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Background: Transesophageal echocardiography (TEE) remains the preferred test to rule out infective endocarditis (IE) but is resource intensive and carries risk. Multiple studies report low sensitivity of transthoracic echocardiography (TTE) for detection of IE; however, these studies did not account for TTE quality. We test the validity of a simple valve visualization grading tool to stratify TTEs by quality and determine whether a high-quality TTE may be used to exclude valvular vegetation and forgo the need for TEE., Methods: The Valve Visualization on Echocardiography Grade (VEG) tool scores the TTE from 0 to 10 based on leaflet visualization and valve leaflet clarity. The tool was retrospectively applied to 309 sequential patients who underwent both TTE and TEE at an academic teaching hospital between 2011 and 2015. The TEE report was the gold standard for presence or absence of vegetation. Patients with prosthetic valves and pacemaker wires were excluded. Sensitivity of TTE for detecting vegetation was calculated at each VEG score, and the optimal cutoff was identified., Results: A total of 309 patients were included in the analysis. Among the 216 negative TTEs, 19 (9%) had a positive TEE. The median VEG score was 4. A VEG score cutoff >6 provided optimal sensitivity and was used as the cutoff. Overall, 75 (25%) patients had a VEG score >6, and 234 (75%) had a score ≤6. Sensitivity and negative predictive value for IE were higher in the VEG >6 versus VEG ≤6 group (sensitivity 96% vs 66%, negative predictive value 97.5% vs 90%; P < .05). The false-negative rate was lower (2.5% vs 10%; P = .04) in VEG > 6 versus VEG ≤ 6 groups, respectively., Conclusions: Leaflet visualization and valve leaflet clarity are important components in the TTE evaluation of patients with suspected IE. This study demonstrates that the better the valve leaflets are visualized on TTE (as represented in this population by a score >6), the higher the confidence one can have that the TTE will not be falsely negative for vegetation(s) when vegetation(s) are not noted on these TTEs. If validated in future prospective studies, this may reduce the need to perform an invasive TEE in selected patients undergoing evaluation for native valve IE., (Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease, making up 10% of all congenital heart defects. Annual follow-up echocardiograms are recommended in patients with repaired ToF, but evidence-based guidelines do not exist. We hypothesized that most echocardiograms performed in asymptomatic patients with repaired ToF and no physical exam change do not result in an actionable change (AC) in management. We retrospectively reviewed records of all patients with ToF and prior complete repair at our institution between January 2000 and September 2015. Changes in echocardiograms resulting in hospital admission, medication addition/change, cardiac catheterization, or surgical procedure were identified via chart review. These changes were referred to as an AC. A total of 1135 echocardiograms were reviewed from 233 patients (160 with initial complete repair, 70 with prior shunt, and 3 with other initial surgery). The median number of echocardiograms per patient was 5. Of the 1135 echocardiograms, 15 (1.3%) were associated with AC. Of the 15 patients with AC echocardiograms, 9 underwent a shunt prior to complete repair (9/70, 12.9%) and 6 had undergone an initial complete repair (6/160, 3.8%). The median age at AC was 6.3 years (IQR 4.4, 6.8) in the shunt group and 0.90 years (IQR 0.87, 1.1) in the initial complete repair group. In asymptomatic patients with repaired ToF and no physical exam change, echocardiograms rarely lead to a change in clinical management. In conclusion, the likelihood and timing of AC echocardiograms and reinterventions vary based on the type of initial surgery.

Background: No echocardiographic indices for predicting the need for preterm patent ductus arteriosus (PDA) surgery have been tested with an adequate sample size. We tested the hypothesis that some echocardiographic indices have better predictive ability for the need for PDA surgery., Methods: We prospectively collected data from infants with gestational ages between 23 and 29 weeks at 34 Japanese neonatal intensive care units over 14 months. Data points were 1, 3, 7, and 14 days of age and, if applicable, before PDA surgery. We assessed five echocardiographic indices. Volume and dimension indices were adjusted for birth body weight (BBW). For each echocardiographic index, the worst value among all data points in nonsurgical patients or the value just before surgery in surgical patients was used. Multivariate logistic regression was applied with adjustment for clinical status., Results: In total, 691 patients were analyzed, of whom 61 (8.8%) underwent surgery, as guided using the criteria in the protocol. The areas under the receiver-operating characteristic curve for PDA diameter (0.86) and PDA diameter/BBW (0.86) were the largest, followed by those of left pulmonary artery end-diastolic velocity (LPAedv) (0.80), and left atrial volume/BBW (0.80)., Conclusions: Considering the measurement's easiness and independence of body size, PDA diameter and LPAedv may serve as useful indices for assessing the need for PDA surgery in early preterm infants., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Objectives: The goal of this study was to determine the diagnostic yield of focused cardiac ultrasound (FOCUS) in hemodynamically stable patients in the emergency department and secondarily to confirm the accuracy of these studies when compared to formal echocardiography., Methods: All hemodynamically stable adult patients who had an emergency physician-performed FOCUS examination completed over a 1-year period were identified using our electronic ultrasound database. Hemodynamic stability was defined as presenting systolic blood pressure higher than 90 mm Hg and not requiring any form of positive pressure ventilation., Results: There were 1198 FOCUS examinations performed: 976 in hemodynamically stable patients who were included in our analysis. Twenty-seven percent of patients had new findings, including 154 (16%) new diagnoses of reduced left ventricular function, 105 (11%) new pericardial effusions, and 44 (5%) new diagnoses of RV dilatation. Dyspnea as an indication for the FOCUS examination was the strongest predictor of a positive study. Of patients included, 28% underwent formal echocardiography within 2 days and were analyzed for concordance with regard to left ventricular function and the presence of pericardial effusion. Of 270 studies, 208 were accurate, and 62 were inaccurate, for raw agreement of 77% (κ = 0.53). When stratified by sonographer experience, there was no impact on accuracy., Conclusions: Focused cardiac ultrasound in the emergency department for hemodynamically stable patients revealed new findings in 27% of studies, with a modest correlation with formal echocardiography. In stable patients, FOCUS has the potential for rapid diagnosis of cardiac disease, particularly in patients with dyspnea., (© 2019 by the American Institute of Ultrasound in Medicine.)

Chronic thromboembolic pulmonary hypertension (CTEPH), a late complication of pulmonary embolism (PE), is associated with high mortality. However, whether the right ventricular (RV) echocardiographic parameters can predict - in the short- and long-term - the development of CTEPH and mortality after PE remains unknown. Herein, we aim to investigate the incidence of CTEPH after acute PE and to evaluate the risk factors of CTEPH. In this retrospective cohort, patients with PE were followed for 10 years for the onset of CTEPH. The screening was initially conducted through echocardiography and confirmed by right heart catheterization. Also, transient and permanent risk factors were identified. Among 358 patients with PE, 8 patients (4%) were subsequently diagnosed with CTEPH at a median time of 36 months and 47 died during the follow-up period. Notably, both short- and long-term RV dilatation, hypertrophy, and increased pulmonary pressure increased the incidence of CTEPH. However, RV echocardiographic parameters failed to differentiate survivors from non-survivors. Instead, malignancy, respiratory, or chronic heart failure was strongly associated with post PE mortality in the multivariable analysis. According to our findings, post PE screening of CTEPH may facilitate early diagnosis and intervention for patients at high risk of developing CTEPH. Also, RV echocardiographic parameters are associated with subsequent CTEPH, but mortality is mainly dependent on underlying comorbidities.

Left atrial (LA) remodeling has been identified to predict atrial fibrillation (AF) and heart failure. However, the role of LA diameter (LAD) in patients with heart failure (HF) with preserved (HFpEF), mid-range (HFmrEF), and reduced ejection fraction (HFrEF) remains poorly understood.A total of 142 patients including 71 subjects with AF (21 of HFpEF, 22 of HFmrEF, and 28 of HFrEF) and 71 ejection fraction (EF)-matched subjects with sinus rhythm (SR) were included in the study. Baseline characteristics and echocardiographic parameters including LAD were compared between both groups as well as among HFpEF, HFmrEF, and HFrEF.In receiver-operating characteristic (ROC) analyses, LAD predicted AF in HFpEF, HFmrEF, and HFrEF [area under the curve (AUC): 0.646; P = .03]. LAD was negatively association with left ventricular ejection fraction while positively with Nt-proNP and left ventricular end-diastolic diameter (regression coefficient: -0.239, P = .004; regression coefficient: 0.191, P = .023; regression coefficient: 0.357, P < .001). In ROC analyses, LAD predicted HFrEF among the 3 categories (AUC: 0.629, P = .01).In the setting of HF, LAD was higher in AF than in and SR, and predicted AF. Furthermore, LAD was associated with severity of HF in HFpEF, HFmrEF, and HFrEF, and also predicted HFrEF.

Background: Neonatologist performed echocardiography (NPE) has increasingly been used to assess the hemodynamic status in neonates. Aim of this survey was to investigate the utilization of NPE in Italian neonatal intensive care units (NICUs)., Methods: We conducted an on-line survey from June to September 2017. A questionnaire was developed by the Italian neonatal cardiology study group and was sent to each Italian NICU., Results: The response rate was 77%. In 94% of Italian NICUs functional echocardiography was used by neonatologists, cardiologists or both (57, 15 and 28% respectively). All the respondents used NPE in neonates with patent ductus arteriosus and persistent pulmonary hypertension, 93% in neonates with hypotension or shock, 85% in neonates with perinatal asphyxia, 78% in suspicion of cardiac tamponade, and 73% for line positioning. In 30% of center, there was no NPE protocol. Structural echocardiography in stable and critically ill neonates was performed exclusively by neonatologists in 46 and 36% of center respectively., Conclusions: NPE is widely used in Italian NICUs by neonatologists. Structural echocardiography is frequently performed by neonatologists. Institutional protocols for NPE are lacking. There is an urgent need of a formal training process and accreditation to standardize the use of NPE.

