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Background: The response of diastolic Doppler indices to exercise is not well defined for young subjects. The aims of this study were to evaluate this in nonathletic and endurance-trained probands and to correlate echocardiographic data with maximal oxygen consumption., Methods: In this prospective study, Doppler echocardiography was performed at rest and after exercise in 40 nonathletes (NAs) and 20 endurance-trained athletes (ETs) aged < 40 years, matched for age and gender. Diastolic function was assessed by mitral inflow and early diastolic velocities of the septal (e' septal) and lateral (e' lateral) mitral annulus. Maximal oxygen consumption quantification was performed simultaneously., Results: All cardiac chambers were larger in ETs than NAs. ETs had higher e' lateral at rest (18.1 ± 2.7 vs 16.3 ± 3.3 cm/sec, P = .02) and higher mitral E (141 ± 15 vs 132 ± 15 cm/sec, P = .02) and e' lateral (23.5 ± 2.5 vs 21.4 ± 3.0 cm/sec, P = .01) with exercise than NAs. There was a slight increase in E/e' septal (overall, from 6.8 ± 1.3 to 7.2 ± 1.2; P = .02) and E/e' lateral (overall, from 5.0 ± 0.8 to 6.2 ± 0.9; P < .0001) with exercise. Changes in diastolic parameters with exercise were similar in ETs and NAs. Percentage of predicted maximal oxygen consumption was correlated with exertional E (r = 0.28, P = .03) and e' lateral (r = 0.32, P = .01), but the strongest predictor was indexed left ventricular end-diastolic volume (r = 0.66, P < .0001)., Conclusions: During exercise, E/e' increases but remains within normal ranges in healthy young subjects, and the response to exercise does not differ between ETs and NAs. These data help define the normal diastolic stress echocardiographic response in the young. Exercise capacity shows a correlation with enhanced exertional early diastolic velocities but is more closely related to cardiac structural adaption to endurance training., (Copyright © 2014 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

The authors report the case of a 77-year-old male patient with sinus rhythm and a first-degree atrioventricular (AV) block who was referred for echocardiographic follow-up 18 years after aortic valve replacement. Left ventricular systolic function as well as the function of the aortic prosthesis was normal. Systolic mitral regurgitation (MR) was virtually absent, but isolated late diastolic MR was detected by colour Doppler imaging. Coincidental to the occurrence of diastolic MR, a second late diastolic forward flow in the pulmonary veins was observed. Therefore, during the prolonged left atrial relaxation caused by first-degree AV block, the left atrial pressure drops below the pressure in both adjacent chambers in late diastole, resulting in both late diastolic MR and a second diastolic pulmonary venous forward flow.

Background: Exercise testing is often normal despite the presence of exertional symptoms. We hypothesized that left ventricular (LV) dyssynchrony might occur in some patients in the absence of ischemia, LV dysfunction, or wide QRS, and might contribute to exertional symptoms and diminished exercise capacity., Methods: Echocardiographic parameters were assessed before and with exercise in 40 patients (age 62 +/- 8 years, 27 with exertional symptoms). All had normal clinically indicated exercise echocardiograms and narrow QRS. The time to peak systolic velocity (Ts) was measured in 12 segments to calculate the standard deviation (Ts-SD) and the maximal difference (Ts-diff)., Results: At rest, 25 patients (63%) had dyssynchrony by Ts-SD. With exercise, mean Ts-SD did not increase significantly (34.9 +/- 19.3 ms vs 39.5 +/- 27.2 ms, P = .28). However, Ts-SD increased by greater than 40% in 15 patients (37.5%), remained stable in 19 patients (47.5%), and decreased by greater than 40% in 6 patients (15%). Similar responses were observed for Ts-diff. Patients with exercise-induced dyssynchrony were not more likely to have symptoms. Exercise capacity was inversely correlated with resting Ts-SD (r = -0.37, P = .02) and resting Ts-diff (r = -0.38, P = .02), but not with exercise-induced changes in dyssynchrony. Patients with resting dyssynchrony had higher resting heart rate (73 +/- 12 vs 63 +/- 11 beats/min, P = .02)., Conclusion: LV dyssynchrony may occur more frequently than previously thought and may develop with exercise in the absence of ischemia. Exercise-induced LV dyssynchrony was not related to exertional symptoms or exercise capacity. Patients with dyssynchrony at rest had a higher resting heart rate and achieved a lower workload; this may indicate early myocardial impairment.

