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Rationale: The COVID-19 pandemic disrupted non-COVID critical care trials globally as intensive care units (ICUs) prioritized patient care and COVID-specific research. The international randomized controlled trial CYCLE (Critical Care Cycling to Improve Lower Extremity Strength) was forced to halt recruitment at all sites in March 2020, creating immediate challenges. We applied the CONSERVE (CONSORT and SPIRIT Extension for RCTs Revised in Extenuating Circumstance) statement as a framework to report the impact of the pandemic on CYCLE and describe our mitigation approaches., Methods: On March 23, 2020, the CYCLE Methods Centre distributed a standardized email to determine the number of patients still in-hospital and those requiring imminent 90-day endpoint assessments. We assessed protocol fidelity by documenting attempts to provide the in-hospital randomized intervention (cycling or routine physiotherapy) and collect the primary outcome (physical function 3-days post-ICU discharge) and 90-day outcomes. We advised sites to prioritize data for the study's primary outcome. We sought feedback on pandemic barriers related to trial procedures., Results: Our main Methods Centre mitigation strategies included identifying patients at risk for protocol deviations, communicating early and frequently with sites, developing standardized internal tools focused on high-risk points in the protocol for monitoring patient progress, data entry, and validation, and providing guidance to conduct some research activities remotely. For study sites, our strategies included determining how institutional pandemic research policies applied to CYCLE, communicating with the Methods Centre about capacity to continue any part of the research, and developing contingency plans to ensure the protocol was delivered as intended. From 15 active sites (12 Canada, 2 US, 1 Australia), 5 patients were still receiving the study intervention in ICUs, 6 required primary outcomes, and 17 required 90-day assessments. With these mitigation strategies, we attempted 100% of ICU interventions, 83% of primary outcomes, and 100% of 90-day assessments per our protocol., Conclusions: We retained all enrolled patients with minimal missing data using several time-sensitive strategies. Although CONSERVE recommends reporting only major modifications incurred by extenuating circumstances, we suggest that it also provides a helpful framework for reporting mitigation strategies with the goal of improving research transparency and trial management., Trial Registration: NCT03471247. Registered on March 20, 2018., (© 2022. The Author(s).)

Introduction: Despite availability of selection criteria, different interpretations can lead to variability in the appreciation of donor eligibility with possible viable organs missed. Our primary objective was to test the perception of feasibility of potential organ donors through the survey of a small sample of external evaluators. Methods: Clinical scenarios summarizing 66 potential donors managed in the first year of our Organ Recovery Center were sent to four critical care physicians to evaluate the feasibility of the potential donors and the probability of organ procurement. Results: Potential donors procuring at least one organ were identified in 55 of the 66 cases (83%). Unanimity was reached in 38 cases, encompassing 35 out of the 55 converted and 3 of the non-converted donors. The overall agreement was moderate (kappa = 0.60, 95% CI: 0.37-0.82). For the organs finally procured for transplantation, organ donation was predicted for the majority of the cases, but high discrepancy was present with the final outcome of organs not procured (particularly liver and kidney). Conclusion: The assessment of a potential donor is a complex dynamic process. In order to increase organ availability, standardized electronically clinical data, as well a "donor board" structure of decision might inform future systems., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Marsolais, Larouche, Lagacé, Williams, Serri, Bernard, Rico, Frenette, Williamson, Albert and Charbonney.)

Background: The volumetric method in cardiac magnetic resonance (CMR), the reference standard for right ventricular ejection fraction (RVEF), requires expertise because of the complex right ventricular geometry and anatomical landmarks., Aim: The aim of our retrospective study was to describe a new method to evaluate RVEF based on wall motion score index (WMSI) in CMR., Methods: Visual assessment of wall motion was performed using an eight-segment model (normokinesia=1, hypokinesia=2, akinesia=3). Correlation between WMSI (WMS/8) and the reference volumetric RVEF was analysed. A regression equation was derived to convert the WMSI into RVEF. The accuracy of CMR WMSI-derived RVEF compared with CMR volumetric RVEF was evaluated using Bland-Altman analysis., Results: In the 112 patients using the volumetric method, the mean RVEF was 48±14%. Fifty-nine patients had normal RV kinetics (WMSI=1), which corresponded to a volumetric RVEF of 56% (standard deviation 7%; range 43-76%). CMR WMSI showed a strong correlation with CMR volumetric RVEF (Spearman's Rho=-0.69). A regression equation was created: RVEF=80-22×WMSI. Overall, the WMSI-derived RVEF resulted in good agreement with the CMR volumetric RVEF (mean bias-3%, standard deviation±7.5%). In addition, using a WMSI cut-off of≥1.5 was highly accurate (92%) to predict a reference RVEF of˂45%, an important prognostic indicator in CMR., Conclusions: Our results suggest that using the WMS in CMR (eight-segment) to estimate RVEF is accurate, and correlates well with the volumetric method. A WMSI≥1.5 is optimal to categorize patients in the higher-risk subset of CMR RVEF˂45%., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

In patients with Fontan palliation, the systemic and pulmonary circulation is in series and supported by a single ventricle, resulting in fragile hemodynamics. Cardiac output is driven by low pressure nonpulsatile pulmonary flow and is highly dependent on pulmonary vascular resistance. An acute respiratory distress syndrome (ARDS) can rapidly alter this physiology and lead to severe cardiogenic shock. Herein, we describe the case of a 40 year old man with a classic modified Fontan procedure and bidirectional Glenn shunt who developed ARDS with cardiogenic shock following a resuscitated cardiac arrest with presumed aspiration pneumonia. In light of poorly tolerated positive end-expiratory pressure ventilation and underlying anatomical complexities, a multidisciplinary team was convened to optimize care. In part owing to the lack of femoral venous access, a veno-venous extracorporeal membrane oxygenation circuit was devised using bilateral internal jugular venous access. Under fluoroscopic guidance in a hybrid operating room, one cannula was placed in the inferior vena cava by means of the right internal jugular venous access, with the second cannula positioned in the right pulmonary artery through the left internal jugular vein. Oxygenation and hemodynamic status promptly improved, allowing the patient to recover from ARDS., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2020.)

