Ultrasound-Enhancing Agent Safely Enhances Left Ventricular Visualization by Transthoracic Echocardiography in Patients on ECMO Support.

OBJECTIVE: The authors investigated if the use of ultrasound-enhancing agents (UEA) can safely improve left ventricular (LV) image quality by transthoracic echocardiography (TTE) in patients on extracorporeal membrane oxygenation (ECMO). DESIGN AND SETTING: This study was performed in a tertiary cardiothoracic and ECMO center in London, United Kingdom. PARTICIPANTS: The authors included 18 prospectively identified consecutive patients requiring TEE supported on peripherally implanted ECMO. INTERVENTION AND MEASUREMENTS: TTE was performed before and after the UEA administration. The authors assessed the LV image quality using the biplane (apical-4-chamber and apical-2-chamber views) endocardial border definition index (1 = good, 2 = suboptimal, 3 = poor, and 4 = unavailable), as well as the feasibility of LV ejection fraction (LVEF) measurement. The authors also gathered sequential clinical information for the next 24 hours. MAIN RESULTS: The patients' median age was 47 years (35, 65), and 5 (28%) were women. The biplane endocardial border definition index improved from the suboptimal to the good range (2.167 [1.812, 3.042] v 1.500 [1.417, 1.792], p = 0.0004) after the use of UEA. The feasibility of LVEF tripled from 25% (n = 5) to 83% (n = 15) (p = 0.0008) with UEA use. The UEA did not set off the bubble alarm and did not impact clinical or ECMO parameters. CONCLUSION: The use of UEA significantly improved the quality of LV biplane images by transthoracic echocardiography, transforming them from suboptimal to good in patients supported with peripherally implanted ECMO. UEA use tripled the feasibility of measuring LVEF by TTE without affecting clinical and ECMO parameters.

PROTEUS Study: A Prospective Randomized Controlled Trial Evaluating the Use of Artificial Intelligence in Stress Echocardiography.

BACKGROUND: Stress echocardiography (SE) is one of the most commonly used diagnostic imaging tests for coronary artery disease (CAD) but requires clinicians to visually assess scans to identify patients who may benefit from invasive investigation and treatment. EchoGo Pro provides an automated interpretation of SE based on artificial intelligence (AI) image analysis. In reader studies, use of EchoGo Pro when making clinical decisions improves diagnostic accuracy and confidence. Prospective evaluation in real world practice is now important to understand the impact of EchoGo Pro on the patient pathway and outcome. METHODS: PROTEUS is a randomized, multicenter, 2-armed, noninferiority study aiming to recruit 2,500 participants from National Health Service (NHS) hospitals in the UK referred to SE clinics for investigation of suspected CAD. All participants will undergo a stress echocardiogram protocol as per local hospital policy. Participants will be randomized 1:1 to a control group, representing current practice, or an intervention group, in which clinicians will receive an AI image analysis report (EchoGo Pro, Ultromics Ltd, Oxford, UK) to use during image interpretation, indicating the likelihood of severe CAD. The primary outcome will be appropriateness of clinician decision to refer for coronary angiography. Secondary outcomes will assess other health impacts including appropriate use of other clinical management approaches, impact on variability in decision making, patient and clinician qualitative experience and a health economic analysis. DISCUSSION: This will be the first study to assess the impact of introducing an AI medical diagnostic aid into the standard care pathway of patients with suspected CAD being investigated with SE. TRIAL REGISTRATION: Clinicaltrials.gov registration number NCT05028179, registered on 31 August 2021; ISRCTN: ISRCTN15113915; IRAS ref: 293515; REC ref: 21/NW/0199.

Comparison of the Recent Updates to the ACC/AHA and ESC Guidelines for the Management of Valvular Heart Disease: Similarities and Differences.

PURPOSE OF REVIEW: There have been several advances in the diagnosis and management of valvular heart disease (VHD) over the last decade. These have been reflected in the latest European and North American guidelines, although both contain significant similarities and differences. In this review, we highlight the important overlaps and variations between the updated guidelines and their previous versions to help guide the general cardiologist. RECENT FINDINGS: There has been extensive revision on the use of percutaneous treatments, the indications for intervention in asymptomatic VHD, and perioperative bridging therapies. The updated guidelines provide new recommendations in many aspects of VHD; however, there remain significant gaps in the role of biomarkers in VHD and the long-term outcomes of novel oral anticoagulants (NOACs) and transcatheter therapies.

