No effects of cardiac resynchronization therapy and right ventricular pacing on the right ventricle in patients with heart failure and atrial fibrillation.

BACKGROUND: The right ventricle (RV) function is crucial in heart failure with reduced ejection fraction (HFrEF), especially in patients with atrial fibrillation (AF). Aims. To assess the RV structure and function in patients with HFrEF, permanent atrial fibrillation (AF), cardiac resynchronization therapy (CRT) and RV pacing (RVp) with two- and three-dimensional echocardiography. Methods. Patients with ischemic HFrEF (NYHA II-III; LVEF ≤40%) were enrolled. The studied groups were: sinus rhythm (SR, control); AF and no implanted devices - AF/0; AF and CRT - AF/CRT; AF and RVp - AF/RVp. Two- and three-dimensional echocardiographic parameters of RV structure and function were analyzed in study groups. Results. The study included a group of 126 patients: n = 32 with SR, n = 28 with AF/0, n = 25 with AF/CRT and n = 41 with AF/RVp. Results were worse in AF groups than in SR: right ventricular ejection fraction, %, mean (SD): SR - 48.2 (7.5), AF/0 - 36.5 (6.5), AF/CRT - 38.3 (7.6), AF/RVp - 37.1 (7.7), p < .001. Other parameters lower in AF groups than in SR were: RV end-systolic volume, longitudinal strain of the free wall and tricuspid lateral annular systolic velocity. There were no differences between groups with AF and CRT and RV pacing in other analyzed parameters between AF groups and SR. Conclusions. In heart failure with reduced left ventricular ejection fraction and atrial fibrillation right ventricular pacing and cardiac resynchronization therapy were not associated with modified right ventricular function. Further prospective studies are needed to evaluate prognostic significance of these results.

Diagnostic utility of two-dimensional speckle tracking echocardiography to identify ischemic etiology of left ventricular systolic dysfunction.

BACKGROUND: The differentiation between dilated cardiomyopathy (DCM) and systolic dysfunction caused by coronary artery disease (CAD) based on clinical and echocardiographic presentation can be difficult in some cases. AIM: Our study aimed to define differences in myocardial function between patients with ischemic and nonischemic etiology of reduced left ventricular ejection fraction using 2D speckle tracking echocardiography (STE). MATERIAL AND METHODS: We retrospectively analyzed 90 patients (mean age 65 ± 11 years, 70% male) with de novo diagnosed reduced left ventricular ejection fraction (≤45% as determined by the transthoracic echocardiography), who were referred for coronary angiography to determine the presence of significant CAD. On the basis of coronary angiography results, patients were divided into two subgroups as follows: 45 subjects with significant CAD (group A) and 45 subjects without CAD (group B). Acquired transthoracic echocardiographic images were assessed off-line using 2DSTE. In each patient, we calculated arithmetic mean, median value, and standard deviation of regional longitudinal strain and strain rate of 18 left ventricular segments. RESULTS: Standard deviation of the regional peak early diastolic strain rate was significantly higher in group A than in group B (P = 0.01). The cutoff value with the highest diagnostic value was >0.37/s-its sensitivity and specificity for the diagnosis of CAD were 73% and 53%, respectively. The remaining parameters did not differ significantly between the study groups. CONCLUSIONS: Patients with systolic dysfunction resulting from CAD have significantly more heterogeneous regional longitudinal early diastolic strain rate assessed by 2DSTE than patients with DCM.

Quality control of B-lines analysis in stress Echo 2020.

BACKGROUND: The effectiveness trial "Stress echo (SE) 2020" evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion. PURPOSE: To provide web-based upstream quality control and harmonization of B-lines reading criteria. METHODS: 60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module ( http://se2020.altervista.org ). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics. RESULTS: All 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p < .01), the first attempt success rate was higher (43 vs 28%, p < 0.01), and the drop-out of readers smaller (0 vs 28%, p < .01). CONCLUSIONS: Web-based learning is highly effective for teaching and harmonizing B-lines reading. Echocardiographers without previous experience with B-lines learn quickly.

Incremental value of left atrial mechanical dispersion over CHA2 DS2 -VASc score in predicting risk of thrombus formation.

