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Aims: The population treated with cryoballoon (CB) ablation is relatively young, and radiation protection is of major importance. We aimed to demonstrate that radiation exposure can be markedly reduced by intracardiac echocardiography (ICE) and optimized settings of the X-ray system., Methods and Results: We analysed 100 patients undergoing CB pulmonary vein isolation (PVI) for treatment of paroxysmal atrial fibrillation. In 50 consecutive patients (25 male, 59 ± 13 years; Group 1), we used ICE, skipped PV angiography prior to CB inflation, and avoided fluoroscopy whenever possible. Furthermore, we reduced the frame rate, minimized distance between patient and detector, and consequently applied collimation. These patients were compared with 50 similar preceding patients in Group 2 (29 male, 61 ± 12 years). Total fluoroscopy time was reduced from 18 ± 6 min in Group 2 to 12 ± 5 min in Group 1 (P < 0.001). Moreover, the dose area product was significantly lower (1555 ± 1219 vs. 4935 ± 2094 cGycm2, P < 0.001), total freezing time was significantly shortened (1855 ± 399 vs. 2121 ± 756 s, P = 0.031), and contrast media use was significantly reduced (66 ± 25 vs. 109 ± 27 mL, P < 0.001). At the same time, total procedure duration and complication rates did not differ significantly between both groups. After a 12 months follow-up, a similar percentage of patients was free from recurrences (74% in Group 1 vs. 78% in Group 2, P = 0.640)., Conclusion: Radiation exposure in CB PVI can be markedly reduced without prolonging procedure times, affecting the outcome or complication rates. Moreover, ICE seems to shorten total freezing time., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Background: Until now, there is no consensus regarding the definition of a clinical response to cardiac resynchronization therapy (CRT) in patients with chronic heart failure (CHF) and systolic left ventricular (LV) dysfunction. The aim of this study was to evaluate if echocardiography is predictive for an objective improvement in exercise capacity during long-term follow-up of CRT., Methods: Each patient underwent echocardiography and spiroergometry both at baseline and at last follow-up. Left ventricular dyssynchrony (LVD) before CRT was defined by tissue Doppler imaging (TDI) as intra-LV delay ≥40 msec (septal-lateral or anterior-posterior). Clinical response to CRT was defined as increase of peakVO2 or as increase of maximal workload >10% as compared to baseline., Results: Mean follow-up was 69 ± 37 months. From the 238 consecutive patients included in the study, 141 (59%) were classified as clinical responders and 97 (41%) as nonresponders. Baseline data of responders and nonresponders were comparable. However, clinical responders showed more often LVD (64%) than nonresponders (42%, P = 0.004). On multivariate regression analysis, nonischemic origin of CHF (β-coefficient in the final model 0.1, P = 0.04) and LVD at baseline (β-coefficient in the final model 0.2, P < 0.001) were independently associated with clinical response during long-term follow-up. Patients with LVD at baseline had significant more often an improvement of left ventricular ejection fraction >10% (P = 0.02) and a reduction of left ventricular end-diastolic diameter (LVEDD) >10% (P < 0.01) than patients without LVD at baseline., Conclusions: LVD at baseline as assessed by a straightforward echocardiographic approach predicts the long-term clinical response to CRT and is associated with a more pronounced reverse LV remodeling., (© 2013, Wiley Periodicals, Inc.)

Aims: Image integration of three-dimensional (3D) reconstructions of left atrial (LA) and pulmonary vein (PV) anatomy into electroanatomical mapping (EAM) plays a major role in atrial fibrillation (AF) ablation. Point-by-point EAM is commonly used for registration of imported LA and PV anatomy. We aimed to assess the accuracy of intraprocedural rotational angiography-based LA imaging registered by spatial reconstruction of intracardiac echocardiography (ICE) in patients undergoing AF ablation., Methods and Results: Twenty-two patients (11 males, 66 ± 12 years) were studied. Reconstructions of LA and PVs based on rotational angiography were registered by a second 3D reconstruction based on ICE. In a second step, EAM points were added to ICE 3D reconstructions. A 3D image of the LA and PVs was reconstructed in all patients by both imaging modalities. Rotational angiography and ICE-based LA 3D reconstructions took 11.5 ± 5.2 and 20.4 ± 11.2 min, respectively. A total of 17 ± 6 two-dimensional ICE fans were used for spatial reconstruction of ICE. The deviation between the two 3D shells was 2.6 ± 0.5 mm. Integration of 78 ± 58 EAM points into ICE 3D reconstruction did not significantly reduce the deviation to rotational angiography-based reconstructions (2.7 ± 0.6 mm). All PVs were isolated successfully., Conclusions: Intraprocedural 3D reconstruction of LA and PVs for ablation of AF is feasible based on both rotational angiography and ICE. LA reconstructions based on rotational angiography can accurately be registered using 3D ICE shells. Additional EAM does not enhance accuracy. Therefore, registration of rotational angiography-based 3D reconstructions by 3D reconstructions from ICE seems to be an alternative technique to support AF ablation.