18F-FDG PET/CT improves diagnostic certainty in native and prosthetic valve Infective Endocarditis over the modified Duke Criteria.

BACKGROUND: International guidance recognizes the shortcomings of the modified Duke Criteria (mDC) in diagnosing infective endocarditis (IE) when transoesophageal echocardiography (TOE) is equivocal. 18F-FDG PET/CT (PET) has proven benefit in prosthetic valve endocarditis (PVE), but is restricted to extracardiac manifestations in native disease (NVE). We investigated the incremental benefit of PET over the mDC in NVE. METHODS: Dual-center retrospective study (2010-2018) of patients undergoing myocardial suppression PET for NVE and PVE. Cases were classified by mDC pre- and post-PET, and evaluated against discharge diagnosis. Receiver Operating Characteristic (ROC) analysis and net reclassification index (NRI) assessed diagnostic performance. Valve standardized uptake value (SUV) was recorded. RESULTS: 69/88 PET studies were evaluated across 668 patients. At discharge, 20/32 had confirmed NVE, 22/37 PVE, and 19/69 patients required surgery. PET accurately re-classified patients from possible, to definite or rejected (NRI: NVE 0.89; PVE 0.90), with significant incremental benefit in both NVE (AUC 0.883 vs 0.750) and PVE (0.877 vs 0.633). Sensitivity and specificity were 75% and 92% in NVE; 87% and 86% in PVE. Duration of antibiotics and C-reactive Protein level did not impact performance. No diagnostic SUV cut-off was identified. CONCLUSION: PET improves diagnostic certainty when combined with mDC in NVE and PVE.

Left Ventricular Ejection Fraction Correlation With Stroke Volume as Estimated by Doppler Echocardiography in Cardiogenic Shock: A Retrospective Observational Study.

OBJECTIVES: Echocardiography is the main tool for cardiac assessment and helps to guide management in patients admitted to the intensive care unit (ICU) with cardiogenic shock (CS). Left ventricular ejection fraction (LVEF) is a commonly used echocardiographic surrogate for left ventricular (LV) systolic function. In this hypothesis-generating study, the authors investigated the correlation between LVEF and stroke volume (SV)/SV index (SVI) estimated by Doppler echocardiography in patients admitted to the ICU with CS and reduced LVEF. DESIGN AND SETTING: This retrospective analysis was performed in a single tertiary cardiac center in London, United Kingdom. PARTICIPANTS: Patients admitted to the ICU over a 34-month period with ST elevation myocardial infarction (STEMI) complicated by CS and LVEF <40%. INTERVENTIONS: Clinical and echocardiographic data were collected. LVEF (total, by visual estimate and by modified Simpson's method) was correlated with SV and SVI estimated by Doppler echocardiography. MEASUREMENTS AND MAIN RESULTS: One-hundred patients were included. The mean age was 62.6 ± 12.7 years and 78% were male patients. The median LVEF was 29% (20-35) and the mean SV and SVI by Doppler echocardiography were 47 mL ± 16 and 25 mL ± 9, respectively. Analysis revealed a weak yet statistically significant correlation among LVEF and Doppler SV and SVI (r = 0.44, confidence interval [CI] 0.26-0.60, p < 0.0001, r = 0.47, CI 0.28-0.62, p < 0.001, respectively). Visually estimated LVEF (n = 74) correlated weakly with Doppler SV and SVI yet better compared to LVEF by Simpson's method (n = 25) (r = 0.48, CI 0.27-0.65, p < 0.0001 and r = 0.49, CI 0.28-0.66, p < 0.0001, respectively, v r = 0.36, CI 0.05-0.67, p = 0.08 and r = 0.37, CI -0.04-0.67, p 0.07, respectively). CONCLUSIONS: There is a weak correlation between LVEF and SV or SVI estimated by Doppler echocardiography in patients admitted to the ICU with STEMI complicated by CS and reduced LVEF. Visually estimated LVEF correlated slightly better with Doppler SV compared to modified Simpson's LVEF.

