Effect of maximum exercise on left ventricular deformation and its correlation with cardiopulmonary exercise capacity in competitive athletes.

BACKGROUND: Global longitudinal strain (GLS) and global myocardial work index (GWI) allow early detection of subclinical changes in left ventricular (LV) systolic function. The aim of the study was to investigate the immediate effects of maximum physical exercise by different exercise testing methods on early post exercise LV deformation parameters in competitive athletes and to analyze their correlation with cardiopulmonary exercise capacity. METHODS: To reach maximum physical exercise, cardiopulmonary exercise testing (CPET) was performed by semi-recumbent ergometer in competitive handball players (n = 13) and by treadmill testing in competitive football players (n = 19). Maximum oxygen uptake (VO2max) indexed to body weight (relative VO2max) was measured in all athletes. Transthoracic echocardiography and blood pressure measurements were performed at rest and 5 min after CPET in all athletes. GLS, GWI and their changes before and after CPET (ΔGLS, ΔGWI) were correlated with (relative) VO2max. RESULTS: In handball and football players, GLS and GWI did not differ significantly before and after CPET. There were no significant correlations between GLS and relative VO2max, but moderate correlations were found between ΔGWI and relative VO2max in handball (r = 0.631; P = 0.021) and football players (r = 0.592; P = 0.008). Furthermore, handball (46.7 ml/min*kg ± 4.7 ml/min*kg vs. 37.4 ml/min*kg ± 4.2; P = 0.004) and football players (58.3 ml/min*kg ± 3.7 ml/min*kg vs. 49.7 ml/min*kg ± 6.8; P = 0.002) with an increased ΔGWI after CPET showed a significant higher relative VO2max. CONCLUSION: Maximum physical exercise has an immediate effect on LV deformation, irrespective of the used testing method. The correlation of relative VO2max with ΔGWI in the early post exercise period, identifies ΔGWI as an echocardiographic parameter for characterizing the current individual training status of athletes.

The impact of upright posture on left ventricular deformation in athletes.

Besides LV ejection fraction (LVEF), global longitudinal strain (GLS) and global myocardial work index (GWI) are increasingly important for the echocardiographic assessment of left ventricular (LV) function in athletes. Since exercise testing is frequently performed on a treadmill, we investigated the impact of upright posture on GLS and GWI. In 50 male athletes (mean age 25.7 ± 7.3 years) transthoracic echocardiography (TTE) and simultaneous blood pressure measurements were performed in upright and left lateral position. LVEF (59.7 ± 5.3% vs. 61.1 ± 5.5%; P = 0.197) was not affected by athletes' position, whereas GLS (- 11.9 ± 2.3% vs. - 18.1 ± 2.1%; P < 0.001) and GWI (1284 ± 283 mmHg% vs. 1882 ± 247 mmHg%; P < 0.001) were lower in upright posture. Longitudinal strain was most frequently reduced in upright posture in the mid-basal inferior, and/or posterolateral segments. Upright posture has a significant impact on LV deformation with lower GLS, GWI and regional LV strain in upright position. These findings need to be considered when performing echocardiography in athletes.

Expert proposal to characterize cardiac diseases with normal or preserved left ventricular ejection fraction and symptoms of heart failure by comprehensive echocardiography.

Currently, the term "heart failure with preserved left ventricular ejection fraction (HFpEF)" is based on echocardiographic parameters and clinical symptoms combined with elevated or normal levels of natriuretic peptides. Thus, "HFpEF" as a diagnosis subsumes multiple pathophysiological entities making a uniform management plan for "HFpEF" impossible. Therefore, a more specific characterization of the underlying cardiac pathologies in patients with preserved ejection fraction and symptoms of heart failure is mandatory. The present proposal seeks to offer practical support by a standardized echocardiographic workflow to characterize specific diagnostic entities associated with "HFpEF". It focuses on morphological and functional cardiac phenotypes characterized by echocardiography in patients with normal or preserved left ventricular ejection fraction (LVEF). The proposal discusses methodological issues to clarify why and when echocardiography is helpful to improve the diagnosis. Thus, the proposal addresses a systematic echocardiographic approach using a feasible algorithm with weighting criteria for interpretation of echocardiographic parameters related to patients with preserved ejection fraction and symptoms of heart failure. The authors consciously do not use the diagnosis "HFpEF" to avoid misunderstandings. Central illustration: Scheme illustrating the characteristic echocardiographic phenotypes and their combinations in patients with "HFpEF" symptoms with respect to the respective cardiac pathology and pathophysiology as well as the underlying typical disease.

