Diastolic Stress Echocardiography Research Articles

Heart failure with preserved ejection fraction: diagnostic value of HFA-PEFF score, H₂FPEF score, and the diastolic stress echocardiography.

The aim of our study was to compare 3 diagnostic pathways: diastolic stress echocardiography (DSE) based on the ASE/EACVI 2016 guidelines, the 2018 H₂FPEF score, and the 2019 HFA-PEFF algorithm, in patients suspected of heart failure with preserved ejection fraction (HFpEF). The study group included 80 consecutive patients with a clinical suspicion of HFpEF. The H₂FPEF and HFA-PEFF scores and serum NT-proBNP concentrations were assessed in all the patients before they were sent for DSE. The DSE-based pathway confirmed HFpEF in 17 (21%) patients, the HFA-PEFF algorithm in 43 (54%), and H₂FPEF scoring in 4 (5%) patients. The ROC analysis showed that HFA-PEFF score > 5 predicts a DSE-positive test with a sensitivity of 70.5% and a specificity of 65%, (AUC = 0.711, p = 0.002) with a negative predictive value of 89.1% and positive predictive value of 35.3%. The H₂FPEF score > 3 had a negative predictive value of 90%, a positive predictive value of 29.8%, and predicted positive DSE result with a sensitivity of 82.3% but rather poor specificity of 47.6% (AUC = 0.692, p = 0.004). Both H₂FPEF and HFA-PEFF showed similar predictive values (AUC) in the prediction of positive DSE test (p = ns). The HFA-PEFF score overestimated the rate of HFpEF in comparison to DSE and the H₂FPEF score. The H₂FPEF and HFA-PEFF scores showed only modest predictive values of the positive DSE and had a diagnostic power to rule out the HFpEF.

Impact of enzyme replacement therapy on cardiac function in patients with Fabry disease cardiomyopathy: A prospective multimodality imaging study using diastolic stress echocardiography and cardiac MRI

Impact of enzyme replacement therapy on cardiac function in patients with Fabry disease cardiomyopathy: A prospective multimodality imaging study using diastolic stress echocardiography and cardiac MRI

Left ventricular mass index versus results of diastolic stress echocardiography in patients with heart failure with preserved ejection fraction

Background: Left ventricular mass and left ventricular mass index (LVMI) is an index reflecting the thickness of the cardiac muscle, and the E/e’ ratio is a specific indicator for identifying increased left ventricular filling pressure. Limited data exist regarding the prognostic value of incorporating left ventricular mass index in heart failure with preserved ejection fraction (HFpEF). Aim: This study aimed to assess diagnostic value of LVMI at rest versus diastolic stress echo results in patients with HFpEF. Patients and methods: This study is a cross sectional descriptive study. In our study, we investigated 80 patients with unexplained exertional dyspnea with normal resting LV filling pressure at rest. Some of these patients may show elevated LV filling pressure with exercise. The current guidelines recommend to do diastolic stress echocardiography for those patients. All patients underwent complete resting echocardiography including assessment of diastolic dysfunction using the recommended 2016 guidelines and left ventricular mass index. Then we did diastolic stress echocardiography for all participants and the result of diastolic stress echocardiography was compared with the resting LVMI results.

Abstract 16438: Effect of Enzyme Replacement Therapy on Diastolic Function in Patients With Fabry Disease

Introduction: The effects of ERT (enzyme replacement therapy) on cardiac manifestations in patients with Fabry disease (FD) are ambiguous. We aimed to investigate the response to ERT using diastolic stress echocardiography (DSE). Hypothesis: Diastolic function of FD would be improved after ERT. Methods: 19 patients with FD who underwent ERT were analyzed. All patients had DSE prior to ERT and post ERT at 1 year follow-up. We measured early diastolic (e’) velocity of the mitral annulus at baseline, 25 Watt (W) and peak exercise. The difference of diastolic reserve (ΔDR) between pre and post ERT was calculated. Diastolic reserve is defined as the change of e’ from baseline to 25W or peak of exercise in DSE. Results: Overall diastolic reserve tends to be improved (ΔDR25W: 0.66±1.36, ΔDRpeak 1.47±2.61) after 1 year of the ERT. However, there was no significant change in left ventricular (LV) wall thickness and LV mass index before and after the ERT. When patients were classified into two groups according to ΔDRpeak (Group 1, n=6, ΔDRpeak ≤0; Group 2, n=13, ΔDRpeak >0), group 2 showed more higher pre-ERT MWE (93.6±3.2 vs 84.8±5.0, p<0.01). The pre-ERT longitudinal strain of LV was better in group 2 compared to group 1 (-14.6±2.6 vs -9.9±2.3m p<0.01). LAVI (44.0±12.9 vs 25.5±8.0, p<0.01), LVEDD (50.8±2.8 vs 46.5 ± 3.0, p<0.01) and LV mass index (204.5±57.5 vs 130.4±45.6, p=0.01) of pre ERT were higher in group 1. Conclusions: Diastolic function of FD was improved generally after ERT in FD patients FD patients who have relatively preserved chamber size and mechanical function before starting ERT showed a better response to ERT. In determining the ERT effect, evaluation of diastolic function is more useful than structural evaluation in patients with Fabry cardiomyopathy.

