and suggest shared pathophysiological mechanisms linking these 2 conditions. Further dietary modification studies could provide insights into the development and progression of hypertensive HFPEF.

Ultrasound strain imaging has been proposed to quantitatively assess myocardial contractility. Cross-correlation-based 2-D speckle tracking (ST) and auto-correlation-based tissue Doppler imaging (TDI) [often called Doppler tissue imaging (DTI)] are competitive ultrasound techniques for this application. Compared with 2-D ST, TDI, as a 1-D method, is sensitive to beam angle and suffers from low strain signal-to-noise ratio because a high pulse repetition frequency is required to avoid aliasing in velocity estimation. In addition, ST and TDI are fundamentally different in the way that physical parameters such as the mechanical strain are derived, resulting in different estimation accuracy and interpretation. In this study, we directly compared the accuracy of TDI and 2-D ST estimates of instantaneous axial normal strain and accumulated axial normal strain using a simulated heart. We then used an isolated rabbit heart model of acute ischemia produced by left descending anterior artery ligation to evaluate the performance of the two methods in detecting abnormal motion. Results showed that instantaneous axial normal strains derived using TDI (0.36% error) were less accurate with larger variance than those derived from 2-D ST (0.08% error) given the same spatial resolution. In addition to poorer accuracy, accumulated axial normal strain estimates derived using TDI suffered from bias, because the accumulation method for TDI cannot trace along the actual tissue displacement path. Finally, we demonstrated the advantage 2-D ST has over TDI to reduce dependency on beam angle for lesion detection by estimating strains based on the principal stretches and their corresponding principal axes.

Background: Aortic insufficiency (AI) following left ventricular assist device (LVAD) placement can affect device performance. The aim of this study was to examine AI development following LVAD implantation., Methods and Results: Echocardiograms (n=315) from 78 subjects undergoing HeartMate-XVE (n=25 [32%]) or HeartMate-II (n=53 [68%]) implantations from 2004 to 2008 were reviewed. Studies were obtained preoperatively and at 1, 3, 6, 12, 18, and 24 months after surgery. AI was graded on an interval scale (0=none, 0.5=trivial, 1=mild, 1.5=mild-moderate, 2=moderate, 2.5=moderate-severe, 3=severe), and the change in AI at follow-up was analyzed with significance tests. Kaplan-Meier estimates for freedom from moderate or worse AI at follow-up were generated. Mixed-model linear regression was used to identify correlates of AI progression during LVAD support. The median (25th, 75th percentile) duration of LVAD support was 239 (112, 455) days, and preoperative AI grade was 0.0 (0.0, 0.0). At 6 months, 89±4% of subjects (n=49 at risk) were free from moderate or worse AI, but this was reduced to 74±7% (n=29 at risk) and 49±13% (n=13 at risk) by 12 and 18 months, respectively. Correlates (slope±SE) of AI progression included female sex (0.002±0.001; P=0.01), smaller body surface area (-0.003±0.001 per m(2); P=0.0017), and HeartMate-II model type (0.002±0.001; P=0.039). Correlates (β±SE) of progressive AI on postoperative echocardiogram included increasing aortic sinus diameter (0.04±0.01 per mm; P=0.001), an aortic valve that remained closed (0.42±0.06; P<0.001) or only intermittently opened (0.34±0.09; P<0.001), and lower left ventricular diastolic (-0.002±0.0004 per cm(3); P<0.001) and systolic (-0.002±0.0004 per cm(3); P<0.001) volumes., Conclusions: AI progresses over time in LVAD-supported patients. As we move toward an era of long-term cardiac support, more studies are needed to determine the clinical significance of these findings.

Background: Current guidelines for the use of implantable cardioverter-defibrillators (ICDs) are broad and significantly increase the cost of caring for patients with heart failure. In an effort to identify the specific subset of patients who benefit from this therapy, the predictive value of numerous echocardiographic parameters have been studied. Severe diastolic dysfunction has been shown to predict adverse events in a group of patients who received an ICD for secondary prevention, but has not been tested in those who receive ICDs for primary prevention., Hypothesis: We tested the hypothesis that a restrictive mitral inflow pattern on echocardiography will predict the risk of appropriate therapy in this patient population., Methods: This retrospective study identified 145 consecutive patients who met primary prevention criteria for ICD implantation and had an echo performed no more than 1 year prior to receiving the ICD. A restrictive pattern was defined as a mitral inflow E/A > 2 or a deceleration time < 150 ms., Results: A restrictive pattern was present in 69 patients (40.7% of the group). Appropriate ICD therapy occurred in 8 (11.5%) subjects with a restrictive pattern and 14 (18.4%) with a nonrestrictive pattern over 680 days of average follow-up (P = not significant). Cox regression analysis showed the presence of a restrictive pattern was not helpful in predicting time to first ICD therapy., Conclusions: In a population of patients who received ICDs for primary prevention, echocardiographic findings of severe diastolic dysfunction were not helpful in targeting the use of ICDs to those at highest risk., (Copyright 2009 Wiley Periodicals, Inc.)

