Echocardiography For Risk Stratification Research Articles

Predicting high-risk pre-capillary pulmonary hypertension: an echocardiographic multiparameter scoring index

BackgroundThe risk stratification of pulmonary arterial hypertension proposed by the European Society of Cardiology /European Respiratory Society guidelines in 2015 and 2022 included two to three echocardiographic indicators. However, the specific value of echocardiography in risk stratification of pre-capillary pulmonary hypertension (pcPH) has not been efficiently demonstrated. Given the complex geometry of the right ventricular (RV) and influencing factors of echocardiographic parameter, there is no single echocardiographic parameter that reliably informs about PH status. We hypothesize that a multi-parameter comprehensive index can more accurately evaluate the severity of the pcPH. The purpose of this study was to develop and validate an echocardiographic risk score model to better assist clinical identifying high risk of pcPH during initial diagnosis and follow-up.MethodsWe studied 197 consecutive patients with pcPH. A multivariable echocardiographic model was constructed to predict the high risk of pcPH in the training set. Points were assigned to significant risk factors in the final model based on β-coefficients. We validated the model internally and externally.ResultsThe echocardiographic score was constructed by multivariable logistic regression, which showed that pericardial effusion, right atrial (RA) area, RV outflow tract proximal diameter (RVOT-Prox), the velocity time integral of the right ventricular outflow tract (TVIRVOT) and S’ were predictors of high risk of pcPH. The area under curve (AUC) of the training set of the scoring model was 0.882 (95%CI: 0.809–0.956, p < 0.0001). External validation was tested in a test dataset of 77 patients. The AUC of the external validation set was 0.852. A 10-point score risk score was generated, with scores ranging from 0 to 10 in the training cohort. The estimate risk of high risk of pcPH ranged from 25.1 to 94.6%.ConclusionsThe echocardiographic risk score using five echocardiographic parameters could be comprehensive and useful to predict the high risk of pcPH for initial assessment and follow-up.

Prognostic Value of Transthoracic Echocardiography in Children With Pulmonary Arterial Hypertension.

Background Transthoracic echocardiography is part of the regular follow-up protocol at most pediatric pulmonary arterial hypertension (PAH) centers. We aimed to develop a comprehensive and simple echocardiographic risk stratification for children with PAH. Methods and Results We included 63 children with PAH and a biventricular cardiac anatomy without relevant shunt lesions (60% female patients; mean age, 9.0years; 42 idiopathic PAH and 21 associated PAH) undergoing a standardized transthoracic echocardiographic assessment. The prognostic value of echocardiographic parameters was assessed using Cox proportional hazards survival analysis and recursive partitioning for classification tree methods. Over a median follow-up period of 4.0years, 17 patients died and 4 underwent lung transplantation. Various echocardiographic parameters were associated with the combined endpoint of death and transplantation on univariate analysis. On further analysis, right atrial area (z score) and left ventricular diastolic eccentricity index (LVEId) emerged as robust and independent predictors of transplant-free survival. Considering mortality alone as an end point, a combination of right atrial area, left ventricular diastolic eccentricity index, and tricuspid annular plane systolic excursion were identified as independent predictors of outcome. Based on these parameters, we propose simple risk scores that can be applied at the bedside without computer assistance. CONCLUSIONS Echocardiographic parameters predict prognosis in children with pulmonary hypertension. A combination of widely available parameters including right atrial area, left ventricular eccentricity index, and tricuspid annular plane systolic excursion emerged as risk stratifiers that await external validation but may assist clinicians determining the prognosis of children with PAH.

Echocardiography for risk stratification in patients with pulmonary embolism at low risk of death: a response.

Echocardiography for risk stratification in patients with pulmonary embolism at low risk of death: a response.

Optimal echocardiographic assessment of myocardial dysfunction for arrhythmic risk stratification in phospholamban mutation carriers.