Haemodynamic validation of the three-step HFA-PEFF algorithm to diagnose heart failure with preserved ejection fraction.

The HFA-PEFF algorithm (Heart Failure Association-Pre-test assessment, Echocardiography and natriuretic peptide score, Functional testing in cases of uncertainty, Final aetiology) is a three-step algorithm to diagnose heart failure with preserved ejection fraction (HFpEF). It provides a three-level likelihood of HFpEF: low (score<2), intermediate (score 2-4), or high (score>4). HFpEF may be confirmed in individuals with a score>4 (rule-in approach). The second step of the algorithm is based on echocardiographic features and natriuretic peptide levels. The third step implements diastolic stress echocardiography (DSE) for controversial diagnostic cases. We sought to validate the three-step HFA-PEFF algorithm against a haemodynamic diagnosis of HFpEF based on rest and exercise right heart catheterization (RHC). Seventy-three individuals with exertional dyspnoea underwent a full diagnostic work-up following the HFA-PEFF algorithm, including DSE and rest/exercise RHC. The association between the HFA-PEFF score and a haemodynamic diagnosis of HFpEF, as well as the diagnostic performance of the HFA-PEFF algorithm vs. RHC, was assessed. The diagnostic performance of left atrial (LA) strain<24.5% and LA strain/E/E'<3% was also assessed. The probability of HFpEF was low/intermediate/high in 8%/52%/40% of individuals at the second step of the HFA-PEFF algorithm and 8%/49%/43% at the third step. After RHC, 89% of patients were diagnosed as HFpEF and 11% as non-cardiac dyspnoea. The HFA-PEFF score resulted associated with the invasive haemodynamic diagnosis of HFpEF (P<0.001). Sensitivity and specificity of the HFA-PEFF score for the invasive haemodynamic diagnosis of HFpEF were 45% and 100% for the second step of the algorithm and 46% and 88% for the third step of the algorithm. Neither age, sex, body mass index, obesity, chronic obstructive pulmonary disease, or paroxysmal atrial fibrillation influenced the performance of the HFA-PEFF algorithm, as these characteristics were similarly distributed over the true positive, true negative, false positive, and false negative cases. Sensitivity of the second step of the HFA-PEFF score was non-significantly improved to 60% (P=0.08) by lowering the rule-in threshold to >3. LA strain alone had a sensitivity and specificity of 39% and 14% for haemodynamic HFpEF, increasing to 55% and 22% when corrected for E/E'. As compared with rest/exercise RHC, the HFA-PEFF score lacks sensitivity: Half of the patients were wrongly classified as non-cardiac dyspnoea after non-invasive tests, with a minimal impact of DSE in modifying HFpEF likelihood.

Value of diastolic stress echocardiography combined with speckle tracking imaging in assessment of patients with exertional dyspnea and normal resting left ventricular functions

Abstract Background A group of patients presenting with exertional dyspnea and a preserved left ventricular ejection fraction (LVEF) have a normal resting left ventricular (LV) filling pressure which increases with exercise or stress due to diastolic dysfunction. Objectives We aimed to study the value of diastolic stress echocardiography combined with speckle tracking imaging in assessment of patients with exertional dyspnea and normal resting LV functions. Patients We prospectively studied 200 patients their age ≤60years who had unexplained exertional dyspnea and unable to do exercise test including those with (severe physical or mental inability, morbid obesity, recent stroke, etc) all patients included in the study had a normal both LV systolic function (LVEF≥50%), and diastolic function by conventional echocardiography. Methods All patients were subjected to a standard DSE protocol with incremental dobutamine infusion rates of 5, 10, 20, 30, and 40 mg/kg/min each stage lasts for 3 minutes, and the following LV echo parameters were recorded at baseline and at peak dose of the DSE; LVEF, (E/e') it is the ratio between early mitral inflow velocity and mitral annular early diastolic velocity, also two-dimensional speckle tracking imaging(2D-STI) was done to measure LV global longitudinal systolic strain (GLS), global longitudinal diastolic strain rate (DSr) during early filling (DSrE), late diastole (DSrA). Results The study included 200 patients their mean age 45.7 ± 8.4 years(60% were males). The LVEF, and the GLS showed non-significant difference at baseline compared to peak dose DSE (P=0.81, 0.73 respectively), the E/e', DSrA and E/DSrE were significantly increased from baseline to peak study(p &amp;lt;0.001, 0.003,and 0.006 respectively), while DSrE was significantly decreased at peak stress(p &amp;lt; 0.001), and the E/DSrE, and DSrE were significantly correlated to E/e'(p &amp;lt; 0.001) Conclusions DSE combined with global diastolic strain rate parameters are valuable methods to evaluate diastolic dysfunction in patients with exertional dyspnea and normal resting myocardial functions. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Diastolic stress echocardiography in patients with normal resting diastolic function: prognostic utility in presence and absence of myocardial ischemia

