The Flow Rate in Patients With Low-Gradient Aortic Stenosis.

PURPOSE:  The decision to assess the severity and determine the ideal timing of intervention for low-gradient aortic stenosis poses a greater challenge. Recently, a novel method for determining the flow status of patients with aortic stenosis has been introduced, utilizing flow rate measurements. In this study, we investigated whether the flow status of patients with low-gradient aortic stenosis is linked to mortality within a three-year timeframe. METHODS: Twenty-nine patients diagnosed with low-gradient aortic stenosis and valve area ≤ 1 cm were identified during 2010-2015. Each patient's flow rate across the aortic valve was computed, and the study scrutinized echocardiographic parameters to ascertain their correlation with mortality over a three-year timeframe. RESULTS:  We observed that among patients with low-gradient aortic stenosis and a valve area of ≤1 cm, a decreased flow rate across the aortic valve emerged as an independent predictor of mortality. A flow rate < 210 ml/s was linked with a three-year mortality rate of 66.7%, whereas a low stroke volume index < 35 ml/m² did not show an association with three-year mortality. This observation might be attributed to the smaller body sizes prevalent among these older patients, particularly females, which could influence the calculation of the stroke volume index. CONCLUSION:  In older patients with low-gradient aortic stenosis, the flow rate can better reflect flow status than the stroke volume index, and it also suggests a prognostic significance in predicting mortality. Additional studies are warranted to validate these findings across broader patient populations and to assess the potential efficacy of early intervention strategies in this particular patient cohort.

Comprehensive Assessment of Cardiac Function in Breast Cancer Patients: Integrating Multiparametric Speckle Tracking Imaging and Conventional Echocardiography Parameters.

Purpose The purpose of this study is to comprehensively evaluate the role of different echocardiography parameters in breast cancer patients undergoing chemotherapy. While echocardiography examination with calculation of ejection fraction (EF), is pivotal for patient monitoring, its operator dependence and insensitivity to subtle changes in left ventricular (LV) contractility present challenges. Global longitudinal strain (GLS), derived from speckle tracking, is more sensitive and stable than EF. Our research aimed to delineate supplementary echocardiography measurements beneficial for the cardiological monitoring of breast cancer patients. Methods Patients were followed up with echocardiography at baseline, during, and after the chemotherapy. Conventional echocardiography and multiple speckle tracking imaging parameters including myocardial work index, atrial strain, twist, and automatic EF were investigated. Results A total of 25 patients were recruited. A subset (15/25) exhibited pronounced GLS reduction, associated with decreased EF and altered cardiac mechanics. Patients with unchanged GLS were often hypertensive and on specific medications, in particular angiotensin-converting enzyme inhibitors (ACE inhibitors)/angiotensin II receptor blockers (ARBs), potentially indicating protective effects. Despite stability in other parameters, GLS and EF sensitivity highlight their importance. A strong correlation between manual and automated EF measurement methods was also observed. Conclusion Despite the small sample size, across diverse echocardiography parameters, GLS and EF are primarily affected by chemotherapy. Hypertensive individuals exhibited lower susceptibility to chemotherapy-induced damage, likely attributed to the cardioprotective properties of ACE inhibitors and angiotensin II receptor blockers. A strong correlation between automatic and Simpson-based EF was found.

The effect of hyperbaric oxygen therapy on myocardial function in post-COVID-19 syndrome patients: a randomized controlled trial.