Aims Phospholamban (PLN) p.Arg14del mutation carriers are at risk of developing malignant ventricular arrhythmias (VAs) and/or heart failure. Currently, left ventricular ejection fraction (LVEF) plays an important role in risk assessment for VA in these individuals. We aimed to study the incremental prognostic value of left ventricular mechanical dispersion (LVMD) by echocardiographic deformation imaging for prediction of sustained VA in PLN p.Arg14del mutation carriers.Methods and resultsWe included 243 PLN p.Arg14del mutation carriers, which were classified into three groups according to the ‘45/45’ rule: (i) normal left ventricular (LV) function, defined as preserved LVEF ≥45% with normal LVMD ≤45 ms (n = 139), (ii) mechanical LV dysfunction, defined as preserved LVEF ≥45% with abnormal LVMD >45 ms (n = 63), and (iii) overt LV dysfunction, defined as reduced LVEF <45% (n = 41). During a median follow-up of 3.3 (interquartile range 1.8–6.0) years, sustained VA occurred in 35 individuals. The negative predictive value of having normal LV function at baseline was 99% [95% confidence interval (CI): 92–100%] for developing sustained VA. The positive predictive value of mechanical LV dysfunction was 20% (95% CI: 15–27%). Mechanical LV dysfunction was an independent predictor of sustained VA in multivariable analysis [hazard ratio adjusted for VA history: 20.48 (95% CI: 2.57–162.84)].Conclusion LVMD has incremental prognostic value on top of LVEF in PLN p.Arg14del mutation carriers, particularly in those with preserved LVEF. The ‘45/45’ rule is a practical approach to echocardiographic risk stratification in this challenging group of patients. This approach may also have added value in other diseases where LVEF deterioration is a relative late marker of myocardial dysfunction.

Assessment of epicardial adipose tissue by echocardiography for risk stratification in young adults with abdominal obesity

The negative role of epicardial adipose tissue (EAT) in the development of cardiovascular diseases makes it possible to use it as a new marker for assessing and predicting cardiovascular risk in obese individuals. Computed tomography (CT) remains the gold standard for determining adipose tissue distribution. However, this method is costly and time consuming. There is a need to search for less expensive and informative methods for visualizing visceral obesity, in particular, EAT.&#x0D; Aim. To study the link between EAT thickness, measured with echocardiography (EchoCG), and adipose tissue distribution, structural and functional parameters of the left ventricle (LV) in young people with abdominal obesity.&#x0D; Materials and methods. The study included 104 patients (62.5% women, 37.5% men) aged 1845 years, with abdominal obesity. In all subjects, height, body weight and waist circumference were measured and body mass index was calculated. EchoCG was performed to assess the LV structural and functional parameters and to determine EAT thickness. The volumes of subcutaneous, visceral, epicardial fat were determined by CT.&#x0D; Results. Correlation analysis revealed a significant link between EAT thickness, measured with EchoCG, both in systole and diastole, and EAT volume, measured with multispiral CT (EAT in systole r=0.85, p0.05, EAT in diastole r=0.68, p0.05). A correlation was revealed between EAT thickness and intra-abdominal fat (EAT in systole r=0.59, p0.05, EAT in diastole r=0.51, p0.05). Analysis showed that the greatest contribution to the risk for LV diastolic dysfunction is made by EAT volume. Using ROC analysis, it has been shown that EAT can be used to identify patients with LV diastolic dysfunction.&#x0D; Conclusion. EAT thickness measured with EchoCG in LV systole closely correlates with EAT and intra-abdominal adipose tissue volumes measured with multispiral CT. EAT thickness in systole more than 7.5 mm, in diastole 4.0 mm can serve as threshold values for assessing cardiovascular risk in obese individuals.

Assessing the future risks of subsequent pregnancies in peripartum cardiomyopathy.

Peripartum cardiomyopathy is a myocardial disease process which occurs in young women either in late pregnancy or the early postpartum period. Due to the young age of women effected by this disease, many of these patients elect to pursue a subsequent pregnancy after their initial diagnosis. Currently, echocardiography is used to better elucidate the cardiovascular risks these young patients face when undergoing a subsequent pregnancy; however, the most accurate modality to determine these risks is debatable. In this review, we explore the current literature regarding the use and accuracy of resting transthoracic echocardiography, exercise stress echocardiography, and dobutamine stress echocardiography in risk stratification of a subsequent pregnancy in a patient with peripartum cardiomyopathy.

The value of three-dimensional echocardiography in risk stratification in pulmonary arterial hypertension: a cross-sectional study.

