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Background The aim of this study was to assess the usefulness of a new miniaturized echocardiographic system (MS) to perform bedside echocardiography in initial outpatient cardiology consultations, in addition to physical examination. Methods One hundred eighty-nine patients referred for initial cardiology outpatient consultations at two tertiary hospitals in two countries were studied. Each patient was submitted to physical examination followed by MS assessment. Scanning time, the number of examinations with abnormal results after physical examination and the MS, and the information obtained by physical examination alone and followed by the MS (in terms of its importance in reaching a diagnosis, in the necessity of performing routine echocardiography, and in the decision to release the patient from the outpatient clinic) were assessed. Results The scanning time with the MS was 180 ± 86 seconds. Its use after physical examination led to diagnoses in 141 patients (74.6%) and to an additional 37 patients (19.6%) being released from the outpatient clinic. After physical examination followed by MS assessment, only 64 patients (33.9%) were sent to the echocardiography lab. The MS modified the decision of whether to send a patient to the echocardiography lab, with referral determined by the MS in 27 patients (14.3%) and no referral determined by the MS in 58 patients (30.7%). Conclusions The new MS caused a negligible increase in the duration of consultations. It showed additive clinical value over physical examination, increasing the number of diagnoses, reducing the use of unnecessary routine echocardiography, increasing the number of adequate echocardiographic studies, and determining a large number of releases from the outpatient clinic.

Introduccion y objetivos. El desarrollo de disfuncion ventricular izquierda tras la sustitucion valvular mitral es un problema frecuente en pacientes con insuficiencia mitral grave cronica. El analisis de la deformacion miocardica permite estimar con precision la contractilidad miocardica. Nuestro objetivo fue comparar el valor predictivo de strain (S) y strain rate (SR) preoperatorios obtenidos por speckle-tracking y Doppler tisular (DTI) para predecir la disminucion de la fraccion de eyeccion del ventriculo izquierdo (FEVI) a medio plazo tras la cirugia. Metodos. Treinta y ocho pacientes consecutivos con insuficiencia mitral grave cronica programados para sustitucion valvular mitral fueron incluidos prospectivamente. Se analizo el S y el SR longitudinal del septo interventricular en el periodo preoperatorio mediante speckle-tracking y DTI. La FEVI preoperatoria y postoperatoria se obtuvo por ecocardiografia tridimensional. Los estudios ecocardiograficos se realizaron dentro de las 48 h previas a la cirugia y 6 meses despues de la cirugia. Resultados. La media de edad de los pacientes era 59,9 ± 11,3 anos; 10 pacientes (29,4%) eran varones. Tanto el speckle-tracking como el DTI resultaron predictores de disminucion de la FEVI > 10% a 6 meses. Sin embargo, el valor predictivo del speckle-tracking fue superior al del DTI. El S longitudinal del septo interventricular basal mediante speckle-tracking fue el parametro con mayor poder predictivo, con un area bajo la curva de 0,85 y un punto de corte optimo de -0,11. Conclusiones. El speckle-tracking permite predecir la disminucion de la FEVI a medio plazo tras la sustitucion valvular mitral. Ademas, el speckle-tracking es mas preciso que el DTI para este fin.

BACKGROUND Segmental analysis in mitral prolapse is important to decide the chances of valvular repair. Multiplane transesophageal echocardiography (TEE) is the only echocardiographic tool validated for this aim hitherto. The aim of the study was to assess if segmental analysis can be performed with transthoracic real-time 3-dimensional (3D) echocardiography as accurately as with TEE, hence representing a valid alternative to TEE. METHODS Forty-one consecutive patients diagnosed with mitral prolapse underwent TEE and a complete 3D echocardiography study, including parasternal and apical real-time; apical full-volume; and 3D color full-volume. Investigators performing TEE were blinded to the 3D results. RESULTS Three-dimensional echocardiogram was feasible in 40 to 41 patients (97.7%). Ages ranged from 15 to 92 years, and all possible anatomical patterns of prolapse were represented. Thirty-seven patients (90.2%) had mitral regurgitation of any degree. The level of agreement was k = 0.93 (P < or = .0001), sensitivity of 96.7%, specificity of 96.7%, likelihood ratio for a positive result of 29.0%, and likelihood ratio for a negative result of 0.03%. Four false positives were found, corresponding to scallops A2 (1), A3 (2), and P3 (1). Four false negatives were found, corresponding to scallops A1 (2) and P1 (2). Sensitivity and specificity in the scallop P2 were 100%. CONCLUSION Segmental analysis in mitral prolapse can be performed with transthoracic real-time 3D echocardiography as accurately as with TEE. False negatives tend to appear around the anterolateral commissure, whereas false positives tend to appear around the posteromedial commissure. Highest accuracy was reached in central scallops.