Post-COVID-19 condition refers to a range of persisting physical, neurocognitive, and neuropsychological symptoms following SARS-CoV-2 infection. Recent evidence revealed that post-COVID-19 syndrome patients may suffer from cardiac dysfunction and are at increased risk for a broad range of cardiovascular disorders. This randomized, sham-control, double-blind trial evaluated the effect of hyperbaric oxygen therapy (HBOT) on the cardiac function of post-COVID-19 patients with ongoing symptoms for at least three months after confirmed infection. Sixty patients were randomized to receive 40 daily HBOT or sham sessions. They underwent echocardiography at baseline and 1-3 weeks after the last protocol session. Twenty-nine (48.3%) patients had reduced global longitudinal strain (GLS) at baseline. Of them, 13 (43.3%) and 16 (53.3%) were allocated to the sham and HBOT groups, respectively. Compared to the sham group, GLS significantly increased following HBOT (- 17.8 ± 1.1 to - 20.2 ± 1.0, p = 0.0001), with a significant group-by-time interaction (p = 0.041). In conclusion, post-COVID-19 syndrome patients despite normal EF often have subclinical left ventricular dysfunction that is characterized by mildly reduced GLS. HBOT promotes left ventricular systolic function recovery in patients suffering from post COVID-19 condition. Further studies are needed to optimize patient selection and evaluate long-term outcomes.This study was registered with ClinicalTrials.gov, number NCT04647656 on 01/12/2020.

Efficacy of Low Doses of Midazolam in Combination with Verbal Sedation during Transesophageal Echocardiography.

BACKGROUND: Traditionally, transesophageal echocardiography (TEE) has been performed under moderate sedation and local pharyngeal anesthesia. Respiratory complications during the TEE can occur. OBJECTIVES: To test the effectiveness of low-dose midazolam combined with verbal sedation during TEE. METHODS: The study comprised 157 consecutive patients who underwent TEE under mild conscious sedation. All patients received local pharyngeal anesthesia and low doses of midazolam combined with verbal sedation. The course of TEE and clinical characteristics of the patients were analyzed. RESULTS: The mean age was 64 ± 15.3 years, 96 males (61%). In 6% of the patients, low dose midazolam in combination with verbal sedation was insufficient and propofol was administrated. In women under 65 years of age with normal renal function, there was a 40% risk of low-dose midazolam being ineffective (P = 0.0018). CONCLUSIONS: In most patients, TEE can be conducted easily using low-dose midazolam combined with verbal sedation. Some patients need deeper sedation with anesthetic agents like propofol. These patients tended to be younger, in good general health, and more often female.

Pitfalls of Echocardiographic Image Perception: How to Overcome Them?

In recent years, the significant development of echocardiography systems has led to a sharp improvement in echocardiographic images' quality. In parallel with this, computerized technologies are also going far forward, which today make it possible to ensure a high level of transmission, storage, and display of echocardiography studies. Despite this, many cardiologists are not familiar with modern computerized technologies' new possibilities and continue to use the old standards. That is why many echocardiography laboratories with the best echocardiography systems work following the old minimalist approach. In this paper, we will look at some of the most common mistakes that result from the improper transmission, storage, and demonstration of echocardiography studies, and describe possible ways to overcome these problems.

Myocardial work index during normal dobutamine stress echocardiography.

Dobutamine stress echocardiography is an alternative method to exercise stress echocardiography for the evaluation of ischemia. Recently, the novel speckle tracking imaging derived parameter, myocardial work index, was suggested for the evaluation of cardiac performance and was evaluated during exercise stress echocardiography. In this study, we analyzed the effect of dobutamine on myocardial work index variables during normal dobutamine stress echocardiography. Echocardiography examinations of patients with normal dobutamine stress echocardiography were collected and underwent off-line speckle tracking imaging analysis. Myocardial work index parameters were calculated at each dose of dobutamine and compared. 286 patients underwent dobutamine stress echocardiography during the study period. 102 patients were excluded due to pre-existed coronary artery disease or ischemia at dobutamine stress echocardiography. 65 patients were excluded due to suboptimal image quality unsuitable for speckle tracking imaging analysis. The remaining 119 patients with normal results were included. The global work index decreased from 2393.3 to 1864.7 mmHg%, p < 0.0004. Global constructive work decreased from 2681.7 to 2152.6 mmHg%, p = 0.001. Global wasted work increased from 78.8 to 128.3 mmHg%, p < 0.003. Global work efficacy decreased from 96.1 to 91.9%, p < 0.00001. Global strain increased from-19.6 to - 23.7%, p < 0.00001. Dobutamine stress echocardiography results in a decrease of all specific myocardial work index parameters even in normal subjects. Only global myocardial strain improved.