To explore the value of right ventricular (RV) parameters detected by three-dimensional echocardiography (3DE) in risk stratification in pulmonary arterial hypertension (PAH) patients. We prospectively recruited 130 pulmonary hypertension patients from National Center for Cardiovascular Diseases, Fuwai Hospital. Each participant was performed a transthoracic echocardiography and 3DE parameters were measured using an off-line software (4D RV Function 2.0, TomTec). Patients were classified into low, intermediate-high risk group based on 2015 ESC Guidelines. A total of 91 PAH patients (34 ± 12years old, 25 males) were enrolled, among which, 42 were classified into low risk group, while 49 were intermediate-high risk group. Compared with low-risk patients, those with intermediate-high risk had significantly larger 3DE-RV volumes, worse ejection fraction (EF) and tricuspid annular plane systolic excursion, and decreased longitudinal strain (LS). Receive operating characteristic curves illustrated all the 3DE parameters were able to predict intermediate-high risk stratification, especially 3D-RVEF (area under curve, 0.82, 95% CI 0.73-0.91, P < 0.001). And 3D-RVEF < 26.39% had a 81.6% sensibility and 73.8% specificity to predict intermediate-high risk stratification. Univariate and multivariate Logistic regression analyses identified 3D-RV end-diastolic (OR 1.02, 95% CI 1.01-1.03, P = 0.002) and end-systolic (OR 1.03, 95% CI 1.01-1.04, P < 0.001) volumes, 3D-RVEF (OR 0.82, 95% CI 0.75-0.90, P < 0.001) and LS of free wall (OR 1.17, 95% CI 1.05-1.31, P = 0.005) as independent predictors of intermediate-high risk stratification. In conclusion, RV volumes, EF and free wall strain detected by 3DE were independent predictors of intermediate-high risk stratification in PAH patients, among which, RVEF showed the best predictive capacity.

Advanced Echocardiographic Imaging for Prediction of SCD in Moderate and Severe LV Systolic Function

ObjectivesThis study sought to determine the long-term prognostic value of myocardial deformation imaging by echocardiography in risk stratification of sudden cardiac death (SCD) and malignant ventricular arrhythmias (VAs) in a large consecutive cohort of patients with left ventricular (LV) systolic impairment, irrespective of its etiology. BackgroundLeft ventricular ejection fraction (LVEF) is limited for prediction of SCD. Echocardiographic strain-derived mechanical dispersion (MD) and global longitudinal strain (GLS) has been linked to VA and SCD. However, due to low event rates, the role of these parameters has not been fully elucidated. MethodsConsecutive clinically stable patients who underwent echocardiographic study performed in an outpatient setting from 2008 to 2014 with a Simpson left ventricular ejection fraction (LVEF) ≤45% were included in the study. Strain analysis was performed in which the LV was separated into 16 segments for regional analysis. Mechanical dispersion (MD) was calculated as the SD of the time to peak of each of the 16 regions. Outcome data were obtained from medical records. ResultsA total of 939 patients were included in the study, with median LVEF of 37% (interquartile range 30% to 42%). At follow-up (91.4 ± 23.4 months), 96 VA events had occurred. Multivariate analysis demonstrated that only MD ≥75 ms (hazard ratio: 9.45; 95% confidence interval: 4.75 to 18.81; p < 0.0001) was predictive of VA events. Low MD predicted a low event rate, irrespective of LVEF. ConclusionsUsing LVEF alone is inferior for prediction of VA and SCD, particularly in patients with moderately reduced LVEF. MD is easily obtained from standard echocardiographic images and can be used to improve risk prognosis, particularly in patients who are currently excluded from cardiac defibrillator insertion based on LVEF.