Abstract Background Abnormal diastolic response to exercise is reportedly associated with worse cardiovascular events. However, this has not been well studied in patients with normal diastolic function at rest. Purpose We sought to study diastolic response to exercise in patients referred for exercise stress echocardiography (ExE) and to explore its association with adverse outcomes in the presence and absence of exercise-induced myocardial ischemia. Methods In a retrospective study, patients referred for ExE to assess myocardial ischemia between April 2017 and December 2018 were enrolled. Patients were included if they had guideline-defined normal diastolic function at rest and availability of a full set of post exercise diastolic variables (post exercise tissue Doppler derived septal mitral annular early diastolic velocity (e'), ratio of pulsed Doppler derived mitral forward flow early diastolic velocity (E) over e' (E/e') and continuous wave Doppler derived maximum tricuspid regurgitation velocity (TRV)). The patients were followed for a median of 3.4 years for the occurrence of composite death, acute coronary syndrome, cardiac hospitalization, and need of follow-up ischemia testing. Abnormal exercise diastolic variables were defined as e' &amp;lt;7 cm/s, E/e' &amp;gt;15, and TRV &amp;gt;2.8 m/s. Results We studied 492 patients [age: 55.7±12.9 year, 268 (54%) women, EF: 61±5.8%]. Mean achieved metabolic equivalents of tasks (METs) was 9.7±3.1, and a total of 49 (10%) patients had evidence of exercise-induced ischemia. At rest, mean left atrial volume index was 25.4±12 ml, e' was 8±2 cm/s, E/e' was 9.5±2.4, and TRV was 2.1±0.44 m/s. Post exercise e' was 10±3 cm/s [&amp;lt;7cm/s in 63 (13%)], E/e' was 11.1±3.9 [&amp;gt;15 in 95 (19%)], and TRV was 2.37±0.68 m/s [&amp;gt;2.8 m/s in 152 (31%)]. Ischemic ExE was found to be strongly associated with the outcome (HR: 4.46, 95% CI: 2.8 to 7.1, p&amp;lt;0.001). In addition, all diastolic variables predicted the outcome in isolation if they were abnormal (e': 2.28, 95% CI: 1.4 to 3.7, p=0.001, E/e': 1.81; 95% CI: 1.15 to 2.84, p=0.01; TRV: 1.58, 95% CI: 1.17 to 2.13, p=0.003). When combined, however, association with the outcome was seen only when 2 or 3 of these variables were abnormal simultaneously (Figure 1A). When patients were stratified by ischemia and abnormal diastolic variables (figure 1B), patients with 2 or 3 abnormal variables were more likely to experience the outcome compared to patients with 0 or 1 abnormal variables in both absence of ischemia (p&amp;lt;0.001) and presence of ischemia (p=0.016). The stratified groups were different in their clinical and exercise profiles, with worse profiles in patients with both ischemia and 2 or 3 abnormal variables, and best profiles in patients with no ischemia and 0 or 1 abnormal variables. Conclusions In patients referred for ExE to assess ischemia with normal baseline diastolic function, exercise can unmask abnormal diastolic properties and stratify patients' risk regardless of the overt myocardial ischemia. Funding Acknowledgement Type of funding sources: None.

Clinical parameters and cardiovascular risk factors related to heart failure with preserved ejection fraction: a comparative analysis between HFA-PEFF and H2FPEF Scores

