Pulmonary Congestion During Exercise Stress Echocardiography in Ischemic and Heart Failure Patients.

BACKGROUND: Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE). METHODS: We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available. RESULTS: During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015-4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268-6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months). CONCLUSIONS: B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03049995.

Stress Echo 2030: The Novel ABCDE-(FGLPR) Protocol to Define the Future of Imaging.

With stress echo (SE) 2020 study, a new standard of practice in stress imaging was developed and disseminated: the ABCDE protocol for functional testing within and beyond CAD. ABCDE protocol was the fruit of SE 2020, and is the seed of SE 2030, which is articulated in 12 projects: 1-SE in coronary artery disease (SECAD); 2-SE in diastolic heart failure (SEDIA); 3-SE in hypertrophic cardiomyopathy (SEHCA); 4-SE post-chest radiotherapy and chemotherapy (SERA); 5-Artificial intelligence SE evaluation (AI-SEE); 6-Environmental stress echocardiography and air pollution (ESTER); 7-SE in repaired Tetralogy of Fallot (SETOF); 8-SE in post-COVID-19 (SECOV); 9: Recovery by stress echo of conventionally unfit donor good hearts (RESURGE); 10-SE for mitral ischemic regurgitation (SEMIR); 11-SE in valvular heart disease (SEVA); 12-SE for coronary vasospasm (SESPASM). The study aims to recruit in the next 5 years (2021-2025) ≥10,000 patients followed for ≥5 years (up to 2030) from ≥20 quality-controlled laboratories from ≥10 countries. In this COVID-19 era of sustainable health care delivery, SE2030 will provide the evidence to finally recommend SE as the optimal and versatile imaging modality for functional testing anywhere, any time, and in any patient.

Hemodynamic Heterogeneity of Reduced Cardiac Reserve Unmasked by Volumetric Exercise Echocardiography.

BACKGROUND: Two-dimensional volumetric exercise stress echocardiography (ESE) provides an integrated view of left ventricular (LV) preload reserve through end-diastolic volume (EDV) and LV contractile reserve (LVCR) through end-systolic volume (ESV) changes. PURPOSE: To assess the dependence of cardiac reserve upon LVCR, EDV, and heart rate (HR) during ESE. METHODS: We prospectively performed semi-supine bicycle or treadmill ESE in 1344 patients (age 59.8 ± 11.4 years; ejection fraction = 63 ± 8%) referred for known or suspected coronary artery disease. All patients had negative ESE by wall motion criteria. EDV and ESV were measured by biplane Simpson rule with 2-dimensional echocardiography. Cardiac index reserve was identified by peak-rest value. LVCR was the stress-rest ratio of force (systolic blood pressure by cuff sphygmomanometer/ESV, abnormal values ≤2.0). Preload reserve was defined by an increase in EDV. Cardiac index was calculated as stroke volume index * HR (by EKG). HR reserve (stress/rest ratio) <1.85 identified chronotropic incompetence. RESULTS: Of the 1344 patients, 448 were in the lowest tertile of cardiac index reserve with stress. Of them, 303 (67.6%) achieved HR reserve <1.85; 252 (56.3%) had an abnormal LVCR and 341 (76.1%) a reduction of preload reserve, with 446 patients (99.6%) showing ≥1 abnormality. At binary logistic regression analysis, reduced preload reserve (odds ratio [OR]: 5.610; 95% confidence intervals [CI]: 4.025 to 7.821), chronotropic incompetence (OR: 3.923, 95% CI: 2.915 to 5.279), and abnormal LVCR (OR: 1.579; 95% CI: 1.105 to 2.259) were independently associated with lowest tertile of cardiac index reserve at peak stress. CONCLUSIONS: Heart rate assessment and volumetric echocardiography during ESE identify the heterogeneity of hemodynamic phenotypes of impaired chronotropic, preload or LVCR underlying a reduced cardiac reserve.

Valor pronóstico del strain longitudinal, medido por velocity vector imaging, en la estenosis aórtica grave asintomática con fracción de eyección conservada / Prognostic Value of Longitudinal Strain Measured by Velocity Vector Imaging, in Asymptomatic Severe Aortic Stenosis with Preserved Ejection