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to sustain circulatory and respiratory support in patients with severe cardiogenic shock or refractory cardiac arrest. Although VA-ECMO allows adequate perfusion of end-organs, it may have detrimental effects on myocardial recovery. Hemodynamic consequences on the left ventricle, such as the increase of afterload, end-diastolic pressure and volume, can lead to left ventricular (LV) distention, increase of myocardial oxygen consumption and delayed LV function recovery. LV distention occurs in almost 50% of patients supported with VA-ECMO and is associated with an increase in morbidity and mortality. Thus, recognizing, preventing and treating LV distention is key in the management of these patients. In this review, we aim to discuss the pathophysiology of LV distention and to describe the strategies to unload the LV in patients supported with VA-ECMO.

Purpose: Montreal has been the epicentre of the coronavirus disease (COVID-19) pandemic in Canada. Given the regional disparities in incidence and mortality in the general population, we aimed to describe local characteristics, treatments, and outcomes of critically ill COVID-19 patients in Montreal., Methods: A single-centre retrospective cohort of consecutive adult patients admitted to the intensive care unit (ICU) of Hôpital du Sacré-Coeur de Montréal with confirmed COVID-19 were included., Results: Between 20 March and 13 May 2020, 75 patients were admitted, with a median [interquartile range (IQR)] age of 62 [53-72] yr and high rates of obesity (47%), hypertension (67%), and diabetes (37%). Healthcare-related infections were responsible for 35% of cases. The median [IQR] day 1 sequential organ failure assessment score was 6 [3-7]. Invasive mechanical ventilation (IMV) was used in 57% of patients for a median [IQR] of 11 [5-22] days. Patients receiving IMV were characterized by a moderately decreased median [IQR] partial pressure of oxygen:fraction of inspired oxygen (day 1 PaO 2 :F i O 2 = 177 [138-276]; day 10 = 173 [147-227]) and compliance (day 1 = 48 [38-58] mL/cmH 2 O; day 10 = 34 [28-42] mL/cmH 2 O) and very elevated estimated dead space fraction (day 1 = 0.60 [0.53-0.67]; day 10 = 0.72 [0.69-0.79]). Overall hospital mortality was 25%, and 21% in the IMV patients. Mortality was 82% in patients ≥ 80 yr old., Conclusions: Characteristics and outcomes of critically ill patients with COVID-19 in Montreal were similar to those reported in the existing literature. We found an increased physiologic dead space, supporting the hypothesis that pulmonary vascular injury may be central to COVID-19-induced lung damage.

Objective: The objectives of this study were to systematically identify and describe guidelines for the care of neurologically deceased donors and to evaluate their methodological quality, with the aim of informing and supporting the new Canadian guidelines for the management of organ donors., Methodology: Following a systematic search, we included any document endorsed by an organ donation organization, a professional society, or a government, that aims to direct the medical management of adult, neurologically deceased, multi-organ donors. We extracted recommendations pertaining to six domains: the autonomic storm, hemodynamic instability, hormone supplementation, ventilation, blood product transfusions, and general intensive care unit (ICU) care. Methodological quality of the guidelines was assessed by the validated AGREE-II tool., Main Findings: This review includes 27 clinical practice guidelines representing 26 countries published between 1993 and 2019. Using the AGREE-II validated tool for the evaluation of guidelines' quality, documents generally scored well on their scope and clarity of presentation. Nevertheless, quality was limited in terms of the scientific rigor of guideline development. Recommendations varied substantially across the domains of managing the autonomic storm, subsequent management of hemodynamic instability, hormone therapy, mechanical ventilation, blood product transfusion, and general ICU care. We found consistent recommendations for low tidal volume ventilation subsequent to the publication of a landmark clinical trial., Conclusion: Highly inconsistent recommendations for deceased donor care summarized in this review likely reflect the relatively slow emergence of high-quality clinical research in this field, as well as a late uptake of recent validated guideline methodology. Even in this context of few randomized-controlled trials, our group supported the need for new Canadian guidelines for the management of organ donors that follow rigorous recognized methodology and grading of the evidence., Trial Registration: PROSPERO (CRD42018084012); registered 25 February 2016.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited., Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19., Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020., Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108)., Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%)., Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively., Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions., Trial Registration: ClinicalTrials.gov Identifier: NCT02735707.

Background: Persistent hypotension is a frequent complication after cardiac surgery with cardiopulmonary bypass (CPB). Midodrine, an orally administered alpha agonist, could potentially reduce intravenous vasopressor use and accelerate ICU discharge of otherwise stable patients. The main objective of this study was to explore the clinical impacts of administering midodrine in patients with persistent hypotension after CPB. Our hypothesis was that midodrine would safely accelerate ICU discharge and be associated with more days free from ICU at 30 days., Results: We performed a retrospective cohort study that included all consecutive patients having received midodrine while being on vasopressor support in the ICU within the first week after cardiac surgery with CPB, between January 2014 and January 2018 at the Montreal Heart Institute. A contemporary propensity score matched control group that included patients who presented similarly prolonged hypotension after cardiac surgery was formed. After matching, 74 pairs of patients (1:1) fulfilled inclusion criteria for the study and control groups. Midodrine use was associated with fewer days free from ICU (25.8 [23.7-27.1] vs 27.2 [25.9-28] days, p = 0.002), higher mortality (10 (13.5%) vs 1 (1.4%), p = 0.036) and longer ICU length of stay (99 [68-146] vs 68 [48-99] hours, p = 0.001). There was no difference in length of intravenous vasopressors (63 [40-87] vs 44 [26-66] hours, p = 0.052), rate of ICU readmission (6 (8.1%) vs 2 (2.7%), p = 0.092) and occurrence of severe kidney injury (11 (14.9%) vs 10 (13.5%) patients, p = 0.462) between groups., Conclusion: The administration of midodrine for sustained hypotension after cardiac surgery with CPB was associated with fewer days free from ICU and higher mortality. Routine prescription of midodrine to hasten ICU discharge after cardiac surgery should be used with caution until further prospective studies are conducted.

