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This chapter summarizes the headlines on bicuspid aortic valve (BAV)-associated aortopathy regarding epidemiology, classification, genetics, haemodynamics, and clinical practice. Importantly, the exact pathogenesis of the BAV-associated aortopathy remains still not well understood. On the one hand, BAV is an autosomal dominant heritable disease with reduced penetrance and some underlying genes have beenidentified. On the other hand, as basic research in combination with advanced cardiac imaging revealed, altered flow characteristics caused by the abnormal geometry of the BAV are found to play a role in aortic dilatation through altered wall shear stress. Moreover, stenosis and regurgitation of these valves seem to be important. Remodelling of the aortic wall, with apoptosis of vascular smooth muscle cells and disruption of the media layer as a result, form the basis ofa loss of structural integrity of the aortic wall, making it prone to dilatation, dissection, and rupture.

Although stent implantation for aortic coarctation (CoA) is associated with acute anatomical and hemodynamic benefit, limited evidence exists regarding the late impact on blood pressure and cardiovascular complications. In this meta-analysis we aimed to evaluate the influence of stent placement for

Analysis of coronary flow velocity pattern has been used to assess microvascular function post acute myocardial infarction (AMI). This study sought to analyze whether the flow level has an impact on parameters of coronary flow velocity pattern. Parameters of coronary flow velocity pattern were determined at baseline and during increased flow due to maximal hyperemia induced by adenosine in 25 patients after PTCA for first AMI using Doppler flow wires. Patients were divided into those with depressed (global wall motion index (GWMI) ≥ 1.5; n = 14) and those with preserved (GWMI < 1.5; n = 11) left ventricular (LV) function at 4 weeks. Coronary flow velocity pattern at rest was different between patients with depressed and patients with preserved LV function at follow-up. A difference in flow pattern between the groups remained at increased flow level. However, increase of flow altered parameters of flow pattern. Diastolic deceleration rate (DSR) increased for patients with preserved LV function (53.7 ± 25.6 at baseline vs. 67.0 ± 29.8 cm/s2 with adenosine) and depressed LV function (95.3 ± 58.6 vs. 110.7 ± 61.4 cm/s2, respectively, p = 0.0012). Induction of hyperemia resulted also in increased systolic and diastolic peak flow velocity and diastolic deceleration time (DDT). Higher flow had no impact on early systolic retrograde flow, systolic flow duration and diastolic–systolic velocity ratio (DSVR). The coronary flow velocity pattern allows prediction of LV function at 4 weeks after AMI. However, it should be considered that some parameters of the flow velocity pattern are affected by the coronary flow level.

Background —This study investigated whether the extent of perfusion defect determined by intravenous myocardial contrast echocardiography (MCE) in patients with acute myocardial infarction (AMI) treated by primary percutaneous transluminal coronary angioplasty (PTCA) relates to coronary flow reserve (CRF) for assessment of myocardial reperfusion and is predictive for left ventricular recovery. Methods and Results —Twenty-five patients with first AMI underwent intravenous MCE with NC100100 with intermittent harmonic imaging before PTCA and after 24 hours. MCE before PTCA defined the risk region and MCE at 24 hours the “no-reflow” region. The no-reflow region divided by the risk region determined the ratio to the risk region. CFR was assessed immediately after PTCA and 24 hours later. Left ventricular wall motion score indexes were calculated before PTCA and after 4 weeks. CFR at 24 hours defined a recovery (CFR ≥1.6; n=17) and a nonrecovery group (CFR P =0.009). A ratio to the risk region of ≤50% defined an MCE reperfusion group. It was associated with improvement of CFR from 1.67±0.47 at baseline to 2.15±0.53 at 24 hours ( P P Conclusions —Intravenous MCE can be used to define perfusion defects after AMI. Assessment of microcirculation by MCE corresponds to evaluation by CFR. Serial intravenous MCE has the potential to identify patients likely to have improved left ventricular function after AMI.