Diagnostic role of echocardiography for patients with heart failure symptoms and preserved left ventricular ejection fraction.

The syndrome heart failure with preserved ejection fraction (HFpEF) represents patients with different comorbidities and specific etiologies, but with a key and common alteration: an elevation in left ventricular (LV) filling pressure or pulmonary capillary wedge pressure (PCWP). Expert consensuses, society guidelines, and diagnostic scores have been stated to diagnose HFpEF syndrome based mainly on the determination of elevated LV filling pressure or PCWP by transthoracic echocardiography (TTE). Echocardiographic parameters such as early (E) and late diastolic mitral inflow velocity (mitral E/A ratio), septal and lateral mitral annular early diastolic velocity (E'), ratio of the early diastolic mitral inflow and annular velocity (E/E'-ratio), maximal left atrial volume index (LAVImax), and tricuspid regurgitation peak velocity (VTR) constitute the pivotal parameters for determining elevated LV filling pressure or PCWP in patients with suspected HFpEF symptoms. Notwithstanding this, taking into consideration the heterogeneity of patients with HFpEF symptoms, the term "HFpEF" should be considered as a syndrome rather than an entity since HFpEF results from different pathological entities that should and can be characterized by echocardiography and multimodality imaging. Comprehensive TTE might help diagnose specific diseases and etiologies by characterization of specific cardiac phenotypes.

SARS-CoV2 infection: functional and morphological cardiopulmonary changes in elite handball players.

There is increasing evidence of cardiac involvement post-SARS-CoV-2 infections in symptomatic as well as in oligo- and asymptomatic athletes. This study aimed to characterize the possible early effects of SARS-CoV-2 infections on myocardial morphology and cardiopulmonary function in athletes. Eight male elite handball players (27 ± 3.5 y) with past SARS-CoV-2 infection were compared with four uninfected teammates (22 ± 2.6 y). Infected athletes were examined 19 ± 7 days after the first positive PCR test. Echocardiographic assessment of the global longitudinal strain under resting conditions was not significantly changed (- 17.7% vs. - 18.1%). However, magnetic resonance imaging showed minor signs of acute inflammation/oedema in all infected athletes (T2-mapping: + 4.1 ms, p = 0.034) without reaching the Lake-Louis criteria. Spiroergometric analysis showed a significant reduction in VO2max (- 292 ml/min, - 7.0%), oxygen pulse (- 2.4 ml/beat, - 10.4%), and respiratory minute volume (VE) (- 18.9 l/min, - 13.8%) in athletes with a history of SARS-CoV2 infection (p < 0.05, respectively). The parameters were unchanged in the uninfected teammates. SARS-CoV2 infection caused impairment of cardiopulmonary performance during physical effort in elite athletes. It seems reasonable to screen athletes after SARS-CoV2 infection with spiroergometry to identify performance limitations and to guide the return to competition.

"Pure" severe aortic stenosis without concomitant valvular heart diseases: echocardiographic and pathophysiological features.