Aims: The EURO-ENDO registry aimed to study the management and outcomes of patients with infective endocarditis (IE)., Methods and Results: Prospective cohort of 3116 adult patients (2470 from Europe, 646 from non-ESC countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Clinical, biological, microbiological, and imaging [echocardiography, computed tomography (CT) scan, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)] data were collected. Infective endocarditis was native (NVE) in 1764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and device-related (CDRIE) in 308 (9.9%). Infective endocarditis was community-acquired in 2046 (65.66%) patients. Microorganisms involved were staphylococci in 1085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). 18F-fluorodeoxyglucose positron emission tomography/computed tomography was performed in 518 (16.6%) patients and presented with cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, presence of a vegetation and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2160 (69.3%) patients, but finally performed in only 1596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson index, creatinine > 2 mg/dL, congestive heart failure, vegetation length > 10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated., Conclusion: Infective endocarditis is still a life-threatening disease with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

The pediatric ultrasound measurement of the inferior vena cava (IVC) and aorta (AO) with the study of the collapsibility index (CI) and of IVC-to-AO ratio (IVC/AO) can provide clinicians in the acute care setting with information on abnormal volume status but one of the major limitations is a lack of reference normal values by body surface area (BSA) and age. The aim of this study was to provide reference ranges for the sonographic measurement of IVC, AO, and IVC/AO ratio in healthy Caucasian Italian children., Methods: We enrolled prospectively 516 healthy Caucasian Italian children aged between 1 month and 16 years. Echocardiographic IVC and AO diameters were collected and presented separately for children aged ≤1 year and for children aged over 1 year. For children >1 year we categorized subjects into 3 years classes. CI and IVC/AO for the systolic aortic diameter were then calculated. For children over 1 year, age reference ranges were age-related or BSA-related; for children of ≤1 year, reference ranges were determined with their 90% confidence intervals regardless of age and of BSA., Results: Tables and charts with reference ranges for all the echocardiographic measurements are presented for children aged >1 year according to age and BSA. The equations to obtain percentile and Z-score for each echocardiographic measurement are provided. The reference ranges for children aged ≤1 year are shown considering the small 90% confidence intervals for upper and lower limits. CI was 30% (SD 17%) in children >1 year and 36% (SD 16%) in children <1 year. IVC/AOs showed age-dependent values from 0.83 (SD 0.20) age <1 year to 1.22 (SD 0.31) in older subjects., Conclusions: We report reliable reference ranges for echocardiographic measurement of IVC, AO, CI, and IVC/AO for a Caucasian Italian healthy pediatric population., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Fetal pulmonary atresia with intact ventricular septum (PA/IVS) is a rare congenital heart disease. The present study aimed to classify PA/IVS and determine the relationship between prenatal echocardiographic characteristics and postnatal biventricular or univentricular repair strategies.A total of 51 fetuses with PA/IVS were examined from 2012 to 2019. Data on prenatal echocardiography, associated anomaly, karyotype, and outcome were collected. Two-dimensional measurements included tricuspid valve (TV) z-score, mitral valve (MV) z-score, TV/MV ratio, and ratio of right to left ventricle (RV/LV) length, whereas color Doppler measurements included degree of tricuspid regurgitation (TR), ventriculo-coronary artery communication (VCAC), tricuspid inflow duration (TID), cardiac cycle duration (CCD), middle cerebral artery pulsatility index (MCA PI), and umbilical artery pulsatility index (UA PI). Diagnostic classification was based on the development of RV and the presence or absence of VCAC. Postnatal evaluation was divided according biventricular or univentricular repair.Of the 51 fetuses with PA/IVS, 20 were type I, 17 were type II, and 14 were type III. Only one fetus exhibited right aortic arch. The karyotype of all the fetuses was normal. Of the 28 patients who underwent postnatal surgery, 13 (46%) underwent biventricular repair and 15 (54%) underwent univentricular repair. TV z-score was significantly higher for the biventricular repair group compared with univentricular repair group (-1.20 ± 0.98 vs -4.33 ± 0.80, P = .000). TV/MV, RV/LV length, and TID/CCD were significantly higher for the biventricular repair group than the univentricular repair group (0.81 ± 0.14 vs 0.54 ± 0.09, 0.71 ± 0.11 vs 0.49 ± 0.09, 39.20 ± 3.84 vs 29.16 ± 4.58, P = .000). Moderate or severe TR and VCAC were significantly different between the 2 groups (P = .000). Gestational age, MCA PI, and UA PI did not differ between the 2 groups (P = .72, P = .36, P = .06). The cutoff values for the biventricular repair characteristic curves were TV z-score >-3.28, TV/MV ratio >0.71, RV/LV length >0.62, and TID/CCD >33.95%. The sensitivities of the TV z-score, TV/MV, RV/LV length, and TID/CCD were 100%, 77%, 85%, and 92%, respectively. The specificities of the TV z-score, TV/MV, RV/LV length, and TID/CCD were 94%, 100%, 100%, and 94%, respectively.Fetal echocardiography was able to classify PA/IVS according to variable degree of RV and VCAC. In fetal PA/IVS, TV z-score >-3.28, TV/MV >0.71, RV/LV length >0.62, TID/CCD >33.95%, moderate and severe TR, and the absence of VCAC were associated with postnatal biventricular repair strategy. These findings may have implications for prenatal counseling and prediction of fetal outcome.

Left ventricular ejection fraction (EF) is helpful to differentiate heart failure (HF) phenotype in clinical practice. The aim of the study was to identify simple echocardiographic predictors of post-discharge all-cause mortality in hospitalized HF patients. Patients with acute HF (75 ± 9.8 years), classified in preserved (≥ 50%) and reduced (< 50%) EF (HFpEF and HFrEF, respectively), were enrolled. The mean follow-up period was of 25.4 months. Patients definitively analyzed were 135. At multivariate Cox model, right ventricular diameter (RVd), inferior vena cava diameter (IVCd) and blood urea nitrogen (BUN) resulted to be significantly associated with all-cause mortality in HFpEF (HR 2.4, p = 0.04; HR 1.06, p = 0.02; HR 1.02, p = 0.01), whereas, left atrial volume (LAV) was significantly associated with mortality in HFrEF (HR 1.06, p = 0.006). Excluding LAV from the model, only COPD remained an independent predictor of all-cause mortality (HR 2.15, p = 0.04) in HFrEF. At Kaplan-Meier analysis, no differences of survival between HFrEF and HFpEF were found, however, significantly increased all-cause mortality for higher values of basal-RVd, BUN, and IVCd (log-rank p = 0.0065, 0.0063, 0.0005) in HFpEF, and for COPD and higher LAV (log-rank p = 0.0046, p = 0.033) in HFrEF. These data are indicative that in patients hospitalized with HF, EF is not a suitable predictor of long-term all-cause mortality, whereas, right ventricular volumetric remodeling and IVCd have a prognostic role in HFpEF as well as LAV in HFrEF. Our study suggests that besides EF, other echocardiographic parameters are helpful to optimize the phenotyping and prognostic stratification of HF.

Background: Atrial fibrillation (AF) is characterized by a progression from paroxysmal to persistent or permanent AF. Recent studies have shown that AF progression is related to a worse morbidity and mortality, and poorer outcomes of radiofrequency catheter ablation (RFCA). We previously showed that left ventricular (LV) compliance assessed by diastolic wall strain (DWS) was a strong determinant of prevalent AF., Methods and Results: We studied 306 paroxysmal AF patients with structurally normal hearts. The DWS was non-invasively measured with echocardiography. During a follow-up of 35±19 months, AF progression occurred in 60 of 172 (35%) patients treated with medications only (medication group), and 3 of 134 (2%) who underwent RFCA (RFCA group) (p<0.001). In the medication group, patients with a DWS <0.38 had a higher incidence of AF progression than those without (log-rank p<0.001), while the AF progression rate was low irrespective of the DWS in the RFCA group. In a multivariate analysis, the DWS and left atrium volume index (LAVI) were independent predictors of AF progression in the medication group (hazard ratio, 1.13 per 0.01 decrease; 95% CI: 1.08-1.18; p<0.001, and 1.04 per 1mm increase; 95% CI: 1.01-1.08; p=0.012, respectively). In the medication group, AF progression occurred in only 5 of 61 (8%) patients with a DWS ≥0.38, whereas 27 of 40 (68%) with a DWS <0.38 and LAVI >34mL/m 2 progressed to persistent or permanent AF., Conclusions: The LV compliance estimated by the DWS was independently associated with AF progression. The DWS would be useful to stratify patients at risk of AF progression who could benefit from an earlier RFCA intervention., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

The objective of this study was to examine the findings of computed tomographic (CT) angiography in patients with aortic arch anomalies in comparison with transthoracic echocardiography findings who referred to a private imaging center in Tehran during 2009-2012. The cases included 203 patients with clinical symptoms or echocardiogram of congenital heart disease to assess the presence of aortic arch anomalies among patients referred to imaging center. This study is a retrospective study based on the CT angiographic findings in comparison with transthoracic echocardiography findings of chest among patients with aortic arch anomalies. In this study, 203 patients with congenital anomalies were enrolled in the study, among those, 107 patients were men and 96 were female. The most common anomaly of the aortic arch was found to be coarctation (19.7%), followed by right sided arch with mirror image branching (19.2%). Furthermore, the most common cardiac anomalies associated with aortic arch anomalies were VSD, PA and PDA. The sensitivity and specificity of transthoracic echocardiography in the diagnosis of aortic arch anomalies was 59% and 100% in comparison with CT angiography. In addition, the agreement between the two methods (kappa) in the diagnosis of aortic arch anomalies was 0.72. But, transthoracic echocardiography is the first diagnostic method for patients with congenital heart disease. In some patients, the ability of this method was limited to the detection of coronary artery anomalies and thoracic vessels. Therefore, CT is used for morphological evaluation of congenital heart disease (CHD) due to its main advantages including fast acquisition time, large anatomical coverage, high speed, and great spatial resolution. Moreover, CT is essential for proper evaluation of CHD regarding its high spatial and temporal resolution.