Aim: Myocardial performance index (MPI) is usually measured with pulsed wave Doppler (PWD). Our aim was to assess the degree of agreement be- tween PWD and a method based on tissue Doppler imaging (TDI). Methods and results: Seventy-five patients with prior myocardial infarction and 20 healthy subjects underwent measurement of time intervals and MPI with PWD and pulsed TDI at septal and lateral sides of mitral annulus. MPI and TDI-MPI at septal side showed the best intraclass correlation coefficient (ICC Z 0.54; p ! 0.0005). Ninety-five percent interval of agreement ranged from 0.27 to 0.22. These differ- ences were attributed to discrepancies in isovolumic contraction and relaxation times. In the healthy group the results were similar (ICC Z 0.44), although the 95% interval of agreement was lower (from 0.13 to 0.12). Conclusions: The agreement between PWD and TDI in the measurement of MPI is only moderate. This should be taken into account in the interpretation of studies

Objectives We sought to evaluate the prognostic significance of left ventricular (LV) transient ischemic dilation (TID) for patients with a positive stress echocardiogram (SE). Background TID during SE has been related to the presence of extensive coronary artery disease, but its long-term prognostic implications have not been reported. Methods In all, 99 consecutive patients with a positive SE comprised the study group. LV volumes were evaluated according to the modified Simpson's rule. TID during SE was defined as the presence of an increase in LV end-diastolic volume during the stress test. A clinical history was fulfilled for each patient and all of them were followed up. Results Of 99 patients, 32 (32.3%) showed TID. Mean age was 65.8 ± 9.8 years for non-TID group and 70.2 ± 8.4 for TID group ( P = .048). Baseline characteristics and subsequent treatment were similar in both groups. Mean follow-up was 21.4 ± 15.8 months. In non-TID group the mean survival free of acute myocardial infarction was 47.28 months and 39.7 months in TID group (log rank=0.012). In the univariate and multivariate analysis only TID and the wall motion score index were found as independent predictors related to long-term prognosis (risk ratio=6.9; 95% confidence interval=0.8-59.6; P = .042; and risk ratio=0.4; 95% confidence interval=0.18-0.89; P = .047, respectively). Conclusions LV TID during SE is an easy and independent prognostic marker. It helps to select patients with increased risk.

Background and objectives: In addition to the myocardium, the microvasculature may be also damaged in acute myocardial infarction. The aim was to evaluate the capability of myocardial contrast echocardiography in the detection of microvasculature damage after myocardial infarction. Patients and methods: Twelve patients with recent acute myocardial infarction and five control subjects with normal coronary arteries and without history of myocardial infarction were studied. Myocardial contrast echocardiography with power modulation was performed, and quantitative data were measured off-line. Power modulation uses a combination of low (0.1) and high (1.7) mechanical indexes, allowing a real-time evaluation of myocardial perfusion. Contrast agent was administered as a 3-min bolus. The quantitative analysis was performed off-line by a different blinded investigator. The refilling velocity was calculated as the difference between the peak myocardial refilling value and the value at 1 s after the impulse divided by the time from the first second after the impulse to the peak refilling value. Results: Eighty-one myocardial segments (75%) were analysed qualitatively and quantitatively in AMI patients, and 18 (60%) in control subjects (P=NS). The peak refilling intensity was not significantly different in patients and control subjects (6.62±5.85 vs. 7.53±4.06 dB, respectively). However, time to peak refilling intensity was significantly longer (5.25±1.57 vs. 4.00±0.53, P=0.004) and the velocity of refilling was significantly lower (2.74±5.34 vs. 6.58±8.02, P=0.028) in patients with myocardial infarction. Conclusion: There is microvasculature damage after myocardial infarction that is reflected as a delayed velocity of refilling in myocardial contrast echocardiography.