PURPOSE: In echocardiography the severity of aortic stenosis (AS) is defined by effective orifice area (EOA), mean pressure gradient (mPGAV) and transvalvular flow velocity (maxVAV). The hypothesis of the present study was to confirm the pathophysiological presence of combined left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with "pure" severe AS. METHODS AND RESULTS: Patients (n = 306) with asymptomatic (n = 133) and symptomatic (n = 173) "pure" severe AS (mean age 78 ± 9.5 years) defined by indexed EOA < 0.6 cm2 were enrolled between 2014 and 2016. AS patients were divided into 4 subgroups according to mPGAV and indexed left ventricular stroke volume: low flow (LF) low gradient (LG)-AS (n = 133), normal flow (NF) LG-AS (n = 91), LF high gradient (HG)-AS (n = 21) and NFHG-AS (n = 61). Patients with "pure" severe AS showed mean mPGAV of 31.7 ± 9.1 mmHg and mean maxVAV of 3.8 ± 0.6 m/s. Only 131 of 306 patients (43%) exhibited mPGAV > 40 mmHg and maxVAV > 4 m/s documenting incongruencies of the AS severity assessment by Doppler echocardiography. LVH was documented in 81%, DD in 76% and PAH in 80% of AS patients. 54% of "pure" AS patients exhibited all three alterations. Ranges of mPGAV and maxVAV were higher in patients with all three alterations compared to patients with less than three. 224 (73%) patients presented LG-conditions and 82 (27%) HG-conditions. LVH was predominant in NF-AS (p = 0.014) and PAH in LFHG-AS (p = 0.014). Patients' treatment was retrospectively assessed (surgery: n = 100, TAVI: n = 48, optimal medical treatment: n = 156). CONCLUSION: In patients with "pure" AS according to current guidelines the presence of combined LVH, DD and PAH as accepted pathophysiological sequelae of severe AS cannot be confirmed. Probably, the detection of these secondary cardiac alterations might improve the diagnostic algorithm to avoid overestimation of AS severity.

[Echocardiographic emergency diagnostics]. / Echokardiographische Notfalldiagnostik.

Echocardiography is a non-invasive, versatile imaging modality for the diagnostics and monitoring of life-threatening cardiac diseases. This article summarizes the currently valid recommendations on emergency echocardiography of the German Cardiac Society and the European Association of Cardiovascular Imaging and provides practical guidance for their implementation in emergency medicine. Echocardiography is especially important for the diagnostics of acute coronary syndrome and its potential complications, of pulmonary embolism and endocarditis as well as the differential diagnosis of patients in shock and in emergencies. A domain of increasing importance in echocardiography is the treatment monitoring of patients supported by modern cardiac assist devices.

[Transesophageal echocardiography in emergency and intensive care medicine : Indication and implementation]. / Transösophageale Echokardiographie in der Notfall- und Intensivmedizin : Einsatzgebiet und Durchführung.

Transesophageal echocardiography (TEE) in emergency and intensive care medicine represents an additional semi-invasive method to confirm or rebut suspected diagnoses in critically ill patients. Three-dimensional (3D)-TEE investigations are established in the clinical workflow of emergency and intensive care units because 3D-TEE investigations permit a differentiation of artifacts due to oblique views by simultaneous documentation of sectional planes and en face views of characteristic cardiac structures. Thus, the level of diagnostic validity can be significantly increased by 3D-TEE investigation. The main indications of TEE investigation in emergency medicine are hemodynamic instability due to myocardial, pericardial or valvular heart diseases as well as suspected endocarditis and aortic dissection.

[New and established aspects of cardiological diagnostics using TEE : Do we need 3D technology in clinical routine?] / Neues und Bewährtes in der kardiologischen Diagnostik mithilfe der TEE : Wird die 3­D-Technik in der klinischen Routine benötigt?

In comparison to transthoracic echocardiography (TTE) transesophageal echocardiography (TEE) enables an acquisition of images with better spatial resolution due to the use of higher ultrasound frequencies. Thus, the morphology and function of cardiac structures can principally be analyzed better and more accurately with TEE than with TTE. In addition, using three-dimensional (3D) TEE data sets standardized sectional planes can be constructed by post-processing, which enables quantitative assessment of the target structures. The size and function of the left ventricle can objectively and reproducibly be measured. End diastolic left ventricular volume and total stroke volume of the left ventricle can be accurately determined in patients with heart valve disease. Furthermore, particular cardiac structures that cannot be totally evaluated by two-dimensional (2D) echocardiography, can be completely analyzed by 3D TEE. In 2D images for example, only analyses of the right coronary cusp of the aortic valve are possible because only the center of the right coronary cusp can be visualized using conventional sectional level presentation. Using 3D TEE the non-coronary cusp and the left coronary cusp can also be visualized in the mid-sectional plane by post-processing of the 3D data set. Additional important structures of 3D TEE analysis are the left atrial auricle, the interatrial septum and the mitral valve. Planimetry of valvular and regurgitation orifices as well as the monitoring of interventions for treatment of structural heart diseases are further fields of application of clinically established 3D TEE diagnostics.