Background Our objective was to estimate receipt of preconception health care among women with congenital heart defects (CHD), according to 2017 American Heart Association recommendations, as a baseline for evaluating recommendation implementation. Methods and Results Using 2007 to 2013 IBM MarketScan Commercial Databases, we identified women with CHD diagnosis codes ages 15 to 44 years who became pregnant and were enrolled in health insurance for ≥11 months in the year before estimated conception. We assessed documentation of complete blood count, electrolytes, thyroid-stimulating hormone, liver function, ECG, comprehensive echocardiogram, and exercise stress test, using procedural codes, and outpatient prescription claims for US Food and Drug Administration category D and X cardiac-related medications. Differences were examined according to CHD severity, age, region of residence, year of conception, and documented encounters at obstetric and cardiology practices. We found 2524 pregnancies among 2003 women with CHD (14.4% severe CHD). In the 98.3% of women with a healthcare encounter in the year before conception, <1% received all and 22.6% received no American Heart Association-recommended tests or assessments (range: 54.4% for complete blood count to 3.1% for exercise stress test). Women with the highest prevalence of receipt of recommended care were 35 to 44 years old, pregnant in 2012 to 2013, or had a documented obstetric or cardiology encounter in the year before conception ( P <0.05 for all). In 9.0% of pregnancies, ≥1 prescriptions for US Food and Drug Administration category D or X cardiac-related medications were filled in the year before conception. Conclusions A low percentage of women with CHD received American Heart Association-recommended preconception health care in the year before conception.

Objective: To evaluate the performance of B-type natriuretic peptide as a diagnostic tool for heart failure in pregnant or postpartum women with singleton gestations., Methods: We conducted a retrospective study of diagnostic accuracy. We identified pregnant and postpartum women with B-type natriuretic peptide and echocardiography performed at an obstetric teaching hospital from 2007 to 2018. Women with known cardiac disease or multiple gestation were excluded. A panel of two cardiovascular disease experts, blinded to B-type natriuretic peptide values, determined the diagnosis of heart failure by consensus. Their judgement was based on detailed clinical features and parameters at the time of presentation with suspected heart failure. Where consensus could not be reached, differences were adjudicated by a third expert. A receiver operating characteristic curve estimated the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of B-type natriuretic peptide at various thresholds., Results: In total, 22 pregnant and 38 postpartum women were included in the cohort. Average age was 32±6.8 years. The most common clinical features at the time of presentation with suspected heart failure included preeclampsia (33/60, 55%), dyspnea (50/60, 83%), chest discomfort (34/60, 58%), and bilateral lower extremity edema (32/60, 53%). In total, 39 (65%) women had heart failure. The median B-type natriuretic peptide level was 326 pg/mL (interquartile range 200.5-390.5) in women with heart failure, as compared with 75.5 pg/mL (interquartile range 19-245) in women without heart failure (P<.01). The estimated optimal B-type natriuretic peptide cutoff was 111 (95% CI 78-291) pg/mL. Using this threshold, 45 (75%) women had an elevated B-type natriuretic peptide, which yielded a 95% sensitivity (95% CI 83-99), 62% specificity (95% CI 38-82), a positive likelihood ratio of 2.5 (95% CI 1.4-4.3), and a negative likelihood ratio of 0.1 (95% CI 0.0-0.3) for heart failure., Conclusions: B-type natriuretic peptide is a useful clinical tool to evaluate pregnant and postpartum women with suspected heart failure.

Objectives: This study assessed the frequency and utility of echocardiographic examination in patients with all forms of Ehlers-Danlos syndrome and sought to identify clinical variables associated with an abnormal echocardiogram., Design/setting: This was a retrospective study of all patients carrying a diagnosis of Ehlers-Danlos syndrome of any type who were evaluated by a pediatrician or pediatric subspecialist at a single tertiary medical center with an affiliated children's hospital during the period January 2013 to December 2018., Patients: Chart review was performed on all patients carrying a diagnosis of Ehlers-Danlos syndrome in the electronic medical record., Outcome Measures: Data from genetics examination, cardiovascular examination where applicable, genetic test results when available, and echocardiography were recorded., Results: Of 262 patients identified, echocardiography and cardiac evaluation were common occurring in 90% and 50% of patients with any form of Ehlers-Danlos syndrome. Cardiovascular complications occurred in 50% of patients with vascular Ehlers-Danlos syndrome but echocardiography was normal in all. Aortic dilation was common in classic Ehlers-Danlos syndrome but absent in hypermobile Ehlers-Danlos syndrome. Mitral valve prolapse and bicuspid aortic valve occurred at the same incidence as the general population. Cardiac symptoms were present in 12% but did not correlate with abnormal cardiac structure. Presentation with symptoms of musculoskeletal pain was inversely related to the presence of cardiac pathology., Conclusions: In light of the absence of cardiac pathology in patients with hypermobile Ehlers-Danlos syndrome, routine cardiac evaluation and echocardiography are not required for patients with hypermobile Ehlers-Danlos syndrome., (© 2019 Wiley Periodicals, Inc.)

The aim of this study was to evaluate comparative clinical outcomes of discordant electrocardiographic (ECG) and echocardiographic (Echo) findings compared with concordant findings during treadmill exercise echocardiography in patients with chest pain and no history of coronary artery disease (CAD).A total of 1725 consecutive patients who underwent treadmill echocardiography with chest pain and no history of CAD were screened. The patients were classified into 4 groups: ECG-/Echo- (negative ECG and Echo), ECG+/Echo- (positive ECG and negative Echo), ECG-/Echo+, and ECG+/Echo+. Concomitant CAD was determined using coronary angiography or coronary computed tomography. Major adverse cardiac events (MACEs) were defined as a composite of coronary revascularization, acute myocardial infarction, and death.MACEs were similar between ECG-/Echo- and ECG+/Echo- groups. Compared with ECG+/Echo- group, ECG-/Echo+ group had more MACEs (adjusted hazard ratio [HR] adjusted by clinical risk factors [95% confidence interval {CI}], 3.57 [1.75-7.29], P < .001). Compared with ECG+/Echo+ group, ECG-/Echo+ group had lower prevalence of concomitant CAD and fewer MACEs (HR, 0.49 [0.29-0.81], P = .006).Positive exercise Echo alone during treadmill exercise echocardiography had worse clinical outcomes than positive ECG alone, and the latter had similar outcomes to both negative ECG and Echo. Positive exercise Echo alone also had better clinical outcomes than both positive ECG and Echo. Therefore, exercise Echo findings might be superior for predicting clinical outcomes compared with exercise ECG findings. Additional consideration of ECG findings on positive exercise Echo will also facilitate better prediction of clinical outcomes.

Objectives: Variation in hospital resource allocations across weekdays and weekends have led to studies of the 'weekend effect' for ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), heart failure (HF) and stroke. However, few studies have explored the 'weekend effect' on unplanned readmission. We aimed to investigate 30-day unplanned readmissions and processes of care across weekend and weekday hospitalisations for STEMI, NSTEMI, HF and stroke., Design: We grouped hospitalisations for STEMI, NSTEMI, HF or stroke into weekday or weekend admissions. Multivariable adjusted ORs for binary outcomes across weekend versus weekday (reference) groups were estimated using logistic regression., Setting: We included all non-elective hospitalisations for STEMI, NSTEMI, HF or stroke, which were recorded in the US Nationwide Readmissions Database between 2010 and 2014., Participants: The analysis sample included 659 906 hospitalisations for STEMI, 1 420 600 hospitalisations for NSTEMI, 3 027 699 hospitalisations for HF, and 2 574 168 hospitalisations for stroke., Main Outcome Measures: The primary outcome was unplanned 30-day readmission. As secondary outcomes, we considered length of stay and the following processes of care: coronary angiography, primary percutaneous coronary intervention, coronary artery bypass graft, thrombolysis, brain scan/imaging, thrombectomy, echocardiography and cardiac resynchronisation therapy/implantable cardioverter-defibrillator., Results: Unplanned 30-day readmission rates were 11.0%, 15.1%, 23.0% and 10.9% for STEMI, NSTEMI, HF and stroke, respectively. Weekend hospitalisations for HF were associated with a statistically significant but modest increase in 30-day readmissions (OR of 1.045, 95% CI 1.033 to 1.058). Weekend hospitalisation for STEMI, NSTEMI or stroke was not associated with increased risk of 30-day readmission., Conclusion: There was no clinically meaningful evidence against the supposition that weekend and weekday hospitalisations have the same 30-day unplanned readmissions. Thirty-day readmission rates were high, especially for HF, which has implications for service provision. Strategies to reduce readmission rates should be explored, regardless of day of hospitalisation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