Pulmonary embolism response team implementation improves awareness and education among the house staff and faculty

A subset of high-risk pulmonary embolism (PE) patients requires advanced therapy beyond anticoagulation. Significant variation in delivery of care has led institutions to standardize their approach by developing Pulmonary Embolism Response Team (PERT). We sought to assess the impact of PERT implementation on house staff and faculty education. After implementation of PERT, we employed a targeted educational intervention aimed to improve PERT awareness, familiarity with treatment options, role of echocardiogram and Doppler ultrasound, and knowledge of acute PE risk stratification tools. We conducted an anonymous survey among the house staff and faculty before and after intervention to assess the impact of PERT implementation on educational objectives among clinicians. Initial and follow up samples included 115 and 109 responses. The samples were well represented across the subspecialties and all levels of training, as well as junior and senior faculty. Following the educational campaign, awareness of the program increased (72.2-92.6%, p < 0.01). Proportion of clinicians with reported comfort level of managing PE increased (82.4-90.8%, p = 0.07). Proportion of clinicians with self-reported comfort with explaining all available treatment modalities to patients increased (49.1-67.9%, p = 0.005). Proportions of responders who correctly identified the role of echocardiography in risk stratification of patients with known PE increased (73.9-84.4%, p = 0.07). Accurate clinical risk stratification of acute PE increased (60.2-73.8%, p = 0.03). The implementation of a targeted educational program at a tertiary care center increased awareness of PERT among house staff and faculty and improved physician's accuracy of clinical risk stratification and comfort level with management of acute PE.

Tricuspid Regurgitation Peak Gradient (TRPG)/Tricuspid Annulus Plane Systolic Excursion (TAPSE) - A Novel Parameter for Stepwise Echocardiographic Risk Stratification in Normotensive Patients With Acute Pulmonary Embolism.

Patients with intermediate-risk acute pulmonary embolism (APE) are a heterogeneous group with an early mortality rate of 2-15%. The tricuspid annulus plane systolic excursion (TAPSE) and tricuspid regurgitation peak gradient (TRPG) can be used for risk stratification, so we analyzed the prognostic value of a new echo parameter (TRPG/TAPSE) for prediction of APE-related 30-day death or need for rescue thrombolysis in initially normotensive APE patients.Methods and Results:The study group consists of 400 non-high-risk APE patients (191 men, age: 63.1±18.9 years) who had undergone echocardiography within the first 24 h of admission. The TRPG/TAPSE parameter was calculated. The clinical endpoint (CE) was a combination of 30-day APE-related death and/or rescue thrombolysis. The CE occurred in 8 (2%) patients. All patients with TAPSE ≥20 mm (n=193, 48.2%) had a good prognosis. Among 206 patients with TAPSE <20 mm, 8 cases of the CE occurred (3.9%). NPV and PPV for TRPG/TAPSE >4.5 were 0.2 and 0.98, respectively. The CE was significantly more frequent in 19 (9.2%) patients with TRPG/TAPSE >4.5 than in 188 (90.8%) with TRPG/TAPSE ≤4.5 (4 (21.1%) vs. 4 (2.1%), P=0.0005). Among normotensive APE patients with TAPSE <20 mm, TRPG/TAPSE >4.5 was associated with 21.1% risk of APE-related death or rescue thrombolysis. TRPG/TAPSE, a novel echocardiographic parameter, may be useful for stepwise echocardiographic risk stratification in normotensive patients with APE, and it identifies patients with a poor prognosis.

Echocardiographic Risk Stratification in Asymptomatic Patients with Paradoxical Low Flow Low Pressure Gradient Severe Aortic Stenosis

Echocardiographic Risk Stratification in Asymptomatic Patients with Paradoxical Low Flow Low Pressure Gradient Severe Aortic Stenosis

Comparison Between Echocardiography and Cardiac Magnetic Resonance Imaging in Predicting Transplant-Free Survival After the Fontan Operation

Adverse outcomes increase in frequency as patients after Fontan operation approach adulthood. Cardiac magnetic resonance (CMR) imaging-derived parameters have been shown to predict death/transplant; however, limited data are available on the usefulness of echocardiography in risk stratification. We conducted a retrospective, single-center review of records of patients after Fontan operation with an echocardiogram and CMR within 1year of each other. The primary end point was time to all-cause mortality or listing for transplant. Of the 127 eligible patients, there were 12 end points (9%; 10 deaths and 2 listing for transplant). Median age was 16.8 years (interquartile range 12 to 23.1) with a median follow-up of 3.8 years (interquartile range 2.6 to 5.7). Among clinical parameters, protein-losing enteropathy had the strongest association with the outcome. Among echocardiographic variables, global circumferential strain showed the strongest association (hazard ratio 1.3 per unit change, 95% confidence interval 1.1 to 1.5, p value 0.001, C-index 0.81), whereas among CMR variables indexed ventricular end-diastolic volume showed the strongest association with the outcome (hazard ratio 1.04 per 10ml/BSA(1.3) increase in volume, 95% confidence interval 1.02 to 1.06, p value 0.001, C-index 0.82). Cox proportional hazards analysis revealed echocardiography and CMR models to each individually have a higher predictive ability than the clinical model; however, in direct comparison, neither technique was superior. In conclusion, both echocardiography-derived circumferential strain and CMR-derived ventricular end-diastolic volume index are associated with transplant-free survival in patients after Fontan operation. Echocardiography and CMR parameters have higher discriminative ability than clinical variables. Although neither imaging technique is superior in this cohort, both introduce important factors for risk stratification.