Abstract Background Heart failure with preserved ejection fraction (HFpEF) diagnosis remains challenging, since several mechanisms (diastolic and systolic reserve abnormalities, chronotropic incompetence, ventricular or vascular stiffening, atrial dysfunction, pulmonary hypertension, impaired vasodilation, endothelial dysfunction, energetic abnormalities and autonomic dysfunction) play different roles in HFpEF development. European Society of Cardiology HF guidelines recently suggested a stepwise non-invasive diagnostic approach consisting of three steps: the first is clinical, the second includes echocardiographic and laboratory data (natriuretic peptides), named HFA-PEEF score, and finally, in case of inconclusive findings, diastolic stress echocardiography is recommended. On the other hand, in United States, another multiparametric score, named H2FPEF, has been proposed for HFpEF diagnosis, and including, in addition to echocardiographic parameters, also clinical data; thereby more applicable in the outpatient clinical arena. Purpose Whether there is a clinical overlap between the two scores (HFA-PEEF and H2FPEF) as well as whether the addition of clinical data to the HFA-PEEF could improve its ability to identify different HFpEF phenotypes is still an open issue and these were the aims of our study. Methods HFA-PEEF and H2FPEF scores were systematically applied on 1,156 consecutive subjects with preserved ejection fraction who undergone cardiovascular evaluation at the Cardiovascular Prevention Center of Fondazione Don Gnocchi &amp; University of Parma. All subjects underwent cardiovascular risk assessment followed by echocardiography and cardiopulmonary exercise testing; due to the outpatient (non-acute) setting of the evaluation, natriuretic peptides assay was not performed. Clinical data and cardiovascular risk factors data were compared between different groups of HFpEF risk. Results According to H2FPEF score, low risk (&amp;lt;40%) of HFpEF was found in 659 (57%), moderate in 300 (26%) and high (&amp;gt;75%) in 197 (17%); according to HFA-PEEF score, 675 (58%) had 0 or 1 point, 253 (22%) had 2 points and 230 (20%) had 3 or 4 points (moderate-to-high risk). Patients with higher HFA-PEEF score were older (p&amp;lt;0.001), had higher prevalence of HTN (p&amp;lt;0.001), diabetes (p&amp;lt;0.001), obesity (p&amp;lt;0.001), sedentary lifestyle (p&amp;lt;0.001), AF (p&amp;lt;0.001) and CCS (p&amp;lt;0.001) (figure 1). More specifically, AF was associated to a 6.3-fold higher risk (p&amp;lt;0.001) of high (3–4) HFA-PEEF Score, age &amp;gt;75 years to a 4.6-fold higher risk, HTN to a 3.6-fold higher risk (p&amp;lt;0.001), CCS to a 3.3-fold higher risk (p&amp;lt;0.001), obesity to a 2.2-fold higher risk (p&amp;lt;0.001), diabetes to a 1.9-fold higher risk (p&amp;lt;0.001) and sedentary to a 1.7-fold higher risk (p=0.001). Conclusions Although HFA-PEEF score does not include clinical data, patients with older age, atrial fibrillation, hypertension, hypertensive heart, diabetes, sedentary lifestyle and chronic coronary syndrome show a higher ESC risk of HFpEF. Funding Acknowledgement Type of funding sources: None.

Cardiopulmonary response to exercise and heart failure with preserved ejection fraction risk: a comparative analysis of HFA-PEFF and H2FPEF scores

Abstract Background Exercise intolerance evaluation in Heart failure with preserved ejection fraction (HFpEF) remains challenging, since several mechanisms (diastolic and systolic reserve abnormalities, low chronotropic reserve (CR), ventricular or vascular stiffening, atrial dysfunction, pulmonary hypertension, endothelial dysfunction, energetic abnormalities and autonomic dysfunction) play different roles. European Society of Cardiology HF guidelines recently suggested a stepwise non-invasive HFpEF diagnostic approach consisting of three steps: clinical, echocardiographic and laboratory data (natriuretic peptides), named HFA-PEEF Score, and finally, in case of inconclusive findings, diastolic stress echocardiography data. Cardiopulmonary exercise testing (CPET) may represent a promising further non-invasive diagnostic tool in HFpEF evaluation since allow to assess the presence of reduced functional capacity as well as to differentiate between cardiovascular, ventilatory or peripheral causes. Purpose Whether increased risk of HFpEF is associated with different and specific cardiopulmonary responses to exercise is still an open issue and this was the aim of our study. Methods 1.156 consecutive subjects with preserved ejection fraction undergoing cardiovascular evaluation at the Cardiovascular Prevention Center of Fondazione Don Gnocchi &amp; University of Parma were enrolled. All subjects underwent cardiovascular evaluation and echocardiography, HFA-PEEF and H2FPEF Score assessment and cardiopulmonary exercise testing. Different cardiopulmonary response to exercise were compared between different groups of HFpEF risk. Results According to HFA-PEEF Score, 675 (58%) had 0 or 1 point, 253 (22%) had 2 points and 230 (20%) had 3 or 4 points (moderate-to-high risk). Patients with both higher HFA-PEEF and H2FPEF Score showed lower functional capacity, expressed as low peak V02 (p&amp;lt;0.001) associated with lower oxygen pulse (V02/HR) (p&amp;lt;0.001), cardiac output (CO) at peak (p&amp;lt;0.001), CR (p&amp;lt;0.001), ventilatory efficiency (expressed as VE/VC02 slope) (p&amp;lt;0.001) and oxygen uptake extraction (OUES) (p&amp;lt;0.001). Moreover, higher H2FPEF Score patients showed lower stroke volume (SV) at peak (p&amp;lt;0.001), while high HFA-PEEF score was not associated to SV at peak (Table 1 and Figure 1). More specifically, the presence of reduced cardiovascular efficiency (V02/Watt Slope &amp;lt;7) was associated to a 2.2-fold higher risk of HFpEF (p=0.003), impaired ventilator efficiency (VE/VCO2 Slope &amp;gt;35) to a 2.4-fold higher risk (p&amp;lt;0.001), reduced CR (&amp;lt;70%) 4.3-fold higher risk (p&amp;lt;0.001). Conclusions Different degrees HFpEF risk, estimated using both HFA-PEEF and H2FPEF score, are associated with different cardiopulmonary responses to exercise. High HFpEF risk patients show low functional capacity, cardiovascular and ventilator efficiency due to lower cardiac output at peak, despite preserved ejection fraction, associated to lower chronotropic response to exercise. Funding Acknowledgement Type of funding sources: None.