Purpose: Right ventricular RV dysfunction among transplant recipients correlates with transplant outcome, but its frequency in donors is unknown. The purpose of this study was to describe the epidemiology of RV dysfunction in potential heart donors.", Methods: In a seven-year retrospective study of potential heart donors, we explored the incidence of RV dysfunction as observed on echocardiography and explored the association of four distinct factors with RV dysfunction: brain injury diagnosis, thoracic trauma, vasopressin infusion and left ventricular (LV) dysfunction., Results: All 123 potential heart donors underwent echocardiography: 55 had RV dysfunction (44.7%). Fourty-one (33.3%) had LV dysfunction. Isolated RV dysfunction was present in 27 subjects (22%). LV dysfunction was the only factor significantly associated with RV dysfunction (OR = 4.6 (95% CI 1.9-11.4)). We observed no difference in heart acceptance between subjects with or without RV dysfunction., Conclusion: We observed a high frequency of RV dysfunction in a sample of potential heart donors. However, the temporal evolution of RV dysfunction, the hemodynamic predictors of RV dysfunction, as well the link between donor RV dysfunction and recipient outcomes need to be assessed with further prospective studies., (Copyright © 2019. Published by Elsevier Inc.)

Background: Although commonly prescribed, the efficacy of levothyroxine to improve heart function in neurologically deceased donors is unclear. We evaluated the feasibility of a randomized controlled trial to compare levothyroxine to placebo on the variation of left ventricular ejection fraction, in hemodynamically unstable donors., Methods: We conducted a pilot, double-blinded, randomized controlled trial. Deceased donors with reduced left ventricular ejection fraction or needing vasopressors were included. We randomized participants to a 20 μg bolus followed by a 20 μg/h infusion of levothyroxine or an identically appearing placebo. We report the proportion of recruited participants, the time to the administration of the study drug, and protocol violations., Results: Twenty-four participants (N = 24/104; 23.1%) were eligible. Five of them (N = 5/24; 20.8%) were excluded by the attending physician. Four others were not included, due to family refusal for research (n = 2/24;8.3%) and unavailability of research staff (n = 2/24; 8.3%). Fifteen participants were randomized (N = 15/104; 14.4%). Mean time between the echocardiography and the initiation of the drug was 1.73 hours, and14 (93.3%) of 15 of the participants received the drug within 2 hours after the echocardiography. We report no study violation. The study was stopped prematurely because of low recruitment., Conclusion: This pilot trial suggests that the success of a definitive randomized control trial to assess the efficacy of levothyroxine in deceased donors could benefit from a multicenter recruitment and education on the evidence surrounding the pharmacological management of organ donors. The need for consent to research interventions in deceased donors should also be clarified.

Objective: Avoiding decreases in brain tissue oxygenation (PbtO2) after traumatic brain injury (TBI) is important. How best to adjust PbtO2 remains unclear. The authors investigated the association between partial pressure of oxygen (PaO2) and PbtO2 to determine the minimal PaO2 required to maintain PbtO2 above the hypoxic threshold (> 20 mm Hg), accounting for other determinants of PbtO2 and repeated measurements in the same patient. They also explored the clinical utility of a novel concept, the brain oxygenation ratio (BOx ratio = PbtO2/PaO2) to detect overtreatment with the fraction of inspired oxygen (FiO2)., Methods: A retrospective cohort study at an academic level 1 trauma center included 38 TBI patients who required the insertion of a monitor to measure PbtO2. Various determinants of PbtO2 were collected simultaneously whenever a routine arterial blood gas was drawn. A PbtO2/PaO2 ratio was calculated for each blood gas and plotted over time for each patient. All patients were managed according to a standardized clinical protocol. A mixed effects model was used to account for repeated measurements in the same patient., Results: A total of 1006 data points were collected. The lowest mean PaO2 observed to maintain PbtO2 above the ischemic threshold was 94 mm Hg. Only PaO2 and cerebral perfusion pressure were predictive of PbtO2 in multivariate analysis. The PbtO2/PaO2 ratio was below 0.15 in 41.7% of all measures and normal PbtO2 values present despite an abnormal ratio in 27.1% of measurements., Conclusions: The authors' results suggest that the minimal PaO2 target to ensure adequate cerebral oxygenation during the first few days after TBI should be higher than that suggested in the Brain Trauma Foundation guidelines. The use of a PbtO2/PaO2 ratio (BOx ratio) may be clinically useful and identifies abnormal O2 delivery mechanisms (cerebral blood flow, diffusion, and cerebral metabolic rate of oxygen) despite normal PbtO2.

Purpose: To obtain a point prevalence estimate of alterations in central venous pressure (CVP) produced by active expiration in a consecutive series of intensive care patients., Methods: We evaluated CVP tracings taken by the nurses at their morning shift change in a consecutive series of 60 cardiac surgery and 59 noncardiac surgery patients. We also assessed change in values due to the change in transducer level. Three physicians and a nurse instructor independently reviewed the tracings and determined whether there was evidence of forced expiration and whether it was type A, defined by decreasing CVP during expiration, or type B, defined by increasing CVP during expiration., Results: Agreement for CVP value was 96% between a physician and a bedside nurse. Twenty-nine percent of participants had active expiration, evenly distributed between A and B types. Active expiration was not related to the type of surgery, use of bronchodilators, and the presence of chronic obstructive lung disease or abdominal distention. Active expiration was more common in nonventilated patients and patients not receiving vasopressor drugs, suggesting they were more awake., Conclusion: Active expiration is common in critically ill patients. Failure to recognize it can result in important errors in the estimation of CVP and other hemodynamic measurements.