The prognostic impact of diastolic dysfunction in patients with chronic heart failure and post-acute myocardial infarction: Can age-stratified E/A ratio alone predict survival?

ObjectiveTo determine the prognostic implications of diastolic filling grades and identify whether age-stratified E/A ratio alone can identify patients at high risk of death post-AMI and HF. We hypothesized that in response to ageing and pathology, a normal E/A (>1) could be considered abnormal in patients post-AMI older than 65years, and that in patients with symptomatic HF, a normal E/A always represents advanced diastolic dysfunction. Methods and resultsThis is a sub-analysis of the Meta-analysis Research Group in Echocardiography (MeRGE) which combined individual patient data from 30 prospective studies and demonstrated that restrictive filling was an important and independent predictor of all-cause mortality. This sub-analysis is restricted to those studies in which continuous E/A data were available (20 studies) and includes a total of 3082 AMI and 2321 HF patients. Patients were classified at the time of echocardiography into four filling patterns: normal, abnormal relaxation, pseudonormal, and restrictive filling. Post-AMI patients were divided into four groups on the basis of age and E/A, while patients with HF were classified into three groups, based on only E/A. Mortality across groups was compared using Kaplan–Meier survival analysis and Cox proportional hazards. In multivariable analyses in the AMI patients, age-stratified E/A was an independent predictor of outcome (HR 1.43 (95% CI: 1.31–1.56)), and in the HF cohort, E/A was confirmed as an independent predictor of mortality (HR 1.12 (95% CI 1.09–1.16)) alongside age and ejection fraction. ConclusionsAge-stratified E/A is an independent predictor of mortality after AMI and in HF patients, regardless of left ventricular ejection fraction, age and gender. E/A ratio could be a first step echocardiographic risk stratification, which could precede and indicate the need for more advanced diagnostic and prognostic considerations in high-risk AMI and HF patients.

Different Prognostic Value of Functional Right Ventricular Parameters in Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia

The value of standard 2-dimensional transthoracic echocardiographic parameters for risk stratification in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is controversial. We investigated the impact of RV fractional area change (FAC) and tricuspid annulus plane systolic excursion (TAPSE) for the prediction of major adverse cardiovascular events (MACE) defined as the occurrence of cardiac death, heart transplantation, survived sudden cardiac death, ventricular fibrillation, sustained ventricular tachycardia, or arrhythmogenic syncope. Among 70 patients who fulfilled the 2010 ARVC/D Revised Task Force Criteria and underwent baseline transthoracic echocardiography, 37 (53%) patients experienced MACE during a median follow-up period of 5.3 (interquartile range, 1.8-9.8) years. Average values for FAC, TAPSE, and TAPSE indexed to body surface area (BSA) decreased over time (P=0.03 for FAC, P=0.03 for TAPSE, and P=0.01 for TAPSE/BSA, each versus baseline). In contrast, median RV end-diastolic area increased (P=0.001 versus baseline). Based on the results of Kaplan-Meier estimates, the time between baseline transthoracic echocardiography and experiencing MACE was significantly shorter for patients with FAC <23% (P<0.001), TAPSE <17 mm (P=0.02), or right atrial short axis/BSA ≥25 mm/m(2) (P=0.04) at baseline. A reduced FAC constituted the strongest predictor of MACE (hazard ratio, 1.08 per 1% decrease; 95% confidence interval, 1.04-1.12; P<0.001) on bivariable analysis. This long-term observational study indicates that TAPSE and dilation of right-sided cardiac chambers are associated with an increased risk for MACE in patients with ARVC/D with advanced disease and a high risk for adverse events. However, FAC is the strongest echocardiographic predictor of adverse outcome in these patients. Our data advocate a role for transthoracic echocardiography in risk stratification in patients with ARVC/D, although our results may not be generalizable to lower-risk ARVC/D cohorts.

