Echocardiographic assessment of atrial, ventricular, and valvular function in patients with atrial fibrillation-an expert proposal by the german working group of cardiovascular ultrasound.

Echocardiography in patients with atrial fibrillation is challenging due to the varying heart rate. Thus, the topic of this expert proposal focuses on an obvious gap in the current recommendations about diagnosis and treatment of atrial fibrillation (AF)-the peculiarities and difficulties of echocardiographic imaging. The assessment of systolic and diastolic function-especially in combination with valvular heart diseases-by echocardiography can basically be done by averaging the results of echocardiographic measurements of the respective parameters or by the index beat approach, which uses a representative cardiac cycle for measurement. Therefore, a distinction must be made between the functionally relevant status, which is characterized by the averaging method, and the best possible hemodynamic status, which is achieved with the most optimal left ventricular (LV) filling according to the index beat method with longer previous RR intervals. This proposal focuses on left atrial and left ventricular function and deliberately excludes problems of echocardiography when assessing left atrial appendage in terms of its complexity. Echocardiography of the left atrial appendage is therefore reserved for its own expert proposal.

Echocardiographic assessment of left atrial appendage morphology and function-an expert proposal by the German Working Group of Cardiovascular Ultrasound.

The left atrial appendage is a blind ending cardiac structure prone to blood stasis due to its morphology. This structure is a preferred region of thrombogenesis in relation to reduced myocardial contractility of the atrial wall. Blood stasis occurs primarily in low flow conditions. One of the tasks of echocardiography is the analysis of morphology and function of the left atrial appendage. The detection of thrombi by echocardiography is difficult and must be carried out thoroughly and carefully to avoid potential complications-especially in the context of rhythm control. The assessment of thromboembolic risk, especially in patients with unknown and presumed atrial fibrillation is a second challenge by characterizing atrial function and flow conditions in the left atrial appendage. Thus, this proposal focuses on the obvious problems of echocardiography when assessing left atrial appendage and the role of this method in planning a potential interventional closure of left atrial appendage.

[Echocardiography in cardiac arrhythmias]. / Echokardiographie in der Rhythmologie.

Echocardiography plays a key role in planning and guidance of electrophysiological procedures. After exclusion of structural heart disease, echocardiography provides insight into the extent of left atrial remodeling by determining left atrial metrics. This "biomarker" is associated with the risk of new-onset atrial fibrillation and predictive of atrial fibrillation recurrence after ablation. Transesophageal echocardiography is necessary to exclude left atrial thrombi and is able to guide a transseptal puncture. In case of a rare but life-threatening cardiac tamponade, an echocardiographic-guided pericardiocentesis ensures quick and effective treatment. Left ventricular ejection fraction and deformation analysis determined by echocardiography are established methods for risk stratification in patients with systolic dysfunction and used to guide pharmacological and device therapy.

[Standardized contrast-enhanced ultrasound (CEUS) in clinical acute and emergency medicine and critical care (CEUS Acute) : Consensus statement of DGIIN, DIVI, DGINA, DGAI, DGK, ÖGUM, SGUM and DEGUM]. / Standardisierte Kontrastmittelsonographie (CEUS) in der klinischen Akut- und Notfallmedizin sowie Intensivmedizin (CEUS Akut) : Konsensuspapier der DGIIN, DIVI, DGINA, DGAI, DGK, ÖGUM, SGUM und DEGUM.

The present document describes the possible applications of contrast-enhanced ultrasound (CEUS) in emergency examinations. Guidelines on contrast medium ultrasound in acute and emergency care and intensive care medicine have not yet been published. Evidence-based CEUS guidelines were first provided by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and the World Federation for Ultrasound in Medicine and Biology (WFUMB). The presented recommendations describe the possible applications and protocols of CEUS in acute care.

Disproportionate mitral regurgitation: another myth? A critical appraisal of echocardiographic assessment of functional mitral regurgitation.

The contradictory findings of recent prospective randomized controlled trials assessing the impact of percutaneous edge-to-edge repair in patients with functional or secondary mitral regurgitation have triggered a lively discussion about an "integrated" echocardiographic approach for grading severity of mitral regurgitation. In the MITRA-FR trial, the COAPT trial and the REDUCE-FMR trial echocardiographic assessment of the severity of mitral regurgitation was consistent with principles set forth by the current echocardiographic guidelines and analysed in its best settings by expert international leaders in the field of echocardiography. However, serious inconsistencies appeared in the presented echocardiographic assessments regarding cardiac output and regurgitant fraction. A new term "disproportionate functional mitral regurgitation" was introduced describing a situation where the increase of effective regurgitant orifice area exceeds the enlargement of the left ventricular end-diastolic volumes. Further discussion resulted in the idea of a "new conceptional framework" for distinguishing "proportionate" and "disproportionate" functional mitral regurgitation. The aim of this viewpoint is to dispute conclusions based on the term "disproportionate" mitral regurgitation. A "disproportionate" FMR is highly questionable because disproportionateness of flow in communication vessels cannot exist. In addition, a proposal of echocardiographic assessment based on a conventional comprehensive transthoracic echocardiography is given to avoid obvious hemodynamic contradictions.

Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness.

The echocardiographic assessment of mitral valve regurgitation (MR) by characterizing specific morphological features and grading its severity is still challenging. Analysis of MR etiology is necessary to clarify the underlying pathological mechanism of the valvular defect. Severity of mitral regurgitation is often quantified based on semi-quantitative parameters. However, incongruent findings and/or interpretations of regurgitation severity are frequently observed. This proposal seeks to offer practical support to overcome these obstacles by offering a standardized workflow, an easy means to identify non-severe mitral regurgitation, and by focusing on the quantitative approach with calculation of the individual regurgitant fraction. This work also indicates main methodological problems of semi-quantitative parameters when evaluating MR severity and offers appropriateness criteria for their use. It addresses the diagnostic importance of left-ventricular wall thickness, left-ventricular and left atrial volumes in relation to disease progression, and disease-related complaints to improve interpretation of echocardiographic findings. Finally, it highlights the conditions influencing the MR dynamics during echocardiographic examination. These considerations allow a reproducible, verifiable, and transparent in-depth echocardiographic evaluation of MR patients ensuring consistent haemodynamic plausibility of echocardiographic results.

Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation.

According to recent recommendations on echocardiographic assessment of aortic valve stenosis direct measurement of transvalvular peak jet velocity, calculation of transvalvular mean gradient from the velocities using the Bernoulli equation and calculation of the effective aortic valve area by continuity equation are the appropriate primary key instruments for grading severity of aortic valve stenosis. It is obvious that no gold standard can be declared for grading the severity of aortic stenosis. Thus, conclusions of the exclusive evaluation of aortic stenosis by Doppler echocardiography seem to be questionable due to the susceptibility to errors caused by methodological limitations, mathematical simplifications and inappropriate documentation. The present paper will address practical issues of echocardiographic documentation to satisfy the needs to analyze different scenarios of aortic stenosis due to various flow conditions and pressure gradients. Transesophageal and multidimensional echocardiography should be implemented for reliable measurement of geometric aortic valve area and of cardiac dimensions at an early stage of the diagnostic procedure to avoid misinterpretation due to inconsistent results.