PURPOSE: To assess the potential ability of two-dimensional speckle tracking analysis (STE) during atrial fibrillation (AF) to identify patients with LA appendage thrombi (LAAT). METHODS: This study involved 93 patients with AF (39% female, 67.1 ± 9.5 years) who were referred for a clinical indication for transesophageal echocardiography (TEE). TEE revealed LAAT in 39 (42%) patients. We analyzed standard parameters of the left ventricle (LV) and LA in transthoracic echocardiography. Using STE, we assessed LV global longitudinal strain (LVGLS), peak atrial longitudinal strain (PALS), and intra-atrial asynchrony. The PALS was calculated using the global strain curve (GPALS) and as the mean of peaks derived from segmental strain curves (MPALS). RESULTS: Patients were comparable with regard to the clinical data. A subgroup with LAAT had lower LV ejection fraction (LVEF) and a lower absolute value of the LVGLS, as well as greater impairment in the LA standard parameters, PALS, and asynchrony. Receiver operating characteristic curve analysis revealed that the LVEF of 30% (P < .001), the LVGLS of -7% (P < .0001), the GPALS of 11% (P < .005), and the LA asynchrony of 22% (P < .01) were the optimal cutoff values for distinguishing both subgroups. LA asynchrony, LVEF, and LVGLS were independently associated with the presence of LAAT in multivariate analyses, and PALS had additional significance over the CHA2 DS2 -VASc score. CONCLUSIONS: Left ventricular systolic dysfunction characterized by both LVEF and LVGLS is an independent factor for LAAT. LA asynchrony provides additional diagnostic value for discriminating between patients with and without LAAT.

Bicuspid aortic valve morphology and its impact on aortic diameters-A systematic review with meta-analysis and meta-regression.

AIM: To evaluate the impact of the 2 most common bicuspid aortic valve (BAV) morphology patterns [right-left (RL) vs right-noncoronary (RN) cusp fusion] on the aortic diameters and the impact of gender, aortic stenosis (AS), aortic regurgitation (AR), and age on the observed effects. METHODS: The PubMed databases was searched up to December 31, 2016 to identify studies investigating the morphology of BAV and aortic diameters. Inclusion criteria were as follows: the data on diameter of sinuses of Valsalva (SVD) and/or ascending aorta (AAD) and BAV morphology. The additional characteristics [gender, AS and AR (% of patients with moderate or severe AS/AR) and mean age] were collected to perform a meta-regression analysis. RESULTS: A total of 12 studies with 2192 patients with indexed AAD, 15 studies with 3104 patients with nonindexed AAD and 8 studies with 1271 patients with indexed SVD, and 16 studies with 3454 patients with nonindexed SVD were included. There was no difference between RL and RN group in indexed/nonindexed AAD-mean difference (MD): 0.06 mm/m2 (95% CI: -0.65 to 0.77 mm/m2 , P = .87) and -0.06 mm (95% CI: 1.10-0.97 mm, P = .91). Differently, the RL BAV was associated with larger indexed/nonindexed SVD than RN phenotype-MD: 1.66 mm/m2 (95% CI: 0.83-2.49 mm/m2 , P < .001) and 2.03 mm (95% CI: 0.97-3.09 mm, P < .001). Age, gender, AS, and AR had no influence on observed differences. CONCLUSIONS: RL BAV phenotype is associated with larger SVD than RN BAV, and the observed differences are independent from aortic valve dysfunction degree, age, and gender.

The impact of the latest echocardiographic chamber quantification recommendations on the prediction of left atrial appendage thrombus presence by transthoracic echocardiography.

INTRODUCTION: The latest recommendations for echocardiographic chamber quantification have implemented updated normal values for all cardiac chambers. PURPOSE: To evaluate the incidence of normal and abnormal values of routine echocardiographic parameters such as left ventricular ejection fraction (LVEF) and left atrial volume indexed to body surface area (LAVi) in patients with non-valvular atrial fibrillation (AF) and to determine the influence of LVEF and LAVi reclassification on the prediction of LAAT by transthoracic echocardiography. METHODS: We retrospectively analysed the database of 1674 transesophageal echocardiograms performed between 2012 and 2015 in our echo lab. The study involved patients (mean age 70 ± 7 years, 80% men) with paroxysmal or persistent AF (35 patients with left atrial appendage thrombus [LAAT] and 35 sex- and age-matched controls without LAAT). LVEF and LAVi were categorised in two ways: semi-quantitative using four-degree scale (normal or abnormal graded from mild and moderate to severe) and qualitative (normal vs. abnormal). RESULTS: We reclassified 6 (9%) and 4 (6%) patients with regard to LVEF as well as 38 (54%) and 16 (23%) with regard to LAVi on semi-quantitative and qualitative scale, respectively. After adjustment for effective anticoagulation and approved risk factors in the multivariate models, we identified LVEF categorised in semi-quantitative manner according to both documents, LAVi categorised in a binary manner by new guidelines and semi-quantitative scale by both recommendations as independently associated with LAAT. CONCLUSIONS: Differentiation between normal and abnormal value enhanced the diagnostic meaning of LAVi in the aspect of higher LAAT risk. LVEF reclassification had no significant influence.