Ultrasound strain imaging using 2-D speckle tracking has been proposed to quantitatively assess changes in myocardial contractility caused by ischemia. Its performance must be demonstrated in a controlled model system as a step toward routine clinical application. In this study, a well-controlled 2-D cardiac elasticity imaging technique was developed using two coplanar and orthogonal linear probes simultaneously imaging an isolated retroperfused rabbit heart. Acute ischemia was generated by left anterior descending (LAD) artery ligation. An excitation-contraction decoupler, 2,3-butanedione monoxime, was applied at a 4-mM concentration to reversibly reduce myocardial contractility. Results using a single probe demonstrate that directional changes in the in-plane principal deformation axes can help locate the bulging area as a result of LAD ligation, which matched well with corresponding Evans Blue staining, and strains or strain magnitude, based on principal stretches, can characterize heart muscle contractility. These two findings using asymmetric displacement accuracy (i.e., normal single-probe measurements with good axial but poor lateral estimates) were further validated using symmetric displacement accuracy (i.e., dual-probe measurements using only accurate axial tracking estimates from each). However, the accuracy of 2-D cardiac strain imaging using a single probe depends on the probe's orientation because of the large variance in lateral displacement estimates.

Objectives: We examined the feasibility of transesophageal echocardiography (TEE) using a 10F monoplane probe developed for intracardiac ultrasound (AcuNav, Acuson/Siemens, Mountain View, Calif)., Background: Traditional TEE uses a 10- to 12-mm-diameter probe, and conscious sedation is customary to minimize patient discomfort. Because of its small size (3.2-mm diameter), the 10F monoplane probe can be inserted into the esophagus using only topical anesthesia. This provides the potential for a more easily tolerated examination., Methods: A total of 20 patients underwent a comprehensive TEE using an adult multiplane probe. Immediately afterward, the 10F monoplane probe was inserted into the esophagus and a targeted examination completed. The 10F monoplane studies were blindly reviewed by 3 observers for the study indication and for 16 diagnostic elements. These were graded against an expert's review of standard TEE., Results: The 10F monoplane probe was well tolerated in all patients. Observers A, B, and C answered the clinical question in 80%, 85%, and 100%, respectively, with the 10F probe. The percentage of clinical elements deemed evaluable was 71%, 78%, and 80%, respectively. Limitations included incomplete visualization of the mitral valve and a systematic underestimation of the severity of valve regurgitation., Conclusions: The 10F monoplane probe is safe, well-tolerated, and capable of evaluating many clinical questions. Because of its small size, conscious sedation may not be necessary. It may be useful for targeted evaluations, for monitoring invasive procedures, or for intermediate or long-term monitoring in an intensive care department.

Objectives: The purpose of this study was to evaluate the ability of novel Doppler indices of left ventricular (LV) systolic and diastolic function to predict survival in patients with congestive heart failure (CHF)., Background: Congestive heart failure is associated with an increased risk of death or cardiac transplantation, yet techniques to predict survival are limited., Methods: Doppler-derived dP/dt and - dP/dt were determined prospectively from the continuous-wave Doppler spectrum of the mitral regurgitation jet (dP/dt = 32/time between 1 and 3 m/s; -dP/dt = 32/time between 3 and 1 m/s) in 56 patients with chronic CHF (age, 60 +/- 15 years; LV ejection fraction, 23 +/- 9%). Baseline clinical and echocardiographic variables were also obtained, and clinical follow-up was performed in all patients., Results: Twenty-four patients experienced a primary event of cardiac death (n = 15), United Network for Organ Sharing status I (inotrope-dependent) heart transplant (n = 3) or urgent implantation of a LV assist device (n = 6). Doppler-derived dP/dt (dichotomized to > or = or <600 mm Hg/s; p = 0.0002) and -dP/dt (trichotomized to <450, 450 to 550 and >550 mm Hg/s; p = 0.0001) predicted event-free survival, as did Doppler-derived risk groups determined by the combination of the two (low risk, dP/dt > or = 600; intermediate risk, dP/dt < 600 and -dP/dt > or = 450; high risk, dP/dt < 600 and -dP/dt < 450; p = 0.0001). Multivariable analysis revealed Doppler-derived risk groups, intravenous inotrope requirement and blood urea nitrogen as significant independent predictors of outcome., Conclusion: New Doppler indices of dP/dt, - dP/dt and risk groups defined by the combination of dP/dt and -dP/dt predict event-free survival in patients with CHF.

The goal of this study was to characterize differences in contractile responsiveness to several potassium channel antagonists in vascular smooth muscle from stroke-prone spontaneously hypertensive rats (SHRSP) and Wistar-Kyoto normotensive rats (WKY). Helically-cut strips of carotid arteries (endothelium removed) from SHRSP and WKY were mounted in muscle baths for measurement of isometric force generation. Contractile responses to tetraethylammonium (10(-4) to 3 x 10(-2) mol/L) and barium (3 x 10(-5) mol/L), blockers of the voltage-dependent and large conductance, calcium activated potassium channels, were greater in carotid arteries from SHRSP than in those from WKY. In contrast, contractile responses to the voltage-dependent potassium channel blockers 3,4-diamino-pyridine (10(-6) to 3 x 10(-3) mol/L) and sparteine (10(-6) to 3 x 10(-2) mol/L) in arteries from SHRSP did not differ from WKY values. Carotid arteries from SHRSP and WKY did not contract to apamin (10(-9) to 10(-6) mol/L), an antagonist of the small conductance, calcium activated potassium channel. Furthermore, relaxation responses to diazoxide (3 x 10(-4) mol/L), an activator of the ATP-sensitive potassium channel, and subsequent contractions to the ATP-sensitive potassium channel blocker glyburide (10(-8) to 3 x 10(-6) mol/L) in arteries from SHRSP did not differ from WKY values. Carotid artery segments from SHRSP were more sensitive to the contractile effects of elevated potassium than those from WKY. We conclude that altered activity of the large conductance, calcium activated potassium channel may play a role in the increased responsiveness observed in arteries from SHRSP.