To evaluate the value of dual-source computed tomography (DSCT) compared with transthoracic echocardiography (TTE) in assessing intracardiac and extracardiac anomalies in patients with coarctation of aorta (CoA) and interrupted aortic arch (IAA). Seventy-five patients (63 with CoA and 12 with IAA) who received preoperative DSCT and TTE were retrospectively studied. Intracardiac and extracardiac anomalies were recorded and compared by DSCT and TTE, in reference to surgical or cardiac catheterization findings. A total of 155 associated anomalies were finally found. Collateral circulation (56, 74.70%), patent ductus arteriosus (PDA; 41, 54.67%) were the most common anomalies. PDA, aortopulmonary window, and collateral circulation were more frequently present in patients with IAA than those with CoA (100% vs. 46.03%, 16.67% vs. 0%, and 100% vs. 69.84%, respectively, all p < 0.05). DSCT was superior to TTE in assessing associated extracardiac-vascular anomalies (sensitivity: 100% vs. 39.81%; specificity: 100% vs. 100%; positive predictive value: 100% vs. 100%; negative predictive value: 100% vs. 76.06%). Extracardiac-vascular anomalies, including collateral circulation and PDA, were the most common anomalies in patients with IAA and CoA. Compared with TTE, DSCT is more reliable in providing an overall preoperative evaluation of morphological features and extracardiac anomalies for surgical planning.

The availability of miniaturized ultrasound machines has changed our approach to many cardiovascular diseases. Handheld ultrasound imaging can be performed at the bedside, it is easy to use, and the information provided, although limited, is of unquestionable importance for a quick diagnosis that leads to early treatment. They have unique characteristics: Low cost, wide availability, safety, accuracy, and can be used in different clinical scenarios and by operators with different backgrounds. Image acquisition and interpretation is rapid and provides, in each situation, useful information for diagnosis, prognosis, and clinical and therapeutic management. This review focuses on the use of handheld ultrasound devices, describes differences with other equipment, their limitations, and the numerous advantages derived from their use., Competing Interests: The authors declare no conflict of interest.

Background: Androgen-deprivation therapy (ADT) is a treatment option for locally advanced and metastatic prostate cancer (PCA). The aim of the study was to evaluate the effect of ADT on left ventricular (LV) functions assessed by speckle-tracking echocardiography (STE) in prostate cancer (PCA) patients., Methods: Forty-nine consecutive PCA patients (mean age 71.5 ± 6.7 years) who would be treated with radiotherapy and ADT and 32 consecutive PCA patients (mean age 71.9 ± 7.0 years) who would be treated with radical or partial prostatectomy and 42 age-matched healthy men (mean age 70.5 ± 9.1 years) were included in our study. The left ventricular functions were assessed by both conventional echocardiography and STE at baseline and 6 months later., Results: There were not any significant difference in characteristics of the patients and controls. There were not any significant differences in conventional echocardiographic measures at baseline and at 6th month among the PCA patients and controls. Although there were not any significant differences in STE measures at baseline among the PCA patients and controls, the strain measures of the PCA patients receiving ADT decreased significantly at the 6th month and were significantly lower compared to strain measures of PCA patients undergoing prostatectomy and controls. There was not any statistically significant difference in baseline and 6th-month strain measures of the PCA patients undergoing prostatectomy., Conclusions: ADT might be associated with decrease in LV longitudinal, circumferential, and radial strain measures in patients with PCA. STE might be useful for early identification of LV subclinical impairment in PCA patients treated with ADT.

Background: The electrocardiogram (ECG) is the first and often the only investigation available prior to definitive therapy in patients with ST elevation myocardial infarction (STEMI). A good prognostic marker is the left ventricular ejection fraction (LVEF) on ECG. Our aim was to assess the correlation between ST elevation (STE) in ECG and the LVEF and thereby aid the prognosis of patients with STEMI., Methods: This was a prospective cohort study of 230 patients with STEMI. A baseline 12-lead ECG was taken to calculate the sum of STE at the J point in all the leads showing elevation. The STE was measured 90 min after revascularization to calculate the ST resolution percentage (STR%). All patients underwent echocardiography, and the LVEF was measured using biplane Simpson's method., Results: A total of 136 patients with anterior myocardial infarction (MI), 35 with inferior MI, and 59 with inferoposterior MI were included in the study. Mean STE was 13 mm and was significantly higher among patients with anterior MI. There was a good inverse correlation between the STE and the LVEF with a correlation coefficient of -0.64. STR% had a correlation coefficient of 0.59 to the LVEF. A formula was generated to calculate the LVEF based on the STE as follows: LVEF = (37.34 - STE)/0.567. An STE ≥15 mm predicted an LVEF <35% with a sensitivity and specificity of 70%., Conclusion: The STE and STR% are useful surrogate markers in prognosticating patients irrespective of the type of STEMI., Competing Interests: There are no conflicts of interest.

Introduction: Left ventricular diastolic dysfunction (LVDD) is a common condition in both sexes that may deteriorate into heart failure (HF) with preserved ejection fraction (pEF), although this seems to happen more often in women than in men. Both LVDD and HFpEF often go unrecognised, necessitating the discovery of biomarkers that aid both the identification of individuals with LVDD at risk of developing HF and identification of individuals most likely to benefit from treatment., Methods and Analysis: HELPFul is an ongoing case-cohort study at a Dutch cardiology outpatient clinic enrolling patients aged 45 years and older without history of cardiovascular disease, who were referred by the general practitioner for cardiac evaluation. We included a random sample of patients and enriched the cohort with cases (defined as an E/e' ≥8 measured with echocardiography). Information about medical history, cardiovascular risk factors, electrocardiography, echocardiography, exercise test performance, common carotid intima-media thickness measurement and standard cardiovascular biomarkers was obtained from the routine care data collected by the cardiology outpatient clinic. Study procedure consists of extensive venous blood collection for biobanking and additional standardised questionnaires. Follow-up will consist of standardised questionnaires by mail and linkage to regional and national registries. We will perform cardiac magnetic resonance imaging and coronary CT angiography in a subgroup of patients to investigate the extent of macrovascular and microvascular coronary disease., Ethics and Dissemination: The study protocol was approved by the Institutional Review Board of the University Medical Center Utrecht. Results will be disseminated through national and international conferences and in peer-reviewed journals in cardiovascular disease., Trial Registration: NTR6016;Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: African American (AA) has higher prevalence of abnormal electrocardigrams (ECG) in general population. However, the degree of these abnormalities in a healthy population undergoing screening echocardiography is not known. The goal of this study was to evaluate the prevalence of ECG abnormalities reported during screening echocardiography based on race., Method: The Anthony Bates Foundation has been performing screening across the United States for the prevention of sudden death since 2001. We evaluated a total of 633 participants with documented race and ECG for the presence of any abnormalities., Results: The age of the study population ranged between 6 and 75 years old. The prevalence of abnormal ECG in AA participant was 20.7% (12/58) versus 6.6% (38/578) in other races [odds ratio (OR), 3.70; confidence interval (CI), 1.8-7.58; P < 0.001]. Using multivariate analysis adjusting for age, sex, body mass index, left ventricular hypertrophy, and hypertension (systolic blood pressure >140 and diastolic blood pressure of >90), AA race remained independently associated with abnormal ECG (OR, 2.58; CI, 1.12-5.97; P = 0.02). Limiting our study only to teenagers (age, 13-19 years), AA race remained significantly associated with higher prevalence of ECG abnormalities [23.1% (12/58) of teenage AA had abnormal ECG vs. 7.5% (24/321) of other teenage races; OR, 3.71; CI, 1.36-10.11; P = 0.006]. After excluding benign ECG abnormalities such as sinus bradycardia and early repolarization, AA race remained significantly associated with higher prevalence of abnormal ECG (16.7% vs. 7.3%; OR, 2.52; CI, 0.998-6.39; P = 0.054)., Conclusions: The prevalence of abnormal ECG is higher in AA race independent of echocardiographic abnormalities or demographics. However, some of these abnormalities appear to be related to sinus bradycardia and early repolarization.

Background: Information on the clinical and echocardiographic characteristics of young patients with heart failure with reduced ejection fraction is scant, especially among racially diverse populations., Methods: Patients admitted to Montefiore Medical Center between 2000 and 2016 with heart failure and ejection fraction of <40% were categorized as young (18-39 years), middle-aged (40-64 years), and elderly (≥65 years). Multivariable Cox regression models were used to evaluate mortality risk., Results: A total of 1032 young, 8336 middle-aged, and 13,315 elderly patients were included. Median follow-up was 36 (14-69) months. The young group had more black individuals, lower socioeconomic scores, larger left ventricular chambers, but lower N-terminal pro b-type natriuretic peptide levels (P < 0.001). Better survival outcomes were observed in the young compared to the middle-aged [hazard ratio (HR), 1.52; 95% confidence interval (CI), 1.31-1.77] and elderly (HR, 3.19; 95% CI, 2.75-3.70). After multivariable adjustments, only β-blockers were associated with a significant reduction of mortality in young patients (HR, 0.33; 95% CI, 0.22-0.51)., Conclusion: In conclusion, young patients with heart failure with reduced ejection fraction have distinct demographic, clinical, and echocardiographic characteristics. They had lower socioeconomic status yet received more aggressive treatments and had lower mortality rates. Only β-blockers were associated with improved survival in young patients from our cohort.