Contractile Reserve in Heart Failure with Preserved Ejection Fraction.

Background: Diastolic stress echocardiography (SE) is useful for confirming the diagnosis of heart failure with preserved left ventricular ejection fraction (HFpEF) when it is uncertain. The aim of this study was to assess the value of new echocardiographic parameters during diastolic SE in patients with dyspnea and suspected HFpEF. Methods: Sixty-two patients with exertional dyspnea and inconclusive rest echocardiography for a diagnosis of HFpEF were enrolled. Exercise SE was performed in all patients. Contractile reserve (LVCR) was assessed by measuring: 1. changes in the left ventricular ejection fraction (LVEF) between rest and peak stress; 2. stress-to-rest ratio of force (force was defined as the ratio between systolic arterial pressure and left ventricular end-systolic volume); and 3. mechanical reserve, defined as the change in systolic strain (GLS) between rest and peak stress. Results: Diagnosis of HFpEF was performed by SE in 26 patients. Comparing patients with a diagnosis of HFpEF (group A) to patients with other causes of dyspnea (group B), we found a significant increase in the E/e’ ratio in group A at peak stress. LV GLS was significantly reduced in group A compared to group B at rest and stress (p value 0.01 at rest; p value 0.04 at stress). At peak stress, GLS did not significantly increase in group A, while it increased in group B (p value 0.04). LVEF increased significantly in both groups. Conclusion: Patients with HFpEF have impaired LVCR when assessed using GLS. Thus, the assessment of mechanical reserve could give additional diagnostic information during stress tests in patients with HFpEF.

Value of Diastolic Stress Echocardiography Combined with Speckle Tracking Imaging in Assessment of Patients with Exertional Dyspnea and Normal Resting Left Ventricular Functions

Value of Diastolic Stress Echocardiography Combined with Speckle Tracking Imaging in Assessment of Patients with Exertional Dyspnea and Normal Resting Left Ventricular Functions

Diastolic stress echocardiography and biomarkers in patients with preserved left ventricle ejection fraction and heart failure symptoms.

Diastolic dysfunction (DD) is a diagnostic challenge in clinical practice. Our study aimed to evaluate the value of diastolic stress echocardiography (DSE) and heart failure (HF) biomarkers in patients with preserved left ventricular ejection fraction (LVEF) and HF symptoms. All the consecutive patients with HF symptoms, preserved LVEF, and suspected DD were examined on transthoracic echocardiography (TTE) and DSE using the protocol according to the American Society of Echocardiography recommendations. Moreover, blood samples were taken 30 minutes before and after DSE for the following lab markers: N-terminal pro-B type natriuretic peptide (NT-proBNP), mid regional pro-atrial natriuretic peptide (MR-proANP), and serum soluble ST2 receptor (ST2). The study group included 80 patients (mean [standard deviation, SD] age, 69 (8.1) years; 25% males) with dyspnea (New York Heart Association classification IIa - 53; IIb - 17; III - 10) and risk factors: hypertension (96%), diabetes (41%), obesity (56%), and known coronary artery disease (10%). The rest transthoracic echocardiography (TTE) showed preserved systolic function (mean [SD], LVEF 61.1 [10.5]%) and normal or indeterminate diastolic function. DSE revealed a positive result for diastolic dysfunction in 17 patients (21%). The receiver operating characteristic (ROC) analysis showed that age (the area under the curve [AUC], 0.725; P < 0.01), left atrial volume indexed for body surface area [LAVI] rest (AUC, 0.722; P < 0.01), E/e' rest (AUC, 0.790; P < 0.01), and baseline NT-proBNP (AUC, 0.713; P < 0.01) predicted positive DSE. Other parameters, including body mass index, baseline E/A, DT, or e' were not predictive of DSE results. DSE revealed diastolic dysfunction in 21% of study patients and improved the diagnostic value of echocardiography. Rest NT-proBNP, but not MR-proANP and ST2, provided a diagnostic value for diastolic dysfunction.