Bedside screening with the use of pocket-size imaging device can be useful for ruling out carotid artery stenosis in patients scheduled for cardiac surgery.

BACKGROUND: Patients (pts) scheduled for coronary artery bypass grafting, burdened with high risk of carotid stenosis, are recommended to undergo duplex ultrasonography (DUS) of carotid arteries. PURPOSE: To validate pocket-size imaging device (PSID) equipped with linear probe as an easily accessible tool enabling bedside screening for carotid artery stenosis (CAS). METHODS: A total of 100 pts (60 men, mean age 69±11 years) with multivessel coronary artery disease underwent bedside DUS of carotid arteries with the use of PSID performed by a cardiology resident trained in DUS. Subsequently, DUS with the use of stationary high-end ultrasound system was performed in all pts to verify findings of PSID examination. RESULTS: Initial diagnosis of atherosclerotic plaque presence obtained with PSID in 59 patients was confirmed by high-end ultrasound system examination in all cases. There was a statistically significant correlation of intima-media thickness measurements between PSID and stationary system (r=.58; 95% CI: 0.48-0.66; P<.0001), but the coefficient of agreement (κ) between the two methods in classification of intima-media as normal or thickened (>0.9 mm) was only .38 (95% CI: 0.299-0.459). During PSID examination, turbulent flow was observed in 21 pts-CAS was confirmed in all these pts-5 pts were diagnosed with significant CAS, the rest with CAS ranging from 30% to 70%. CONCLUSIONS: Pocket-size imaging device equipped with linear probe allows for identification of patients with atherosclerotic plaques and turbulent flow in carotid arteries; however, the degree of CAS cannot be reliably determined. The measurement accuracy of intima-media thickness is insufficient for a diagnostic purpose.

Left Atrial Dysfunction Assessed by Two-Dimensional Speckle Tracking Echocardiography in Patients with Impaired Left Ventricular Ejection Fraction and Sleep-Disordered Breathing.

AIMS: To evaluate the relationship between left atrial (LA) structure and deformation obtained by two-dimensional speckle tracking echocardiography (2DSTE): peak longitudinal systolic strain (LAs), peak longitudinal systolic strain rate (LAS-SR), peak longitudinal early diastolic strain rate (LAE-SR), peak longitudinal late diastolic strain rate (LAA-SR), and sleep-disordered breathing (SDB) estimated by means of apnea-hypopnea index (eAHI). METHODS: Thirty-two individuals with ischemic heart disease (IHD) and impaired left ventricular ejection fraction (EF < 50%) were included in the study. LA function was assessed using 2DSTE. eAHI index was calculated by means of the 24-hour ambulatory Holter electrocardiogram monitoring. Patients were categorized into two subgroups: SDB group (eAHI ≥ 15; n = 15) and non-SDB group (eAHI < 15; n = 17). RESULTS: All 2DSTE parameters were decreased in the SDB group: LAS-SR (0.90 [0.60-1.25] 1/sec vs. 1.25 [1.00-1.27] 1/sec, P = 0.043), LAE-SR (-0.76 ± 0.49 1/sec vs. -1.18 ± 0.55 1/sec, P = 0.033), and LAA-SR (-1.26 ± 0.71 1/sec vs. -1.48 ± 0.75 1/sec, P = 0.049). The eAHI was negatively correlated with LA reservoir function: LAS (r = -0.53, P = 0.002) and LAS-SR (r = -0.47, P = 0.006), while it is positively correlated with LAE-SR (r = 0.67, P < 0.001) and LAA-SR (r = 0.46, P = 0.009). Moreover, SDB severity was an independent predictor of impaired LA compliance (P = 0.016) and conduit function (P = 0.002) in multivariate linear regression model, even after adjustment for age, BMI, gender, LV systolic (EF), and diastolic (E/e') function and comorbidities. CONCLUSIONS: LA dysfunction and remodeling assessed using 2DSTE in patients with impaired systolic LV function, and IHD is influenced by the severity of sleep apnea independently from LV function.