Global longitudinal strain and long-term outcome in patients presenting to the emergency department with suspected acute coronary syndrome.

AIMS: We have previously shown that 2-dimentional strain is not a useful tool for ruling out acute coronary syndrome (ACS) in the emergency department (ED). The aim of the present study was to determine whether in patients with suspected ACS, global longitudinal strain (GLS), measured in the ED using 2-dimensional strain imaging, can predict long-term outcome. METHODS: Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure, or atrial fibrillation) and all-cause mortality data were available in 525/605 patients (87%) enrolled in the Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. GLS was computed using echocardiograms performed within 24 hours of chest pain. MACE of patients with worse GLS (>median GLS) were compared to patients with better GLS (≤ median GLS). RESULTS: Median GLS was -18.7%. MACE occurred in 47/261 (18%) of patients with worse GLS as compared with 45/264 (17%) with better GLS, adjusted HR 0.87 (95% CI 0.57-1.33, P = .57). There was no significant difference in all-cause mortality or individual endpoints between groups. GLS did not predict MACE even in patients with optimal 2-dimensional image quality (n = 164, adjusted HR=1.51, 95% CI 0.76-3.0). CONCLUSIONS: Global longitudinal strain did not predict long-term outcome in patients presenting to the ED with chest pain and suspected ACS, supporting our findings in the 2DSPER study.

Diagnosis of patent foramen ovale using maximum intensity T-projection imaging.

Accurate diagnosis of patent foramen ovale (PFO) and grading of right-to-left shunt severity by the standard method of transthoracic or transesophageal echocardiography (TEE) with bubble injection is often challenging. We proposed the novel Maximum Intensity T-Projection (MIP) Imaging method as a complementary or alternative approach for simplified diagnosis and grading of PFO. MIP Imaging represents the superimposition of all frames of an echocardiographic video onto one image. Thus, all bubbles passing from right to left atrium are represented in this single image. Diagnosis and quantification of PFO by MIP Images were compared to those obtained by standard echocardiographic methods, using the same echocardiography video loops. We applied the MIP Imaging approach to 122 echo examinations (75% of them TEE studies), performed to rule out PFOs. The average time needed to manually analyze video loops taken during bubble injection was 102 ± 52 s vs. less than 1 s using the MIP Imaging method. There was good concordance between the conventional echo method and MIP Imaging in the diagnosis and quantification of PFOs. MIP Imaging for diagnosis and quantification of PFOs was much less time consuming than the classical method and at least as accurate as the classical method. Thus MIP Imaging may be used initially as an adjunct method for PFO diagnosis and quantification and may eventually replace the classical method.

The effect of hyperbaric oxygenation therapy on myocardial function.

Hyperbaric oxygenation therapy is successfully implemented for the treatment of several disorders. Data on the effect of hyperbaric oxygenation on echocardiographic parameters in asymptomatic patients is limited. The current study sought to evaluate the effect of hyperbaric oxygenation therapy on echocardiographic parameters in asymptomatic patients. Thirty-one consecutive patients underwent a 60-sessions course of hyperbaric oxygenation therapy in an attempt to improve cognitive impairment. In all subjects, echocardiography examination was performed before and after a course of hyperbaric oxygenation therapy. Conventional and speckle tracking imaging parameters were calculated and analyzed. The mean age was 70 ± 9.5 years, 28 [90%] were males. History of coronary artery disease was present in 12 [39%]. 94% suffered from hypertension, 42% had diabetes mellitus. Baseline wall motion abnormalities were found in eight patients, however, global ejection fraction was within normal limits. During the study, ejection fraction [EF], increased from 60.71 ± 6.02 to 62.29 ± 5.19%, p = 0.02. Left ventricular end systolic volume [LVESV], decreased from 38.08 ± 13.30 to 35.39 ± 13.32 ml, p = 0.01. Myocardial performance index [MPi] improved, from 0.29 ± 0.07 to 0.26 ± 0.08, p = 0.03. Left ventricular [LV] global longitudinal strain increased from - 19.31 ± 3.17% to - 20.16 ± 3.34%, p = 0.036 due to improvement in regional strain in the apical and antero-septal segments. Twist increased from 18.32 ± 6.61° to 23.12 ± 6.35° p = 0.01, due to improvement in the apical rotation, from 11.76 ± 4.40° to 16.10 ± 5.56°, p = 0.004. Hyperbaric oxygen therapy appears to improve left ventricular function, especially in the apical segments, and is associated with better cardiac performance. If our results are confirmed in further studies, HBOT can be used in many patients with heart failure and systolic dysfunction.

