Marine Litter Tracking System: A Case Study with Open-Source Technology and a Citizen Science-Based Approach.

It is well established that most of the plastic pollution found in the oceans is transported via rivers. Unfortunately, the main processes contributing to plastic and debris displacement through riparian systems is still poorly understood. The Marine Litter Drifter project from the Arno River aims at using modern consumer software and hardware technologies to track the movements of real anthropogenic marine debris (AMD) from rivers. The innovative "Marine Litter Trackers" (MLT) were utilized as they are reliable, robust, self-powered and they present almost no maintenance costs. Furthermore, they can be built not only by those trained in the field but also by those with no specific expertise, including high school students, simply by following the instructions. Five dispersion experiments were successfully conducted from April 2021 to December 2021, using different types of trackers in different seasons and weather conditions. The maximum distance tracked was 2845 km for a period of 94 days. The activity at sea was integrated by use of Lagrangian numerical models that also assisted in planning the deployments and the recovery of drifters. The observed tracking data in turn were used for calibration and validation, recursively improving their quality. The dynamics of marine litter (ML) dispersion in the Tyrrhenian Sea is also discussed, along with the potential for open-source approaches including the "citizen science" perspective for both improving big data collection and educating/awareness-raising on AMD issues.

Drones for litter mapping: An inter-operator concordance test in marking beached items on aerial images.

Unmanned aerial systems (UAS, aka drones) are being used to map macro-litter on the environment. Sixteen qualified researchers (operators), with different expertise and nationalities, were invited to identify, mark and categorize the litter items (manual image screening, MS) on three UAS images collected at two beaches. The coefficient of concordance (W) among operators varied between 0.5 and 0.7, depending on the litter parameter (type, material and colour) considered. Highest agreement was obtained for the type of items marked on the highest resolution image, among experts in litter surveys (W = 0.86), and within territorial subgroups (W = 0.85). Therefore, for a detailed categorization of litter on the environment, the MS should be performed by experienced and local operators, familiar with the most common type of litter present in the target area. This work provides insights for future operational improvements and optimizations of UAS-based images analysis to survey environmental pollution.

Feasibility and functional correlates of left atrial volume changes during stress echocardiography in chronic coronary syndromes.

An enlarged left atrial volume index (LAVI) at rest mirrors increased LA pressure and/or impairment of LA function. A cardiovascular stress may acutely modify left atrial volume (LAV) within minutes. Aim of this study was to assess the feasibility and functional correlates of LAV-stress echocardiography (SE) Out of 514 subjects referred to 10 quality-controlled labs, LAV-SE was completed in 490 (359 male, age 67 ± 12 years) with suspected or known chronic coronary syndromes (n = 462) or asymptomatic controls (n = 28). The utilized stress was exercise in 177, vasodilator in 167, dobutamine in 146. LAV was measured with the biplane disk summation method. SE was performed with the ABCDE protocol. The intra-observer and inter-observer LAV variability were 5% and 8%, respectively. ∆-LAVI changes (stress-rest) were negatively correlated with resting LAVI (r = - 0.271, p < 0.001) and heart rate reserve (r = -.239, p < 0.001). LAV-dilators were defined as those with stress-rest increase ≥ 6.8 ml/m2, a cutoff derived from a calculated reference change value above the biological, analytical and observer variability of LAVI. LAV dilation occurred in 56 patients (11%), more frequently with exercise (16%) and dipyridamole (13%) compared to dobutamine (4%, p < 0.01). At multivariable logistic regression analysis, B-lines ≥ 2 (OR: 2.586, 95% CI = 1.1293-5.169, p = 0.007) and abnormal contractile reserve (OR: 2.207, 95% CI = 1.111-4.386, p = 0.024) were associated with LAV dilation. In conclusion, LAV-SE is feasible with high success rate and low variability in patients with chronic coronary syndromes. LAV dilation is more likely with reduced left ventricular contractile reserve and pulmonary congestion.

Normal basic 2D echocardiographic values to screen and follow up the athlete's heart from juniors to adults: What is known and what is missing. A critical review.