RESUMEN Introducción: Se han descripto alteraciones en el strain longitudinal sistólico (SLS) en pacientes con fracción de eyección (FE) conservada. El valor pronóstico del SLS en la estenosis aórtica (EAo) grave asintomática está en discusión. Objetivos: Evaluar si la medición de SLS mediante velocity vector imaging (VVI) predice la progresión y la indicación de reemplazo valvular aórtico (RVA) en pacientes asintomáticos con EAo grave y FE conservada, inicialmente asintomáticos. Materiales y métodos: Se seleccionaron pacientes con EAo grave y FE conservada que fueron considerados asintomáticos sin indicación inicial de RVA. A todos los pacientes se les realizó un ecocardiograma que evaluó el SLS de cada segmento en dos y tres y cuatro cámaras y el SLS global por el método VVI. Además, se realizó la medición del NT-proBNP. Se consideró como punto final el requerimiento de RVA. Resultados: Se evaluaron 57 pacientes con una edad de 69 ± 8 años, 49% mujeres. Luego de dos años de seguimiento 13 pacientes (22,8%) requirieron RVA. El grupo que requirió RVA presentó menor SLS global (-15,5 ± 3,4 versus -18,9 ± 3,1, p = 0,03) y SLS en dos cámaras (-12,8 ± 5,5 versus -16,3 ± 5,6, p = 0,04). En el análisis univariado, el SLS global, en NT-proBNP y la relación E/e´ fueron predictores del punto final, mientras que, en el multivariado, solo el SLS global se comportó como predictor independiente de requerimiento de RVA (HR: 1,28 (IC 95% 1,04-1,58), p = 0,01). Conclusiones: El SLS global medido por VVI fue predictor independiente de requerimiento de RVA.

ABSTRACT Background: Longitudinal systolic strain (LSS) abnormalitiess have been described in patients with preserved ejection fraction (EF). The prognostic value of LSS in asymptomatic severe aortic stenosis (AoS) is under discussion. Objetive: The aim of this study was to assess whether LSS assessment using velocity vector imaging (VVI) predicts the progression and indication of aortic valve replacement (AVR) in asymptomatic patients with severe AoS and preserved EF. Methods: The study included patients with severe AoS and preserved EF who were considered asymptomatic and without initial indication for AVR. They underwent two, three and four-chamber echocardiography that evaluated LSS of each segment and global longitudinal strain (GLS) by VVI, as well as NT-proBNP assessment. The primary endpoint was need for AVR. Results: A total of 57 patients with mean age 69±8 years, 49% women, were included in the study. After two years of follow-up, 13 patients (22.8%) required AVR. This group had lower GLS (-15.5±3.4 vs.-18.9±3.1, p=0.03) and two-chamber LSS (-12.8±5.5 vs.-16.3±5.6, p=0.04). In univariate analysis, GLS, NT-proBNP and the E/e' ratio were predictors of the endpoint, while in the multivariate analysis, only GLS was an independent predictor of need for AVR (HR: 1.28 (95% CI 1.04-1.58), p=0.01). Conclusions: Global longitudinal strain measured by VVI was an independent predictor of need for AVR.

Prediction of interatrial and interventricular electromechanical delays from P/QRS measurements: value for pacemaker timing optimization.

UNLABELLED: Cardiac pacing creates spurious delays between and within the cardiac chambers. These are: 1. Left atrial (LA) transport delay (ATD) either sensed (s) or paced (p), (time from right atrial P-wave to the end of LA transport (mitral Doppler A-wave)). 2. Interventricular delay (IVD), (time from onsets of right (RV) to left ventricular (LV) contractions). 3. P-sense offset (PSO), (time from P-onset to P-detection). Thus, restoration of left heart atrioventricular (AV) synchrony can be accomplished by compensating above delays, according to a previously published equation: RAV = ATD-IVD-PSO, where RAV = right heart AV. OBJECTIVE: To test the hypothesis that ATD could be predicted from Ps and Pp, and that interventricular delay (IVD) could be predicted from QRSp, using three-lead surface electrocardiograms (ECGs). METHODS: Thirty-six patients aged 63.5 +/- 15.5 years, 64% males, all with previously implanted DDD pacemakers, were studied by echo-Doppler and surface ECG obtained with a pacemaker programmer. Measurements included Ps; Pp; intrinsic QRSs; and paced QRSp, ATDs, ATDp, and IVD (difference between RVp and RVs left preejection intervals, PEI). Regressions between ECG and echo-Doppler intervals were calculated. RESULTS: Regressions and correlation coefficients: ATD (s+p) = 0.96*P + 55 (R = 0.94, P < 0.0001); PEIp = 0.75 * QRSp + 34.8 (R = 0.89, P< 0.0001); IVD = 0.39 *QRSp - 7.9 ms (R = 0.87, P = 0.002). CONCLUSIONS: Inter-atrial and inter-ventricular electromechanical delays can be predicted from P-wave and QRS durations. These measurements allow AV delay optimization in DDD and cardiac resynchronization therapy devices with no need of Doppler echocardiography.