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Aims Our aim was to assess the feasibility and safety of real-time (RT) three-dimensional (3D) transoesophageal echocardiography (TEE) for guiding transcatheter closure of interatrial communications and to evaluate its additional benefit over conventional 2D TEE in reducing radiation exposure for the patient. Methods and results Twenty-five patients undergoing device closure of their interatrial defect had the procedure guided by fluoroscopy, 2D TEE, and RT 3D TEE. We retrospectively compared this group with a historical control group in which interventional guidance was performed using fluoroscopy and 2D TEE alone. The application of RT 3D TEE allowed safe device deployment in all patients without any complications, resulting in a reduction of mean fluoroscopy time (10 ± 6 to 6 ± 4 min, P < 0.01), mean dose area product (DAP) (964 ± 628 to 535 ± 464 cGy cm2, P < 0.01), and mean DAP per individual body surface area (494 ± 317 to 273 ± 221 cGy cm2/m2, P < 0.01). Conclusion RT 3D TEE as an adjunct to 2D TEE is a feasible and safe tool to guide transcatheter device closure of interatrial communications, resulting in a reduction of radiation exposure. These data indicate that RT 3D TEE can be used to safely monitor interatrial defect closure in clinical routine.

Aims To evaluate deformation parameters of an endocardial, mid-myocardial, and epicardial myocardial layer in different transmurality of myocardial infarction and assess whether layer-specific deformation analysis allows definition of infarct transmurality. Methods and results Fifty-six patients (mean age 55 ± 9 years, 38 men) with chronic ischaemic left ventricular (LV) dysfunction underwent two-dimensional echocardiography and contrast-enhanced magnetic resonance imaging (ceMRI). The extent of myocardial infarction was determined as relative amount of hyperenhancement by ceMRI in a 16-segment LV model (0%, no infarction; 1–50%, non-transmural infarction; 51–100%, transmural infarction). On the basis of two-dimensional echocardiographic parasternal short-axis views peak systolic circumferential strain was determined for the total wall thickness and for each of three myocardial layers (endocardial, mid-myocardial, and epicardial) using an automatic frame-by-frame tracking system of acoustic echocardiographic markers (EchoPAC, GE Ultrasound). In non-transmural infarction impairment of circumferential strain was greater in the endocardial than the epicardial layer, relative reduction compared with control segments, 45% vs. 28% ( P < 0.001), respectively. In transmural infarction additional impairment of circumferential strain was greater in the epicardial than the endocardial layer, relative reduction compared with non-transmural infarction 29% vs. 7% ( P < 0.001), respectively. Endocardial layer circumferential strain allowed distinction of non-transmural vs. no infarction with higher accuracy than total wall thickness strain [area under the curve (AUC) 0.842 vs. 0.774, respectively, P = 0.001]. Epicardial layer circumferential strain allowed distinction of transmural from non-transmural infarction with higher accuracy than total wall thickness strain (AUC 0.819 vs. 0.762, respectively, P = 0.005). Conclusion Non-transmural infarction results in greater functional impairment of the endocardial than of the epicardial myocardial layer. In transmural infarction both layers are affected similarly compared with controls. A layer-specific analysis of myocardial deformation allows accurate discrimination between different transmurality categories of myocardial infarction.

Aims: We sought to evaluate whether left ventricular (LV) mass (M) determined by M-mode echocardiography is overestimated compared with LVM calculated by threedimensional (3D) echocardiography (E) in patients with normal LV shape. Methods and Results: A total of 112 studies in 56 patients (60 � 13 years) with hypertension ðn ¼ 25Þ or aortic stenosis ðn ¼ 31Þ and 30 control subjects (57 � 14 years) evaluated for cardiac sources of embolism were analyzed. LVM by M-mode and 3DE was highly correlated (r ¼ 0:85; p < 0:001). However, there were broad limits of agreement (� 58 to 110 g) demonstrating large variability between the methods. M-mode overestimated 3DE LVM by a mean of 15 � 24% ðp < 0:001Þ with overestimation in controls and the different patient groups. Variability was unrelated to increasing quartiles of LVM values. Using techniquespecific partition values for normal LVM, the agreement between M-mode and 3DE for the detection of LV hypertrophy was 83% (Kappa ¼ 0.59; p < 0:001). Conclusion: Although M-mode and 3DE correlate well for the calculation of LVM, there is a systematic difference between the two techniques leading to overestimation of LVM by the 1D technique. Thus, previously published cutoff values for normal LVM derived from M-mode may not apply for 3DE. However, the use of techniquespecific partition values allows stratification of patients for the presence of LV hypertrophy with reasonable agreement.