Giant J-wave and Brugada-like pattern in a patient with severe hypothermia.

We describe a patient with severe hypothermia, in whom the electrocardiogram showed giant J-waves, also known as Osborn waves, distinguishable in the inferior and anterolateral leads. Moreover, a Brugada-like pattern was also visible in leads V2 and V3. The presented case and ECG findings may contribute to the discussion about the pathophysiologic mechanism underlying Brugada syndrome and giant J-wave.

The use of artificial intelligence for predicting postinfarction myocardial viability in echocardiographic images.

BACKGROUND: Evaluation of standard echocardiographic examination with artificial intelligence may help in the diagnosis of myocardial viability and function recovery after acute coronary syndrome. METHODS: Sixty-one consecutive patients with acute coronary syndrome were enrolled in the present study (43 men, mean age 61 ± 9 years). All patients underwent percutaneous coronary intervention (PCI). 533 segments of the heart echo images were used. After 12 ± 1 months of follow-up, patients had an echocardiographic evaluation. After PCI each patient underwent cardiac magnetic resonance (CMR) with late enhancement and low-dose dobutamine echocardiographic examination. For texture analysis, custom software was used (MaZda 5.20, Institute of Electronics).Linear and non-linear (neural network) discriminative analyses were performed to identify the optimal analytic method correlating with CMR regarding the necrosis extent and viability prediction after follow-up. Texture parameters were analyzed using machine learning techniques: Artificial Neural Networks, Namely Multilayer Perceptron, Nonlinear Discriminant Analysis, Support Vector Machine, and Adaboost algorithm. RESULTS: The mean concordance between the CMR definition of viability and three classification models in Artificial Neural Networks varied from 42% to 76%. Echo-based detection of non-viable tissue was more sensitive in the segments with the highest relative transmural scar thickness: 51-75% and 76-99%. The best results have been obtained for images with contrast for red and grey components (74% of proper classification). In dobutamine echocardiography, the results of appropriate prediction were 67% for monochromatic images. CONCLUSIONS: Detection and semi-quantification of scar transmurality are feasible in echocardiographic images analyzed with artificial intelligence. Selected analytic methods yielded similar accuracy, and contrast enhancement contributed to the prediction accuracy of myocardial viability after myocardial infarction in 12 months of follow-up.

Handheld ultrasound in cardiology: Current perspective.

The advantages of ultrasonography do not need to be discussed. It is suitable for use in diverse clinical settings and environments by operators with different backgrounds. Recent technological advances have led not only to the enhancement of the diagnostic capabilities of stationary ultrasound systems but also to miniaturization, which in turn led to the introduction of smartphone-sized handheld ultrasound devices (HUDs), designed to be used at bedside to improve and extend the scope of physical examination. Although diagnostic capabilities of HUDs are expanding, according to guidelines, they cannot be perceived as a tool suitable for performing full echocardiographic examination. However, their ultraportability made them essential for the bedside assessment, with the particular emphasis on the bedside focus cardiac ultrasound (FoCUS)-goal-oriented, limited echocardiographic screening. Clinically relevant cardiological targets suggested for HUDs include the assessment of left ventricular (LV) systolic function and size, assessment of other cardiac chambers, identification of gross valvular abnormalities, and detection of the pathological masses within the heart cavities. Handheld ultrasound devices may be also helpful in identifying pleural effusion or subpleural consolidations; furthermore, brief ultrasonographic assessment of "lung comets" enables the estimation of the level of congestion. Ultrasound screening for certain vascular abnormalities also appears promising. The limitations of HUDs are rather obvious and caution is needed to distinguish the role of HUD-based bedside-limited scan from comprehensive stationary echocardiography. It appears that the right approach is to treat them as complementary tools proving their capabilities in diverse clinical scenarios.

Integrated Assessment of Heart, Lung and Lower Extremity Veins Using Hand-Held Ultrasound Device in COVID-19 Patients: Feasibility and Clinical Application.