Background: Simpson biplane method and 3D by transthoracic echocardiography (TTE), radionuclide angiography (RNA) and cardiac magnetic resonance imaging (CMR) are the most accepted techniques for left ventricular ejection fraction (LVEF) assessment. Wall motion score index (WMSI) by TTE is an accepted complement. However, the conversion from WMSI to LVEF is obtained through a regression equation, which may limit its use. In this retrospective study, we aimed to validate a new method to derive LVEF from the wall motion score in 95 patients., Methods: The new score consisted of attributing a segmental EF to each LV segment based on the wall motion score and averaging all 16 segmental EF into a global LVEF. This segmental EF score was calculated on TTE in 95 patients, and RNA was used as the reference LVEF method. LVEF using the new segmental EF 15-40-65 score on TTE was compared to the reference methods using linear regression and Bland-Altman analyses., Results: The median LVEF was 45% (interquartile range 32-53%; range from 15 to 65%). Our new segmental EF 15-40-65 score derived on TTE correlated strongly with RNA-LVEF ( r  = 0.97). Overall, the new score resulted in good agreement of LVEF compared to RNA (mean bias 0.61%). The standard deviations (s.d.s) of the distributions of inter-method difference for the comparison of the new score with RNA were 6.2%, indicating good precision., Conclusion: LVEF assessment using segmental EF derived from the wall motion score applied to each of the 16 LV segments has excellent correlation and agreement with a reference method., (© 2018 The authors.)

Background: Fabry disease (FD) is characterized by the accumulation of sphingolipids in multiple organs, including the left atrium. It is uncertain if the left atrial (LA) reservoir, conduit, and contractile functions evaluated by speckle-tracking echocardiography are affected in Fabry cardiomyopathy and whether enzyme replacement therapy can improve LA function., Methods: In this retrospective cohort study, LA strain, strain rates, and phasic LA volumes were studied in 50 patients with FD and compared with values in 50 healthy control subjects., Results: All three LA phasic functions were altered. Peak positive strain (reservoir function) was 38.9 ± 14.9% versus 46.5 ± 10.9% (P = .004), and late diastolic strain (contractile function) was 12.6 ± 5.9% versus 15.6 ± 5.3% (P = .010). In 15 patients who started enzyme replacement therapy during the study, most of the LA parameters improved at 1-year follow-up (peak positive strain from 32.0 ± 13.5% to 38.0 ± 13.5%, P = .006), whereas there was a trend toward deterioration in 15 patients who never received treatment (peak positive strain from 47.3 ± 10.8% to 41.3 ± 9.3%, P = .058). Nine patients with FD (21%) experienced new-onset atrial fibrillation or stroke during 4-year follow-up. By univariate analysis, peak positive strain and early diastolic strain demonstrated significant associations with clinical events, surpassing conventional echocardiographic parameters and clinical characteristics., Conclusions: LA reservoir, conduit, and contractile functions by speckle-tracking echocardiography were all affected in FD. Enzyme replacement therapy improved LA function. LA strain parameters were associated with atrial fibrillation and stroke., (Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: The optimal approach to titrate vasopressor therapy is unclear. Recent sepsis guidelines recommend a mean arterial pressure (MAP) target of 65 mmHg and higher for chronic hypertensive patients. As data emerge from clinical trials comparing blood pressure targets for vasopressor therapy, an accurate description of usual care is required to interpret study results. Our aim was to measure MAP values during vasopressor therapy in Canadian intensive care units (ICUs) and to compare these with stated practices and guidelines., Method: In a multicenter prospective cohort study of critically ill adults with severe hypotension, we recorded MAP and vasopressor doses hourly. We investigated variability across patients and centres using multivariable regression models and Analysis of variance (ANOVA), respectively., Results: We included data from 56 patients treated in 6 centers. The mean (standard deviation [SD]) age and Acute Physiology and Chronic Health Evaluation (APACHE) II score were 64 (14) and 25 (8). Half (28 of 56) of the patients were at least 65 years old, and half had chronic hypertension. The patient-averaged MAP while receiving vasopressors was 75 mm Hg (6) and the median (1st quartile, 3rd quartile) duration of vasopressor therapy was 43 hours (23, 84). MAP achieved was not associated with history of underlying hypertension (p = 0.46) but did vary by center (p<0.001)., Conclusions: In this multicenter, prospective observational study, the patient-level average MAP while receiving vasopressors for severe hypotension was 75 mmHg, approximately 10 mmHg above current recommendations and stated practices. Moreover, our results do not support the notion that clinicians tailor vasopressor therapy to individual patient characteristics such as underlying chronic hypertension but MAP achieved while receiving vasopressors varied by site., Competing Interests: The authors have declared that no competing interests exist.

Despite important advances in the care of postcardiac arrest patients, severe brain injury remains one of the major causes of death in the cardiac intensive care unit. Neurological prognostication after cardiac arrest has evolved significantly since the introduction of therapeutic hypothermia. It now relies on a multimodal approach and a minimal observation period of 72 hours is usually advocated. However, when brain injury is severe and the prognosis considered dismal, patients become eligible for organ donation. Patients with severe anoxic encephalopathy might evolve toward brain death and be candidates for donation after brain death. In the presence of severe brain injury without brain death criteria, when withdrawal of life-sustaining therapy is considered, patients might be eligible for donation after cardiocirculatory death. The diagnosis of brain death, the differences between donation after brain death and donation after cardiocirculatory death, family approach, and donor management in the intensive care unit are discussed. Because these are increasingly encountered situations in the cardiac intensive care unit, it is essential that physicians involved in cardiac critical care be familiar with these concepts., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Myocardial dysfunction has been well described with catastrophic neurological events, such as subarachnoid hemorrhage and brain death. There is very limited data describing myocardial function in the context of traumatic brain injury (TBI), as no prospective study has yet examined this association. The objective of our study was to evaluate cardiac function using echocardiography in patients with clinically important TBI., Methods: We conducted a prospective observational study of consecutive TBI patients admitted to the intensive care unit. All patients older than 16 years with moderate to severe TBI according to the Glascow Coma Scale (GCS) were eligible for the study. Only patients with a prior history of heart disease or cardiomyopathy or evidence of brain death on admission were excluded. A complete transthoracic echocardiogram was performed within 4 days of admission., Results: Forty-nine patients (67% males, median age 34 years) were included in the study. Forty-one patients had severe TBI (84%) with a median GCS of six, 44 patients (90%) required mechanical ventilation and 36 (74%) intracranial pressure monitoring. Hospital mortality was 18%. No patients had global left ventricular dysfunction as defined by a left ventricular ejection fraction (LVEF) below 50% (95% CI, 0-0.07). Average LVEF was 65 +/- 4%. Four patients (8%) had regional wall motion abnormalities with preserved LVEF., Discussion: The main finding of this study is the absence of clinically significant myocardial dysfunction in patients with moderate or severe TBI. Although myocardial dysfunction has been well described in a variety of neurological settings, it is possible that the young age of TBI patients and the absence of cardiovascular risk factors are protective against significant myocardial injury from catecholamine excess., Conclusions: In a group of patients with clinically important TBI, we did not identify any significant cardiac dysfunction.