Aims: To evaluate the ability of tissue tracking for rapid assessment of left ventricular function by determination of the systolic mitral annular displacement. Tissue racking is a new echocardiographic modality based on Doppler Tissue maging allowing rapid visual assessment of the systolic baso-apical displacement of each myocardial segment in apical views by a graded colour display. Methods and Results: We studied 90 patients (69 male, age 60·410·1 years) with different left ventricular function (25 subjects with normal left ventricular function, 25 patients with homogeneous depression of left ventricular function and 40 patients with prior myocardial infarction). Systolic mitral annular displacement was determined by tissue tracking and M-mode echocardiography. Apical two-, three- and four-chamber views were used to determine the mitral annular displacement of six sites. Left ventricular ejection fraction was determined by two-dimensional echocardiography using Simpson’s rule. Tissue tracking was possible in all patients. In the 50 patients with normal left ventricular function or homogeneous depression of left ventricular function, mean mitral annular displacement correlated closely with mitral annular displacement determined by M-mode (r=0·99, P

Recent studies have evaluated the diagnostic accuracy and predictive value of dobutamine echocardiography without considering the additional information implied by the magnitude of induced wall motion abnormalities. We sought to evaluate the positive predictive value of dobutamine echocardiography for coronary artery disease from the extent and severity of the induced wall motion abnormality. In addition, we intended to determine factors associated with false-negative dobutamine echocardiography.Two hundred and eighty-three consecutive patients with suspected coronary artery disease underwent dobutamine echocardiography (up to 40 microg x kg(-1) x min(-1)+atropine up to 1 mg) and coronary angiography. The number of segments and the degree of deterioration were used to describe the extent and severity of induced wall motion abnormality. Analysis of clinical, procedural and echocardiographic variables was performed to determine factors associated with false-negative results. The positive predictive value of dobutamine echocardiography increased from 85% to 90%, 94% and 94% with deterioration of wall motion by one grade in/=1,/=2,/=3 and/=4 segments, respectively (P0.05). Deterioration of wall motion by two grades in one segment had a positive predictive value of 96% as compared to 85% for deterioration by only one grade in one segment (P0.05). Patients with false-negative test results received atropine more frequently (28% vs 13%, odds ration [OR]=3.87, 95% confidence interval [CI]=1.54-9.75, P=0.028) than patients with a correct positive result. However, angina (15 vs 37%, OR=0.26, 95% CI=0.09-0.71, P=0.010), ECG changes during dobutamine stress (15% vs 35%, OR=0.49, 95% CI 0.19-1.25, P=0.014) and high image quality (OR 1.59, 95% CI 1.07-2.37, P=0.015) were less frequent. The sensitivity of dobutamine echocardiography increased from 67% to 71% and 86% (P0.05) with increasing achieved maximal heart rate (75%, 75-85% and85% of maximal heart rate).The positive predictive value of dobutamine echocardiography increases significantly as the extent and severity of induced wall motion abnormality increases. Thus, the degree of test positivity should be reported in clinical practice. Despite high pharmacological drug doses, the haemodynamic response may still be insufficient in some patients to induce myocardial ischaemia, resulting in false-negative dobutamine echo tests. To maximize the sensitivity of dobutamine echocardiography, the highest haemodynamic stress level, with a heart rate above 85% of the predicted heart rate, should be reached.

A 59-year-old female was admitted with tachycardia and atypical chest pain. Physical examination was normal. The initial electrocardiogram (ECG) showed atrial fibrillation with a heart rate of 140/min. Laboratory results on admission were unremarkable except for a markedly elevated C-reactive protein of 180 mg/dL (normal value

The presence of left ventricular outflow tract (LVOT) obstruction in hypertrophic obstructive cardiomyopathy (HOCM) has important therapeutic implications(surgical or catheter based treatment). LVOT obstruction in HOCM is diagnosed by asymmetric septal hypertrophy, mitral leaflet systolic anterior motion and a systolic LVOT gradient. We describe a new sign for LVOT obstruction obtained by colour-coded tissue Doppler imaging (TDI), which may help to identify affected patients (pts) and to monitor therapy. Methods: Septal longitudinal motion was studied by TDI (>100 frames/s) in 26 pts with suspected HOCM (septal wall thickness >15mm). We identified in 15/26 pts a characteristic biphasic systolic velocity pattern with an early (S1) and a late (S2) positive systolic peak velocity, interrupted by an abrupt mid-systolic septal deceleration (MSSD) notch (defined as >25% relative and >1 cm/s absolute decrease from S1). Isovolumic events were excluded from the analysis by identification of onset and end of ejection by aortic valve Doppler. The presence of an MSSD pattern identified severe LVOT obstruction (>30mmHg peak gradient at rest) with 92% sensitivity and 91% specificity. Doppler derived LVOT gradient was significantly higher in pts with MSSD compared to those without MSSD (71±27 vs. 17±10 mmHg, p