In the last few years, multiple echocardiographic nomograms have been published. However, normal values calculated in the general population are not applicable to athletes, whose hearts may be enlarged and hypercontractile. Accordingly, athletes require specific nomograms. Our aim is to provide a critical review of echocardiographic nomograms on two-dimensional (2D) measures for athletes. We performed a systematic search in the National Library of Medicine for Medical Subject Headings and free text terms including echocardiography, athletes, normal values and nomograms. The search was refined by adding the keywords heart, sport, elite, master, children and young. Twenty-eight studies were selected for the final analysis. Our research revealed that currently available ranges of normality for athletes reported by different authors are quite consistent, with limited exceptions (e.g. atria, aorta). Numerical and methodological limitations, however, emerged. Numerical limitations included a limited sample size (e.g. < 450 subjects) of the population assessed and the paucity of data in women, non-Caucasian athletes, and junior and master athletes. Some data on M-mode measurements are available, while those for some specific structures (e.g. left atrial (LA) area and volumes, right ventricular diameters and aorta) are limited or rare (e.g. LA area). There was heterogeneity in data normalization (by gender, sport type and ethnicity) and their expression was limited to mean values (Z-scores have rarely been employed), while variability analysis was often lacking or incomplete. We conclude that comprehensive nomograms using an appropriate sample size, evaluating a complete dataset of 2D (and three-dimensional) measures and built using a rigorous statistical approach are warranted.

Functional, Anatomical, and Prognostic Correlates of Coronary Flow Velocity Reserve During Stress Echocardiography.

BACKGROUND: The assessment of coronary flow velocity reserve (CFVR) in left anterior descending coronary artery (LAD) expands the risk stratification potential of stress echocardiography (SE) based on stress-induced regional wall motion abnormalities (RWMA). OBJECTIVES: The purpose of this study was to assess the feasibility and functional correlates of CFVR. METHODS: This prospective, observational, multicenter study initially screened 3,410 patients (2,061 [60%] male; age 63 ± 11 years; ejection fraction 61 ± 9%) with known or suspected coronary artery disease and/or heart failure. All patients underwent SE (exercise, n = 1,288; vasodilator, n = 1,860; dobutamine, n = 262) based on new or worsening RWMA in 20 accredited laboratories of 8 countries. CFVR was calculated as the stress/rest ratio of diastolic peak flow velocity pulsed-Doppler assessment of LAD flow. A subset of 1,867 patients was followed up. RESULTS: The success rate for CFVR on LAD was 3,002 of 3,410 (feasibility = 88%). Reduced (≤2.0) CFVR was found in 896 of 3,002 (30%) patients. At multivariable logistic regression analysis, inducible RWMA (odds ratio [OR]: 6.5; 95% confidence interval [CI]: 4.9 to 8.5; p < 0.01), abnormal left ventricular contractile reserve (OR: 3.4; 95% CI: 2.7 to 4.2; p < 0.01), and B-lines (OR: 1.5; 95% CI: 1.1 to 1.9; p = 0.01) were associated with reduced CFVR. During a median follow-up time of 16 months, 218 events occurred. RWMA (hazard ratio: 3.8; 95% CI: 2.3 to 6.3; p < 0.001) and reduced CFVR (hazard ratio: 1.5; 95% CI: 1.1 to 2.2; p = 0.009) were independently associated with adverse outcome. CONCLUSIONS: CFVR is feasible with all SE protocols. Reduced CFVR is often accompanied by RWMA, abnormal LVCR, and pulmonary congestion during stress, and shows independent value over RWMA in predicting an adverse outcome.

Software integral de eco estrés para protocolo ABCDE de última generación / Stress Echo Comprehensive Software (SECS) for State-of-the-art ABCDE Protocol