Natriuretic peptide release during exercise in patients with valvular heart disease: A systematic review.

AIM: Serum biomarkers have a potential role in the risk stratification of patients with heart valve disease and may help determine the optimal timing of intervention. Much of the published literature relates to biomarker sampling in a resting state, but the relationship of exercise biomarkers is less well described. We performed a systematic review to examine the significance of exercise natriuretic peptides on echocardiographic variables and cardiovascular events, in valvular heart disease. METHODS: A search for studies that assessed exercise biomarkers in patients with moderate to severe valve lesions was performed. We examined the relationship between rest and exercise BNP and also the endpoints of symptoms, haemodynamic or echocardiographic variables and clinical outcomes. RESULTS: Eleven prospective studies were identified (844 participants). 61% were male and the mean age was 55.2 ± 9.6 years. The majority of the blood samples were taken at baseline and within 3 minutes of stopping exercise. There was a significant increase in exercise BNP compared with rest, in patients with aortic stenosis, mitral regurgitation and mitral stenosis. Elevated exercise BNP levels correlated with mean gradient and left atrial area, and there was a relationship between a higher exercise BNP and a blunted blood pressure response, in aortic stenosis. Furthermore, exercise BNP was independently associated with cardiac events, over and above resting values, in patients with mitral regurgitation and aortic stenosis. CONCLUSION: The results suggesting that exercise natriuretic peptide levels may have additive prognostic importance over resting levels, as well as demographic and echocardiographic data.

Clinical and echocardiographic predictors of decompensation in acute severe aortic regurgitation due to infective endocarditis.

BACKGROUND: Patients with acute severe aortic regurgitation (AR) due to infective endocarditis can progress rapidly from the hemodynamically stable patient to pulmonary edema and cardiogenic shock. We sought to identify patients at risk of decompensation where emergent surgery should be undertaken. METHODS: We identified 90 patients with acute severe AR from the echocardiography laboratory database. Baseline clinical, hemodynamic (heart rate (HR) and blood pressure (BP)), and echocardiographic data including mitral filling, premature mitral valve closure (PMVC), and diastolic mitral regurgitation (DMR) were identified. The primary endpoint was subsequent development of pulmonary edema or severe hemodynamic instability. RESULTS: Patients who met the primary endpoint had a higher HR (98.5 bpm vs 80.5 bpm), lower diastolic BP (54 mm Hg vs 61.5 mm Hg), higher mitral E-wave velocity (113 cm/s vs 83 cm/s), higher E/e' ratio (12.4 vs 8), higher proportion of DMR (27.8% vs 7.4%), and PMVC (25% vs 9.3%) than patients who did not meet the endpoint. The proportion of patients with the primary endpoint increased as HR increased ((≤81 bpm) 3/30 (10%), (81-94 bpm) 11/31 (35.5%), (≥94 bpm) 22/29 (75.9%), P < .0001) and as the diastolic BP reduced ((≤54 mm Hg) 19/31 (61.3%), (54-63 mm Hg) 12/31 (38.7%), (≥63 mm Hg) 5/28 (17.9%), P = .003). Independent predictors were a higher HR (OR 1.08 (95% CI 1.04-1.13) P = .0003) and DMR (OR 4.71 (95% CI 1.23-18.09), P = .02). CONCLUSION: Decompensation in acute severe AR is common. Independent predictors of decompensation are increasing HR(≥94 bpm) and the presence of DMR. Those with these adverse markers should be considered for emergent surgery.

Association of Vegetation Size With Valve Destruction, Embolism and Mortality.