Standards on Digital Echocardiography: An Israel Heart Society Position Paper Presented by the Israel Working Group on Echocardiography.

BACKGROUND: The output settings of echocardiographic systems should be set to the full (original) frame rate and lossless compression (e.g., run-length encoding) in order to transmit echocardiographic videos so that they retain their original quality. In addition, monitors and display cards of echocardiography systems and workstations should be able to support an adaptive refresh rate for displaying video at an arbitrary frame rate, including a high frame rate (90+ fps) without dropping frames and preserving the original frame duration. Currently, the only available option for echocardiography monitors is 144-165 Hz (or higher) based on adaptive frame rate G-Sync or FreeSync technology monitors. These monitors should be accompanied by compatible display cards. Echocardiography systems and workstation video playback software should support G-Sync or FreeSync adaptive frame rate technology to display echocardiography videos at their original frame rates without the effects of jitter and frame drops. Echocardiography systems should support an online display of the videos on the workstations during acquisition with the original quality. The requirements for web-based workstations are the same as for desktops workstations. Hospital digital networks should provide transmission and long-term archiving of the echocardiographic videos in their original acquisition quality.

How to facilitate the placement of a transesophageal probe in a ventilated patient?

PURPOSE: Transesophageal probe insertion in the ventilated patients often is difficult. Different complex techniques were suggested for easier placement of the transesophageal probe. In this work, we describe a simple technique of TEE probe insertion in ventilated patients. METHODS AND RESULTS: In the period 2015-2018, 66 transesophageal echocardiographic examinations in anesthetized ventilated patients were carried out in accordance with the standard algorithm developed by us. During the transesophageal examination, all the patients were in the left decubital position and with their head tilted forward. In all the patients, TEE was done smoothly, from the 1st attempt, without complications. CONCLUSION: In the anesthetized intubated and ventilated patients, the TEE probe can be easily inserted when the patient is in the left decubital position. We suggest this algorithm in all such patients, when appropriate.

Effect of image quality on accuracy of two-dimensional strain echocardiography for diagnosing ischemic chest pain: a 2DSPER multicenter trial substudy.

Few data exist regarding the effect of image quality on measurements of two-dimensional longitudinal strain (2DLS). In the 2DLS for Diagnosing Chest Pain in the Emergency Room (2DSPER) multicenter study, 2DLS was not useful for ruling out acute coronary syndromes (ACS) in the emergency department (ED). The aim of this substudy was to determine the effect of 2D image quality on the diagnostic accuracy of 2DLS for ACS. We reviewed apical views used for 2DLS analysis in all 605 patients included in the 2DSPER study. Studies with the best image quality (HighQ, n = 177), were compared to the lower quality group (LowQ, n = 428). Abnormal 2DLS was defined as PSS20% > - 17% (PSS20% being the peak left ventricular systolic strain value identifying the 20% worst strain values). Global longitudinal strain (GLS) and PSS20% were significantly worse in LowQ compared to HighQ patients. LowQ independently predicted abnormal 2DLS (OR 1.9, 95% CI 1.3-2.9, P = 0.003). The sensitivity of PSS20% > - 17% for ACS was 85% for LowQ vs. 73% for HighQ (P = 0.2), specificity 22% vs. 38% (P < 0.0001) and overall accuracy 29% vs. 44% (P = 0.0004). Despite better overall accuracy in the HighQ group there was no significant difference between the receiver operating characteristic curves of either GLS or PSS20% in the two groups and abnormal 2DLS did not predict ACS even in HighQ patients (OR 1.7, 95% CI 0.7-4.3, P = 0.3). LowQ echo is associated with worse 2DLS. Abnormal 2DLS was not clinically useful for excluding ACS in the ED even in patients with optimal 2D image quality.Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT01163019.