For the non-cardiologist emergency physician and intensivist, performing an accurate estimation of left ventricular ejection fraction (LVEF) is essential for the management of critically ill patients, such as patients presenting with shock, severe respiratory distress or chest pain. Our objective was to develop a semi-quantitative method to improve visual LVEF evaluation. A group of 12 sets of transthoracic echocardiograms with LVEF in the range of 18-64% were interpreted by 17 experienced observers (PRO) and 103 untrained observers or novices (NOV), without previous training in echocardiography. They were asked to assess LVEF by two different methods: i) visual estimation (VIS) by analysing the three classical left ventricle (LV) short-axis views (basal, midventricular and apical short-axis LV section) and ii) semi-quantitative evaluation (base, mid and apex (BMA)) of the same three short-axis views. The results for each of these two methods for both groups (PRO and NOV) were compared with LVEF obtained by radionuclide angiography. The semi-quantitative method (BMA) improved estimation of LVEF by PRO for moderate LV dysfunction (LVEF 30-49%) and normal LVEF. The visual estimate was better for lower LVEF (<30%). In the NOV group, the semi-quantitative method was better than than the visual one in the normal group and in half of the subjects in the moderate LV dysfunction (LVEF 30-49%) group. The visual estimate was better for the lower LVEF (ejection fraction <30%) group. In conclusion, semi-quantitative evaluation of LVEF gives an overall better assessment than VIS for PRO and untrained observers.

Background: Focused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents' proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone., Methods: Junior residents (n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents (n = 15) were the traditionally trained group and were not provided with the educational interventions., Results: After the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher's exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher's exact test p = 0.0055)., Conclusions: Our study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.

Background: After the approval of transcatheter aortic valve replacement (TAVR) for high-risk or inoperable patients with severe aortic stenosis (AS), many low- and moderate-volume TAVR programs were initiated. Contemporary outcomes from these newly initiated centres remain unknown., Methods: In March 2013, our institution was authorized by the Québec Ministry of Health to perform 30 TAVR procedures. After thorough clinical screening and imaging evaluation, suitable patients underwent transfemoral TAVR with the balloon-expandable SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter heart valve (THV). In-hospital and 30-day outcomes were prospectively collected and reported according to Valve Academic Research Consortium 2 guidelines., Results: From April 2013 to January 2014, 30 consecutive high-risk (n = 16 [53.3%]) or inoperable (n = 14 [46.7%]) patients (mean age, 84.6 years; mean Society of Thoracic Surgery score, 7) with symptomatic severe AS underwent transfemoral TAVR. No catastrophic intraprocedural complications such as annulus rupture, valve embolization, aortic dissection, or coronary occlusion occurred, and there were no deaths at 30 days. Disabling stroke occurred in 1 (3.3%) patient 48 hours after THV implantation. Major vascular complications and major bleeding occurred in 1 (3.3%) patient. No moderate or severe paravalvular leak was observed. The median length of stay was 2 (1-3) days, with 8 (26.7%) patients discharged within 24 hours after the procedure., Conclusions: Excellent outcomes can be achieved in newly initiated relatively low-volume centres, which compares favorably to previously published large series. Important considerations include appropriate team training, rigorous patient screening, use of multimodality imaging techniques, a heart team approach, constant integration of lessons learned from larger published experiences, and maintaining a recommended minimum volume of 25 cases per year., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Data regarding the effect of high altitude on heart function are sparse and conflicting. We aimed to assess the right and left ventricular responses to altitude-induced hypoxia and the occurrence of subclinical pulmonary edema., Methods: Echocardiography was performed according to protocol on 14 subjects participating in an expedition in Nepal, at 3 altitude levels: Montreal (30 m), Namche Bazaar (3450 m), and Chukkung (4730 m). Systematic lung ultrasound was performed to detect ultrasound lung comets., Results: Pulmonary artery systolic pressure increased in all subjects between Montreal and Chukkung (mean 27.4 ± 5.4 mm Hg vs. 39.3 ± 7.7 mm Hg; P < 0.001). Right ventricular (RV) myocardial performance index (MPI) increased significantly (0.32 ± 0.08 at 30 m vs. 0.41 ± 0.10 at 4730 m; P = 0.046). A trend toward deteriorated RV free wall longitudinal strain was observed between Montreal and Chukkung (-25.9 [5.3%] vs. -21.9 [6.4%]; P = 0.092). The left ventricular early diastolic inflow velocity/atrial mitral inflow velocity and early diastolic inflow velocity/mean of the maximal early diastolic mitral annulus tissue doppler velocities ratios remained unchanged. At 4730 m, ultrasound lung comets were seen in all subjects except 1. None had clinical criteria for high-altitude pulmonary edema (HAPE). All altered parameters normalized after return to sea level., Conclusion: Subclinical HAPE is frequent in healthy lowlander climbers. This is the first study to document a trend towards decreased RV free wall strain and MPI increment at high altitude. Whether rising RV MPI is a physiologic adaptive mechanism to hypoxia or a pathologic response identifying HAPE-susceptible subjects needs further study., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Left ventricular ejection fraction (LVEF) is an important indicator of left ventricular function and of the severity and prognosis of ischaemic heart disease. Assessment of regional function using the wall motion score index (WMSI) is an alternative means of evaluating left ventricular function., Aim: We attempted to evaluate LVEF by a method using the WMSI with cardiac magnetic resonance imaging (MRI)., Methods: One hundred and twenty-two patients referred for evaluation of heart disease had rest WMSI evaluation by cardiac MRI. The WMSI was evaluated using the 16-segment model and score proposed by the American Society of Echocardiography. In our first group of 80 patients, a correlation between WMSI and cardiac MRI LVEF was established and a regression equation was derived. This regression equation was then used in 42 consecutive patients to compare WMSI LVEF with the gold standard MRI LVEF., Results: In the first 80 patients, MRI LVEF and WMSI correlated very well (r=0.93). Similarly, in the second group of 42 patients, WMSI LVEF derived from the regression equation correlated very well with MRI LVEF (r=0.94)., Conclusion: An objective evaluation of LVEF can be easily made using the WMSI with cardiac MRI, which correlates very well with standard MRI planimetric methods., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Aims: The mechanisms associated with cardiac resynchronization therapy (CRT) benefits have been elucidated in part, however little is known about the effects of biventricular pacing (BVP) on regional myocardial contractility., Methods and Results: Twenty patients with conventional CRT criteria were studied before and after device implantation. Speckle tracking strain analysis was performed from standard bidimensional acquisitions during different pacing configurations. Longitudinal and transverse strains were measured for the six basal left ventricular (LV) segments. Acute CRT improved LV end-diastolic and end-systolic volumes without significantly modifying LV ejection fraction. Moreover, CRT produced significant changes in regional strain. When compared with spontaneous rhythm, simultaneous BVP caused a significant increase in longitudinal septal strain (-4.8 vs. -7.3%, P = 0.003) and a significant decrease in longitudinal lateral strain (-8.2 vs. -5.9%, P = 0.03). Simultaneous BVP also induced a significant decrease in transverse lateral strain from 17.9 to 10.9% (P = 0.004)., Conclusion: In this acute echocardiographic study, BVP decreased lateral wall deformation while improving septal wall contraction, thus potentially improving LV contractile pattern.