The development of new contrast agents and new imaging methods has lead to an emerging field of applications for myocardial contrast echocardiography (MCE) in patients suffering from chronic ischemic heart disease. Echo contrast allows the assessment of myocardial perfusion (MP) by imaging the coronary microcirculation. Several echocardiographic modalities are available, the main difference between them being the acoustic power needed to perform the study. MP is evaluated by assessing the changes in myocardial videointensity that occur after intravenous contrast injection. Evaluation of these patients is performed by using different techniques. Evaluation of coronary stenosis may be performed by using stress tests or without its use. Coronary artery stenosis50% of the coronary luminal diameter reveals a decreased hyperemic response when myocardial oxygen demand is increased. Different methods to evaluate the presence of relevant coronary stenosis have been developed: evaluation of myocardial blood flow reserve, evaluation of myocardial blood volume, and evaluation of the transmural distribution of myocardial blood flow. The combination of wall motion analysis with MCE assessment has been demonstrated to achieve the best balance between sensitivity (86%) and specificity (88%), with the highest accuracy (86%). Without the need of any stress, the ratio systolic/diastolic myocardial blood volume has been described to increase with the presence of a epicardial coronary stenosis and it may be measured by MCE. Myocardial viability is also one of the potentials of MCE. Microvascular integrity, demonstrated by MCE, is an indicator of preserved viability and predicts functional recovery that has been validated in the setting of chronic left ventricular dysfunction secondary to chronic coronary artery disease and in the setting of post acute myocardial infarction left ventricular dysfunction.contrast echocardiography provides an interesting tool that offers the potential of a complete evaluation of patients with chronic coronary artery disease. This includes both diagnostic and prognostic evaluation.

Introduction and objectives. Chronic liver disease increases the susceptibility to bacterial infections and infective endocarditis. Our aim was to determine the clinical and microbiological features and the prognosis in patients with chronic liver disease who also had infective endocarditis. Patients and method. One hundred and seventy-four consecutive inpatients at our institution were recruited and followed. Thirty of them had chronic liver disease. Clinical, microbiological and echocardiographic variables were analyzed and, in some cases, histological variables were also recorded. Results. Patients with chronic liver disease were younger (36 ± 11 vs 54 ± 18 years; p < 0.01) and had a larger proportion of intravenous drug users (73 vs 16%; p < 0.01), HIV infection (47 vs 10%; p < 0.01), right valve involvement and spleen enlargement, but heart failure appeared less often (7 vs 34%; p = 0.003). Thirty percent of the patients with and 51% of patients without chronic liver disease underwent surgery for infective endocarditis. Total mortality among patients with and without chronic liver disease was 40% and 31%, respectively. After adjustment for age and for the incidence of congestive heart failure, chronic liver disease doubled mid-term mortality with a RR = 2.45 (p = 0.015). Conclusions. Chronic liver disease has a significant impact on the prognosis in patients with infective endocarditis, and these patients should therefore be considered a high risk group.

Aims: The microvasculature damage after myocardial infarction has important implications. The hypothesis of the study was that wall motion abnormalities and microcirculation status do not necessarily match after myocardial infarction, and therefore the study of only myocardial wall motion could offer an incomplete evaluation in these patients. Methods: Wall motion and myocardial perfusion assessed by contrast echocardiography were evaluated by two different blinded investigators in 29 patients with recent (

Aim: Interobserver variability is an important limitation of the stress echocardiography and depends on the echocardiographer training. Our aim was to evaluate if the use of contrast agents during dipyridamole stress echocardiography would improve the agreement between an experienced and a non-experienced observer in stress echo and therefore if contrast would affect the learning period of dypyridamole stress echo. Methods and results: Two independent observers without knowledge of any patient data interpreted all stress studies. One observer was an experienced one and the other had experience in echocardiography but not in stress echo. Two observers analysed 87 non-selected and consecutive studies. Out of the 87 studies, 46 were performed without contrast administration, whereas i.v. contrast (2.5 g Levovist® by two bolus at rest and at peak stress) was administered in 41. In all cases, second harmonic imaging and stress digitalisation pack was used. The agreement between observers showed a κ index of 0.58 and 0.83 without and with contrast administration, respectively. Conclusions: The use of contrast agents provides a better agreement in the evaluation of stress echo between an experienced and a non-experienced observer in stress echo. Adding routinely contrast agents could probably reduce the number of exams required for the necessary learning curve in stress echocardiography.