The emergence of the COVID-19 pandemic caused a significant shortage of medical personnel and the prioritization of life-saving procedures on internal medicine and cardiology wards. Thus, the cost- and time-effectiveness of each procedure proved vital. Implementing elements of imaging diagnostics into the physical examination of COVID-19 patients could prove beneficial to the treatment process, providing important clinical data at the moment of admission. Sixty-three patients with positive COVID-19 test results were enrolled into our study and underwent physical examination expanded with a handheld ultrasound device (HUD)-performed bedside assessment included: right ventricle measurement, visual and automated LVEF assessment, four-point compression ultrasound test (CUS) of lower extremities and lung ultrasound. Routine testing consisting of computed-tomography chest scanning, CT-pulmonary angiogram and full echocardiography performed on a high-end stationary device was completed in the following 24 h. Lung abnormalities characteristic for COVID-19 were detected in CT in 53 (84%) patients. The sensitivity and specificity of bedside HUD examination for detecting lung pathologies was 0.92 and 0.90, respectively. Increased number of B-lines had a sensitivity of 0.81, specificity 0.83 for the ground glass symptom in CT examination (AUC 0.82; p < 0.0001); pleural thickening sensitivity 0.95, specificity 0.88 (AUC 0.91, p < 0.0001); lung consolidations sensitivity 0.71, specificity 0.86 (AUC 0.79, p < 0.0001). In 20 patients (32%), pulmonary embolism was confirmed. RV was dilated in HUD examination in 27 patients (43%), CUS was positive in two patients. During HUD examination, software-derived LV function analysis failed to measure LVEF in 29 (46%) cases. HUD proved its potential as the first-line modality for the collection of heart-lung-vein imaging information among patients with severe COVID-19. HUD-derived diagnosis was especially effective for the initial assessment of lung involvement. Expectedly, in this group of patients with high prevalence of severe pneumonia, HUD-diagnosed RV enlargement had moderate predictive value and the option to simultaneously detect lower limb venous thrombosis was clinically attractive. Although most of the LV images were suitable for the visual assessment of LVEF, an AI-enhanced software algorithm failed in almost 50% of the study population.

Diagnostic utility and clinical usefulness of the pocket echocardiographic device.

BACKGROUND: The pocket echocardiograph (PE) with color Doppler imaging belongs to a new class of diagnostic tools, the feasibility and accuracy of which is not well established. The aim of this study was to assess the feasibility and diagnostic value of transthoracic echocardiography (TTE) performed with the use of PE by a cardiology resident (2nd year of training) and by an experienced cardiologist. METHODS: The study population comprised 220 consecutive patients (142 men, mean age 63 ± 8 years), 110 of whom were admitted to our intensive cardiac care unit (ICU) and 110 patients referred for TTE from the outpatient clinic. All patients had PE TTE performed by a resident (60 ICU patients, 60 outpatients) or a cardiologist (50 ICU patients, 50 outpatients). Within 24 h of PE TTE, all subjects had a standard TTE (sTTE) performed by an experienced echocardiographer. RESULTS: 96% of patients had echocardiographic measurements completed by both PE TTE and sTTE. The dimensions measured with PE TTE by the resident and the cardiologist showed good to excellent correlation with sTTE (r = 0.64-0.96, P < 0.001). The agreement in detection of various pathologies between PE TTE performed by the resident and sTTE examinations was moderate to very good, whereas it was good to excellent if PE TTE was performed by the experienced cardiologist. CONCLUSION: The diagnostic accuracy of the PE in basic assessment of cardiac morphology and function as compared to standard echocardiography is moderate to very good for a cardiology resident and good to excellent for an experienced cardiologist. (Echocardiography 2012;29:1-6).

Continuous hands-free monitoring of echocardiographic exercise test using probe fixation device.

BACKGROUND: Stress echocardiography has been widely used in clinical practice for decades and has recently gained even more importance in diagnostic approaches to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise tests. The aim herein, is to assess the feasibility of probe fixation for use during exercise echocardiography. METHODS: Forty-eight subjects (47 men, mean age 42 ± 17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). The semi-quantitative quality of acquired apical views were assessed at each stage using a four-point grading system. RESULTS: The mean time required for probe fixation was 9 ± 2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. Twenty-five patients required probe repositioning during exercise (more often on a treadmill). During peak exercise quality of images in all views declined, but for diagnostic purposes it remained sufficient in 29 patients. Thus, 76% of performed tests (60% study population) had sufficient image quality. CONCLUSIONS: Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. The device is suitable almost exclusively for male patients and in some patients requires repositioning.