Prevalence and Significance of Restrictive Filling Pattern in an Echocardiography Laboratory.

BACKGROUND: A cardiac restrictive filling patterns are associated with unfavorable prognoses. Cardiac interventions may change the natural history of patients. OBJECTIVES: To investigate the prevalence of restrictive filling pattern in routine echocardiographic examinations and their association with morbidity and mortality. METHODS: The clinical and echocardiographic data of patients with newly diagnosed restrictive filling pattern were analyzed and summarized. RESULTS: Among 8000 patients who underwent an echocardiographic examination in our hospital in 2013, a restrictive filling pattern was identified in 256. Of these, 134 showed a restrictive filling pattern that was newly diagnosed. Mean age was 69 years. Hypertension, diabetes, and ischemic heart disease were found in 81%, 60%, and 53%, respectively. Left ventricular ejection fraction was 42% ± 16%. Severe valvular abnormalities were found in 18%. During follow-up (29 ± 15 months), 40% of patients died. The strongest predictor of mortality (73%) was moderate or more advanced aortic stenosis, P = 0.005. Renal failure was an important independent predictor of mortality (53%, P < 0.05). A very high E/E' ratio ≥ 20, was another independent mortality predictor (50%, P < 0.03). Patients who died were less likely to have undergone cardiac interventions than those who survived (26% vs. 45%, P < 0.03). CONCLUSIONS: Prevalence of restrictive filling among echocardiographic studies is 3.2%. In a half of these, the restrictive filling pattern is a new diagnosis. Patients who are diagnosed with a new restrictive filling pattern have higher mortality rates. Patients with restrictive filling should be evaluated thoroughly for possible coronary artery or valvular heart disease.

Adjunctive laser-stimulated stem-cells therapy to primary reperfusion in acute myocardial infarction in humans: Safety and feasibility study.

BACKGROUND: Low-level laser therapy (LLLT) has photobiostimulatory effects on stem cells and may offer cardioprotection. This cell-based therapy may compliment primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI). OBJECTIVE: In this randomized control trial, our primary objective was to determine the safety and feasibility of LLLT application to the bone marrow in patients with STEMI undergoing PPCI. METHODS: We randomly assigned patients undergoing PPCI to LLLT or non-laser therapy (NLT). In the LLLT group, 100 s of laser therapy was applied to the tibia bone prior to PPCI, as well as 24 and 72 h post-PPCI. In the control group, the power source was turned off. The primary outcome was the difference in door-to-balloon (D2B) time, and additional outcomes included differences in circulating cell counts, cardiac enzymes, and left-ventricular ejection fraction (LVEF) at pre-specified intervals post-PPCI. RESULTS: Twenty-four patients were randomized to LLLT (N = 12) or NLT (N = 12). No adverse effects of the treatment were detected. The D2B time was not significantly different between the groups (41 ± 8 vs 48 ± 1 min; P = 0.73). Creatinine Phosphokinase area under the curve, was lower after LLLT (22 ± 10) compared to NLT (49 ± 12), but this was not statistically significant (P = 0.08). Troponin-T was significantly lower after LLLT (2.7 ± 1.4 ng/mL) in comparison to NLT (5.2 ± 1.8 ng/mL. P < 0.05). At 9 months, LVEF improved in both groups without a significant difference between LLLT (55 ± 9%) and NLT (52 ± 9%; P = 0.90). CONCLUSION: LLLT is a safe and feasible adjunctive cell-based therapy to PPCI that may benefit ischemic myocardium.

Carbon monoxide poisoning in a young, healthy patient: A case study of heart failure recovery after Hyperbaric Oxygenation Treatment.