A systematic review and meta-analysis was conducted to estimate the prevalence of PH in adolescents and adults living with HIV at the global level. PubMed, EMBASE, Web of Science, and Global Index Medicus were searched to identify articles published until November 4, 2018. PH had to be investigated with transthoracic echography or right heart catheterization (RHC). A random-effects model was used to pool individual studies. Overall, 25 studies with 42,642 participants from 17 countries were included. One study reported the prevalence of PH among HIV-infected adults based on RHC: 0.5% (95% confidence interval (CI): 0.3-0.6). The global prevalence of PH based on echography was 8.3% (95% CI: 4.6-12.8; 22 studies) among HIV-infected adults. In subgroup analysis, there was no difference between regions, human development indicator, and HIV burden in countries. Among HIV-infected adolescents, the prevalence of PH based on echography was 14.0% (95% CI: 2.2-33.1; 2 studies). This study suggests a high prevalence of PH in the global adolescent and adult population infected with HIV. As such, PH in this vulnerable population should be prioritized by HIV healthcare providers, policy makers and stakeholders for improved detection, overall proper management and efficient control.

Background: The association between appropriate use criteria and echocardiographic findings in patients with chronic cardiovascular diseases is unknown., Methods: As a substudy of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial, 9,230 transthoracic echocardiographic (TTE) examinations from six Ontario academic hospitals were linked to a registry of echocardiographic findings. The TTE studies were rated appropriate), rarely appropriate, or may be appropriate according to the 2011 appropriate use criteria. TTE findings of appropriately ordered examinations were compared with those of rarely appropriate examinations for specific disease subsets, including heart failure and valvular heart disease., Results: There were 7,574, 1,087, and 569 TTE examinations ordered for appropriate, rarely appropriate, and may be appropriate indications, and of the 7,574 appropriate studies, 6,399 were ordered for specific indications and 1,175 for general indications. TTE examinations ordered for general indications had lower rates of left ventricular dysfunction (19.6% vs 9.1%, P < .001) and moderate to severe aortic stenosis (15.5% vs 2.6%, P < .001). Of the 2,395 TTE examinations ordered for patients with heart failure, appropriately ordered studies were more likely to result in left ventricular segmental abnormality (37.0% vs 24.9%, P = .012) but similar rates of right ventricular dilatation (15.4% vs 14.7%, P = .79), right ventricular dysfunction (14.8% vs 11.3%, P = .22), and moderate to severe mitral regurgitation (12.1% vs 9.2%, P = .35). Of the 2,859 studies ordered to assess valvular heart disease, appropriately ordered studies were significantly more likely to find moderate to severe valvular pathology, including aortic stenosis (30.4% vs 24.6%, P = .008), aortic regurgitation (8.9% vs 1.6%, P < .001), mitral stenosis (6.7% vs 3.1%, P = .002), and mitral regurgitation (16.1% vs 6.1%, P < .001), but similar rates of tricuspid regurgitation (11.2% vs 13.0%, P = .60)., Conclusions: Overall, appropriately ordered TTE examinations for heart failure and valvular heart disease were significantly more likely to have abnormal findings than rarely appropriate examinations. TTE studies ordered for general indications had fewer, although still a significant proportion, of abnormalities compared with studies ordered for specific indications., (Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of fetal growth restriction (FGR) at term on fetal and neonatal cardiac geometry and function., Methods: This was a prospective study of 87 pregnant women delivering at term, comprising 54 normally grown and 33 FGR pregnancies. Fetal and neonatal conventional and spectral tissue Doppler and two-dimensional speckle tracking echocardiography were performed a few days before and within hours after birth. Fetal cardiac geometry, global myocardial deformation and performance and systolic and diastolic function were compared between normal and FGR pregnancies before and after birth., Results: Compared with normally grown fetuses, FGR fetuses exhibited more globular ventricular geometry and poorer myocardial deformation and cardiac function (left ventricular (LV) sphericity index (SI), 0.54 vs 0.49; right ventricular (RV) SI, 0.60 vs 0.54; LV torsion, 1.2 °/cm vs 3.0 °/cm; LV isovolumetric contraction time normalized by cardiac cycle length, 121 ms vs 104 ms; interventricular septum early diastolic myocardial peak velocity/atrial contraction myocardial diastolic peak velocity ratio, 0.60 vs 0.71; P < 0.01 for all). The poorest perinatal outcomes occurred in FGR fetuses with the most impaired cardiac functional indices. When compared with normally grown neonates, FGR neonates showed persistent alteration in cardiac parameters (LV-SI, 0.53 vs 0.50; RV-SI, 0.54 vs 0.44; LV torsion, 1.1 °/cm vs 1.4 °/cm; LV myocardial performance index (MPI'), 0.52 vs 0.42; P < 0.01 for all). Paired comparison of fetal vs neonatal cardiac indices in FGR demonstrated that birth was associated with a significant improvement in some, but not all, cardiac indices (RV-SI, 0.60 vs 0.54; RV-MPI', 0.49 vs 0.39; P < 0.001 for all)., Conclusions: Compared with normal pregnancies, FGR fetuses and neonates at term exhibit altered cardiac indices indicative of myocardial impairment that reflect adaptation to placental hypoxemia and alterations in hemodynamic load around the time of birth. Elucidating potential mechanisms that contribute to the alterations in perinatal cardiac adaptation in FGR could improve management and aid the development of better therapeutic strategies to reduce the risk of adverse pregnancy outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.)

Purpose: Mechanisms of circulatory failure are complex and frequently intricate in septic shock. Better characterization could help to optimize hemodynamic support., Methods: Two published prospective databases from 12 different ICUs including echocardiographic monitoring performed by a transesophageal route at the initial phase of septic shock were merged for post hoc analysis. Hierarchical clustering in a principal components approach was used to define cardiovascular phenotypes using clinical and echocardiographic parameters. Missing data were imputed., Findings: A total of 360 patients (median age 64 [55; 74]) were included in the analysis. Five different clusters were defined: patients well resuscitated (cluster 1, n = 61, 16.9%) without left ventricular (LV) systolic dysfunction, right ventricular (RV) failure or fluid responsiveness, patients with LV systolic dysfunction (cluster 2, n = 64, 17.7%), patients with hyperkinetic profile (cluster 3, n = 84, 23.3%), patients with RV failure (cluster 4, n = 81, 22.5%) and patients with persistent hypovolemia (cluster 5, n = 70, 19.4%). Day 7 mortality was 9.8%, 32.8%, 8.3%, 27.2%, and 23.2%, while ICU mortality was 21.3%, 50.0%, 23.8%, 42.0%, and 38.6% in clusters 1, 2, 3, 4, and 5, respectively (p < 0.001 for both)., Conclusion: Our clustering approach on a large population of septic shock patients, based on clinical and echocardiographic parameters, was able to characterize five different cardiovascular phenotypes. How this could help physicians to optimize hemodynamic support should be evaluated in the future.

Aims: There is a paucity of data regarding the changes of cardiac geometry in highly trained international and multiracial university athletes. We aimed to investigate the incidence of structural cardiac abnormalities and changes of cardiac geometry in highly trained university athletes., Methods and Results: Comprehensive echocardiographic studies were performed in 1185 university athletes through the Check-up Your Heart Program during the 2015 Gwangju Summer Universiade. Participants were divided into two groups: normal vs. abnormal left ventricular (LV) geometry (concentric remodelling, concentric hypertrophy, or eccentric hypertrophy). Structural heart diseases associated with sudden cardiac death were not identified, but minor structural cardiac abnormalities were common in university athletes. One hundred and fifty-six athletes (13.2%) had abnormal LV geometry; concentric remodelling (n = 73, 6.2%), concentric hypertrophy (n = 25, 2.1%), and eccentric hypertrophy (n = 58, 4.9%). Abnormal LV geometry was significantly more common in athletes of African descent and in endurance, mixed, or power disciplines. In multivariate logistic regression analysis, athletes of African descent [odds ratio (OR) 2.16, 95% confidence interval (CI) 1.34-3.46; P = 0.001], endurance disciplines (OR 1.79, 95% CI 1.26-2.54; P = 0.001), and training time (OR 1.01, 95% CI 1.00-1.02; P = 0.045) were independent predictors of abnormal LV geometry., Conclusion: A large scale cardiovascular screening programme of the 2015 Summer Universiade demonstrated that abnormal LV geometry is not uncommon (13.2%) and concentric remodelling is the most common pattern of LV geometric change in young trained university athletes. Race, type of sport, and training time are significant predictors of abnormal LV geometry. Structural cardiac abnormalities are common in university athletes even though they are minor abnormalities., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Hip fracture is a common reason for urgent inpatient surgery. In the past few years, several professional societies have identified preoperative echocardiography and stress testing for noncardiac surgeries as low-value diagnostics. We utilized data on hospitalizations with a primary diagnosis of hip fracture surgery between 2011 and 2015 from the State Inpatient Databases (SID) of Maryland, New Jersey, and Washington, combined with data on hospital characteristics from the American Hospital Association (AHA). We found that the rate of preoperative ischemic testing is surprisingly but encouragingly low (stress tests 1.1% and cardiac catheterizations 0.5%), which is consistent with studies evaluating the outpatient utilization of these tests for low-and intermediate-risk surgeries. The rate of echocardiograms was 12.6%, which was higher than other published reports. Our findings emphasize the importance of ensuring that quality improvement efforts are directed toward areas where quality improvement is, in fact, needed.