Complexity of changes in right ventricular morphology and function in patients undergoing cardiac surgery - 3D echocardiographic study.

BACKGROUND: An impairment of standard echocardiographic parameters of right ventricular (RV) function is a known phenomenon in patients undergoing cardiac surgery, but its significance remains unclear. AIMS: This study aimed to assess changes in RV function in patients undergoing cardiac surgery using speckle tracking and 3D echocardiography. METHODS: The study population comprised 122 patients referred for cardiac surgery. Transthoracic echocardiographic (TTE) examinations were performed: before the surgery (TTE1), 1 week after surgery (TTE2), and 1 year after surgery (TTE 3). Parameters measured during these examinations included both standard and advanced indices of the RV size and function, as well as a new parameter introduced by our team - RV shortening fraction (RV SF). RESULTS: TTE1 was performed on average (standard deviation [SD]) 24 (15) hours before surgery, whereas TTE2 and TTE3 were performed on average 7.2 (3) days and 346 (75) days after the surgery, respectively. A postoperative impairment of parameters of RV longitudinal function was observed (P <0.001). However, neither the RV size assessed by both 2D and 3D techniques changed, nor the global RV function measured with the use of fractional area change and ejection fraction. Additionally, during the postoperative period, an increase in the value of an RV SF by 12.9% was observed. After 12 months we observed an improvement in the parameters of the longitudinal RV function. CONCLUSIONS: Uncomplicated cardiac surgery causes transient impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RV SF. After 12 months, an improvement of the longitudinal function can be observed.

Feasibility and clinical utility of real-time tele-echocardiography using personal mobile device-based pocket echocardiograph.

Introduction: Recently introduced microUSB ultrasound probe, which can be connected to personal mobile device constitutes a new class of diagnostic pocket size imaging devices (PSID).The aim of this study was to assess the feasibility and clinical utility of real-time tele-echocardiography with the use such device. Material and methods: The study group comprised 30 patients (18 men and 12 women; mean age: 54 ±14 years; mean body mass index: 27 ±6 kg/m2), admitted to various hospital departments (infectious diseases, internal medicine and cardiology). All patients underwent focused echocardiographic examination performed by an inexperienced operator using PSID and collaborating remotely in real-time with cardiologist by means of tele-consultation. Before commencing the examination, the operators underwent 1 h training in use of the PSID. Results: In most of patients PSID imaging provided sufficient diagnostic image quality. The dimensions of left ventricle, left atrium and the aorta obtained during the this examination showed good correlation with standard echocardiography (r = 0.89, r = 0.82, r = 0.92 respectively), but the correlation for TAPSE measurements was less pronounced (r = 0.52). The agreement in detection of pathologies (wall motion abnormalities, morphological and functional valvular abnormalities) between the tele-echocardiography and standard echocardiographic examination was good to very good (κ ranged from 0.648 to 0.823). Conclusions: Pocket size imaging devices allows an inexperienced operator to perform a focused echocardiographic examination under a remote supervision of an experienced cardiologist. The introduction of new technology in the form of PSID with tele-echocardiography feature can revolutionize access to this imaging technique.

Flow-mediated skin fluorescence: A novel method for the estimation of sleep apnea risk in healthy persons and cardiac patients.

BACKGROUND: A pilot study revealed a relationship between the results of flow mediated skin fluorescence (FMSF) and of ECG-Holter-based estimated apnea/hypopnea index (eAHI) in asymptomatic individuals. The aim of this study was to test whether the results of FMSF show a relationship with the eAHI in patients with coronary artery disease or aortic stenosis. METHODS: Twenty-one patients (12 coronary disease, 9 aortic stenosis) and 37 healthy volunteers were included. FMSF was assessed before, during and after the pressure occlusion of the brachial artery, using a prototype device allowing the quantification of skin fluorescence. The values of FMSF expressed as baseline (BASE), maximum (MAX), and minimum (MIN) were analyzed. The percentages of ischemic response (IR) and hyperemic response (HR) were calculated. The eAHI was assessed from night ECG-Holter recordings. Differences between the groups and the relationships between the parameters were analyzed statistically. RESULTS: Mean ± standard deviation of BASE, MAX, MIN and IR were not significantly different in both groups (p > 0.05). HR was significantly lower in cardiac patients (14.7 ± 7.5 vs. 11.8 ± 5.1; p = 0.048), whose eAHI was significantly higher (11.0 ± 7.4 vs. 36.3 ± 16.5; p < 0.01). Negative correlation for MAX and eAHI was found in volunteers and patients: r = -0.38, p = 0.02 and r = -0.47, p = 0.03, respectively. In volunteers, HR had a negative correlation with eAHI: r = -0.34, p = 0.04. CONCLUSIONS: This pioneer study confirms that FMSF can be used to detect the negative correlation between MAX fluorescence and eAHI not only among healthy volunteers, but also among cardiac patients with coronary artery disease or aortic stenosis.

