The feasibility, reliability, and incremental value of two-dimensional speckle-tracking for the detection of significant coronary stenosis after treadmill stress echocardiography.

BACKGROUND: Two-dimensional speckle-tracking echocardiography (STE) may help detect coronary artery disease (CAD) when combined with dobutamine stress echocardiography. However, few studies have explored STE with exercise stress echocardiography (ESE). We aimed to evaluate the feasibility, reliability, and incremental value of STE combined with treadmill ESE compared to treadmill ESE alone to detect CAD. METHODS: We conducted a case-control study of all consecutive patients with abnormal ESE in 2018-2020 who subsequently underwent coronary angiography within a six-month interval. We 1:1 propensity score-matched these patients to those with a normal ESE. Two blinded operators generated a 17-segment bull's-eye map of longitudinal strain (LS). We utilized the mean differences between stress and baseline LS values in segments 13-17, segment 17, and segments 15-16 to create receiver operator curves for the overall examination, the left anterior descending artery (LAD), and the non-LAD territories, respectively. RESULTS: We excluded 61 STEs from 201 (30.3%) eligible ESEs; 47 (23.4%) because of suboptimal image quality and 14 (7.0%) because of excessive heart rate variability precluding the calculation of a bull's-eye map. After matching, a total of 102 patients were included (51 patients in each group). In the group with abnormal ESE patients (mean age 66.4 years, 39.2% female), 64.7% had significant CAD (> 70% stenosis) at coronary angiogram. In the group with normal ESE patients (mean age 65.1 years, 35.3% female), 3.9% were diagnosed with a new significant coronary stenosis within one year. The intra-class correlation for global LS was 0.87 at rest and 0.92 at stress, and 0.84 at rest, and 0.89 at stress for the apical segments. The diagnostic accuracy of combining ESE and STE was superior to visual assessment alone for the overall examination (area under the curve (AUC) = 0.89 vs. 0.84, p = 0.025), the non-LAD territory (AUC = 0.83 vs. 0.70, p = 0.006), but not the LAD territory (AUC = 0.79 vs. 0.73, p = 0.11). CONCLUSIONS: Two-dimensional speckle-tracking combined with treadmill ESE is relatively feasible, reliable, and may provide incremental diagnostic value for the detection and localization of significant CAD.

Arrhythmic Risk Following Recovery of Left Ventricular Ejection Fraction in Patients with Primary Prevention ICD.

BACKGROUND: Left ventricular ejection fraction (LVEF) recovers during follow-up in a significant proportion of patients implanted with a cardioverter defibrillator (ICD) for primary prevention. Little is known about the midterm arrhythmic risk in this population, particularly in relation to the presence or absence of ischemic cardiomyopathy. METHODS AND RESULTS: We retrospectively analyzed 286 patients with an ICD implanted for primary prevention between 2002 and 2010. Patients were divided into two groups based on their last LVEF assessment: (1) Recovery, defined as an LVEF > 35%; and (2) No-Recovery, defined as an LVEF ≤ 35%. Kaplan-Meir curves and multivariate Cox regression analysis were performed separately for patients with ischemic (211 patients) and nonischemic (75 patients) cardiomyopathy. Forty-nine patients (17.1%) had LVEF recovery to >35% at last follow-up. Overall, 72 patients (25.2%) experienced ventricular arrhythmias requiring ICD therapy during a median follow-up of 4.4 years. With multivariate Cox regression, LVEF recovery was associated with a lower arrhythmic risk in the whole cohort (hazard ratio [HR]: 0.38 [0.13-0.85]; P = 0.02) and in the nonischemic cardiomyopathy cohort (HR: 0.10 [0.005-0.55]; P = 0.005), but not in the ischemic cardiomyopathy cohort (HR: 0.84 [0.25-2.10]; P = 0.74). CONCLUSION: In conclusion, patients with nonischemic cardiomyopathy who improved their LVEF to >35% after primary prevention ICD implantation were at very low absolute arrhythmic risk. Our study raises the possibility that the LVEF cutoff to safely withhold ICD replacement might be higher in patients with ischemic compared to nonischemic cardiomyopathy. This will need to be confirmed in prospective studies.

Left ventricular ejection fraction assessment by non-cardiologists from transverse views using a simplified wall motion score index.

For the non-cardiologist emergency physician and intensivist, performing an accurate estimation of left ventricular ejection fraction (LVEF) is essential for the management of critically ill patients, such as patients presenting with shock, severe respiratory distress or chest pain. Our objective was to develop a semi-quantitative method to improve visual LVEF evaluation. A group of 12 sets of transthoracic echocardiograms with LVEF in the range of 18-64% were interpreted by 17 experienced observers (PRO) and 103 untrained observers or novices (NOV), without previous training in echocardiography. They were asked to assess LVEF by two different methods: i) visual estimation (VIS) by analysing the three classical left ventricle (LV) short-axis views (basal, midventricular and apical short-axis LV section) and ii) semi-quantitative evaluation (base, mid and apex (BMA)) of the same three short-axis views. The results for each of these two methods for both groups (PRO and NOV) were compared with LVEF obtained by radionuclide angiography. The semi-quantitative method (BMA) improved estimation of LVEF by PRO for moderate LV dysfunction (LVEF 30-49%) and normal LVEF. The visual estimate was better for lower LVEF (<30%). In the NOV group, the semi-quantitative method was better than than the visual one in the normal group and in half of the subjects in the moderate LV dysfunction (LVEF 30-49%) group. The visual estimate was better for the lower LVEF (ejection fraction <30%) group. In conclusion, semi-quantitative evaluation of LVEF gives an overall better assessment than VIS for PRO and untrained observers.

Ventricular septal rupture and right ventricular free wall dissection after inferior myocardial infarction: a case report and review of the literature.

Ventricular septal rupture (VSR) with dissection of the right ventricular free wall is an extremely rare complication after inferior myocardial infarction. Mortality is 100% without surgical treatment. The optimal surgical strategy remains unclear because of the limited number of cases, but repair of VSR alone might be equally effective as repair of VSR and right ventricular free wall reconstruction. Transesophageal echocardiography is an important adjunct to transthoracic echocardiography to establish the diagnosis.