AIM: The mortality of patients with infective endocarditis (IE) is high. The management of patients with large vegetations is controversial. This study sought to investigate the association of vegetation size on outcomes including valve destruction, embolism and mortality. METHODS AND RESULTS: One hundred and forty-two (142) patients with definite IE and transoesophageal echocardiography (TEE) imaging available for analysis were identified and data retrospectively reviewed. Vegetation length, width and area were measured. Severe valve destruction was defined as the composite of one or more of severe valve regurgitation, abscess, pseudoaneurysm, perforation or fistula. Associations with 6-month mortality were identified by Cox regression analysis. Eighty (80) (56.3%) patients had evidence of valve destruction on TEE. Vegetation length ≥10 mm and vegetation area ≥50 mm2 were significantly associated with increased risk of valve destruction, (both odds ratio OR 1.21, p=0.03 and p=0.02 respectively). Thirty-nine (39) (72.2%) patients who had an embolic event, did so prior initiation of antibiotics. Six (6)-month mortality was 18.3%. In the surgically managed group, vegetation size was not associated with mortality. In the medically managed group, vegetation area (mm2) was associated with increased mortality (HR 1.01, p<0.01) along with age (HR 1.06, p=0.03). CONCLUSION: Vegetation length ≥10 mm or area ≥50 mm2 are associated with increased risk of valve destruction. Vegetation size may also predict mortality in medically managed but not surgically managed patients with IE. Further studies to evaluate whether surgery in patients with large vegetation size improves outcomes is warranted.

Association between mitral annular calcification and progression of mitral and aortic stenoses.

BACKGROUND: Mitral annular calcification (MAC) is a chronic degenerative process affecting the annular fibrosus of the mitral valve. We sought to examine the relationship between MAC and the progression of valve disease. METHODS: The echocardiography database was searched for patients with MAC who had undergone at least two studies more than 1 year apart. The degree of MAC was quantified according to both extent and thickness. The degree of aortic stenosis (AS) and mitral stenosis (MS) was classified according to valve area and mean gradient, respectively. RESULTS: Of 125 patients, moderate or greater AS was present in 8 of 86 (9.3%) patients with mild, 12 of 29 (41.4%) patients with moderate, and 4 of 10 (40%) patients with severe MAC extent, P = .0002. The rate of progression of AS was highest in those with greatest MAC extent (0.21 cm2 /y) or greatest MAC thickness (0.28 cm2 /y) compared with those with least MAC extent (0.09 cm2 /y) or thickness (0.07 cm2 /y), P = .04 and <.0001, respectively. The rate of progression of mean mitral gradient was highest in those with greatest MAC extent (0.71 mm Hg/y) or greatest MAC thickness (0.17 mm Hg/y) compared with those with least MAC extent (0.07 mm Hg/y) or thickness (0.07 mm Hg/y), P = .0003 and P < .0001, respectively. Patients with greatest MAC extent had lower survival than those with lower MAC extent, P = .03. However, there was no difference in survival between patients with different MAC thickness, P = .43. CONCLUSION: Both the degree of MAC extent and thickness are associated with the rate of progression of aortic and mitral stenosis and may serve as a risk marker for future progression.

Appropriateness, diagnostic value, and outcomes of repeat testing following index echocardiography.

AIMS: Emergency admission to hospital is associated with an economic burden and mortality. Echocardiography is often the first-line cardiovascular imaging investigation. Repeat testing is common; however, there are sparse data on the prevalence, appropriateness, or outcome of repeat testing. METHODS: We performed an electronic database search for patients with emergency admissions to our institution in February 2015. An electronic patient record review of inpatient echocardiograms was undertaken. Indications for echocardiography were classified as appropriate, may be appropriate, or rarely appropriate. One-year follow-up for repeat testing and mortality was investigated. RESULTS: A total of 409 of 2306 (17.7%) unplanned/emergency admissions underwent inpatient echocardiography. Abnormalities were identified in 165/409 (40.3%) of these patients; 154 of 409 (37.7%) had a repeat echocardiogram within the next year. Rarely appropriate indications for echocardiography occurred in 51 (33%) of repeat vs 53 (16%) of index echocardiograms, P < .0001. Repeat testing was associated with a change in findings in 17/154 (11%) patients overall. All of whom had an abnormal index echocardiogram and had an appropriate indication. There was no difference in mean survival time between patients who underwent repeat and those who only underwent a single index echocardiogram (310 days vs 327 days), P = .34. CONCLUSION: Inpatient echocardiography in emergency hospital admissions identifies clinically important pathology. Repeated testing is common within 1 year of hospital admission. New diagnostic findings occurred in 11% of patients and only in patients with appropriate studies and an abnormal index echocardiogram. Identification of methods to reduce repeat testing and implement appropriateness criteria is warranted.