The effectiveness of hyperbaric oxygen treatment for acute cardiac diseases is unknown. Similarly, the effectiveness of hyperbaric oxygen treatment for carbon monoxide intoxication is also unknown, particularly for cases in which carboxyhemoglobin (COHb) levels return to normal. Our case study revolved around a healthy twenty-year-old male patient, who suffered from carbon monoxide intoxication. The patient presented to the Emergency Department unconscious. Blood workup revealed significant carbon monoxide intoxication and cardiac injury (COHb = 41%, troponin T = 0.38 ng/dl, ST depression). He was intubated and transferred to a specialist Centre for hyperbaric oxygenation treatment, whilst mechanically ventilated. COHb on arrival (5 hours later) was 4.3%. First echocardiography revealed estimated ejection fraction of 30%, moderate-severe left ventricular dysfunction and global hypokinesis. Patient received 3 rounds of HBOT; each round was 2.4 ATA, 100% O2 and 120 minutes long within the following 24 hours. Afterwards, the patient was successfully extubated. Three days later, a second echocardiography showed remarkable improvement with normal left ventricular size and function. The patient discharged the following day without complaints or the need for long-term medication. Hyperbaric treatment for carbon monoxide intoxication with compromised cardiac function should be considered even when carboxyhaemoglobin levels have returned to normal. This is due to mitochondrial impairment caused by carbon monoxide intoxication that eventually can lead to significant cardiac deterioration.

Intramyocardial dissecting hematoma: Two case reports and a meta-analysis of the literature.

Until recently, diagnosis of intramyocardial dissecting hematoma (IDH) was performed during necropsy or at surgery. During the recent years, echocardiography has permitted clinical suspicion, which usually needed confirmation with magnetic resonance imaging (MRI). In this study, we tried to define clinical and imaging features of IDH and predictors of mortality. We searched the literature for proven cases of IDH and analyzed them together with 2 of our cases. A total of 40 cases of IDH (2 our original and 38 literature cases) were included. Mean age was 60. In 32 cases, IDH was a complication of myocardial infarction (MI), in 66% anterior, a mean time from symptoms to diagnosis was 9 days. Thirty-eight % underwent surgery. In-hospital mortality was 23%. Multivariate analysis showed that the strongest independent predictor of mortality (42%) was EF < 35%; in patients with age >60, mortality risk was 44%; and in the presence of MI or late diagnosis (>24 hours since symptoms started), mortality risk was 50%. In summary, IDH is a diagnostic challenge. A high level of suspicion is needed for prompt diagnosis. Management of these patients is based on individual clinical and imaging parameters. Low EF, age > 60, and late diagnosis, all are predictors of in-hospital mortality.

Speckle tracking imaging in inflammatory heart diseases.

Accurate diagnosis of acute myocarditis is important for the prognosis and risk stratification of these patients. Cardiac magnetic resonance (CMR) has become a major modality for diagnosis of myocarditis, but not widely available. In this study, we tried to evaluate regional and global longitudinal strain by speckle tracking echocardiography in patients with acute inflammatory myocardial diseases in correlation with CMR. Patients with suspected acute myocarditis were recruited prospectively. Clinical diagnosis was established based on clinical, electrocardiographic, laboratory and conventional echocardiographic data. All patients underwent CMR and repeat echocardiographic examination within 24 h of CMR. Echocardiographic examinations were analyzed offline with speckle tracking imaging software. Thirty-two patients with acute perimyocarditis and myopericarditis were included. Mean age was 29 ± 8, 30 males. All patients presented with chest pain and an abnormal electrocardiogram, in 28 ST elevation was found. Troponin was elevated in 30 and was 0.7 ± 0.5 ng/ml. Creatine kinase was 487 ± 319 U. LVEF was 56 ± 5%. Wall motion abnormalities were present in postero-lateral (53%), and inferior wall (21%). Delayed enhancement on CMR was found in 29 patients. Echocardiographic EF based on speckle tracking imaging correlated with CMR calculated EF. There was a positive correlation between the amplitude of regional strain and delayed enhancement, r = 0.52. Sensitivity and specificity of regional strain for prediction of delayed enhancement was 85 and 73% respectively. Speckle tracking imaging can help in the diagnosis of acute myocarditis when CMR is not readily available. Speckle tracking imaging based EF correlates with CMR calculated LVEF and with global strain.