Objective: To compare the appropriateness and diagnostic yield of initial outpatient transthoracic echocardiography (TTE) between a community pediatric cardiology practice and an academic children's hospital., Study Design: Initial outpatient pediatric TTE ordered by pediatric cardiologists between January and March 2014 at a community practice (Packard Children's Health Alliance [PCHA]; n = 238) and an academic tertiary center (Lucile Packard Children's Hospital [LPCH]; n = 76) were evaluated based on appropriate use criteria (AUC) released in December 2014. Multivariate logistic regression was used to identify predictors of "rarely appropriate" indications and abnormal TTE findings., Results: Of 314 TTEs, 165 (52.5%) were classified as "appropriate," 40 (12.7%) were classified as "may be appropriate," 100 (31.9%) were classified as "rarely appropriate," and 9 (2.9%) were unclassifiable. The proportion of abnormal findings did not differ between the 2 practice settings (5.3% for LPCH vs 7.6% for PCHA; P = .61). TTEs performed at PCHA were significantly more likely to be "rarely appropriate" (OR, 2.57; 95% CI, 1.28-5.15; P = .008). Children aged <1 year (OR, 1.90; 95% CI, 1.03-3.50; P = .04) and ordering providers with <10 years since the completion of their fellowship (OR, 2.15; 95% CI, 1.20-3.87; P = .01) were associated with "rarely appropriate" indications. "Appropriate" TTEs were associated with abnormal findings (OR, 8.69; 95% CI, 1.77-42.68; P = .008)., Conclusion: The community practice was independently associated with greater inappropriate ordering of initial outpatient pediatric TTEs compared with the academic practice. The assessment of practice patterns following AUC release should account for physician and practice-related factors that could influence differences in TTE ordering patterns., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Appropriate use criteria (AUC) represent an important mechanism by which to promote the rational utilization of healthcare resources. No study to date has been conducted assessing the applicability of current AUC to transthoracic echocardiograms (TTEs) performed in a cardiac intensive care unit (CICU). We analyzed 2 years of consecutive TTEs performed in a CICU at a quaternary-care academic medical center, hypothesizing that current AUC may not adequately describe the role of TTE in a modern CICU., Methods: Indications for TTEs were independently classified by two investigators in accordance with 2011 AUC. If investigators were unable to assign an AUC classification to a given study, it was deemed to be unclassifiable. Disagreements between investigators were resolved by consensus. Cases in which consensus could not be reached underwent definitive adjudication by a third investigator., Results: Of the 826 TTEs, 619 TTEs were classified as appropriate (74.9%, CI 71.8%-77.9%), 12 as uncertain (1.5%, CI 0.75%-2.5%), 21 as rarely appropriate (2.5%, CI 1.6%-3.9%), and 174 were unable to be classified (21.1%, CI 18.3%-24.0%). The most common unclassifiable indication was "initial evaluation of cardiac structure or function after cardiac arrest of unknown etiology" (n = 101)., Conclusion: Current AUC for TTEs may not adequately address the complexity of clinical cases encountered in the CICU. In our study of 826 consecutive TTEs, 21.1% were unable to be classified, reflecting the difficulty in applying AUC to this unique clinical environment. Further studies are therefore needed to better delineate the appropriateness of TTEs performed in the CICU., (© 2019 Wiley Periodicals, Inc.)

Background: Coronary artery disease (CAD), a leading cause of mortality, affects patient health-related quality of life (HRQoL). Elective percutaneous coronary interventions (ePCIs) are usually performed to improve HRQoL of CAD patients. The aim of this study was to design models using admission data to predict the outcomes of the ePCI treatments on the patients' HRQoL., Methods: This prospective cohort study was conducted with CAD patients who underwent ePCIs at the King Abdullah University Hospital in Jordan from January 2014 through May 2015. Six months after their ePCI procedures, the participants completed the improved MacNew (QLMI-2) questionnaire, which was used for evaluating three domains (physical, emotional and social) of HRQoL. Multivariate linear regression was used to design models to predict the three domains of HRQoL from echocardiographic findings and clinical data that are routinely measured on admission., Results: The study included 239 patients who underwent ePCIs and responded to the QLMI-2 questionnaire. The mean age (± standard deviation) of the participants was 55.74 ± 11.84 years, 54.58 ± 11.37 years for males (n = 174) and 59.11 ± 12.49 years for females (n = 65). The average scores for physical, emotional and social HRQoL were 4.38 ± 1.27, 4.4 ± 1.11, and 4.37 ± 1.32, respectively. Out of the 42 factors inputted to the models to predict HRQoL scores, 10, 9, and 9 factors were found to be significant determinants for physical, emotional and social domains, respectively, with adjusted coefficients of determination of 0.630, 0.604 and 0.534, respectively. Basophil levels on admission showed a significant positive correlation with the three domains of HRQoL, while aortic root diameter showed a negative correlation. Scores for the three domains were significantly lower in women than in men. Hypertensive and diabetic patients had significantly lower HRQoL scores than patients without hypertension and diabetes., Conclusion: The prediction of HRQoL scores 6 months after an ePCI is possible based on data acquired on admission. The models developed here can be used as decision-making tools to guide physicians in identifying the efficacy of ePCIs for individual patients, hence decreasing the rate of inappropriate ePCIs and reducing costs and complications.

Quantification guidelines for pediatric echocardiograms were published in 2010 establishing consensus regarding standard measurements. However, a standard protocol for performance and analysis of pediatric echocardiograms was not defined. This study aims to identify practice variations among pediatric laboratories. A survey was sent to 85 North American pediatric laboratory directors. The survey included 29 questions assessing: demographics, methods of image acquisition, parameters routinely evaluated and reported, and methods used to assess chamber sizes, valves, and ventricular function. There were 47/85 (55%) responses; 83% were academic centers and 77% in an urban setting. Wide variations exist in acquisition method (clips versus sweeps) and color scale settings. The most commonly used methods for left ventricular (LV) function are M-mode shortening fraction, qualitative assessment, and Doppler Tissue Imaging. The most commonly used parameter for right ventricular function is qualitative. LV mass is routinely measured by the majority of centers with variations in methods of calculation. Conversely, while a minority measure left atrial volume, there is consensus regarding the preferred method. While multiple techniques exist for assessing valves, qualitative assessment is reported to be the preferred method. Despite quantification guidelines, there is a lack of uniformity in performance and analysis of pediatric echocardiograms. Further studies are needed to determine why variations exist and whether development of consensus guidelines might improve interpretation, consistency and quality of reports, patient care, and provide a standardized system allowing for comparative research among centers.

The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) classification, based on structural changes and symptoms, classifies stages of heart failure (HF) development as Stages A-D. This HF classification emphasizes the development and progression of the disease and can be used to describe individuals and populations. Since HF is considered a progressive disorder that can be represented as a clinical continuum, individuals at a particular HF stage require specific management with the long-term goal of avoiding HF development and progression. Although early detection of subclinical left ventricular (LV) dysfunction is essential for delaying progression to HF, the assessment of such dysfunction can be challenging. While echocardiography plays a pivotal role in the quantification and early detection of LV structural findings, two-dimensional speckle-tracking echocardiographic parameters, especially global longitudinal strain (GLS), have recently been reported to be sensitive markers of early subtle abnormalities of LV myocardial performance. They are thus helpful for prediction of outcomes for various cardiac diseases, and superior to conventional echocardiographic indices such as LV ejection fraction, mitral inflow E and mitral e' annular velocities ratio. Strain imaging, especially GLS-guided management for patients at a particular stage of HF, may therefore have the potential to prevent progression to later HF stages and may offer new insights into the management of HF patients. This article reviews the utility of strain imaging, especially GLS in conjunction with HF stage classification, and future perspectives for HF patient management.

Aims: To examine sex differences in clinical characteristics, echocardiographic features, quality of life and 1-year death or heart failure (HF) hospitalization outcomes in patients with/without diabetes mellitus (DM)., Methods and Results: Utilizing the Asian Sudden Cardiac Death in HF (ASIAN-HF) registry, 5255 patients (mean age 59.6 ± 13.1, 78% men) with symptomatic HF with reduced ejection fraction (HFrEF) were stratified by DM status to address the research aims. Despite similar prevalence of DM between Asian men (43%) and women (42%), the odds of DM increased at lower body mass index in women vs. men (≥ 23 vs. ≥ 27.5 kg/m 2 , P interaction  = 0.014). DM was more strongly related to chronic kidney disease in women vs. men [adjusted odds ratio (OR) 1.85, 95% confidence interval (CI) 1.33-2.57 vs. OR 1.32, 95% CI 1.11-1.56, P interaction  = 0.009]. Sex also modified the relationship between DM and left ventricular geometry (P interaction  = 0.003), whereby DM was associated with a more concentric left ventricular geometry in women than men. Women had lower quality of life than men (P < 0.001), in both DM and non-DM groups. DM was associated with worse composite outcomes at 1 year in women vs. men [hazard ratio (HR) 1.79, 95% CI 1.24-2.60 vs. HR 1.32, 95% CI 1.12-1.56; P interaction  = 0.005)., Conclusions: Asian women with HFrEF were more likely to have DM despite a lean body mass index, a greater burden of chronic kidney disease and more concentric left ventricular geometry, compared to men. Furthermore, DM confers worse quality of life, irrespective of sex, and a greater risk of adverse outcomes in women than men. These data underscore the need for sex-specific approaches to diabetes in patients with HF., (© 2018 The Authors. European Journal of Heart Failure © 2018 European Society of Cardiology.)