Role of Echocardiography Before Transcatheter Aortic Valve Implantation (TAVI).

Aortic stenosis (AS) is the most common primary valve disorder in the elderly with an increasing prevalence; transcatheter aortic valve implantation (TAVI) has become an accepted alternative to surgical aortic valve replacement (AVR) in the high risk or inoperable patient. Appropriate selection of patients for TAVI is crucial and requires a multidisciplinary approach including cardiothoracic surgeons, interventional cardiologists, anaesthetists, imaging experts and specialist nurses. Multimodality imaging including echocardiography, CT and MRI plays a pivotal role in the selection and planning process; however, echocardiography remains the primary imaging modality used for patient selection, intra-procedural guidance, post-procedural assessment and long-term follow-up. The contribution that contemporary transthoracic and transoesophageal echocardiography make to the selection and planning of TAVI is described in this article.

Aortic Stenosis, a Left Ventricular Disease: Insights from Advanced Imaging.

Aortic stenosis (AS) is the most common primary valve disorder in the elderly with an increasing prevalence. It is increasingly clear that it is also a disease of the left ventricle (LV) rather than purely the aortic valve. The transition from left ventricular hypertrophy to fibrosis results in the eventual adverse effects on systolic and diastolic function. Appropriate selection of patients for aortic valve intervention is crucial, and current guidelines recommend aortic valve replacement in severe AS with symptoms or in asymptomatic patients with left ventricular ejection fraction (LVEF) <50 %. LVEF is not a sensitive marker and there are other parameters used in multimodality imaging techniques, including longitudinal strain, exercise stress echo and cardiac MRI that may assist in detecting subclinical and subtle LV dysfunction. These findings offer potentially better ways to evaluate patients, time surgery, predict recovery and potentially offer targets for specific therapies. This article outlines the pathophysiology behind the LV response to aortic stenosis and the role of advanced multimodality imaging in describing it.

Echocardiographic assessment of aortic regurgitation: a narrative review.

Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.

High-definition blood flow imaging improves quantification of left ventricular volumes and ejection fraction.

AIMS: The accuracy and reproducibility of echocardiography to quantify left ventricular ejection fraction (LVEF) is limited due to image quality. High-definition blood flow imaging is a new technique which improves cavity delineation without the need for medication or intravenous access. We sought to examine the impact of high-definition blood flow imaging on accuracy and reproducibility of LV systolic function assessment. METHODS AND RESULTS: Prospective observational study of consecutive patients undergoing 2D and 3D transthoracic echocardiography (TTE), high-definition blood flow imaging, and cardiac magnetic resonance (CMR) within 1 h of each other. Left ventricular systolic function characterized by left ventricular end-systolic volumes and left ventricular end-diastolic volumes and LVEF were measured. Seventy-six patients were included. Correlation of 2D TTE with CMR was modest (r = 0.68) with a worse correlation in patients with three or more segments not visualized (r = 0.58). High-definition blood flow imaging was feasible in all patients, and the correlation of LVEF with CMR was excellent (r = 0.88). The differences between 2D, high-definition blood flow, and 3D TTE compared to CMR were 5 ± 9%, 2 ± 5%, and 1 ± 3%, respectively. The proportion of patients where the grade of LV function was correctly classified improved from 72.3% using 2D TTE to 92.8% using high-definition blood flow imaging. 3D TTE also had excellent correlation with CMR (r = 0.97) however was only feasible in 72.4% of patients. CONCLUSION: High-definition blood flow imaging is highly feasible and significantly improves the diagnostic accuracy and grading of LV function compared to 2D echocardiography.

Predictors of outcome in patients with moderate mixed aortic valve disease.