Ergot-derived dopamine receptor agonists, especially pergolide and cabergoline, have been associated with an increased risk of valvular heart disease in patients treated for Parkinson's disease. Cabergoline at lower doses than those employed in Parkinson's disease is widely used in patients with prolactinomas, because of its high efficacy and tolerability; however, its safety with regard to cardiac valve disease is unknown. In order to assess the prevalence of cardiac valve regurgitation in patients with prolactinomas treated with long-term cabergoline, we performed a prospective and multicentric study including four university centers in the province of Quebec. A transthoracic echocardiogram was performed in 70 patients with prolactinomas treated with cabergoline for at least 1 year (duration of treatment, 55 +/- 22 months; cumulative dose 282 +/- 271 mg, mean +/- SD) and 70 control subjects matched for age and sex. Valvular regurgitation was graded according to the American Society of Echocardiography recommendations as mild, moderate, or severe. Moderate valvular regurgitation was found in four patients (5.7%) and five control subjects (7.1%) (P = 0.73). No patient had severe valvular regurgitation. There was no correlation between the presence of significant heart-valve regurgitation and cabergoline cumulative dose, duration of cabergoline treatment, prior use of bromocriptine, age, adenoma size, or prolactin levels. Our results show that low doses of cabergoline seem to be a safe treatment of hyperprolactinemic patients. However, in patients with prolonged cabergoline treatment, we suggest that echocardiographic surveillance may be warranted.

Cardiac resynchronization therapy (CRT) has become a proven therapeutic strategy for refractory heart failure. Large clinical trials have shown a reduction in both morbidity and mortality in patients treated with CRT. Initial patient selection has relied mainly on electrocardiographic criteria that allowed identifying only 70% of responders. Accordingly, echocardiographic criteria were developed to identify dyssynchrony in the hope of improving patient selection. Multiple echocardiographic criteria have since been proposed, with no consensus as to which parameter better predicts CRT response. Although comparison studies using the different criteria are underway, the current evaluation of dyssynchrony should probably be an integrated multiparameter approach. The objective of this article is to review the role of echocardiography in the evaluation of cardiac dyssynchrony and propose a practical algorithm in order to improve CRT patient selection.

Background: Speckle tracking is a new technique based on pure 2D grayscale ultrasound acquisition allowing calculation of segmental strains. To facilitate clinical application, speckle tracking has been integrated into the most recent echocardiographic systems for quick, automated evaluation of left ventricular function (Automated Function Imaging, AFI)., Objective: To evaluate the feasibility, calculation time, accuracy and reproducibility of global longitudinal strain (GLS) from AFI in determining LV function in comparison to reference echocardiographic and angiographic methods-whatever the operator's experience., Methods: Echocardiography was performed in 65 patients scheduled for cardiac catheterization using a Vivid 7 system. They were divided into 3 groups according to EF (>55%, 35< or =EF< or =55%,<35%). Image quality, global LV function parameters (ejection fraction, aortic flow, dp/dt) and segmental contraction were analyzed by one experienced operator and one beginner. GLS was obtained from apical 2, 3 and 4 chamber views. GLS was compared to both echocardiographic and angiographic EF, as well as to other echocardiographic parameters., Results: GLS was obtained successfully in 97% of patients. Mean calculation time including correction of endocardial detection was less than 60 seconds. GLS was significantly different between the 3 groups, respectively -18.1+/-2.5%, -11.5+/-2.1% and -6.0+/-1.2% (p<0.01). Strong correlations were observed between GLS and LV function (r from 0.68 to 0.87) with a high level of reproducibility. No difference was observed between experienced and inexperienced operators., Conclusion: AFI is clinically applicable and an effective means of assessing LV function due to its short acquisition time, feasibility and accuracy, whatever the experience of the operator.