Introduction: cryoballoon ablation has been adopted for pulmonary vein (PV) isolation (PVI) in many centers. Complete occlusion of PV by an adequately sized balloon is crucial for effectiveness of cryoenergy delivery. The aim of this study was to evaluate intracardiac echocardiography (ICE) as an alternative imaging technique compared to angiographic imaging in cryoballoon PVI., Methods and Results: a total of 75 PVs were treated in 22 patients (61 ± 13 years, 17 male) undergoing PV cryoballoon ablation for drug refractory paroxysmal atrial fibrillation. Decision for an adequate balloon size was based on diameters of the PV antra assessed by ICE and PV angiography. Per PV 2.4 ± 0.4 cryoenergy pulses were applied. Decision for the balloon size was similar either based upon angiography or on ICE. A single 23 or 28 mm balloon was chosen in 10 and 3 patients, respectively. Two different sized balloons were used in 9 patients. PVI was evaluated after 2 cryoenergy applications. Total occlusion of the PV confirmed by ICE color flow Doppler (CFD) during ablation predicted successful PVI in 70 of 75 (93%) and unsuccessful PVI in 8 of 8 (100%). PV flow registered by pulsed wave Doppler at the PV ostium pre- and postablation was 0.48 ± 0.10 and 0.51 ± 0.12 m/s, respectively (n.s.). PVI was finally confirmed by entrance block in all PVs. No procedural complications occurred., Conclusions: ICE is a feasible novel imaging technique in cryoballoon ablation procedures. It allows decision for adequate balloon size, exact balloon placement, prediction of acute ablation success, and excludes acute narrowing of PV ostia.

Background: All current cardiac resynchronization therapy (CRT) devices allow the programming of the atrioventricular (AV/PV) delays and the sequential stimulation of the ventricles via the inter ventricular (VV) delay., Aim: This post hoc analysis of the RHYTHM II study was conducted to compare the reverse remodeling associated with VV delay optimization in patients randomly assigned to simultaneous (SIM) biventricular stimulation versus patients assigned to optimized VV delay programming (OPT) (1:3 randomization scheme)., Methods: The analysis included 14 patients assigned to the SIM group and 34 patients to the OPT group who completed the 6-month follow-up period with paired echocardiographic recordings., Results: In both study groups, changes consistent with left ventricular (LV) remodeling were observed between baseline and 6 months, with significant improvements in LV function and decrease in LV dimensions. In the OPT group, there was also a decrease in left atrial diameter and mitral valve closure to opening time. At 6 months, the overall proportion of echocardiographic responders (> or =10% decrease in LV end-systolic volume or > or =5% absolute increase in LV ejection fraction) was similar in both groups. The optimal AV/VV delays, evaluated by maximization of LV outflow tract velocity time integral, changed over time., Conclusions: Ventriculo-ventricular delay optimization was associated with better immediate hemodynamic function than simultaneous biventricular stimulation, though did not promote additional reverse remodeling at 6 months and did not increase the proportion of echocardiographic responders to CRT. Optimization of both the AV and VV intervals was patient-specific and optimal values changed over time.

Background and Introduction: Cardiac resynchronization therapy (CRT) is a promising non-pharmacological treatment option for patients (pts) with severe severe heart failure (CHF), systolic left ventricular (LV) dysfunction, and ventricular conduction abnormalities (VCA). Pt selection for CRT, however, is still controversial. Tissue Doppler echocardiography (TDE) can be used to analyze regional wall motion with high temporal resolution., Patients and Methods: In 33 CHF pts with VCA (QRS width > or =140 ms) and 20 normal probands, left and right ventricular (RV) filling and emptying were analyzed by flow and tissue Doppler to assess regional (anterior, lateral, inferior, and septal) asynchrony within the LV as well as asynchrony between the RVand LV. All time measurements were corrected for a heart rate of 60 bpm. Results Maximum interventricular and segmental intraventricular delay was 30 ms in the normals. LV asynchrony, defined as a regional delay of > or =40 ms, was found in 29/33 (88%) of the CHF pts, in 4 cases there was synchronous LV contraction despite VCA. In the pts with LV asynchrony, 22 (67%) showed the maximum delay in the lateral wall, 7 (21%) in the septum. Inter- and intra-ventricular asynchrony correlated weakly., Conclusions: In many CHF pts with VCA, there is a delay both between the two ventricles, and among different LV regions. Predominantly but not exclusively, the LV lateral wall shows the maximum intra-LV delay. Some CHF pts, however, seem to have a synchronous LV contraction despite VCA. TDE thus adds important information for pt selection with respect to CRT.