Exercise Stress Echocardiography in the Diagnostic Evaluation of Heart Failure with Preserved Ejection Fraction

More than half of patients with heart failure have a preserved ejection fraction (HFpEF). The prevalence of HFpEF has been increasing worldwide and is expected to increase further, making it an important health-care problem. The diagnosis of HFpEF is straightforward in the presence of obvious objective signs of congestion; however, it is challenging in patients presenting with a low degree of congestion because abnormal elevation in intracardiac pressures may occur only during physiological stress conditions, such as during exercise. On the basis of this hemodynamic background, current consensus guidelines have emphasized the importance of exercise stress testing to reveal abnormalities during exercise, and exercise stress echocardiography (i.e., diastolic stress echocardiography) may be used as an initial diagnostic approach to HFpEF owing to its noninvasive nature and wide availability. However, evidence supporting the use of this method remains limited and many knowledge gaps exist with respect to diastolic stress echocardiography. This review summarizes the current understanding of the use of diastolic stress echocardiography in the diagnostic evaluation of HFpEF and discusses its strengths and limitations to encourage future studies on this subject.

Novel method of diastolic stress echocardiography during bottle-feeding for infants with congenital heart disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Recent studies have demonstrated the utility of diastolic stress echocardiography in evaluating diastolic dysfunction during exercise in adults. However, there have been no such reports in infants. This study determined whether measuring cardiac function using echocardiography during bottle feeding is a valid method of stress testing in infants with congenital heart disease. Methods The study population comprised 25 infants with congenital heart disease (Table 1). Echocardiographic measurements of the infants were taken during and after bottle feeding (Figure 1A). Active feeding (AF) was defined as the start of feeding during which the heart rate started increasing. End of feeding (EF) was defined as the time of completion of feeding during which the heart rate slowed down. The 25 infants were divided into two groups according to brain natriuretic peptide levels: less than 50 pg/ml (low group) and more than 50 pg/ml (high group). Cardiac function was compared between the groups using 2D speckle tracking analysis, and intraventricular pressure differences (IVPD) via color M-mode Doppler (Figures 1B and 1C) and 2D echocardiography. We compared the fractional change (FC%), defined as (AF and EF measurements)/EF measurements, between the two groups. Results Heart rate increased AF comparing with EF, significantly in both groups, the low group from 162 to 139 bpm; the high group from 152 to 140 bpm. The FC_IVPD was higher in the low group than in the high group (Figure.2). There were negative correlations between brain natriuretic peptide levels and the FC_IVPD (Figure 3). There were 4 cases were performed the intra-cardiac repair (ICR). In 2 cases, VSD and right ventricular outflow tract obstruction (RVOTO) velocity were increased during feeding. Indication of ICR, VSD case was aortic regurgitation with aortic cusp prolapse, TOF case was RVOTO. In VSD peak velocity in 2 cases did not increase during feeding (Table2). Indication of ICR, two VSD cases were moderate left to right shunt, or pulmonary hypertension. Conclusions Our findings indicate that stress echocardiography during bottle-feeding might be a substitute for diastolic stress echocardiography in infants. The VSD or RVOT peak velocity, and FC% in IVP D and IVPG are sensitive markers for cardiac function in infants with congenital heart disease. Abstract Table1 Abstract Figure.

Comprehensive diastolic exercise stress echocardiography in heart failure with preserved ejection fraction

Abstract Background In heart failure with preserved ejection fraction (HFpEF), diastolic exercise stress echocardiography (ESE) is currently recommended with E/e' and systolic pulmonary artery pressure (SPAP) from tricuspid regurgitant jet velocity (TRV). Purpose To evaluate conventional and advanced ESE parameters in patients with HFpEF. Methods We prospectively screened 124 patients with suspected HFpEF (dyspnea, resting EF &amp;gt;50%, increased natriuretic peptide levels) and HFA-PEFF score ≥1. Of these 124, 10 patients were excluded for history of coronary artery disease, 3 for severe mitral regurgitation (MR), 12 for inducible ischemia. The final study population consisted of 99 patients (mean age 63±7 yrs, 57 females). All underwent ESE, with semi-supine bike (n=35), upright bike (n=20) or treadmill (n=44 patients) in 11 accredited labs from 9 countries (Argentina, Brazil, Bulgaria, Hungary, Italy, Lithuania, Mexico, Russia and Spain). In addition to E/e' average (abnormal stress response ≥15 units) and TRV (abnormal stress response &amp;gt;3.4 m/s), we measured 8 additional criteria: B-lines (4-site simplified scan, abnormal stress value ≥2); cardiac index (CI) reserve (increase from rest to stress, abnormal &amp;lt;1.63 l/min/m2), ejection fraction (EF, abnormal increase &amp;lt;5%), global longitudinal strain (GLS, abnormal increase &amp;lt;2%), end-diastolic volume (EDV, abnormal stress &amp;lt; rest); heart rate reserve (HRR, abnormal &amp;lt;1.80); left atrial volume index, (LAVI, abnormal increase &amp;gt;6.8 ml/m2); MR (abnormal, stress value more than mild). Results Technical success rate during stress ranged from 100% for B-lines to 75% for GLS: see Table. At individual criteria analysis, positivity rate in interpretable studies ranged from 67% of HRR to 10% of peak MR: see table. At individual patient analysis, an abnormal response in 1 ESE criterion occurred in 4 pts (4%), of 2 to 4 criteria in 71 pts (72%) and of ≥5 criteria in 24 (24%). Conclusion In suspected HFpEF, ESE is helpful in the screening phase to identify extra-diastolic causes of dyspnea such as myocardial ischemia or severe MR. In the diagnostic phase, a comprehensive ESE captures the functional heterogeneity of HFpEF, with variable association of multiple phenotypes, the most frequent represented by reduced chronotropic, cardiac or contractile reserve and pulmonary congestion. Funding Acknowledgement Type of funding sources: None.