[Alcohol and arrhythmias]. / Alkohol und Rhythmusstörungen.

The effects of alcohol on induction of arrhythmias is dose-dependent, independent of preexisting cardiovascular diseases or heart failure and can affect otherwise healthy subjects. While the probability of atrial fibrillation increases with the alcohol dosage, events of sudden cardiac death are less frequent with low and moderate consumption but occur more often in heavy drinkers with alcoholic cardiomyopathy. Men are first affected at higher dosages of alcohol but women can suffer from arrhythmias at lower dosages. Thromboembolisms and ischemic stroke can occur less often at lower dosages of alcohol; however, hemorrhagic stroke and subarachnoid hemorrhage are increased with higher alcohol dosages. Recognizable protective mechanisms of alcohol with respect to cardiovascular diseases only occur with lower amounts of alcohol of less than 10 g per day. Underlying mechanisms explain these controversial effects. Specific therapeutic options for alcohol-related arrhythmias apart from abstinence from alcohol consumption are not known.

[Implantable cardioverter-defibrillator at the end of life]. / Implantierbarer Kardioverter-Defibrillator am Ende des Lebens.

Brady- and tachyarrhythmias at the end of life are common observations. Implantable cardioverter-defibrillators answer with antibrady and antitachycardia pacing, which will not be associated with any complaints of the dying patient. In contrast, defibrillation and cardioversion shocks are extremely painful. Therefore shocks should be inactivated at the end of life. Family doctors, internists, emergency physicians and paramedics are unable to inactivate shocks. Deactivation of shocks at the end of life is not comparable to euthanasia or assisted suicide, but allow the patient to die at the end of an uncurable endstage disease. Deactivation of shocks should be discussed with the patient before initial implantation of the devices. The precise moment of the inactivation at the end of life should be discussed with patients and relatives. There is no common recommendation for the time schedule of this decision; therefore it should be based on the individual situation of the patient. Emergency health care physicians need magnets and sufficient information to inactivate defibrillators. The wishes of the patient have priority in the decision process and should be written in the patient's advance directive, which must be available in the final situation. However the physician must not necessarily follow every wish of the patient. As long as the laws in the European Union are not uniform, German recommendations are needed.

The impact of foreshortening on regional strain--a comparison of regional strain evaluation between speckle tracking and tissue velocity imaging.

PURPOSE: The conventional parameter of systolic function is global left ventricular (LV) ejection fraction (EF), but this parameter will be replaced by global strain because it seems to be more robust. However, regional strain differences can have a significant impact on global strain. Thus, the aim of the present study was to evaluate the effect of non-standardized scanning on regional strain values determined by 2D speckle tracking and tissue velocity imaging (TVI). Regional longitudinal peak systolic strain (PSS) was measured in standardized data sets of the apical 4-chamber view (ChV) and in a standardized oblique foreshortened view in patients with normal wall motion patterns. MATERIALS AND METHODS: A standardized 4ChV and a foreshortened 4ChV - defined by distinct cardiac structures - were acquired using a Vivid E9 system in 54 patients. All regional PSS values measured in monoplane 2D loops in lateral and septal regions were analyzed to detect the differences between regional strain measured in the standard and the foreshortened view. RESULTS: Significant PSS differences due to FS were detected in patients using 2D speckle tracking for the basal septal regions (p < 0.001). No significant differences due to FS were detected in patients during the analysis of TVI-based strain values (p > 0.05, paired sample T-test). CONCLUSION: To our knowledge this is the first study focusing on methodological aspects - especially standardization - using speckle tracking and TVI. Due to the lower accuracy of strain calculation based on TVI in basal regions, foreshortening has no significant impact on quantitative parameters of TVI-derived strain values in normal contracting hearts. Using speckle tracking, however, foreshortening induces significant differences of basal septal strain in normal contracting hearts. In the presence of regional wall motion defects, a lack of standardization of the views will cause inhomogeneous patterns of regional strain depending on the scan planes through the center of the infarction or its penumbra. Thus, non-standardization will have a significant impact on deformation parameters in 2D echocardiography.