RESUMEN Introducción: Existen diversos softwares especializados en el mercado para el almacenamiento electivo de datos de eco estrés (EE). El EE de última generación incorpora nuevos parámetros además de la motilidad parietal. Objetivo: Desarrollar un nuevo software para el almacenamiento de datos e informe de EE. Métodos: Desarrollamos el prototipo de Software Integral de EE (SIEE) con un conjunto mínimo de datos que permite la eventual recolección estandarizada de datos. El software corre en computadoras con capacidad de trabajo mediana-baja y con los sistemas operativos más usados (Windows, MAC OS y Linux). Las funciones de exportación hacia formatos altamente aceptados permiten compartir los datos fácilmente. El software es capaz de generar un informe personalizado que se puede expandir en PDF y en formatos de valores separados por comas. Resultados: El ingreso de datos en el programa prototipo requiere menos de 2 minutos por estudio. Las páginas principales se concentran en las 5 fases ABCDE del EE: fase A (motilidad parietal regional); fase B (líneas B con escaneo simplificado de 4 sitios); fase C (reserva contráctil con fuerza derivada de la presión arterial sistólica y volumen de fin de sístole; fase D (Doppler de reserva coronaria de la arteria descendente anterior); y fase E (reserva cronotrópica derivada del electrocardiograma medida como la razón de frecuencia cardíaca pico/reposo). La última página resume la información ABCDE en un modelo de predicción de riesgo (tasa de muerte cardiovascular anual, abarcando desde riesgo bajo <1% hasta riego alto >3%. Conclusión: El SIEE puede proporcionar una infraestructura adecuada para una aplicación clínica y de investigación avanzada, con un formato gráfico simple y opción de informe satisfactoria. Puede representar una solución intermedia entre la información exhaustiva requerida por los estándares científicos y la prioridad de un flujo de trabajo fluido de actividades relacionadas a la clínica con gran volumen de pacientes. Su validación en gran escala y la adaptación de acuerdo a la opinión de los usuarios es necesaria antes de su difusión a demanda.

ABSTRACT Background: Several specialized softwares are commercially available for the elective storage of stress echo (SE) data. State-of-the-art SE is based upon novel parameters in addition to regional wall motion. Objective: To develop a novel software for SE data storage and reporting. Methods: We developed the prototype of a SE Comprehensive Software (SECS) with a minimum data set eventually allowing standardized collection of data. The software runs with medium-low performance computers as well as with the most popular operating systems (Windows, MAC OS and Linux). The export functions towards widely accepted formats allow easy data sharing. The software is able to generate a customized report which can be expanded in PDF and comma-separated value formats. Results: The program prototype data entry requires <2 min per study. The main pages focus on the 5 steps of ABCDE-SE: step A (regional wall motion); step B (B-lines with 4-site simplified scan); step C (contractile reserve with force derived from systolic blood pressure and end-systolic volume); step D (Doppler-based coronary flow velocity reserve in left anterior descending coronary artery); step E (EKG-based chronotropic reserve measured as peak/rest heart rate). The final page graphically summarizes the ABCDE information in a risk prediction model (cardiac death rate per year, from low risk <1% to high risk >3 %). Conclusion: SECS may provide a suitable infrastructure for an advanced clinical and research application, with simple graphic format and convenient reporting option. It may represent a trade-off between exhaustive information required by scientific standards and smooth workflow priority of busy, high volume, clinically-driven activities. Large scale validation and adaptation from users' feedback is necessary prior to dissemination on demand.

Entrenamiento por etapas basado en la web: el camino hacia el Eco Estrés 2020 / Multi-step Web-based Training: the Road to Stress Echo 2020

RESUMEN Introducción: Una plataforma de entrenamiento estandarizada ayuda a armonizar la lectura de la ecocardiografía de estrés (EE) más allá de las anormalidades en la motilidad parietal regional (AMPR) Objetivo: Armonizar los criterios de lectura del EE a través de diferentes laboratorios. Métodos: El laboratorio central preparó para los lectores de ecocardiografía un módulo obligatorio de 5 parámetros basado en la web de 2 horas de duración: AMPR; líneas B, reserva de la velocidad de flujo coronario (RVFC) evaluada mediante la velocidad pico del flujo diastólico en la arteria coronaria descendente anterior; reserva contráctil ventricular izquierda (RCVI, evaluada a partir de mediciones crudas del volumen de fin de sístole, VFS); y presión sistólica de la arteria pulmonar (basada en mediciones crudas de la velocidad del jet de regurgitación tricuspídea, VRT). La prueba de control de calidad consistió en 20 casos seleccionados por el centro coordinador. El umbral de aprobación determinado a priori fue de 18/20 (> 90%) con un coeficiente de correlación intraclase entre el laboratorio coordinador y el lector periférico > 0.90. Resultados: Ochenta y cuatro lectores completaron la certificación para las AMPR, 65 para las líneas B, 30 para la RVFC, 24 para el VFS y 20 para la VRT. El tiempo de lectura medio por intento fue más corto para la VRT (9 ± 4 min), la RVFC (13 ± 6 min) y las líneas B (17 ± 3 min), intermedio para el VFS (24 ± 7 min), y más prolongado para las AMPR (29 ± 12 min, p < 0.01). La tasa de acierto del primer intento fue más alta para la RVFC (85%), intermedia para la VRT (75%) y las líneas B (43%), menor para el VFS (35%) y más baja para las AMPR (28%, p < 0.01). Conclusiones: La plataforma de aprendizaje basada en la web mejora las habilidades de interpretación de imágenes sin necesidad de un equipamiento de imágenes costoso o de estudiar un paciente. El camino hacia la certificación es más largo para las AMPR, intermedio para el VFS y más corto para la VRT, la RVFC y las líneas B.