OBJECTIVES: Grading the severity of moderate mixed aortic stenosis and regurgitation (MAVD) is challenging and the disease poorly understood. Identifying markers of haemodynamic severity will improve risk stratification and potentially guide timely treatment. This study aims to identify prognostic haemodynamic markers in patients with moderate MAVD. METHODS: Moderate MAVD was defined as coexisting moderate aortic stenosis (aortic valve area (AVA) 1.0-1.5 cm2) and moderate aortic regurgitation (vena contracta (VC) 0.3-0.6 cm). Consecutive patients diagnosed between 2015 and 2019 were included from a multicentre registry. The primary composite outcome of death or heart failure hospitalisation was evaluated among these patients. Demographics, comorbidities, echocardiography and treatment data were assessed for their prognostic significance. RESULTS: 207 patients with moderate MAVD were included, aged 78 (66-84) years, 56% male sex, AVA 1.2 (1.1-1.4) cm2 and VC 0.4 (0.4-0.5) cm. Over a follow-up of 3.5 (2.5-4.7) years, the composite outcome was met in 89 patients (43%). Univariable associations with the primary outcome included older age, previous myocardial infarction, previous cerebrovascular event, atrial fibrillation, New York Heart Association >2, worse renal function, tricuspid regurgitation ≥2 and mitral regurgitation ≥2. Markers of biventricular systolic function, cardiac remodelling and transaortic valve haemodynamics demonstrated an inverse association with the primary composite outcome. In multivariable analysis, peak aortic jet velocity (Vmax) was independently and inversely associated with the composite outcome (HR: 0.63, 95% CI 0.43 to 0.93; p=0.021) in an adjusted model along with age (HR: 1.05, 95% CI 1.03 to 1.08; p<0.001), creatinine (HR: 1.002, 95% CI 1.001 to 1.003; p=0.005), previous cerebrovascular event (85% vs 42%; HR: 3.04, 95% CI 1.54 to 5.99; p=0.001) and left ventricular ejection fraction (LVEF) (HR: 0.97, 95% CI 0.95 to 0.99; p=0.007). Patients with Vmax ≤2.8 m/s and LVEF ≤50% (n=27) had the worst outcome compared with the rest of the population (72% vs 41%; HR: 3.87, 95% CI 2.20 to 6.80; p<0.001). CONCLUSIONS: Patients with truly moderate MAVD have a high incidence of death and heart failure hospitalisation (43% at 3.5 (2.5-4.7) years). Within this group, a high-risk group characterised by disproportionately low aortic Vmax (≤2.8 m/s) and adverse remodelling (LVEF ≤50%) have the worst outcomes.

Prevalence, characteristics and clinical impact of work-related musculoskeletal pain in echocardiography.

BACKGROUND: Work-related musculoskeletal pain (WRMSP) is increasingly recognised in cardiac ultrasound practice. WRMSP can impact workforce health, productivity and sustainability. We sought to investigate the prevalence, characteristics and clinical impact of WRMSP. METHODS: Prospective electronic survey of 157 echocardiographers in 10 institutions. Data acquired on demographics, experience, working environment/pattern, WRMSP location, severity and pattern, the impact on professional, personal life and career. RESULTS: 129/157 (82%) echocardiographers completed the survey, of whom 109 (85%) reported WRMSP and 55 (43%) reported work taking longer due to WRMSP. 40/129 (31%) required time off work. 78/109 (60%) reported sleep disturbance with 26/78 (33%) of moderate or severe severity. 56/129 (45%) required medical evaluation of their WRMSP and 25/129 (19%) received a formal diagnosis of musculoskeletal injury. Those with 11+ years of experience were significantly more likely to receive a formal diagnosis of WRMSP (p = 0.002) and require medication (p = 0.006) compared to those with 10 years or less experience. CONCLUSION: WRMSP is very common amongst echocardiographers, with a fifth having a related musculoskeletal injury. WRMSP has considerable on impact on personal, social and work-related activities. Strategies to reduce the burden of WRMSP are urgently required to ensure sustainability of the workforce and patient access to imaging.

Circulating plasma and platelet 5-hydroxytryptamine in carcinoid heart disease: a pilot study.