[Echocardiography in emergency diagnostics]. / Echokardiographische Notfalldiagnostik.

Echocardiography plays an important role in emergency medicine because this non-invasive method is universally available and provides crucial diagnostic findings for acute decision making. The cardiac etiology in the presence of acute chest pain, acute dyspnea, hemodynamic instability or shock, new heart murmurs, chest trauma, peripheral embolism and cardiac arrest can be determined by echocardiography in the emergency scenario. The analysis of left ventricular function documents myocardial ischemia and myocardial infarction. Analysis of right ventricular function documents right heart infarction, pulmonary embolism, tension pneumothorax and sequelae of chest trauma. Echocardiography differentiates between different entities of shock. The analysis of heart valves is a domain of echocardiography. Affections of the pericardium and the hemodynamic sequelae can also be determined. It is obvious that echocardiography with its multiple diagnostic applications can only be well performed, especially in emergency medicine after in-depth education and training in this method.

[Costs of clinical ultrasound examinations - an economical cost calculation and analysis]. / Kosten von Ultraschalluntersuchungen im Krankenhaus - das Modell einer Deckungsbeitragsrechnung.

PURPOSE: The aim of the study was to calculate the costs for clinical ultrasound examinations in Germany under defined economical aspects in a multicenter setting. MATERIALS AND METHODS: There are fixed and variable costs for all common ultrasound examinations calculated under distinct scenarios for utilization and equipment quality (ultrasound systems classification concerning to DEGUM, German Ultrasound Society). RESULTS: Over 5 years (on average 2007 - 2011) depending on utilization and quality, the basic sonography costs were 131.30 - 171.39 Euros for contrast-enhanced ultrasound (CEUS) and 57.06 - 77.10 Euros for ultrasound guided biopsy per examination. The costs were calculated at 54.84 - 74.88 Euros for endosonography of the lower GI tract, at 79.20 - 109.27 Euros for the upper GI tract without biopsy and at 226.18 - 367.97 Euros with biopsy depending on the needle used. The costs were 34.58 - 47.01 Euros for basic transthoracic echocardiography, 100.04 - 112.20 Euros for CEUS, and 106.15 - 134.29 Euros for the transesophageal approach. CONCLUSION: Cost calculation under defined economical aspects leads to cost transparency for clinical ultrasound examinations. Echocardiography costs were calculated like this for the first time in Germany. Calculation based on fixed and variable cost aspects as well as using distinct scenarios enables prospective planning of resources and investment. The analysis points out deficits in the reimbursement of ultrasound examinations in Germany.

[Do results of transoesophageal echocardiography during closure of patent foramen ovale influence interventional therapy?]. / Beeinflussen Befunde der transösophagealen Echokardiographie bei katheterinterventionellem PFO-Verschluss die Therapie?

PURPOSE: The aim of the present study was to characterise the morphology of patent foramen ovale (PFO) by a standardised protocol during transoesophageal echocardiography and to estimate the final and successful position of PFO-occluding devices (PFO-Star) by evaluation of parameters determined by echocardiography. The echoacardiographic parameters of septum- and PFO-morphology determined before the intervention were analysed with regard to choosing the optimal device-system for transcatheter PFO-closure. MATERIALS AND METHODS: Transoesophageal echocardiography combined with application of contrast-media was performed in 31 patients before, during and after PFO-closure by using the PFO-Star-Device. The pre-interventional morphological parameters were compared with the result after PFO-closure. RESULTS: Quantitative contrast-bubble-shunting, PFO-channel-length and Vena contracta detected by colour flow Doppler do not show any correlation. PFO-channel-length in cases with small angles between aorta and septum seems to be associated with higher risk of clinically irrelevant device-shift as well as residual shunt. CONCLUSION: A standardised procedure in transoesophageal echocardiography is suitable for characterising the morphology of PFO. Neither the morphology in 2D-imaging nor the amount of shunt microbubble seen in the left atrium allows a conclusive statement about the PFO size. For obtaining an optimal closure result, it is important to identify the channel-length and the distance between the interatrial septum and the PFO together with the angles between septum and the surrounding intracardiac structures.