ABSTRACT Background: A standardized training platform helps to achieve reading harmonization in stress echocardiography (SE) beyond regional wall motion abnormalities (RWMA). Objective: To harmonize SE reading criteria across different laboratories. Methods: The core lab prepared for readers an obligatory 2-hour web-based learning module for 5 parameters: RWMA; B-lines; coronary flow velocity reserve (CFVR) based on peak diastolic flow velocity on the left anterior descending coronary artery; left ventricular contractile reserve (LVCR, from raw measurementis of end-systolic volume, ESV); systolic arterial pulmonary pressure (from raw measurementis of peak tricuspid regurgitant jet velocity, TRV). The quality control test consisted of 20 cases selected by the coordinating center. The a priori determined pass threshold was 18/20 (>90%) with intra-class correla-tion coefficient between the coordinating lab and the peripheral reader >0.90. Resultis: The certification was completed by 84 readers for RWMA, 65 for B-lines, 30 for CFVR, 24 for ESV and 20 for TRV The mean reading time per attempt was shorter for TRV (9±4 min), CFVR (13±6 min) and B-lines (17±3 min), intermedi-ate for ESV (24±7 min), and longer for RWMA (29±12 min, p <0.01). The success rate of the first attempt was higher for CFVR (85%), intermediate for TRV (75%) and B-lines (43 %), lower for ESV (35%) and lowest for RWMA (28 %, p <0.01). Conclusions: A web-based learning platform improves image interpretation skills without need for expensive imaging equip-ment or a patient to scan. The road to certification is longer for RWMA, intermediate for ESV, and shorter for TRV, CFVR and B-lines.

Quality control of regional wall motion analysis in stress Echo 2020.

BACKGROUND: The trial "Stress Echo (SE) 2020" evaluates novel applications of SE beyond coronary artery disease. The aim of the study was control quality and harmonize reading criteria. METHODS: One reader from 78 centers of the SE 2020 network asked for credentials to read a set of 20 SE video-clips selected by the core lab. All aspiring centers met the pre-requisite of high-volume and the years of experience in SE ranged from 5 to 31years (mean value 18years). The diagnostic gold standard was a reading by the core lab. The a priori determined pass threshold was 18/20 (≥90%). RESULTS: Of the initial 78 who started, 57 completed the first attempt: individual readers' score on first attempt ranged from 07/20 to 20/20 (accuracy from 35% to 100%, mean 78.7±13%) and 44 readers passed it. There was a very poor correlation between years of experience and the reader's score on first attempt (r=-0.161, p=0.231). Of the 13 readers who failed the first attempt, 12 took it again after the web-based session and their accuracy improved (74% vs. 96%, p<0.001). The kappa inter-observer agreement before and after web-based training was 0.59 on first attempt and rose to 0.91 on the last attempt. CONCLUSIONS: In SE reading, the volume of activity or years of experience is not synonymous with diagnostic quality. Qualitative analysis and operator-dependence can become a limiting weakness in clinical practice, in the absence of strict pathways of learning, credentialing and audit.

B-lines with Lung Ultrasound: The Optimal Scan Technique at Rest and During Stress.