BACKGROUND AND AIM OF THE STUDY: Carcinoid heart disease (CaHD) is a rare form of valvular heart disease in patients with carcinoid syndrome (CS). The role of 5-hydroxytryptamine (5-HT) in the pathogenesis of CaHD is unclear. The study aim was to evaluate the association between platelet 5-HT (5-HTplt) and plasma 5-HT (5-HTpls) and valvular dysfunction. METHODS: Twelve patients with CaHD, 18 with CS and 10 'normal' subjects were recruited. Patients with CaHD underwent cardiac catheterization and echocardiography. 5-HTplt and 5-HTpls was sampled in blood from the femoral vein, right and left ventricle, and left antecubital fossa vein. RESULTS: Levels of 5-HTpls and 5-HTplt were significantly higher in patients with CaHD (median 5-HTpls 325 nmol/l and 5-HTplt 18.9 nmol/10(9) platelets) and CS (median 5-HTpls 155 nmol/l and 5-HTplt 16.4 nmol/10(9) platelets) when compared to healthy controls (median 5-HTpls 9 nmol/l and 5-HTplt 3.7 nmol/10(9) platelets; p < 0.0001 and p = 0.003, respectively). There was a significant increase in 5-HTplt and 5-HTpls between the femoral vein and right heart (p = 0.007 and p = 0.0002, respectively). There was no significant difference in 5-HTplt or 5-HTpls between the right and left side of the heart, irrespective of the presence of a patent foramen ovale or of left-sided CaHD. CONCLUSION: Plasma and platelet 5-HT levels are elevated in patients with CaHD. Despite exposure to similar levels of intracardiac plasma and platelet 5-HT, the development of valve dysfunction is heterogeneous. This suggests that individual heart valves have a susceptibility to the development of valvular dysfunction which is not related solely to plasma or platelet 5-HT levels.

Risk stratification in asymptomatic severe aortic stenosis: a critical appraisal.

Aortic stenosis is one of the most common forms of acquired valvular heart disease. The development of symptoms, namely syncope, angina, or heart failure, in patients with severe aortic stenosis predicts a high likelihood of mortality. Aortic valve replacement is the current standard of care. In truly asymptomatic patients, the risk of sudden death is perceived to be low; therefore many advocate conservative management of these patients until symptoms develop. Emerging data suggest that certain markers may identify subsets of asymptomatic patients who are at a high risk of cardiac events. This review critically appraises the growing plethora of adverse prognostic markers that have been identified and evaluates how these parameters may influence clinical practice and potentially identify patients in whom early surgical intervention is warranted.

Right ventricular echocardiographic parameters and prediction of stroke volume in ischemic cardiogenic shock: A retrospective study.

PURPOSE: This study investigated which commonly used right ventricular (RV) echocardiographic parameter correlates best with stroke volume (SV) estimated by Doppler echocardiography in ischemic cardiogenic shock (CS). MATERIALS AND METHODS: We retrospectively reviewed the records of 100 patients admitted to the ICU over 34 months with CS. Tricuspid annular plane systolic excursion (TAPSE), Tricuspid annulus systolic velocity (RV S'), Tricuspid regurgitation maximum velocity (TR Vmax), and RV outflow tract velocity time integral (RVOT VTI) were correlated to SV. RESULTS: Mean age was 62.6 ± 12.7 years and 78% were male. The mean SV, TAPSE, RV S', TR Vmax, and RVOT VTI were 47 ± 16 ml, 16 ± 5 mm, 11 ± 4 mm/s, 1.97 ± 0.73 m/s, and 12.7 ± 5 cm, respectively. RVOT VTI correlated best to SV (r = 0.39 p = 0.01) compared to TAPSE, RV S', and TR Vmax (r = 0.26 p = 0.01, r = 0.15 p = 0.21, r = 0.03 p = 0.78). RVOT VTI independently predicted SV. Univariate analysis demonstrated that only RVOT VTI predicted SV (OD = 1.18 p = 0.04) and had the best area under the curve (0.70, p = 0.03). CONCLUSION: RVOT VTI correlated better (albeit weakly) to and best predicted SV compared to TAPSE, RV S', and TR Vmax in patients admitted to intensive care with CS. This study suggests that RVOT VTI has the potential as a therapeutic target to optimize SV in CS.