EACVI survey on the evaluation of left ventricular diastolic function.

The aim of this study is to analyse how current recommendations on left ventricular (LV) diastolic function assessment have been adopted. Identifying potential discrepancies between recommendations and everyday clinical practice would enable us to better understand and address the remaining challenges in this controversial and complex field. A total of 93 centres, mainly from tertiary care settings, responded to the survey. More than three-quarters (77%) of centres follow the 2016 ASE/EACVI recommendations for LV diastolic function evaluation in patients with preserved ejection fraction based upon e', E/e', tricuspid regurgitation velocity, and left atrial (LA) volume. These recommendations were generally preferred to the previous 2009 version. Many centres also consider strain assessments in the LV (48%) and left atrium (53%) as well as diastolic stress echocardiography (33%) to be useful as additional assessments of LV diastolic function. Echocardiographic assessments of LV diastolic function were used frequently to guide therapy in 72% of centres. There is widespread adoption of current recommendation on the evaluation of LV diastolic function and these are frequently used to guide patient management. Many centres now also consider LV and LA strain assessments useful in the clinical assessment of diastolic function. These may be considered in future recommendations.

Rest NT-proBNP but not MR-proANP predicts positive diastolic stress echocardiography test result in patients with preserved left ventricle ejection fraction and heart failure symptoms

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Silesia Introduction Diastolic dysfunction and heart failure (HF) with preserved ejection fraction are diagnostic challenges in rest transthoracic echocardiography (TTE) and clinical practice. The aim of our study was to evaluate the clinical value of diastolic stress echocardiography (DSE) and its corelation with NT-proBNP and MR-proANP testing in patients with preserved left ventricle ejection fraction (LVEF) and HF symptoms. Methods: All the consecutive patients with HF symptoms, preserved LVEF and suspected diastolic dysfunction were examined with DSE with the protocol according to the EACVI 2016 recommendations. Patients with cardiomyopahties, significant valve defects or extracardiac diseases causing similar symptoms were excluded. The assessment of diastolic function was obtained at rest transthoracic echocardiography (TTE) and at peak exertion in DSE: left atrium volume index (LAVI), average E/e’ &amp;gt;14, peak tricuspid regurgitation velocity &amp;gt;2,8 m/s, septal e’ velocity &amp;lt;7 cm/s or lateral e’&amp;lt; 10cm/s (&amp;gt;50% positive – diastolic dysfunction). Moreover, blood samples for NT-proBNP and MR-proANP were taken just before and 30 minutes after DSE. Results The study group included 80 patients (age: 69 ± 8.3 years; 24% males) with dyspnea (NYHA IIa – 53pts; IIb – 17pts; III – 10pts) and risk factors: hypertension (77pts), diabetes (33pts), known coronary artery disease (8pts) and chronic kidney disease (21pts). The rest TTE showed preserved systolic function (LVEF 61.6 ± 8.8%) and normal or indeterminate diastolic function in all patients. DSE revealed positive result for diastolic dysfunction in 17 patients (21%). The levels of NT-proBNP :267(160-518) vs 310(172-522) (p = 0.46) and MR-proANP: 16,2(7,8-542) vs 14,7(6,1-646) p = 0,38 did not significantly change before and after DSE. The ROC analysis showed that age (AUC = 0.720; p &amp;lt; 0.001), LAVI rest (AUC = 0.722, p &amp;lt; 0.01), E/e’ rest (AUC 0.790;p &amp;lt; 0.001) and baseline NT-proBNP (AUC 0.770; p = 0.002) predicted positive DSE. Other parameters, including BMI, baseline E/A, DT or e’ and MR-proANP were not predictive for DSE result. There was a positive correlation between stress NTproBNP and stress LAVI (r = 0.3;p &amp;lt; 0.05) and stress E/e’ (r = 0.5; p &amp;lt; 0.05) There wasn’t such correlation between MRproANP and stress LAVI and stress E/e’. Conclusions Diastolic stress echocardiography revealed diastolic dysfunction in 21% of study patients and improved the diagnostic value of echocardiography. Rest NT-proBNP but not rest MR-proANP predicted positive DSE.