Various lung ultrasound (LUS) scanning modalities have been proposed for the detection of B-lines, also referred to as ultrasound lung comets, which are an important indication of extravascular lung water at rest and after exercise stress echo (ESE). The aim of our study was to assess the lung water spatial distribution (comet map) at rest and after ESE. We performed LUS at rest and immediately after semi-supine ESE in 135 patients (45 women, 90 men; age 62 ± 12 y, resting left ventricular ejection fraction = 41 ± 13%) with known or suspected heart failure or coronary artery disease. B-lines were measured by scanning 28 intercostal spaces (ISs) on the antero-lateral chest, 2nd-5th IS, along with the midaxillary (MA), anterior axillary (AA), mid-clavicular (MC) and parasternal (PS) lines. Complete 28-region, 16-region (3rd and 4th IS), 8-region (3rd IS), 4-region (3rd IS, only AA and MA) and 1-region (left 3rd IS, MA) scans were analyzed. In each space, the B-lines were counted from 0 = black lung to 10 = white lung. Interpretable images were obtained in all spaces (feasibility = 100 %). B-lines (>0 in at least 1 space) were present at ESE in 93 patients (69%) and absent in 42. More B-lines were found in the 3rd IS and along AA and MA lines. The B-line cumulative distribution was symmetric at rest (right/left = 1.10) and asymmetric with left lung predominance during stress (right/left = 0.67). The correlation of per-patient B-line number between 28-S and 16-S (R2 = 0.9478), 8-S (R2 = 0.9478) and 4-S scan (R2 = 0.9146) was excellent, but only good with 1-S (R2 = 0.8101). The average imaging and online analysis time were 5 s per space. In conclusion, during ESE, the comet map of lung water accumulation follows a predictable spatial pattern with wet spots preferentially aligned with the third IS and along the AA and MA lines. The time-saving 4-region scan is especially convenient during stress, simply dismissing dry regions and focusing on wet regions alone.

Stress echocardiography with smartphone: real-time remote reading for regional wall motion.

The diffusion of smart-phones offers access to the best remote expertise in stress echo (SE). To evaluate the reliability of SE based on smart-phone filming and reading. A set of 20 SE video-clips were read in random sequence with a multiple choice six-answer test by ten readers from five different countries (Italy, Brazil, Serbia, Bulgaria, Russia) of the "SE2020" study network. The gold standard to assess accuracy was a core-lab expert reader in agreement with angiographic verification (0 = wrong, 1 = right). The same set of 20 SE studies were read, in random order and >2 months apart, on desktop Workstation and via smartphones by ten remote readers. Image quality was graded from 1 = poor but readable, to 3 = excellent. Kappa (k) statistics was used to assess intra- and inter-observer agreement. The image quality was comparable in desktop workstation vs. smartphone (2.0 ± 0.5 vs. 2.4 ± 0.7, p = NS). The average reading time per case was similar for desktop versus smartphone (90 ± 39 vs. 82 ± 54 s, p = NS). The overall diagnostic accuracy of the ten readers was similar for desktop workstation vs. smartphone (84 vs. 91%, p = NS). Intra-observer agreement (desktop vs. smartphone) was good (k = 0.81 ± 0.14). Inter-observer agreement was good and similar via desktop or smartphone (k = 0.69 vs. k = 0.72, p = NS). The diagnostic accuracy and consistency of SE reading among certified readers was high and similar via desktop workstation or via smartphone.

Pediatric echocardiographic nomograms: What has been done and what still needs to be done.

Nomograms are essential tools for quantification in pediatric echocardiography. In the last few years, multiple sources highlight that nomograms employed for decades presented significant numerical and methodological limitations. As a result, widely different ranges of normality were generated, thus creating confusion in estimation of several cardiac diseases. New nomograms have recently been generated, overcoming some of the gaps of previous research: wider sample sizes (including neonates/infants), solid statistical/methodological plan, and availability of new data (chamber dimensions, many functional parameters). In particular, robust two-dimensional nomograms covering a wide spectrum of cardiac measurements have recently become available. Significant advances have been made for functional data (i.e. diastolic and deformation indexes) but a few limitations still exist. These include numerical issues (sample size of below 400 subjects) and methodological pitfalls (heterogeneous data normalization/expression). Despite these limitations, however, actual nomograms for functional data present quite reproducible intervals of normality with the exception of neonates and infants. In conclusion, great advances have been made during the last years. A few basic rules for the building of nomograms have been established (i.e. inclusion/exclusion criteria, measurement standardization), while others (i.e. the sample size, the way to express/normalize data, statistical requirements) are basically defined but still require standardization. New pediatric echocardiographic nomograms of good quality are easily accessible due to new electronic tools (online calculators, apps for smart-phone/tablets). Studies are ongoing to generate wider, comprehensive and multi-ethnic nomograms and to evaluate new parameters (e.g. three-dimensional parameters).