Advances in transoesophageal echocardiography (TOE) have made this modality a powerful diagnostic tool in the critical care unit. TOE in combination with stress (atrial pacing, pharmacological stress) provides important information about myocardial ischaemia and myocardial viability. Recent progress in transducer technology and computerized image processing brings three-dimensional and contrast-enhanced TOE closer to the critical care unit. Finally, miniaturization of probes and automated contour detection techniques make TOE a sensitive and continuous monitor of global and segmental left ventricular function.

A first step in the delivery of tailored care is answering the following question: does health care meet the needs of patients? Therefore patients' perspective on health care use and their needs was examined. The design used was cross-sectional questionnaire study.A total of 1109 adult congenital heart defect (CHD) patients attending one of eight Dutch hospitals were randomly selected from a national database (10% of all registered patients).Patient reported questionnaires on in- and outpatient health care use during the past year and need for additional care.A total of 66% and 40% of patients had contact with their cardiologist and general practitioner, respectively. Six to 10 percent were hospitalized, operated upon, or visited the emergency room. For the majority, the amount of contact was sufficient. Most patients indicated that the communication skills and expertise of the cardiologist and general practitioner were sufficient, and health care improvements were not necessary. Frequent health care users had a poor functional status and frequent contact with their cardiologist and general practitioner. Patients who want more contact with their cardiologist rated the communication skills of the cardiologist as insufficient.For most patients, the amount and quality of care are both sufficient. Patients who rate the communication skills of the cardiologist as insufficient have need more contact. In addition to the recommended training program as described in the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines, we recommend the incorporation of communication training. This is the first study to provide insight into health care use and needs of CHD patients in countries with a compulsory health insurance system from the patient perspective.

Background This study evaluated the ability of intravenous myocardial contrast echocardiography (MCE) performed in the setting of acute myocardial infarction for prediction of left ventricular (LV) remodeling. Methods. Intravenous MCE was performed immediately before, 1 hour, and 24 hours after primary percutaneous transluminal coronary angioplasty (PTCA) in 35 patients with a first myocardial infarction. The MCE was used to define the relative perfusion defect size (in %; relMCD). Two-dimensional echocardiography was performed directly after angioplasty and after 4 weeks to determine LV end-diastolic volumes (LVEDV). The increase in LVEDV at 4 weeks defined a remodeling (>15% increase) and a nonremodeling group (less than or equal to15% increase). Results: Patients with remodeling had larger relMCD before (22.0+/-16.1 vs 8.0+/-11.9, P=.015), 1 hour (20.0+/-13.0 vs 4.9+/-11.6, P=.001), and 24 hours after PTCA (22.9+/-14.1 vs 1.2+/-2.8, P

Objectives The aim of this study was to evaluate the coronary blood flow velocity pattern immediately and 24 h after percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) in relation to myocardial reperfusion and follow-up left ventricular (LV) function. Background Analysis of coronary blood flow velocity pattern after AMI may provide information about microvascular damage and the occurrence of a reperfusion injury. Methods Measurement of coronary blood flow velocity pattern was performed immediately after PTCA and after 24 h in 25 patients with first AMI using a Doppler guidewire. Measurements were related to reperfusion determined by intravenous myocardial contrast echocardiography (MCE) performed before PTCA and at 24 h and to LV function at four weeks. Results Using MCE, 13 patients showed reperfusion and 12 patients showed nonreperfusion. Compared with patients with reperfusion, patients with MCE nonreperfusion had a lower systolic peak flow velocity immediately after PTCA (10.0 ± 0.3 cm/s vs. 19.3 ± 0.8 cm/s, respectively) and after 24 h (12.3 ± 0.4 cm/s vs. 21.3 ± 0.1 cm/s, respectively, p = 0.0022), more frequent early systolic retrograde flow (6/12 vs. 0/13, p = 0.0052 immediately after PTCA and 24 h later) and a shorter diastolic deceleration time immediately after PTCA (483 ± 6 ms vs. 737 ± 0 ms, respectively) and after 24 h (551 ± 9 ms vs. 823 ± 2 ms, respectively, p = 0.0091). Similarly, patients with impaired LV function at four weeks had altered coronary flow pattern compared with patients with preserved function. The coronary flow velocity pattern showed a tendency for improvement after 24 h in the reperfusion and the nonreperfusion groups. Conclusions The coronary flow velocity pattern immediately and 24 h after PTCA for AMI relates to myocardial perfusion determined by MCE and LV function at four weeks. The flow velocity pattern shows slight improvement during the first 24 h after revascularization, indicating the absence of a major reperfusion injury.