The purpose of our study in fetal sheep was to assess the measurement agreement between fetal transesophageal echocardiography (FTEE) and conventional maternal transabdominal echocardiography (CMTFE) by the Bland-Altman method. We performed our study in 11 fetal sheep between 95-103 days of gestation (term = 145 days). FTEE was performed by imaging the fetal heart in horizontal planes utilizing a 10-F, 10-MHz intravascular ultrasound catheter. CMTFE was carried out using a 5.0-MHz phased-array transducer replicating the FTEE imaging planes. We found close agreement between FTEE and CMTFE measurements of great vessel and cardiac valvar dimensions. Conversely, the variability between both techniques for measuring ventricular dimensions was inadequate. We conclude that FTEE permits measurement of great vessel and cardiac valve dimensions with high agreement with CMTFE measurements. This finding strengthens the applicability of FTEE as a monitoring tool during experimental open or fetoscopic fetal cardiac interventions.

Background and Aims of the Study: Percutaneous mitral valvulotomy has been shown to be an accept able alternative to surgery as treatment for selected patients with severe mitral stenosis. Uncertainty still exists regarding predictors of unsuccessful outcome., Materials and Methods: 308 patients with severe mitral stenosis underwent Inoue single balloon valvulotomy over a 48-month period and were followed up for a mean of 14.5 +/- 16.8 months (range one to 64 months). Two hundred and sixty-seven (Group I) improved clinically and remained stable throughout the follow up, while subsequent surgery was required in 41 (Group II) after 38.2 +/- 143.5 days (range one to 1,212). Clinical and echocardiographic parameters of the two groups were compared to find significant predictors of an unsuccessful outcome., Results: Significant differences between the groups were observed for NYHA class (2.7 +/- 0.6 vs. 2.9 +/- 0.6, p < 0.05), mitral valve area (1.0 +/- 0.3 vs. 0.9 +/- 0.2 cm2, p < 0.01), left atrial end-systolic dimension by echo (51.3 +/- 8.0 vs. 55.4 +/- 10.2 mm, p < 0.01) and an echocardiographic scoring system including grading for eccentricity of the mitral orifice and distribution of commissural calcification (7.5 +/- 2.0 for Group I and 8.7 +/- 2.0 for Group II, p < 0.001)., Conclusions: Mitral valves that are more likely to have an unsuccessful outcome can be identified by hemodynamic, clinical and echocardiographic criteria, including grading for eccentricity of the mitral orifice and distribution of commissural calcification.

In two infants the anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) was detected prospectively by transoesophageal echocardiography (TEE). Colour flow mapping and pulsed Doppler ultrasound revealed a predominant right-to-left shunt from the pulmonary artery to the left coronary artery. These findings were confirmed by angiography. Transthoracic echocardiography (TTE) failed to show the anomalous origin of the left coronary artery or any abnormal pulmonary flow pattern. TEE may be useful in the diagnosis of ALCAPA in selected cases, when TTE is inconclusive.

Cross-sectional and concurrent M-mode echocardiograms of the left ventricular outflow tract and the ascending aorta were performed in 80 patients with supravalvar aortic stenosis (SVAS) selected from a total of 178 patients in whom the diagnosis had been established earlier by cardiac catheterization and angiocardiography. Visualization of the area of obstruction was possible in 77 patients using the cross-sectional system. In 34 cases recatheterization and angiocardiography of the left heart were carried out. To quantitate the severity of obstruction we used the pressure difference across the stenosis and the ratio of the cross-sectional areas at the level of the aortic annulus and of maximal supravalve stenosis. These cross-sectional areas were estimated from values for aortic diameter derived from scans in the long axis of the aorta, assuming the cross-sections to be circular. There was a good correlation between the ratios calculated from the echocardiogram and those calculated from the angiocardiogram (r = 0.894, n = 34, 0.747 less than p greater than 0.938). There was also a good correlation between the ratio of the surface areas calculated from the echocardiogram and the corresponding measured pressure differences (r = 0.932, n = .36, 0.878 less than p greater than 0.973). This study shows that cross-sectional echocardiography may be useful for estimating the severity of obstruction in SVAS.