Right ventricular dysfunction in hemodynamically stable patients with acute pulmonary embolism

Echocardiography for risk stratification in hemodynamically stable patients with pulmonary embolism (PE) is well-established. Right ventricular dysfunction (RVD) is associated with an elevated mortality and adverse outcome. The aim of our study was to compare RVD criteria and investigate the role of elevated systolic pulmonary artery pressure (sPAP) in the diagnosis of RVD. We retrospectively analyzed the echocardiographic and laboratory data of all hemodynamically stable patients with confirmed PE (2006-2011). The data were compared with three different definitions of RVD: Definition 1: RV dilatation, abnormal motion of interventricular septum, RV hypokinesis or tricuspid regurgitation. Definition 2: as with definition 1 but including elevated sPAP (>30mmHg). Definition 3: elevated sPAP (>30mmHg) as single RVD criterion. A total number of 129 patients (59.7% women, age 70.0years (60.7/81.0)) were included in this study. Median Troponin I level was measured as 0.02ng/ml (0/0.14); mean sPAP 33.9±18.5mmHg. The troponin cut-off levels for predicting a RVD of the 3 RVD definitions were in definition 1-3: >0.01ng/ml, >0.01ng/ml and >0.00ng/ml. Analysis of the ROC curve showed an AUC for RVD definitions 1-3: 0.790, 0.796 and 0.635. The combination of commonly used RVD criteria with added elevated sPAP improves the diagnosis of RVD in acute PE. Troponin I values of >0.01ng/ml in acute PE point to an RVD.

Value of cardiac biomarkers in patients with acute pulmonary embolism

BackgroundPrognostic stratification of patients with PE is important in management and potentially improve clinical outcome. Cardiac biomarkers are used as an adjunct to clinical and echocardiographic risk stratification in a variety of circumstances, (Creatine-kinase-MB “CK-MB”) and cardiac troponin I (cTnI) are most widely used because of their high sensitivities, and very high specificity of troponin for heart muscle injury. Evidence is mounting that myoglobin’s sensitivity for myocardial necrosis combined with its unique release and clearance properties may render it particularly attractive as a risk marker either alone or in combination with other markers. ObjectivesThe aim of the current study is to assess the levels of cardiac specific biomarkers in relation to different clinical, ECG and echocardiogrphic findings in patients with acute PE, as well as evaluating the prognostic value of these biomarkers for inhospital mortality and adverse clinical events. Patients and methodsThis study comprised 40 patients with proved PE (22 males and 18 females), their mean age was 50.05±13.09years (range 22–70years). The following investigations were performed for all patients; 12-leads ECG, Full echo Doppler study, spiral CT of the chest, and laboratory testing: arterial blood gas, serum myoglobin, serum troponin, total CK and CK-MB, kidney and liver function tests. ResultSignificant elevation of CK-MB (>10μ/L) was noted only in 7.5% of patients, while cardiac cTnI was elevated (⩾0.07ng/ml) in 45% of patients and elevated serum myoglobin was found very early after symptoms (<4h) in 55% of patients. Elevated serum cTnI and myoglobin were significantly associated with ECG signs of right ventricular strain and echocardiographic evidence of right ventricular dysfunction. ConclusionThe results of the present study demonstrate the prognostic value of cardiac specific biomarkers, cardiac troponin I & myoglobin in acute pulmonary embolism. Thus, the current data combined with the results of previous studies strongly support the integration of troponin and myoglobin testing into the risk stratification and management of patients with established acute PE.