Long-term prognostic value of dipyridamole stress myocardial contrast echocardiography.

AIMS: The aim of this prospective study was to determine long-term prognostic value of myocardial contrast echocardiography (MCE) combined with high-dose dipyridamole stress echocardiography (DSE) in patients undergoing diagnostic work-up for stable coronary artery disease (CAD). METHODS: A total of 202 consecutive patients (67% males, age 57±8 years) with suspected or known stable CAD scheduled for coronary angiography underwent high-dose dipyridamole/atropine stress echocardiography (dipyridamole 0.84 mg/kg, iv; atropine up to 1 mg, iv) with MCE at baseline and peak stress. In 102 patients MCE was performed using electrocardiographic-triggered end-systolic harmonic imaging and in 100 patients using real-time MCE. Contrast enhancement was obtained by repeated iv boluses of contrast and was visually scored in 18 segments by consensus of 2 experienced observers. All patients completed prospective follow-up regarding major adverse cardiovascular events (cardiac mortality, revascularization, infarction and unstable angina) for a mean period of 32±11 months (range: 1-89 months). The prognostic value of inducible wall motion abnormalities (WMA) and perfusion defects (PD) was then analysed. RESULTS: CAD defined as ≥70% stenosis was found in 152 patients (75%). During follow-up major adverse cardiovascular events (MACE) occurred in 109 (54%) patients (10 deaths, 16 infarctions, 83 revascularizations). The presence of inducible WMA in DSE was associated with high risk of MACE [hazard ratio (HR): 5.4; 95% CI: 3.64-8.05, P<0.0001]. Cardiovascular complications were best predicted by the presence of any inducible abnormality-PD or WMA (HR: 6.1; 95% CI: 4.1-9.1, P<0.0001). CONCLUSION: Stress MCE is highly predictive of cardiovascular events in patients with suspected or known CAD in long-term follow-up.

Elevated resistin opposed to adiponectin or angiogenin plasma levels as a strong, independent predictive factor for the occurrence of major adverse cardiac and cerebrovascular events in patients with stable multivessel coronary artery disease over 1-year follow-up.

BACKGROUND: Adipokines such as adiponectin and resistin, as well as angiogenin, may be associated with inflammation and atherosclerosis. The relationship between their levels and prognosis in high risk patients is, however, still unclear. The aim of this study was to evaluate the prognostic value of these adipokines in patients with stable multivessel coronary artery disease (MCAD). MATERIAL/METHODS: The study group comprised 107 MCAD patients (74% males, mean age 63 ± 8 years). Adiponectin, resistin and angiogenin plasma levels were measured at admission and after 1-year follow-up. Primary end point (major adverse cardiac and cerebrovascular events--MACCE) was defined as cardiac death, nonfatal myocardial infarction, stroke, and hospitalization for angina or heart failure over a 1-year period. RESULTS: After 1-year follow-up, 9 (8%) patients died, all from cardiovascular causes. Primary end point was experienced by 32% of patients. Surgical treatment (CABG) was received by 51% of patients, while 49% were treated medically alone. Total cholesterol concentration levels ≥ 173 mg/dl were associated with a 7-fold increase (OR 7.3; 95% CI, 1.6-33.0); LDL ≥ 93.5 mg/dl with a 16-fold increase (OR 16.3; 95% CI, 2.8-93.8), and resistin ≥ 17.265 ng/ml with a 13-fold increase in MACCE risk (OR 13.5; 95% CI, 2.3-80.3). In multivariate analysis, a medical treatment strategy (p = 0.001), a higher CCS class (p = 0.004), resistin levels (p = 0.003) and a higher Gensini score (p = 0.03) were independent predictors of MACCE. CONCLUSIONS: In stable patients with MCAD, elevated plasma resistin (as opposed to adiponectin or angiogenin) is a strong, independent predictive factor for the occurrence of MACCE over 1-year follow-up.