Background: In patients with hemodynamic instability echocardiography has been recommended as the preferred modality to evaluate the underlying pathophysiology. However, due to the fact that recent scientific data on the utilization of echocardiography in German Intensive Care Units (ICU) are scarce, we sought to investigate current practice., Methods: A structured, web-based, anonymized survey was performed from May until July 2015 among members of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) consisting of 14 questions. Descriptive data analysis was performed., Results: One hundred four intensivists participated in the survey. Two-thirds of participants (66%) used echocardiography regularly for hemodynamic monitoring and stated that it changed the therapy in 26-50% of the cases irrespective of the time performed after ordering the examination. Transthoracic (TTE) were more frequently used than transesophageal (TEE) examinations. Twenty-six percent of the participants held an echocardiography certificate with a formal examination, 27% completed a structured training without an examination and almost half of the questioned ICU personnel (47%) did not complete a comprehensive training., Conclusions: The results of this survey demonstrate a widespread utilization of echocardiography as part of routine diagnostic on frequent number of operative ICUs. However, there might be a lack of structured echocardiographic training especially for anesthesiologists.

There are few data on the incidence of echocardiographic (echo) abnormalities following catheter ablation in children in the era of 3D mapping. Wide practice variation exists regarding routine post-ablation echo. We hypothesized a low incidence of clinically significant echo abnormalities following SVT ablation in otherwise healthy children. Single center data from 2009 to 2015 were reviewed; routine post-ablation echo was standard practice. Cases were categorized as utilizing fluoroscopy alone (FLUORO) or 3D mapping with a low fluoroscopic protocol (CARTO3). Congenital heart disease was excluded. Outcomes of interest included new valvular abnormalities, pericardial effusions, and wall motion abnormalities. Findings were compared to baseline studies when available and classified as normal/unchanged, clinically insignificant, or clinically significant. Outcomes were compared between FLUORO and CARTO3 groups. Of 347 ablations, 319 (92%) underwent post-procedural echo: 57% male; 55% FLUORO; mean age 13.4 ± 3.6 years. The most common ablation target was an accessory pathway (AP) in 66% (n = 144 WPW, 66 concealed), followed by AVNRT in 32% (n = 102). Radiofrequency (RF) energy was utilized in 82% (n = 262). Post-ablation echos were normal in 81% (n = 259). Clinically insignificant findings were seen in 18% (n = 58), most commonly trivial-small pericardial effusions in 11% (n = 34). Two significant findings required additional follow-up or treatment. There were no cases of wall motion abnormalities or clinically significant effusions. There were no differences in frequency of echo abnormalities between the FLUORO and CARTO3 groups. Clinically significant echocardiographic abnormalities are rare following SVT ablation in children with structurally normal hearts, independent of the use of 3D mapping.

Echocardiography and cardiac biomarkers, such as cardiac troponin I (cTnI) and N-terminal pro-B-type natriuretic peptide (NT-pro BNP) are useful tools to evaluate cardiac dysfunction. Left ventricular systolic dysfunction (LVSD) is common in pediatric severe sepsis. The aim of this study is to evaluate the prognostic value of LVSD, cTnI, and NT-pro BNP for pediatric severe sepsis.A prospective, single center, observational study was conducted. Severe sepsis children were enrolled in the study from December 2015 to December 2016 in pediatric intensive care unit of Shanghai Children's Medical Center. Recorded general information, transthoracic echocardiography were performed at day 1, 2, 3, 7, and 10, using Simpson to measure left ventricular end-diastolic dimension and left ventricular end-systolic dimension, obtained echocardiography parameters: left ventricular ejection fraction (LVEF), left ventricular fractional shortening, left ventricular end-diastolic volume, left ventricular end- systolic volume, stroke volume, cardiac output. At the same time collecting the blood sample to measure cTnI, NT-pro BNP. The definition of LVSD was LVEF <50%. According to the prognosis of 28 days, children with severe sepsis were divided into survived group and nonsurvived group.Total of 50 pediatric patients who were diagnosed with severe sepsis (including septic shock) were enrolled, the incidence of LVSD was 52%. The 28-day mortality rate of severe sepsis was 34%. Multivariate logistic regression analyses for predictors of death in pediatric severe sepsis revealed that the 28-day mortality of severe sepsis was associated with mechanical ventilation (MV) within the first 6 hours of admission (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.00-0.07) and total MV time (OR, 0.81; 95% CI, 0.68-0.97). The receiver operating characteristic curves LVEF (area under curve = 0.526), cTnI (area under curve = 0.480), and NT-pro BNP (area under curve = 0.624) were used to predict the 28-day mortality in pediatric severe sepsis. Follow-up echocardiography parameters for survived group and nonsurvived group showed no significant changes in LVEF, LVFS, stroke volume index, cardiac index (CI), left ventricular end-diastolic volume index and left ventricular end-systolic volume index at day 1, 2, 3, 7, and 10, except for CI at day 1 and 2. Kaplan-Meier plot of 28-day mortality and LVSD in pediatric severe sepsis showed there were no statistical differences (χ = 0.042, P = .837).LVSD occurs frequently in pediatric with severe sepsis. The 28-day mortality rate of severe sepsis was also high. In this study, none of LVSD, cTnI, and NT-proBNP was associated with the prognosis of pediatric severe sepsis.

Introduction: The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. Very few studies have assessed how medical centers overseas perform against AUC. Evidence is now emerging that inappropriate referral rates in Europe are similar to those reported in the US., Objective: This study systematically reviewed published evidence to identify (1) whether the 2011 AUC are applicable to medical centers outside the US (2) the level of adherence to the AUC across multiple centers, (3) the main factors which cause deviation from AUC, (4) any changes in referral rates since the publication of AUC, and (5) any factors and/or intervention strategies which promote adherence to AUC., Methods and Results: Electronic databases were systematically searched for papers related to AUC and cardiac imaging. Following screening and application of eligibility criteria, data was extracted from ten reports involving 8561 TTE studies. Classification rates were 99.5 and 98% for US studies and studies outside the US respectively. Overall, 7119 TTE studies were classified as appropriate (83.1%) of which 3724 were US referrals (84.7%) and 3395 originated outside the US (81.5%). Six of the included studies independently observed significantly more appropriate referrals among inpatients compared to outpatients (p < 0.001). US centers observed no significant difference in appropriate referral rates between physician specialties while one UK study showed cardiac surgeons ordered inappropriate TTEs more frequently than other specialties (p < 0.05). This review found no obvious trend in appropriate referral rates between 2012 and 2015 indicating no temporal change in physician ordering patterns. Only one educational interventional study met the author's criteria which showed that while intervention was effective during its implantation (26% reduction in TTEs ordered per day), TTE referral rates regressed to pre-intervention levels overtime., Conclusions: In conclusion, the American guideline AUC are applicable to centers outside the US and their implementation across five international centers suggest almost 1 in 5 scans could be avoided.

Objectives: To evaluate the association between high estimated pulmonary artery systolic pressure (ePASP) obtained by echocardiography and 1-year mortality in patients with acute heart failure (HF), comparing findings in individuals aged 80 and older with those of individuals younger than 80., Design: Retrospective cohort study., Setting: Kyorin University Hospital., Participants: Individuals with acute decompensated HF (N = 335)., Measurements: High ePASP was defined as a tricuspid regurgitation pressure gradient greater than 47 mmHg (ePASP >50 mmHg). Potential risk factors for 1-year mortality were selected using univariate analysis followed by multivariate Cox regression analysis with backward stepwise selection of variables with P < .10 on univariate analysis to identify significant factors., Results: In individuals aged 80 and older, high ePASP (hazard ratio (HR)=3.07; 95% confidence interval (CI)=1.21-7.80), discharge medications without diuretics (HR=4.18, 95% CI=1.66-10.54), and discharge medications without renin-angiotensin-aldosterone system inhibitors (HR=3.38, 95% CI=1.29-8.81) were independent risk factors for 1-year mortality. In contrast, low systolic blood pressure at admission was the sole independent risk factor for 1-year mortality (HR=0.94, 95% CI=0.89-0.99) in those younger than 80., Conclusion: High ePASP is a significant predictor of 1-year mortality in individuals aged 80 and older with acute HF but not in those younger than 80. Elucidation of the pathophysiological mechanisms behind these findings should facilitate the development of more effective individualized therapies for older adults with acute HF. J Am Geriatr Soc 67:323-328, 2019., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Purpose: We sought to assess the trends in use, predictors of echocardiography, and its impact on in-hospital mortality in patients admitted with syncope using a large national database., Methods: Utilizing the Nationwide Inpatient Sample (NIS) database from 2001 to 2014, we identified adult patients (>18 years) with a primary discharge diagnosis of syncope and use of echocardiogram was ascertained., Results: A total of 3 174 619 patients with a primary discharge diagnosis of syncope were identified, of which 184 167 (5.8%) underwent an echocardiogram. The rate of syncope hospitalization remained constant between 2001 and 2009 (1.1/1000 US population) but has since decreased steadily to about 0.5/1000 US population in 2014. After adjusting for patient and hospital characteristics, the rate of echocardiogram use increased significantly from 5.1% in 2001 to 6.8% in 2014 (2.7% relative increase per year [P trend  = 0.024]). Predictors of use were cardiac disorders, hypertension, diabetes, peripheral vascular disease, and renal failure. After adjusting for baseline risk, use of echocardiography was not associated with in-hospital mortality (OR = 0.827, P = 0.155), but was associated with a 14.6% increase in adjusted length of stay and a 22.6% increase in adjusted hospital cost compared to no echocardiography use (both P < 0.001)., Conclusions: The admission rates for syncope are decreasing and use of echocardiography in hospitalized patients with syncope is appropriately low. Given the lack of any favorable impact on mortality and the association with increased costs, there is a continued need to emphasize evidence-based use of echocardiography in patients presenting with syncope., (© 2018 Wiley Periodicals, Inc.)