Introduction and objectives The development of left ventricular dysfunction after mitral valve replacement is a common problem in patients with chronic severe mitral regurgitation. Assessment of myocardial deformation enables myocardial contractility to be accurately estimated. Our aim was to compare the value of the preoperative strain and strain rate derived by either speckle-tracking echocardiography or tissue Doppler imaging (TDI) for predicting the medium-term decrease in left ventricular ejection fraction (LVEF) following surgery. Methods This prospective study involved 38 consecutive patients with chronic severe mitral regurgitation who were scheduled for mitral valve replacement. The longitudinal strain and strain rate in the interventricular septum were measured preoperatively using speckle-tracking echocardiography and TDI. The LVEF was determined preoperatively and postoperatively using 3-dimensional echocardiography. Echocardiographic assessments were performed in the 48 hours prior to surgery and 6 months postoperatively. Results The patients’ mean age was 59.9±11.3 years and 10 (29.4%) were male. Both speckle-tracking echocardiography and TDI were found to be predictors of a >10% decrease in LVEF at 6 months. However, the predictive value of speckle-tracking echocardiography was greater than that of TDI. The longitudinal strain at baseline in the interventricular septum as measured by speckle-tracking echocardiography was the most powerful predictor; the area under the curve was 0.85 and the optimal cut-off value was –0.11. Conclusions Speckle-tracking echocardiography can be used to predict a decrease in LVEF over the medium term after mitral valve replacement. Moreover, the predictive accuracy of speckle-tracking echocardiography was greater than that of TDI.

The study aim was to analyze the mid-term prognosis of infective endocarditis (IE) in patients managed with medical therapy during the in-hospital phase and who had a good initial outcome. Comparison was made with the prognosis of patients treated surgically during this period.A total of 151 patients diagnosed with IE was studied, and in-hospital outcome, clinical characteristics and mid-term follow up data were analyzed. The main end-point was a composite of death and need for surgical repair.Among 151 patients, 84 (56%) underwent surgery or died during the in-hospital phase, while 67 patients (44%) received medical treatment and were discharged clinically stable with a final diagnosis of healed infective endocarditis. A better baseline profile was seen in the medically treated group, but outcome in this group showed extensive mid-term morbidity/mortality. In total, 52.2% of patients underwent surgery to correct complications and 60% died as a consequence of the disease. The event-free survival rate was 20% at five years.Despite a favorable in-hospital clinical course and successful medical treatment, patients with IE are at risk of late complications that result in a need for surgical repair, or in death. A close follow up should be made in order to treat late complications.

Aims Mitral regurgitation (MR) following an acute myocardial infarction (AMI) confers an adverse prognosis during long-term follow-up. There are no studies evaluating the influence of pre-AMI MR in the short- and long-term prognosis of such patients. Our aim was to assess the prognostic value of pre-AMI MR in the short- and long-term follow-up of patients who suffered a first AMI and to assess its influence on left ventricular haemodynamics. Methods and results Sixty-eight consecutive patients with a first AMI and an echocardiographic study before AMI (

Higher morbidity and mortality have been attributed to patients suffering endocarditis but with negative blood cultures. The study aim was to determine whether, in the present era of routine echocardiography, patients with negative-culture endocarditis had a worse short- and long-term outcome, and whether outcomes in patients with true negative and aborted positive blood cultures were different.When endocarditis was clinically suspected, an early (24 h) echocardiographic examination was performed in all patients, regardless of blood culture results. In total, 151 patients diagnosed with infective endocarditis (IE) comprised the study group. Among these patients, 40 (26%) had negative blood cultures, and 28 of this subgroup (70%) had received previous antibiotic therapy. Short- and long-term features and prognosis were compared between both groups. The combined main end-point was death or need for surgical repair.Similar anatomic and clinical characteristics were present among those patients with positive and negative cultures. In addition, mortality and need for surgery with regard to short- and long-term follow up of both groups was similar. There were no significant differences between patients with true- or aborted-negative cultures in terms of short- and long-term prognosis.No differences in short- and long-term prognosis were seen among patients with IE and positive versus negative blood cultures. The prognosis was also similar between those with true negative culture versus aborted negative cultures. Early echocardiography in patients with clinically suspected IE may have changed the outcome in patients with negative cultures.