Deformation analysis using 2-dimensional strain echocardiography can detect early systolic function abnormalities in patients with left ventricular hypertrophy. This study was designed to characterize global and regional myocardial deformation using 2-dimensional strain in professional soccer players (PSPs) compared with control subjects and patients with hypertrophic cardiomyopathy (HC). Twenty nine PSPs, 26 patients with HC, and 17 controls were investigated at rest using transthoracic echocardiography with 2-dimensional strain analysis. Radial and transverse strains were significantly higher in PSPs compared with controls, whereas longitudinal strain was lower. Compared with patients with HC, athletes had higher values for transverse, radial, and circumferential strains. In pathologic hypertrophic segments, longitudinal strain was lower in patients with HC than in PSPs. In conclusion, 2-dimensional strain can identify specific patterns of myocardial deformation in PSPs, controls, and patients with HC. It has the potential to become a routinely used method for the differentiation of athlete's heart and HC.

First described a decade ago, cardiac resynchronization therapy (CRT) has recently become a proven therapeutic strategy for refractory heart failure. Large clinical trials have shown a reduction in both morbidity and mortality in patients treated with CRT. Initial patient selection has relied mainly on electrocardiographic criteria, which allows identification of only 70% of responders. Accordingly, echocardiographic criteria were developed to identify mechanical dyssynchrony in an effort to improve patient selection. Multiple echocardiographic criteria have since been proposed, with no consensus as to which parameter better predicts CRT response. Although comparison studies using different criteria are underway, current evaluation of dyssynchrony should probably use an integrated multiparameter approach. The objective of the present article was to review the role of echocardiography in the evaluation of cardiac dyssynchrony in clinical practice.

Objectives: In normal hearts, the distribution of regional myocardial perfusion is altered by ventricular pacing. Little is known about the impact of ventricular pacing on regional myocardial perfusion in ischemic conditions. In this acute echocardiographic study, we compared the respective effects of right ventricular pacing (RVP), left ventricular pacing (LVP), and biventricular pacing (BVP) on regional perfusion in a swine model of graded ischemia., Methods and Results: Ventricular pacing leads were placed at the apex of the right ventricle and on the lateral wall of the left ventricle in nine open-chest pigs. Myocardial contrast echocardiography was successively performed during spontaneous rhythm (SR), RVP, LVP, and BVP in random order at baseline and during three stages of incremental ischemia (left anterior descending + circumflex). At baseline, RVP decreased myocardial perfusion of the septal and inferior walls compared to SR (P < 0.05), whereas LVP decreased perfusion of the lateral wall (P < 0.05). No significant differences were observed in regional perfusion during BVP compared to SR. In ischemic conditions, RVP worsened myocardial perfusion in the ischemic anterior wall as well as in the septal and inferior walls (P < 0.05), whereas both LVP and BVP did not alter perfusion in the ischemic area compared to SR., Conclusion: Compared to baseline, in ischemic conditions, RVP has a more pronounced detrimental impact on perfusion abnormalities. In contrast, BVP induced a significant improvement in local myocardial perfusion. Therefore, BVP could be preferred to RVP in patients with ischemic cardiomyopathy.

Objective: The aims of this study were to investigate absolute assessment of aortic valve area (AVA), before surgery for aortic stenosis, using cardiovascular magnetic resonance (CMR) in comparison with transesophageal echocardiography (TEE) and with effective AVA indirectly obtained by routine techniques i.e. transthoracic echocardiography (TTE) and cardiac catheterisation., Materials and Methods: Absolute AVA planimetry was performed by TEE and CMR steady state free precession sequences obtained through the aortic valvular plane. Effective AVA was calculated by the continuity equation in TTE and by cardiac catheterisation (Gorlin formula)., Results: Thirty-nine patients with aortic valve stenosis, mean age 71.7 +/- 7.6 years, with a mean AVA of 0.93 +/- 0.31 cm2 as measured by TEE, were enrolled in the study. Mean differences were: between CMR and TEE planimetry: d = 0.01 +/- 0.14 cm2, between CMR and cardiac catheterisation: d = 0.05 +/- 0.13 cm2, between CMR and TTE: d = 0.10 +/- 0.17 cm2, between TTE and TEE: d = 0.10 +/- 0.18 cm2, between TTE and cardiac catheterisation: d = 0.06 +/- 0.16 cm2, and between TEE and cardiac catheterisation: d = 0.07 +/- 0.13 cm2. Mean intraobserver and interobserver differences of CMR planimetry were d = 0.02 +/- 0.07 cm2 and d = 0.03 +/- 0.14 cm2, respectively., Conclusion: CMR planimetry of the AVA is a noninvasive and reproducible technique to evaluate stenotic aortic valves and can be used as an alternative to echocardiography or cardiac catheterisation.

Objectives: We sought to assess the effects of exercise on ventricular dyssynchrony in patients with normal and depressed left ventricular (LV) function., Background: Asynchronous myocardial contraction adversely influences ventricular function and is associated with a poor prognosis in heart failure. Exercise-induced changes in ventricular dyssynchrony may be an important determinant of dynamic changes in cardiac output and mitral regurgitation., Methods: A total of 65 consecutive heart failure patients and 50 matched healthy control patients underwent exercise echocardiography. Conventional and tissue Doppler parameters were measured before and during symptom-limited exercise. Left ventricular dyssynchrony was defined as the standard deviation of 12 LV segmental electromechanical delays. Analysis of the control group allowed delimitation of normal cutoff values., Results: In patients with normal left ventricular function, exercise did not modify the extent of LV asynchrony. In contrast, in heart failure patients, LV dyssynchrony increased by at least 20% in 34%, remained stable in 37%, and decreased by at least 20% in 29%. Moreover, 26% of heart failure patients had either exercise induction or normalization of ventricular dyssynchrony. A significant association was found between exercise-induced changes in dyssynchrony and the presence of ischemic cardiomyopathy (p < 0.05). Rest-exercise differences in ventricular dyssynchrony were correlated with changes in cardiac output and mitral regurgitation (r = -0.63 and 0.56, respectively)., Conclusions: In heart failure patients, exercise can alter the magnitude of ventricular dyssynchrony. Some patients have a response to exertion with induction of ventricular dyssynchrony, whereas others show normalization. Changes in ventricular dyssynchrony during exercise correlate with alterations in cardiac output and mitral regurgitation.