Stress echo 2020: the international stress echo study in ischemic and non-ischemic heart disease.

BACKGROUND: Stress echocardiography (SE) has an established role in evidence-based guidelines, but recently its breadth and variety of applications have extended well beyond coronary artery disease (CAD). We lack a prospective research study of SE applications, in and beyond CAD, also considering a variety of signs in addition to regional wall motion abnormalities. METHODS: In a prospective, multicenter, international, observational study design, > 100 certified high-volume SE labs (initially from Italy, Brazil, Hungary, and Serbia) will be networked with an organized system of clinical, laboratory and imaging data collection at the time of physical or pharmacological SE, with structured follow-up information. The study is endorsed by the Italian Society of Cardiovascular Echography and organized in 10 subprojects focusing on: contractile reserve for prediction of cardiac resynchronization or medical therapy response; stress B-lines in heart failure; hypertrophic cardiomyopathy; heart failure with preserved ejection fraction; mitral regurgitation after either transcatheter or surgical aortic valve replacement; outdoor SE in extreme physiology; right ventricular contractile reserve in repaired Tetralogy of Fallot; suspected or initial pulmonary arterial hypertension; coronary flow velocity, left ventricular elastance reserve and B-lines in known or suspected CAD; identification of subclinical familial disease in genotype-positive, phenotype- negative healthy relatives of inherited disease (such as hypertrophic cardiomyopathy). RESULTS: We expect to recruit about 10,000 patients over a 5-year period (2016-2020), with sample sizes ranging from 5,000 for coronary flow velocity/ left ventricular elastance/ B-lines in CAD to around 250 for hypertrophic cardiomyopathy or repaired Tetralogy of Fallot. This data-base will allow to investigate technical questions such as feasibility and reproducibility of various SE parameters and to assess their prognostic value in different clinical scenarios. CONCLUSIONS: The study will create the cultural, informatic and scientific infrastructure connecting high-volume, accredited SE labs, sharing common criteria of indication, execution, reporting and image storage of SE to obtain original safety, feasibility, and outcome data in evidence-poor diagnostic fields, also outside the established core application of SE in CAD based on regional wall motion abnormalities. The study will standardize procedures, validate emerging signs, and integrate the new information with established knowledge, helping to build a next-generation SE lab without inner walls.

Adult echocardiographic nomograms: overview, critical review and creation of a software for automatic, fast and easy calculation of normal values.

There is a crescent interest on normal adult echocardiographic values and the introduction of new deformation imaging and 3D parameters pose the issue of normative data. A multitude of nomograms has been recently published, however data are often fragmentary, difficult to find, and their strengths/limitations have been never evaluated. AIMS: (I) to provide a review of current echocardiographic nomograms; (II) to generate a tool for easy and fast access to these data. A literature search was conducted accessing the National Library of Medicine using the keywords: 2D/3D echocardiography, strain, left/right ventricle, atrial, mitral/tricuspid valve, aorta, reference values/nomograms/normal values. Adding the following keywords, the results were further refined: range/intervals, myocardial velocity, strain rate and speckle tracking. Forty one published studies were included. Our study reveals that for several of 2D/3D parameters sufficient normative data exist, however, a few limitations still persist. For some basic parameters (i.e., mitral/tricuspid/pulmonary valves, great vessels) and for 3D valves data are scarce. There is a lack of studies evaluating ethnic differences. Data have been generally expressed as mean values normalised for gender and age instead of computing models incorporating different variables (age/gender/body sizes) to calculate z scores. To summarize results a software (Echocardio-Normal Values) who automatically calculate range of normality for a broad range of echocardiographic measurements according to age/gender/weight/height, has been generated. We provide an up-to-date and critical review of strengths/limitation of current adult echocardiographic nomograms. Furthermore we generated a software for automatic, easy and fast access to multiple echocardiographic normative data.