This study evaluated recently suggested invasive and noninvasive parameters of myocardial reperfusion after acute myocardial infarction (AMI), assessing their predictive value for left ventricular function 4 weeks after AMI and reperfusion defined by myocardial contrast echocardiography (MCE). In 38 patients, angiographic myocardial blush grade, corrected Thrombolysis In Myocardial Infarction frame count, ST-segment elevation index, and coronary flow reserve (n = 25) were determined immediately after primary percutaneous transluminal coronary angioplasty [PTCA) for first AMI, and intravenous MCE was determined before, and at I and 24 hours after PTCA to evaluate myocardial reperfusion. Results were related to global wall motion index (GWMI) at 4 weeks. MCE I hour after PTCA showed good correlation with GWMI at 4 weeks (r = 0.684, p

We used visual and videodensitometric evaluation to investigate the influence of intermittent harmonic imaging (IHI) compared with intermittent fundamental imaging on cavity and myocardial signal intensity after administration of the air-filled transpulmonary contrast agent BY963. Twelve patients were studied with intermittent fundamental imaging and IHI after administration of 5 mL and 10 mL of contrast agent. Contrast effect was graded in the parasternal short-axis view. Visually, IHI improved opacification of both the right and left ventricular cavities, especially the left. Densitometrically, right ventricular opacification did not differ significantly between imaging modalities, whereas left ventricular cavity opacification was significantly higher when using IHI. Myocardial opacification was observed in a small minority of segments when assessed by visual estimation, whereas videodensitometry revealed opacification in 42 of 48 anterior, 39 of 48 posterior, and 42 of 48 septal segments. Differences were not significant between doses. We conclude that with IHI and densitometry, air-filled contrast agents like BY963 show significantly improved performance in producing cavity and myocardial contrast effects.

Real-time bedside evaluation of myocardial perfusion after intravenous application of microbubbles is the ultimate goal for contrast echocardiography. Over the past decade rapid evolution has occurred in the development of contrast agents, ultrasound equipment tailored to their detection, and image interpretation. This article offers a review of the basic concepts of the technique's background, contrast agent design, and imaging technology. The major clinical indications of myocardial contrast echocardiography are evaluation of acute ischemic syndromes, diagnosis of viable myocardium following AMI, and the detection of CAD using stress contrast perfusion imaging. Furthermore, the article addresses the most significant practical problems and suggested solutions to master those problems. As major new achievements are realistic expectations for the first decade of the twenty-first century, we conclude that the coupling of a new generation of contrast agents with innovative echocardiographic instrumentation will ultimately enable the full potential of myocardial contrast echocardiography to be realized which may revolutionize modern echocardiography.

Stress echocardiography has entered the clinical domain and has improved the diagnostic capabilities of many echocardiographic laboratoria. Under certain conditions stress echocardiography has demonstrated to be safe and accurate. In experienced hands it has proven to be a valuable diagnostic tool in the management of patients with coronary artery disease. The availability of stress echocardiography permits assessment of myocardial ischemia and thus influences clinical management. Despite its relatively low costs, portability, absence of radiation, safety and its ability to determine the ischemic threshold, there are limitations for its widespread use, e.g. window limitation, subjective interpretation and learning curves being the most important amongst them.