Echocardiographic Risk Stratification of Fetuses with Sacrococcygeal Teratoma and Twin-Reversed Arterial Perfusion

Objective: To evaluate pre-intervention echocardiographic parameters of cardiac function in fetuses who survive without hydrops as compared to fetuses who develop hydrops or perinatal death in the setting of sacrococcygeal teratoma (SCT) and twin-reversed arterial perfusion sequence (TRAP). Methods: Clinical, echocardiographic and sonographic data of fetuses with SCT or TRAP during 1999–2009 were reviewed retrospectively. Measurements of cardiothoracic ratio (CTR), cardiac dimension Z-scores, combined ventricular output (CVO), valvular regurgitation, and cardiovascular profile scores (CVPS) were obtained. Results: In total, 19 fetuses (11 SCT, 8 TRAP) met the inclusion criteria and 26 detailed fetal echocardiographic studies were reviewed. Outcome was poor in 7 pregnancies (group A) and good in 12 (group B). Group A had worse CVPS (8.5 vs. 10, p < 0.01) and higher CTR (0.37 vs. 0.30, p = 0.04). At least one of the following was present in each group A fetus: CTR >0.5, CVO >550 ml/min/kg, tricuspid or mitral regurgitation, or mitral valve Z-score >2. No group B fetus had any of these abnormalities. No fetus in either group had abnormal venous Doppler waveforms at presentation. Conclusions: Fetal echocardiography can identify abnormalities of cardiac size and systolic, but not diastolic, function in all fetuses who subsequently died or developed hydrops.

The Changing Paradigm of Stress Echocardiography: Risk Stratification, Prognosis, and Future Directions

The use of stress echocardiography has undergone considerable evolution in the past 3 decades. Although stress echocardiography was first introduced as a noninvasive diagnostic tool for determining the presence or absence of coronary artery disease (CAD), it later served a prognostic role as well. The importance of stress echocardiography in risk stratification and prognosis is substantially undervalued by clinicians. The identification of patients at risk for future cardiac events has become a primary objective in noninvasive evaluation of patients with suspected or known CAD. In particular, the ability of stress echocardiography to identify patients at low (< 1%), intermediate (1%–5%), or high (> 5%) risk for future cardiac events is essential to decision making in patient management. Moreover, previous studies have conclusively demonstrated the incremental prognostic value of stress echocardiography over clinical and treadmill exercise data in predicting future cardiac events. This article presents a primarily single-center experience of retrospective and observational studies that address the current role of stress echocardiography and summarize its use for risk stratification, prognosis, and determining clinical outcomes, as well as cost-effective integration of such information in patient management decision making.

Exercise echocardiography in aortic stenosis: one more piece in the puzzle

This editorial refers to ‘Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis’, by S. Marechaux et al. doi:10.1093/eurheartj/ehq076 Aortic valve replacement (AVR) is the current standard treatment for severe aortic stenosis (AS) with symptoms or left ventricle (LV) systolic dysfunction.1,2 However, controversy remains regarding the best treatment for asymptomatic patients with severe AS and preserved LV systolic function and also for those with moderate AS. Improved life expectancy has led to an increasing number of elderly patients with these conditions,3 in whom the symptoms are harder to evaluate. Many patients may reduce their level of physical activity to avoid or minimize symptoms and be unaware of subtle changes in effort tolerance. The accurate determination of symptoms is crucial, considering the risk of sudden death and the dismal prognosis once symptoms begin.4 Thus, the exercise test in ‘asymptomatic’ patients with severe AS has already established its role.5 The ESC guidelines recommend AVR whenever patients present symptoms (class I) or develop asymptomatic hypotension (class IIa) or asymptomatic ventricular arrhythmias (class IIb) during the exercise test.1 In contrast, the ACC/AHA guidelines recommend AVR if symptoms or hypotension appear during the exercise test (class IIb).2 The divergent strengths of these recommendations can be explained by the lack of definitive evidence from prospective clinical trials and subsequent different interpretation by the two groups. Conversely, exercise test echocardiography is not even recommended in the guidelines and remains an issue of debate. Lancellotti et al. 6 presented the first study to demonstrate that quantitative Doppler echocardiography has prognostic importance and provides additional information in patients with asymptomatic severe AS. Their results showed that 69 patients with an increase in mean pressure gradient ≥18 mmHg, during … *Corresponding author. Tel: +34 91 3303290, Fax: +34 91 3303292, Email: jlzamorano{at}vodafone.es

Echocardiographic Risk Stratification in Heart Failure: Applying the Better Method for LV Systolic Function Assessment

Echocardiographic Risk Stratification in Heart Failure: Applying the Better Method for LV Systolic Function Assessment