Background: Doppler Tissue Imaging (DTI) has been evaluated in ischaemic heart disease and some cardiomyopathies. In patients with aortic stenosis (AS), left ventricular contraction is slowered. This study aimed to evaluate the possible role of the measurement of isovolumic contraction time (ICT) by DTI in the evaluation of AS severity. Methods: The study population constitutes 30 patients: 15 with AS (nine severe and six non-severe) and 15 control subjects. All of them had normal systolic function, sinus rhythm, and absence of ischaemic heart disease of conduction abnormalities. ICT was defined as the time from the onset of the QRS complex to the beginning of the DTI systolic wave. The correlation between ICT and aortic area obtained by continuity equation, as well as the diagnostic value of ICT in the identification of severe AS were studied. Results: ICT was significantly increased in patients with severe AS (98 � 27 versus 65 � 21 ms, p ¼ 0:024). There was a significant correlation between ICT and aortic area (r ¼� 0:56; p ¼ 0:035). The receiver operator characteristic curve of ICT in the identification of severe AS yielded an area under the curve of 0.852 (95% confidence interval: 0.665–1.0). The two best cut-points were [73 ms (88% sensitivity, 77% specificity) and [85 ms (78% sensitivity, 83% specificity). A value of[41 ms had a 100% sensitivity, but only a 17% specificity, and [91 ms showed a 100% specificity, but only a 44% sensitivity. Conclusions: ICT measured by pulsed-wave DTI is increased in patients with aortic stenosis. (Eur J Echocardiography 2003; 4: 279–285) 2003 Published by Elsevier Ltd on behalf of The European Society of Cardiology.

High morbidity and mortality are attributed to patients with culture-negative endocarditis. The main reason for negative blood culture in infectious endocarditis (IE) is administration of antibiotics before sample withdrawal. The study aim was to determine any difference in prognosis between patients with 'aborted' culture-negative endocarditis (A-CNE) and those with true culture-negative endocarditis (T-CNE).A total of 107 patients with a diagnosis of IE was studied retrospectively. Diagnosis was confirmed pathologically during surgery, at post-mortem examination, or by fulfillment of Duke's criteria. Twenty patients (18.7%) had negative-culture endocarditis and comprised the study population. Of these patients, 14 (70%) had received previous antibiotic therapy (A-CNE), and six (30%) were considered T-CNE cases. In-hospital outcome and clinical characteristics were compared between both patient groups. The main end-point was death or need for surgical repair of the heart valves during hospitalization.There were no significant inter-group differences with respect to mean age, gender distribution, and other clinical characteristics. The composite endpoint of death or surgical repair occurred more frequently in T-CNE patients (100% versus 64%, p = 0.0394). Anatomic complications also occurred more frequently in T-CNE patients, but the difference was statistically not significant.Among patients with IE and a negative blood culture, those without previous antibiotic therapy (T-CNE) have the worse prognosis.

Interobserver variability is an important limitation of the stress echocardiography and depends on the echocardiographer training. Our aim was to evaluate if the use of contrast agents during dipyridamole stress echocardiography would improve the agreement between an experienced and a non-experienced observer in stress echo and therefore if contrast would affect the learning period of dypyridamole stress echo.Two independent observers without knowledge of any patient data interpreted all stress studies. One observer was an experienced one and the other had experience in echocardiography but not in stress echo. Two observers analysed 87 non-selected and consecutive studies. Out of the 87 studies, 46 were performed without contrast administration, whereas i.v. contrast (2.5 g Levovist by two bolus at rest and at peak stress) was administered in 41. In all cases, second harmonic imaging and stress digitalisation pack was used. The agreement between observers showed a kappa index of 0.58 and 0.83 without and with contrast administration, respectively.The use of contrast agents provides a better agreement in the evaluation of stress echo between an experienced and a non-experienced observer in stress echo. Adding routinely contrast agents could probably reduce the number of exams required for the necessary learning curve in stress echocardiography.