Factibilidad del eco estrés vasodilatador de triple imagen en pacientes con sospecha de enfermedad coronaria / Feasibility of Triple Imaging Vasodilator Stress Echo in Patients with Suspected Coronary Artery Disease

Introducción: La detección de anormalidades de la motilidad parietal regional (AMPR) es la base del diagnóstico por eco estrés, pero la tasa de positividad ha ido disminuyendo en las últimas décadas. Por otra parte, se obtiene información adicional de la evaluación simultánea de la reserva de la velocidad de flujo coronario (RVFC) de la arteria coronaria descendente anterior y de la reserva contráctil del ventrículo izquierdo (RCVI) a través de la relación presión-volumen de fin de sístole. Objetivo: Evaluar la posibilidad de obtener triple imagen (AMPR + RVFC + RCVI) durante el eco estrés con dipiridamol. Material y métodos: Se enrolaron 40 pacientes consecutivos (30 hombres, con edad media de 62 ± 11 años y fracción de eyección media del 62% ± 7%), derivados a estudio por sospecha de enfermedad coronaria. Todos los pacientes fueron sometidos a eco estrés con dipiridamol (0,84 mg/kg en 6 min). La RCVI se definió como la relación entre el índice de elastancia máxima y de reposo (presión arterial sistólica medida por esfigmomanometría/volumen de fin de sístole del ventrículo izquierdo por el método de Simpson biplano, con valores normales > 1,0). A su vez, la RVFC se definió como la relación entre la vasodilatación máxima y la velocidad máxima del flujo diastólico de reposo en la arteria coronaria descendente anterior (valores normales > 2,0). Resultados: Se obtuvieron imágenes viables en 40/40 pacientes (100%) para las AMPR, 40/40 (100%) para la RCVI y 40/40 (100%) para la RVFC. La tasa de positividad fue de 1/40 (2%) para las AMPR, 4/40 (10%) para la RCVI, 6/40 (15%) para la RVFC y 9/40 (22,5%) combinando cualquiera de los tres criterios. El promedio de tiempo adicional de adquisición de imágenes en el estrés pico luego de completar la adquisición de AMPR fue de 45 segundos para la RVFC, y no se requirió tiempo extra para la RCVI. El tiempo promedio de análisis off-line fue de 30 segundos para las AMPR, de 55 segundos para la RCVI y de 15 segundos para la RVFC. Conclusiones: El eco estrés vasodilatador de triple imagen es altamente factible y no insume tiempo adicional. La RVFC y la RCVI proporcionan valores anormales más frecuentemente que las AMPR. La triple imagen podría convertirse en el nuevo referente diagnóstico del eco estrés. Actualmente se está llevando a cabo una validación a gran escala en el estudio multicén-trico italiano Stress echo 2020.

The Effects of Vaccinium myrtillus Extract on Hamster Pial Microcirculation during Hypoperfusion-Reperfusion Injury.

INTRODUCTION: The present study was aimed to assess the in vivo hamster pial microvessel alterations due to 30 min transient bilateral common carotid artery occlusion (BCCAO) and reperfusion (60 min); moreover, the neuroprotective effects of Vaccinium myrtillus extract, containing 34.7% of anthocyanins, were investigated. MATERIALS AND METHODS: Two groups of male hamsters were used: the first fed with control diet and the other with Vaccinium myrtillus supplemented diet. Hamster pial microcirculation was visualized by fluorescence microscopy through an open cranial window. Pial arterioles were classified according to Strahler's method. RESULTS: In age-matched control diet-fed hamsters, BCCAO caused a decrease in diameter of all arterioles. At the end of reperfusion, the reduction of diameter in order 3 arterioles was by 8.4 ± 3.1%, 10.8 ± 2.3% and 12.1 ± 1.1% of baseline in the 2, 4 and 6 month control diet-fed hamsters, respectively. Microvascular permeability and leukocyte adhesion were markedly enhanced, while perfused capillary length (PCL) decreased. The response to acetylcholine and papaverine topical application was impaired; 2'-7'-dichlorofluoresceine-diacetate assay demonstrated a significant ROS production. At the end of BCCAO, in age-matched Vaccinium myrtillussupplemented diet-fed hamsters, the arteriolar diameter did not significantly change compared to baseline. After 60 min reperfusion, order 3 arterioles dilated by 9.3 ± 2.4%, 10.6 ± 3.1% and 11.8 ± 2.7% of baseline in the 2, 4 and 6 month Vaccinium myrtillus supplemented diet-fed hamsters, respectively. Microvascular leakage and leukocyte adhesion were significantly reduced in all groups according to the time-dependent treatment, when compared with the age-matched control diet-fed hamsters. Similarly, the reduction in PCL was progressively prevented. Finally, the response to acetylcholine and papaverine topical application was preserved and there was no significant increase in ROS production in all groups. CONCLUSIONS: In conclusion, Vaccinium myrtillusextract protected pial microcirculation during hypoperfusion-reperfusion, preventing vasoconstriction, microvascular permeability, leukocyte adhesion, reduction in PCL and preserving the endothelium function.