This prospective echocardiographic study investigated the respective impacts of left ventricular (LV) pacing and simultaneous and sequential biventricular pacing (BVP) on ventricular dyssynchrony during exercise in 23 patients with compensated heart failure and ventricular conduction delays. During exercise, LV pacing and BVP significantly (p <0.05) improved mitral regurgitation and LV dyssynchrony compared with spontaneous activation. LV segmental electromechanical delays were significantly prolonged during LV pacing, leading to increased systolic time (p <0.05), decreased LV filling time (p <0.05), and decreased stroke volume (p <0.05) compared with BVP. After optimization of the interventricular delay with sequential BVP, additional benefit was obtained during exercise in terms of stroke volume and mitral regurgitation (p <0.05). The optimal interventricular delay was different at rest and during exercise in 57% of the patients. Changes from at rest to exercise in LV dyssynchrony were correlated with changes in stroke volume (r = -0.61, p <0.01) and changes in mitral regurgitation (r = 0.60, p <0.01).

Quantitative coronary angiography (QCA) is routinely performed before valve surgery for severe acquired valvular disease. This technique is relatively invasive, especially in a population with an average risk for significant coronary stenosis. Multidetector computed tomography (MDCT) coronary angiography allows the noninvasive evaluation of the coronary anatomy. The aim of this prospective study was to evaluate the predictive values of 16-slice MDCT in the detection of significant coronary stenosis (> or = 50%) before valve surgery in patients with severe valvular disease without known coronary artery disease and average risk, in comparison with conventional QCA. Forty patients with severe acquired valvular disease (mean age 70 +/- 8.6 years; 20 women; 27 with severe aortic stenosis) underwent coronary MDCT 2 days before cardiac catheterization with QCA. The mean heart rate was 64.7 +/- 8.8 beats/min (range 41 to 78). Four hundred fifty-eight of 600 coronary artery segments (77.3%) were considered assessable by MDCT. In a per-segment analysis, the sensitivity of MDCT for the detection of significant coronary lesions > or = 50% was 77.7%, the specificity was 98%, the positive predictive value was 42.4%, and the negative predictive value was 99%. The main cause of false-positive or false-negative results or nonassessable evaluations was severe coronary calcification. In a per-patient analysis, in comparison with QCA, MDCT correctly classified 33 of 40 patients (82.5%). In conclusion, in patients with an average risk for coronary stenosis before valve surgery, MDCT coronary angiography detected significant obstructive coronary artery disease, with a 99% NPV.

Objectives: Recently, a novel method to measure strain from standard two-dimensional images has been developed. Our goal was to characterize global and regional systolic function abnormalities using this technique in patients with hypertrophic cardiomyopathy (HCM)., Background: Strain has been proposed as a sensitive tool to detect early systolic function abnormalities in HCM. However, the clinical application of conventional Doppler-derived strain has been limited by poor reproducibility and angle dependency., Methods: Echocardiographic examinations were performed in 26 patients with nonobstructive HCM and 45 healthy subjects. Using a dedicated software package, bidimensional acquisitions were analyzed to measure longitudinal and transverse strain in apical views and circumferential and radial strain in parasternal short-axis view., Results: Despite apparently normal left ventricular systolic function, all components of strain were significantly reduced in HCM. Average longitudinal, transverse, circumferential, and radial strain in patients with HCM and controls were -15.1 +/- 6.2% versus -20.3 +/- 5.6%, 23.3 +/- 17.0% versus 27.2 +/- 14.9%, -16.8 +/- 7.1% versus 19.6 +/- 5.2%, and 25.2 +/- 13.9% versus 36.8 +/- 17.2%, respectively (all p < 0.001). In patients with asymmetrical HCM, longitudinal septal strain was significantly lower than for other left ventricular segments combined: -9.2 +/- 4.7% versus -12.7 +/- 7.1% (p = 0.001). Average interobserver and intraobserver variabilities were 11% and 11.3%, respectively., Conclusions: Two-dimensional strain is a new simple, rapid, and reproducible method to measure different components of systolic strain. This technique identified early abnormalities in patients with HCM that have apparently normal left ventricular systolic function.

After mastering epicardial revascularisation, the therapeutic management of acute coronary syndrome has progressively turned towards the preservation of the capillary microcirculation. In this respect, contrast echocardiography provides all the answers to the main questions which arise, and is available within a timeframe and place compatible with the management of such patients. The techniques for microbubble detection, quantification tools, and contrast agents are well optimised for routine use both for initial diagnosis as well as monitoring the therapeutic effectiveness. It is only the administrative authorisation which is currently lacking treatment.

Biventricular resynchronisation has been recently shown to be an effective therapeutic option in patients with refractory dilated cardiomyopathy. Based on the finding of ventricular asynchrony, the aim of the method is to restore uniform contraction of the ventricular walls. However, the initial electrocardiographic criteria for selection of patients were only associated with a 70% rate of response. Consequently, it became necessary to refocus this method in patients with true ventricular asynchrony. Echocardiography is one of the non-invasive techniques which provides morphological and functional analysis of the myocardium with a high degree of accessibility. The multiplication of tools for echocardiographic quantification has been very valuable from a theoretical point of view for assessing ventricular asynchrony. In practice, techniques such as Doppler tissue imaging are being validated, but already offer the possibility of a multi-directional approach to this pathology. The diagnosis of asynchrony is based on a range of echocardiographic findings which not only improve the selection of patients but also optimise the programming of multisite stimulation.