Left ventricular (LV) contraction is slowed in patients with aortic stenosis (AS). Although the possible role of LV systolic function abnormalities in the assessment of AS severity has been evaluated, current echocardiographic techniques cannot offer precise quantification of LV motion velocity. The study aim was to evaluate an automated segmental motion analysis (ASMA) system to assess AS severity.Twenty-two patients with AS, sinus rhythm and preserved LV ejection fraction were studied prospectively. Patients underwent both conventional Doppler echocardiography to measure transaortic gradient and aortic valve area by the continuity equation, and ASMA of the interventricular septum. The ASMA line graph mode displays changes in area through the cardiac cycle. The RR interval and time from the R-wave to peak maximum area shortening were measured, and an ASMA index was calculated.A significant and strong inverse correlation was found between aortic valve area and ASMA index (r = -0.78; 95% CI -0.90 to -0.55; p0.001). The area under the ROC curve in the diagnosis of severe AS (aortic valve areaor =0.8 cm2) was 0.97 (95% CI 0.90-1.0). Sensitivity, specificity, positive and negative predictive values and overall accuracy for an ASMA index0.40 were 100, 91.7, 92.3, 100 and 95.8%, respectively.The ASMA system may be valuable in evaluating AS, as it offers a strong correlation with aortic valve area calculated by the continuity equation, and very high sensitivity and specificity in the diagnosis of severe AS.

The incidence and severity of certain infections appear to be increased in patients with diabetes mellitus (DM). The study aim was to evaluate the effect of DM on short- and long-term outcome in patients with active infective endocarditis (IE).A total of 151 patients with IE was included and followed up for a mean of 3.1 years. Of these patients, 13 (9%) were diabetics. The outcome of patients with or without DM was compared at short-term (in-hospital) and long-term follow up.Patients with DM were older (66 +/- 11 versus 50 +/- 19 years, p0.01) and had a lower frequency of intravenous drug abuse (0 versus 30%, p0.01) and tricuspid valve involvement (0 versus 20%, p = 0.02) than non-DM patients. Mortality was higher in DM patients both in hospital (31% versus 15%, p = NS) and at a mean follow up of 3.1 years (54% versus 31%, p = 0.002). DM patients also had a significantly higher rate of cardiac failure (69% versus 38%, p = 0.03) and renal failure (62% versus 20%, p0.01) during hospitalization. Incidences of anatomic complications (abscess, pseudoaneurysm) (15.4% versus 20.3%), valve rupture or perforation (7.7% versus 16.7%) and need for surgical repair (46.2% versus 45.7%) were similar in both DM and non-DM patients. DM, without secondary pathology like renal failure, did not appear to be an independent risk factor for mortality at either short- or long-term follow up.Although mortality and morbidity in IE were greater in DM than in non-DM patients, diabetes itself does not constitute an independent risk factor.

Background and Objective: The diagnosis of left ventricular pseudoaneurysm after acute myocardial infarction is usually based on echocardiography. However, this technique may have limitations in some patients, especially in cases with suboptimal acoustic window. The objective of this study was to evaluate the usefulness of contrast echocardiography in the diagnosis of left ventricular pseudoaneurysm after myocardial infarction. Methods and Results: The study population comprises six patients in whom a two-dimensional echocardiography showed an image consistent with left ventricular pseudoaneurysm. Levovist® (Schering) 4 gr was administered i.v. to more clearly visualize the blood flow from the left ventricle to the left ventricular pseudoaneurysm cavity in all patients. Infarct location was anterior in five patients, and posterolateral in one. No patient had received thrombolysis or primary angioplasty during the acute phase. The transthoracic echocardiographic study showed an echo-free space adjacent to left ventricle in all patients. In four cases, the diagnosis of left ventricular pseudoaneurysm was made before contrast administration. In the remaining two patients, the definite diagnosis was made only after Levovist® administration. Conclusion: In the diagnosis of postinfarction left ventricular pseudoaneurysm, the administration of contrast agents may be of help in the correct visualization of the blood flow from the left ventricle to the left ventricular pseudoaneurysm cavity, and may allow a definite diagnosis to be obtained in some patients. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

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