Ultrasound tissue characterization of vulnerable atherosclerotic plaque.

A thrombotic occlusion of the vessel fed by ruptured coronary atherosclerotic plaque may result in unstable angina, myocardial infarction or death, whereas embolization from a plaque in carotid arteries may result in transient ischemic attack or stroke. The atherosclerotic plaque prone to such clinical events is termed high-risk or vulnerable plaque, and its identification in humans before it becomes symptomatic has been elusive to date. Ultrasonic tissue characterization of the atherosclerotic plaque is possible with different techniques--such as vascular, transesophageal, and intravascular ultrasound--on a variety of arterial segments, including carotid, aorta, and coronary districts. The image analysis can be based on visual, video-densitometric or radiofrequency methods and identifies three distinct textural patterns: hypo-echoic (corresponding to lipid- and hemorrhage-rich plaque), iso- or moderately hyper-echoic (fibrotic or fibro-fatty plaque), and markedly hyperechoic with shadowing (calcific plaque). Hypoechoic or dishomogeneous plaques, with spotty microcalcification and large plaque burden, with plaque neovascularization and surface irregularities by contrast-enhanced ultrasound, are more prone to clinical complications than hyperechoic, extensively calcified, homogeneous plaques with limited plaque burden, smooth luminal plaque surface and absence of neovascularization. Plaque ultrasound morphology is important, along with plaque geometry, in determining the atherosclerotic prognostic burden in the individual patient. New quantitative methods beyond backscatter (to include speed of sound, attenuation, strain, temperature, and high order statistics) are under development to evaluate vascular tissues. Although not yet ready for widespread clinical use, tissue characterization is listed by the American Society of Echocardiography roadmap to 2020 as one of the most promising fields of application in cardiovascular ultrasound imaging, offering unique opportunities for the early detection and treatment of atherosclerotic disease.

Glucose-related arterial stiffness and carotid artery remodeling: a study in normal subjects and type 2 diabetes patients.

CONTEXT: Hyperglycemia is associated with a higher carotid intima-media thickness (IMT); however, it is not established whether this increase reflects early atherosclerotic changes or adaptive remodeling responding to hyperglycemia-induced alteration in mechanical properties of the arterial wall. OBJECTIVE: The aims of this study were to compare carotid geometry and circumferential wall stress between patients with type 2 diabetes mellitus (T2DM) and healthy controls and to evaluate the associations between chronic glucose exposure and measures of arterial structure and function. DESIGN AND SETTING: This was a case-control and cross-sectional study within institutional practice. PARTICIPANTS: PARTICIPANTS included 133 T2DM patients free of cardiovascular complications and 133 healthy controls with normal glucose metabolism, matched for sex, age, and body mass index. MAIN OUTCOME MEASURES: Common carotid artery (CCA) IMT, luminal diameter, wave speed, and local pulse pressure (PP) were evaluated. RESULTS: As compared with controls, T2DM patients had higher (P < .0001) CCA IMT (640 ± 81 vs 709 ± 118 µm), luminal diameter (6.12 ± 0.67 vs 6.69 ± 0.56 mm), and brachial PP (47 ± 7 vs 57 ± 12 mm Hg), whereas luminal radius to IMT ratio (4.8 ± 0.7 vs 4.8 ± 0.8, P = .57) and circumferential wall stress (49.0 ± 8.3 vs 50.6 ± 10.3 kPa, P = .26) were comparable between the 2 groups. In T2DM patients, glycosylated hemoglobin was independently related to CCA wave speed and local PP, but not to IMT that was determined by age, local PP, and luminal diameter. CONCLUSIONS: This study suggests that the increase in IMT associated with a higher glucose exposure might reflect adaptive remodeling counteracting an increase in pulsatile strain and preventing increase in circumferential wall stress caused by luminal enlargement of stiff arteries.