45 patients with supravalvular aortic stenosis (SVAS) were investigated by cross-sectional echocardiography from a total number of 164 patients observed in Göttingen. In 44 cases the diagnosis of SVAS could be confirmed by this noninvasive method. There was a good correlation between the ratio of the echo-circular surface (aortic anulus and the point of maximal obstruction) and the ratio of the angio-circular surface, as well as the ratio of the echo-circular surface and the measured pressure gradient. Cross-sectional echocardiography is therefore a valuable noninvasive method for evaluating SVAS and for estimating the severity of obstruction.

Aortoventriculoplasty (AVP) is an established operative procedure for the enlargement of different types of severe left ventricular outflow tract obstruction. Between 1974 and 1985 75 aortoventriculoplasties were carried out in 72 patients ranging from 5 to 34 years of age. Three patients had to be reoperated upon due to significant right ventricular outflow tract obstruction, outgrown prosthesis, and dissecting aortic aneurysm. There were 7 early deaths (mortality rate 9.3%) and one late death (1.3%) following AVP. Out of the last 55 patients only 2 died (3.6%). In contrast to the unsatisfactory haemodynamic results of previous conventional operations. AVP reduced the mean residual gradient at rest across the left ventricular outflow tract from 84 +/- 23 mmHg (range 50-160 mmHg) to 12 +/- 12 mmHg (range 0-65 mmHg). Except in 2 patients, no gradient increased more than 15 mmHg with isoproterenol. In the cross-sectional echocardiogram, the left ventricular outflow tract was enlarged from 1.9 +/- 0.42 to 3.1 +/- 0.39 cm after AVP, whereas the aortic annulus had been expanded from 2.4 +/- 0.36 to 3.2 +/- 0.35 cm (n = 17). The mean length of the inner patch covering the septal incision measured 2.1 cm +/- 0.4 cm (n = 37). Our recatheterization studies after AVP revealed equally good haemodynamic results in all types of left ventricular outflow tract obstruction which cannot be relieved by conventional surgery.

Cross sectional and simultaneous M-mode echocardiograms were performed on 15 consecutive patients with infective endocarditis, 14 of whom had pre-existing cardiac lesions. Patients were divided into two groups based on the presence or absence of echocardiographically detected vegetative lesions. In 10 out of 15 patients vegetations were present (66%): aortic valve 5, mitral valve 1, tricuspid valve 1, both aortic and mitral valves 1 and left ventricular endocardium associated with aortic valve lesion 2. In this group 3 had systemic embolic episodes and 2 died, whereas none of the 5 patients without detectable vegetations had complications. In 6 the preoperative echocardiographic findings could be confirmed at surgery or autopsy. Emergency surgery without catheterization was performed in 2 patients. Two dimensional echocardiography provides an important non invasive method of assessing a significant percentage of vegetations, but a negative echocardiogram does not exclude infective endocarditis. From the present experience and that of others the detection of vegetations by echocardiography identifies a subgroup of patients with a higher risk for complications in whom early operative intervention without catheterization can be performed. Cross sectional echocardiography may also prove helpful for serial examination of valve vegetations.

The value of cross-sectional sector echocardiography in the visualization of discrete subaortic stenosis (DSS) was investigated using an 80 degrees phased-array sector scanner with simultaneously derived M-mode outputs. Thirty-three patients (including 22 postoperative patients) with proven DSS were investigated and divided into two groups: group I--discrete membranous type; and group II--diffuse fibromuscular type. In group I (15 patients), two isolated subaortic ridges were identified as discrete linear echoes in the long axis of the outflow tract in five patients. A single distinct and isolated linear echo was observed in three patients, whereas in another five the ridges appeared to be attached to the ventricular septum and/or to the base of the anterior mitral leaflet. In two patients with mild DSS, a false-negative diagnosis was made. Only 2 out of 12 patients in this group showed a short remnant of the ridge after surgical revision. In group II, a more generalized or long-segment narrowing was present in 18 patients; in 14 of them the ridges were continuous with the walls of the outflow tract. Eight out of ten patients reexamined following resection of fibromuscular tissue still had residual obstruction. Analysis of the simultaneous M-mode recordings revealed that the transient appearance of the ridge in the outflow tract depended on the normal movement of the heart within the chest, on the lengthening of the membrane itself, and on the angle between the ultrasound beam and the membrane during different cardiac cycles. Our study shows that a spectrum of one- and two-dimensional patterns exists depending on the nature of the obstructing lesion. Cross-sectional sector echocardiography provides more direct visualization and characterization of various types of DSS than M-mode echocardiography does.