The role of diastolic transthoracic stress echocardiography with incremental workload in the evaluation of heart failure with preserved ejection fraction: indications, methodology, interpretation. Expert consensus developed under the auspices of the National Medical Research Center of Cardiology, Society of Experts in Heart Failure (SEHF), and Russian Association of Experts in Ultrasound Diagnosis in Medicine (REUDM)

Diagnosis of heart failure with preserved ejection fraction (HFpEF) is associated with certain difficulties since many patients with HFpEF have a slight left ventricular diastolic dysfunction and normal filling pressure at rest. Diagnosis of HFpEF is improved by using diastolic transthoracic stress-echocardiography with dosed exercise (or diastolic stress test), which allows detection of increased filling pressure during the exercise. The present expert consensus explains the requirement for using the diastolic stress test in diagnosing HFpEF from clinical and pathophysiological standpoints; defines indications for the test with a description of its methodological aspects; and addresses issues of using the test in special patient groups.

Global constructive work and left atrial reservoir function is reduced in patients with heart failure with preserved ejection fraction compared with patients with preclinical diastolic dysfunction

Abstract Heart failure with preserved ejection fraction (HFpEF) remains an unresolved issue with morbidity and mortality comparable with that of reduced EF HF. Diastolic dysfunction (DD) is the hallmark of HFpEF but it is unclear why some patients do not develop symptoms and remain in preclinical DD (PDD) stage with the same degree of DD as patients with HFpEF. We assumed that patients with HFpEF might have more deteriorated global myocardial work (GW) and left atrial reservoir longitudinal strain (LALS) parameters compared with PDD patients. Methods 210 patients (150 female, mean age 71±5 years) of which 118 with PDD and 92 with HFpEF were enrolled in this study. PDD was diagnosed if patients had normal NT-proBNP values, and at least 3 of the following echocardiographic criteria at rest or after diastolic stress echocardiography: end-systolic left atrial volume index (LAVi) &amp;gt;34 ml/m2, LV E/e' &amp;gt;13, average LV e' &amp;gt;8.5, and systolic pulmonary artery pressure &amp;gt;30 mmHg. GW index (GWI) was obtained from pressure-strain loops composed from speckle tracking analysis indexed to brachial systolic blood pressure, global constructive work (GCW) was measured as the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation, global wasted work (GWW) was calculated as energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation, and GW efficiency (GWE) as the percentage ratio of constructive work to the sum of constructive work and wasted work. LALS was measured by speckle tracking echocardiography as average value of two basal segments in apical 4 chamber view along LAVi and 4D LV mass index (LVMi) offline by experienced echocardiographer who was unaware of the study aims. Results Patients with PDD and HFpEF have comparable values of LAVi, LVMi, GWI, GWW, and GWE (LAVi 38.4±3.9 ml/m2 vs 39.1±4.1 ml/m2, p=NS; LVMi 82.8±11.4 g/m2 vs 83.5±10.2 g/m2, p=NS; PDD GWI 2389±154 mmHg% vs 2368±139 mmHg%, p=NS; GWW 62±5 mmHg% vs 65±4 mmHg%, p=NS; GWE PDD 89±9% vs 87±11%, p=NS). LALS and GCW were significantly reduced in patients with HFpEF compared with PDD patients (LALS 21.3±7% vs 29±5%, p&amp;lt;0.01; GCW 1964±112 mmHg% vs 2259±164 mmHg%, p&amp;lt;0.01). Conclusion Patients with HFpEF have reduced LALS and GCW compared with PDD patients. Both parameters are indicative for LA and LV myocardial fibrotic burden respectively which might be one of the probable explanations of PDD transition to HFpEF. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Committee of Science at Ministry of Education of Republic of Armenia

When does the E/e' index not work? The pitfalls of oversimplifying diastolic function.

Since the E/e' ratio was first described in 1997 as a noninvasive surrogate marker of mean pulmonary capillary wedge pressure, it has gained a central role in diagnostic recommendations and a supremacy in clinical use that require critical reappraisal. We review technical factors, physiological influences, and pathophysiological processes that can complicate the interpretation of E/e'. The index has been validated in certain circumstances, but its use cannot be extrapolated to other situations-such as critically ill patients or children-in which it has either been shown not to work or it has not been well validated. Meta-analyses demonstrated that E/e' is not useful for the diagnosis of HFpEF and that changes in E/e' are uninformative during diastolic stress echocardiography. A similar ratio has been applied to estimate right heart filling pressure despite insufficient evidence. As a composite index, changes in E/e' should only be interpreted with knowledge of changes in its components. Sometimes, e' alone may be as informative. Using a scoring system for diastolic function that relies on E/e', as recommended in consensus documents, leaves some patients unclassified and others in an intermediate category. Alternative methods for estimating left heart filling pressures may be more accurate, including the duration of retrograde pulmonary venous flow, or contractile deformation during atrial pump function. Using all measurements as continuous variables may demonstrate abnormal diastolic function that is missed by using the reductive index E/e' alone. With developments in diagnostic methods and clinical decision support tools, this may become easier to implement.