Purpose: The ironman (IM) triathlon is a popular ultraendurance competition, consisting of 3.8 km of swimming, 180.2 km of cycling, and 42.2 km of running. The aim of this study was to investigate the predictors of IM race time, comparing echocardiographic findings, anthropometric measures, and training characteristics. Methods: Amateur IM athletes (ATHL) participating in the Zurich IM race in 2010 were included. Participants were examined the day before the race by a comprehensive echocardiographic examination. Moreover, anthropometric measurements were obtained the same day. During the 3 months before the race, each IM-ATHL maintained a detailed training diary. Recorded data were related to total IM race time. Results: Thirty-eight IM finishers (mean ± SD age = 38 + 9 yr, 32 men [84%]) were evaluated. Total race time was 684 ± 89 min (mean + SD). For right ventricular fractional area change (45% ± 7%, Spearman p = -0.33, P = 0.05), a weak correlation with race time was observed. Race performance exhibited stronger associations with percent body fat (15.2 ± 5.6%, p = 0.56, P = 0.001), speed in running training (11.7 ± 1.2 km⋅h-1, p = -0.52, P = 0.002), and left ventricular myocardial mass index (98 + 24 g⋅m-2, p = -0.42, P = 0.009). The strongest association was found between race time and right ventricular end-diastolic area (22 ± 4 cm2, p= -0.64, P< 0.0001). In multivariate analysis, right ventricular end-diastolic area (Β = -16.7, 95% confidence interval = -27.3 to -6.1, P = 0.003) and percent body fat ((Β = 6.8, 95% confidence interval = 1.1-12.6, P = 0.02) were independently predictive of IM race time. Conclusions: In amateur IM-ATHL, RV end-diastolic area and percent body fat were independently related to race performance. RV end-diastolic area was the strongest predictor of race time. The role of the RV in endurance exercise may thus be more important than previously thought and needs to be further studied. [ABSTRACT FROM AUTHOR]

Limited information exists regarding the significance of dyspnea in patients who are unable to exercise and the contribution of myocardial ischemia to this symptom. To assess this, we evaluated results of dobutamine stress echocardiography (DSE) and long-term outcome of patients with dyspnea referred for DSE. We studied 6,376 consecutive patients who were unable to perform an exercise test and were referred for DSE. Patients were classified according to presenting symptoms and followed for 5.5 ± 2.8 years. End points were cardiac ischemic events (myocardial infarction or revascularization), hospitalization for heart failure (HF), and death. Dobutamine stress echocardiogram was positive for ischemia in 19% of patients with dyspnea versus 24% (p = 0.002) of those with typical angina and 17% (p = 0.2) of asymptomatic patients. In multivariate analysis, risk of death was increased in dyspneic patients versus asymptomatic patients (hazard ratio [HR] 1.14, p = 0.02) and patients with chest pain (HR 1.20, p <0.001). Hospitalization for HF occurred more often in patients with dyspnea (HR 1.26, p = 0.05 vs asymptomatic; HR 1.24, p = 0.06 vs chest pain), especially in the subset without previous HF (HR 1.45, p = 0.006 vs chest pain). Risk of cardiac ischemic events in patients with dyspnea was similar versus asymptomatic patients (HR 0.92, p = 0.39) and decreased versus patients with chest pain (HR 0.70, p <0.001). In conclusion, in patients referred for DSE, dyspnea was associated with a poor outcome. This increased hazard seems not to be linked to myocardial ischemia, but instead to HF and death. [Copyright &y& Elsevier]

Most carcinoid tumors originate in the gut. Carcinoid heart disease typically occurs when tumor progression results in the formation of hepatic metastases, which allow vasoactive substances to reach the heart without being metabolized in the liver. Except for patients with primary ovarian carcinoid tumors, the occurrence of carcinoid heart disease without hepatic metastases has been reported only anecdotally. From a retrospective analysis of 265 patients, 4 patients were identified who developed carcinoid heart disease in the absence of liver metastases or primary tumors located in the ovaries. All 4 patients had metastases to the retroperitoneal lymph nodes and had carcinoid syndrome. The reasons for referral to cardiac evaluation by transthoracic echocardiography were findings on auscultation in 3 patients and exertional dyspnea in 1 patient. In conclusion, cardiac symptoms or findings on auscultation should prompt further evaluation by transthoracic echocardiography in these patients, although the classic prerequisites for development of carcinoid heart disease are lacking. [Copyright &y& Elsevier]

Background In chronic heart failure, left ventricular ejection fraction (LVEF) is considered to be stable. Intensified therapy may improve survival, but little is known whether this is associated with reverse remodeling and dependent on age and NT-proBNP guidance. We aimed to define the evolution of LVEF under intensified therapy in relation to age and NT-proBNP guidance. Methods and results Echocardiography was performed at baseline, 12 and 18 months in TIME-CHF, a trial comparing NT-proBNP versus symptom-guided therapy in patients aged 60 to 74 and ≥ 75 years. LVEF, LV end diastolic volume index (LVEDVI) and end systolic volume index (LVESVI) were assessed. LVEF increased from 31.3 ± 10.7% to 39.1 ± 11.8% at 18 months (p < 0.001) in symptom-guided, and from 30.3 ± 11.7% to 44.0 ± 13.2% (p < 0.001) in NT-proBNP-guided patients. The increase in LVEF was significantly larger in the NT-proBNP-guided treatment group (p for interaction = 0.006), which was true for both age groups (p for interaction in both = 0.091). LVEDVI and LVESVI decreased without influence by study group allocation. Conclusions In elderly heart failure patients, intensified medical therapy leads to an improvement in LVEF and to reverse remodeling. NT-proBNP guided therapy was associated with a larger improvement in LVEF than symptom guided therapy both in patients aged 60 to 74 and ≥ 75 years. [ABSTRACT FROM AUTHOR]