H63D has been identified as a novel locus associated with the development of hypertension. The quantitative risks for hypertension, cardiac remodeling, and adverse events are not well studied. We analyzed white participants from the ARIC study (Atherosclerosis Risk in Communities) with H63D genotyping (N=10 902). We related genotype status to prevalence of hypertension at each of 5 study visits and risk for adverse cardiovascular events. Among visit 5 participants (N=4507), we related genotype status to echocardiographic features. Frequencies of wild type (WT)/WT, H63D/WT, and H63D/H63D were 73%, 24.6%, and 2.4%. The average age at baseline was 54.9±5.7 years and 47% were men. Participants carrying the H63D variant had higher systolic blood pressure ( P=0.004), diastolic blood pressure (0.012), and more frequently had hypertension ( P<0.001). Compared with WT/WT, H63D/WT and H63D/H63D participants had a 2% to 4% and 4% to 7% absolute increase in hypertension risk at each visit, respectively. The population attributable risk of H63D for hypertension among individuals aged 45 to 64 was 3.2% (95% CI, 1.3-5.1%) and 1.3% (95% CI, 0.0-2.4%) among individuals >65 years. After 25 years of follow-up, there was no relationship between genotype status and any outcome ( P>0.05). H63D/WT and H63D/H63D genotypes were associated with small differences in cardiac remodeling. In conclusion, the HFE H63D variant confers an increased risk for hypertension per allele and, given its frequency, accounts for a significant number of cases of hypertension. However, there was no increased risk for adverse cardiovascular events or substantial left ventricular remodeling.

The objective of this study is to investigate the sensitivity of contrast-enhanced transthoracic echocardiography (c-TTE) versus transesophageal echocardiography (TEE) to detect a residual right-to-left shunt (RLS) following a transcatheter patent foramen ovale (PFO) closure.A self-controlled study was conducted in a tertiary referral hospital. 57 patients with PFO who had experienced migraines underwent percutaneous PFO closure. c-TTE, TEE, and contrast-enhanced transcranial Doppler (c-TCD) at resting and Valsalva maneuver were performed during the 3-month follow-up after the closure.The closure devices were successfully implanted in all patients without complications. Three months after closure, TEE did not detect residual Valsalva shunts in any of the 57 patients; residual valsalva shunts were found via c-TTE in 15 of the 57 patients and were also observed via c-TCD. When c-TTE and/or c-TCD were used, the rate of residual RLSs detected in patients who underwent PFO closure was 26.32%, which was significantly different than the rate detected using TEE (P < .05)c-TTE and c-TCD showed equivalent sensitivity in evaluating transcatheter closure of a PFO. c-TTE could be a more cost-effective and reliable method to detect the residual shunt after PFO closure.

Background: The role of exercise echocardiography (ExE) for the assessment of patients with dyspnea is promising. We aimed to analyze the clinical characteristics and outcome of patients with this condition referred for ExE., Methods: A total of 505 patients (66 ± 11 years, 57% women) referred for evaluation of dyspnea were considered. Mitral regurgitation, ratio of early left ventricular inflow wave to early diastolic annulus wave (E/e'), and wall motion abnormalities (WMAs) were measured at rest and at exercise. Considered events were overall mortality, non-fatal myocardial infarction, late revascularization, and admission for heart failure., Results: Ischemia was observed in 102 patients (20%), whereas WMAs were already present at rest in 55 patients (11%). A percent achieved of predicted metabolic equivalents >100% was found for most of the patients (70%). During a median follow-up of 3.50 years, 66 patients had events (annualized event rate 3.5%). An E/e' value of 13 at post-exercise was the best cut-off value to predict events. After adjustment by clinical and ExE variables, the combination of an abnormal ExE and E/e' values at post-exercise ≥13 was an independent predictor of events (hazard ratio = 3.67, 95% confidence interval = 2.11-6.38, p < 0.001). The worse outcome corresponded to patients with abnormal ExE and raised E/e' values at post-exercise (annualized event rate 17.2%). Patients with normal E/e' values at post-exercise had better outcome irrespective of the ExE results (annualized event rate 2.2% with normal ExE and 2.9% with abnormal ExE), whereas patients with high E/e' values at post-exercise but normal ExE results were at intermediate risk (annualized event rate 5.0%)., Conclusions: Despite favorable ExE results, event rate remains high among patients with dyspnea referred for ExE, which may have a role to predict outcome in this setting. Patients with both raised E/e' values at post-exercise and abnormal ExE results are at the highest event risk., (Copyright © 2018 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Introduction: Echocardiography is an important tool for diagnosis of cardiac abnormalities that can impact the management and outcome of the sick newborn in the intensive care unit. A preliminary echocardiogram performed by the neonatologist under the supervision of a paediatric cardiologist for interpretation and review is an alternate when there is not a cardiologist on site. The aim of this study was to evaluate frequency of use, neonatal characteristics, and indications of neonatologist-performed echocardiography in a Tertiary Neonatal Care Centre in Tunisia., Methods: Prospective observational study in a tertiary Neonatal Intensive Care Unit (NICU) in Monastir (Tunisia) from April 2015 to February 2017.An echocardiography was indicated in these situations: cyanosis, signs of circulatory shock, clinical signs of heart failure, presence of a murmur, arrhythmia, and abnormal pulses in upper and/or lower extremities, suspected persistent pulmonary hypertension in neonates, clinically suspected patent ductus arteriosus, maternal diabetes mellitus and polymalformative syndrome. The findings of echocardiography were confirmed by pediatric cardiologist in case of structural or functional cardiac abnormalities., Results: 675 echocardiography were performed among them 535 were normal and 25 revealed a persistent arterial duct treated with E2 postaglandins (Prostine®) or paracetamol according to a pre-established protocol. 80 Congenital heart diseases were retained, which represented an incidence of 7 ‰ live births. The second time of our work consisted to study the 55 cases of cardiac diseases confirmed after exclusion of atrial communication. The antenatal diagnosis was made in 11% of cases. The main signs indicating the echocardiogram were the heart murmur (22 cases) followed by cyanosis (6 cases). A malformation association and / or a chromosomal aberration have been noted in 36% of cases. For half of the patients, the cardiac ultrasound was performed before the first 24 hours of life. This examination was completed by a thoracic angioscan in 9 patients. 31% of newborns had an infusion of Prostaglandins for an average duration of 11 days [2-60 days]. One-third of newborns (35 cases) required respiratory assistance. A palliative surgery was made in 7 cases and curative one in 4 cases. The average age at the time of the intervention was 20 days. The neonatal mortality rate was 40%., Conclusion: Echocardiography is being utilized progressively on the neonatal unit, and has been indicated to have a high return for both structural and functional cardiac abnormalities. It is important to encourage collaboration with pediatric cardiologists to establish standards for training and to develop guidelines for clinical practice in order to improve neonatal care.

Objective: We investigated whether echocardiography may help identify, among patients admitted with a suspect of non-ST-segment elevation acute myocardial infarction (NSTEMI), those with athero-thrombotic coronary artery disease (CAD)., Patients and Methods: We studied consecutive patients admitted with a clinical suspect of first NSTEMI. Echocardiography was assessed within 24 hours from admission. Patients were divided into two groups, according to the results of coronary angiography: 1) patients with obstructive stenosis (≥ 50%) and/or images of thrombosis in one or more coronary arteries (CAD group); 2) patients with no evidence of obstructive coronary arteries (NOCAD group)., Results: Of 101 patients enrolled in the study, 53 (52.5%) showed obstructive CAD and 48 (47.5%) NOCAD. At echocardiographic examination, regional wall motion abnormalities were found in 52.8% of patients in the CAD group and 43.7% in the NOCAD group (p=0.43). Left ventricle ejection fraction was 56.4±6.8 vs. 54.7±9.8% (p=0.30) and wall motion score index was 1.16±0.26 vs. 1.21±0.32 (p=0.39) in the two groups, respectively. A multivariable logistic regression independent predictors of obstructive CAD included age, male gender, typical angina, diabetes and hypertension., Conclusions: Our data showed that, in patients with acute chest pain and increased serum troponin T concentration, routine standard echocardiography does not significantly improve the diagnostic accuracy for the presence of obstructive CAD.