European Association Of Echocardiography Research Articles

71-Year-Old Man With a New Heart Murmur

71-Year-Old Man With a New Heart Murmur

New advances in medical imaging technology for the evaluation of anthracycline-induced cardiotoxicity.

New advances in medical imaging technology for the evaluation of anthracycline-induced cardiotoxicity.

52-Year-Old Woman With Palpitations, Abdominal Distension, and Severe Abdominal Pain

52-Year-Old Woman With Palpitations, Abdominal Distension, and Severe Abdominal Pain

The flutter-by effect: a comprehensive study of the fluttering cusps of the Perceval heart valve prosthesis.

Sutureless aortic valve prostheses are gaining popularity due to the substantial reduction in cross-clamp time. In this study, we report our observations on the cusp-fluttering phenomenon of the Perceval bioprosthesis (LivaNova, London, UK) using a combination of technical and medical perspectives. Between August 2014 and December 2016, a total of 108 patients (69% women) with a mean age of 78 years had aortic valve replacement using the Perceval bioprosthesis (34 combined procedures). All patients underwent transoesophageal echocardiography (TOE) intraoperatively. TOE was performed postoperatively to detect paravalvular leakage and to measure gradients, acceleration time, Doppler velocity indices (Vmax and LVOT/Vmax AV) and effective orifice area indices. In addition, a TOE examination was performed in 21 patients postoperatively. Data were collected retrospectively from our hospital database. The retrospective evaluation of the intraoperative TOE examinations revealed consistent fluttering in all patients with the Perceval bioprosthesis. The echocardiographic postoperative measurements showed a mean effective orifice area index of 0.91 ± 0.12 cm2/m2. The overall mean pressure and peak pressure gradients were in a higher range (13.5 ± 5.1 mmHg and 25.5 ± 8.6 mmHg, respectively), whereas acceleration time (62.8 ± 16.4 ms) and Doppler velocity indices (0.43 ± 0.11) were within the normal range according to the American Society of Echocardiography or european association of echocardiography (EAE) guidelines. The 2-dimensional TOE in Motion Mode (M-Mode) that was performed in patients with elevated lactate dehydrogenase (LDH) levels revealed remarkable fluttering of the cusps of the Perceval bioprosthesis. In our study cohort, we observed the fluttering phenomenon in all patients who received the Perceval bioprosthesis, which was correlated with elevated LDH levels and higher pressure gradients.

MORPHOLOGICAL AND FUNCTIONAL MYOCARDIAL ABNORMALITIES IN THE CHORNOBYL NPP ACCIDENT CLEAN-UP WORKERS OF «IODINE» PERIOD HAVING GOT TYPE 2 DIABETES MELLITUS.

Evaluation of morphological and functional myocardial abnormalities in the Chornobyl NPP (ChNPP)accident clean-up workers (ACUW) of the «iodine» period exposed to ionizing radiation at a young age and havinggot the type 2 diabetes mellitus (T2DM). The ChNPP ACUW of «iodine» period (n=111) exposed to ionizing radiation (IR) at a young age(18-35 years) were involved in the study. Subjects having got the T2DM were included in study Group I (n = 66), per-sons with normal glucose challenge test were selected as a comparison Group II (n = 45). External radiation doses (ERD)ranged from 10 to 860 mSv. The Group III (clinical control) included persons having got the T2DM with no radiationexposure in a history (n=20). Group IV was the normative one. There was no statistical difference between the groups inage, sociodemographic characteristics and level of education. Echocardiography and cardiac Doppler sonography wereperformed in one- and two-dimensional regimens according to the recommendations of the European Association ofEchocardiography. Total adiponectin and proinflammatory cytokine (TNF-α and IL-6) concentrations were assayed by theimmunoenzyme method. Statistical processing of data was carried out using the Microsoft® Exel 2002 software. Myocardial remodeling in the ChNPP ACUW of a «iodine» period having the T2DM occurred through a sig-nificant increase of its linear parameters. Volumetric parameters (EDV, ESV and their indexes) were within maximumpermissible limits significantly exceeding however the values in the Group IV. There was aт increase in myocardialmass of the left ventricle and its indices with the formation of structural-geometric abnormalities, mainly in theform of concentric hypertrophy with a decrease in the myocardial contractile capacity. There was no differences ofthe vast majority of key morphometric parameters of myocardium in the dose subgroups, while in persons with ERD> 500 mSv the incidence of serious left ventricular hypertrophy (LVMMI > 149 g/m2) significantly exceeded thisvalue in individuals with lower ERD. At a maximum ERD the more intense fibroplastic processes were observed inmyocardium [a significant increase in the interstitial collagen volumetric fraction (ICVF)] as compared to the caseswith ERD up to 50 mSv. Intensification of myocardial fibroblastic processes occurred in the comparizin group andgroup off clinical control. In combination with concentric myocardial hypertrophy this may lead to an increased riskof cardiovascular complications. Strong negative correlation was revealed between the parameters of left ventricu-lar structure in diastole and adiponectin level in the ChNPP ACUW of a «iodine» period with diagnosed T2DM, high-lighting its cardioprotective effect. At the same time, the content of FNP-α and IL-6 proinflammatory cytokines hada positive correlation with the main parameters of abnormal myocardial remodeling, indicating the possibility oftheir role in unfavorable cardiovascular modifications. The decreased adiponectin level and elevated levels of TNF-α and IL-6 in the ChNPP ACUW of a«iodine» period having got the T2DM are the meaningful factors in progression of LV geometric remodeling. Togetherwith fibroplastic processes (a significant increase in ICVF) this may be a basis for the development of myocardialremodeling processes, namely a concentric hypertrophy, which is a prerequisite for the development of complica-tions in cardiovascular system.

Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.

Echocardiography is the key tool for the diagnosis and evaluation of aortic stenosis. Because clinical decision-making is based on the echocardiographic assessment of its severity, it is essential that standards are adopted to maintain accuracy and consistency across echocardiographic laboratories. Detailed recommendations for the echocardiographic assessment of valve stenosis were published by the European Association of Echocardiography and the American Society of Echocardiography in 2009. In the meantime, numerous new studies on aortic stenosis have been published with particular new insights into the difficult subgroup of low gradient aortic stenosis making an update of recommendations necessary. The document focuses in particular on the optimization of left ventricular outflow tract assessment, low flow, low gradient aortic stenosis with preserved ejection fraction, a new classification of aortic stenosis by gradient, flow and ejection fraction, and a grading algorithm for an integrated and stepwise approach of artic stenosis assessment in clinical practice.

Transoesophageal echocardiography: what the general cardiologist needs to know

### Learning objectives Transoesophageal echocardiography (TOE) is an invaluable technique in clinical practice providing immediate, accurate and cost-effective cardiac diagnostics at the bedside at low risk.1 Recent advances have been...

Usefulness of Echocardiography/Doppler to Reliably Predict Elevated Left Ventricular End-Diastolic Pressure in Patients With Pulmonary Hypertension

The ability of echocardiography (echo)/Doppler to predict elevated left ventricular (LV) end-diastolic pressure (EDP) specifically among patients with pulmonary hypertension is not well defined. This was a retrospective analysis of 161 patients referred to a specialized pulmonary hypertension clinic. A model based on an American Society of Echocardiography (ASE)/European Association of Echocardiography (EAE) joint statement was evaluated, and a new model was developed using univariate linear regression and multivariable logistic regression for potentially better prediction of elevated LVEDP. The study cohort had a median pulmonary arterial pressure was 34.0mm Hg and pulmonary vascular resistance was 3.7 Wood units; 81 patients (51%) had LVEDP >15mm Hg on invasive testing. Doppler E/A, E/e' (septal, lateral, and average), e'/a' (lateral and average), and left atrial volume and diameter all had significant correlation with LVEDP (p <0.05). The ASE/EAE model performed poorly (sensitivity 54% and specificity 66%) for detecting elevated LVEDP. Only echo/Doppler grade 3 diastolic dysfunction had an LVEDP significantly different from other grades (grade 0 to 2, median 15mm Hg, interquartile range 13 to 22mm Hg; grade 3, median 22mm Hg, interquartile range 19 to 32mm Hg; p <0.01). An experimental model was statistically significant in its prediction of elevated LVEDP (area under the receiver operating characteristic curve 0.7, p <0.001) but demonstrated poor performance (sensitivity 67% and specificity 61%). In conclusion, numerous echo/Doppler measurements correlate with elevated LV filling pressure. However, both the ASE/EAE model and our experimental model had poor test performance that did not permit confident identification of elevated LVEDP.

Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

Echocardiographic assessment of left ventricular (LV) diastolic function is an integral part of the routine evaluation of patients presenting with symptoms of dyspnea or heart failure. The 2009 American Society of Echocardiography (ASE) and European Association of Echocardiography (now European Association of Cardiovascular Imaging [EACVI]) guidelines for diastolic function assessment were comprehensive, including several two-dimensional (2D) and Doppler parameters to grade diastolic dysfunction and to estimate LV filling pressures.1 Notwithstanding, the inclusion of many parameters in the guidelines was perceived to render diastolic function assessment too complex, because several readers have interpreted the guidelines as mandating all the listed parameters in the document to fall within specified values before assigning a specific grade. The primary goal of this update is to simplify the approach and thus increase the utility of the guidelines in daily clinical practice. LV diastolic dysfunction is usually the result of impaired LV relaxation with or without …

Abstract 14896: Does Echocardiography/Doppler Reliably Predict Elevated LVEDP?

Introduction: Heart failure with preserved ejection fraction is a common cause of group 2 pulmonary hypertension (PH). The utility of echocardiography (echo)/ Doppler for identification of elevated left ventricular end-diastolic pressure (LVEDP) specifically among patients with PH is not well defined. Methods: 161 patients referred to Pulmonary Hypertension Clinic were retrospectively studied. Included patients underwent echo/Doppler and had catheter measurement of LVEDP or pulmonary capillary wedge pressure within a 3-month period, had normal sinus rhythm at the time of the TTE, and had unchanged diuretic and PH regimens during the examination interval. The ability of echo to predict elevated LVEDP (&gt; 15 mm Hg) based on American Society of Echocardiography (ASE) / European Association of Echocardiography (EAE) guidelines was evaluated, and a new model was developed for better prediction of elevated LVEDP with echo data using univariate linear regression and multi-variable logistic regression; receiver operating characteristics were analyzed. Results: Of 161 patients, 81 (51%) had LVEDP &gt; 15 mm Hg on invasive testing; mean PAP was 37.8 ± 14.3 mmHg and PVR was 4.6 ±3.8 WU. Doppler E/A, E/e’ (septal, lateral, average), e’/a’ (lateral and average), LA volume, and LA diameter had significant correlation with LVEDP (p values &lt; 0.05). There was poor test performance of both the ASE/EAE model and the experimental model (area under the ROC 0.7, p &lt; 0.001). Only echo/Doppler grade III had a mean LVEDP significantly different from other grades (p value &lt; 0.05). Conclusions: Numerous echo/Doppler measurements correlate with elevated LV filling pressure. However, both the ASE/EAE model and our experimental model had poor test performance that did not permit confident identification of patients with elevated LVEDP. Assessment using echo/Doppler is not adequate to either reliably include or exclude patients with elevated LVEDP as a cause of severe PH.

Eight years of the EACVI's grant programme: existing developments, impact, and steps forward: Table 1

The European Society of Cardiology (ESC) and its branches have been offering a variety of grants/fellowships, providing opportunities for young doctors to conduct a high-quality research and get trained in novel diagnostic or therapeutic techniques in leading European institutions. The European Association of Cardiovascular Imaging [EACVI, formerly European Association of Echocardiography (EAE)] is a registered branch of the ESC and takes an active part in this initiative. Between 2008 and 2015, EACVI funded a total of 19 one-year research projects (25 000€ each). The need for practical skills in cardiovascular imaging was acknowledged by EACVI Club 35 and has led to the development of Training Grant Programme launched in 2014. Within this programme, training fellowships for a period 3–6 months with a financial support of 2000€ per month also became available since 2014. The first report on the EAE research grant programme demonstrating its success and positive impact on young professionals' careers was published in 2012.1 On the seventh anniversary of the programme, we carried out a survey aimed to evaluate its benefits and identify common problems experienced by applicants to better adapt the grant scheme to the real needs and expectations of the young doctors. During the 8-year period, a total of 234 application forms were requested and sent to 196 candidates. The number of the requested forms varied substantially in different years from 4 to 119, and the number of eligible applications has increased from 4 in 2009 to 36 in 2014. A large proportion of applicants failed to finalize the application process, resulting in increasing numbers of application form requests which never materialized in applications (Supplementary data …

Acute phase IL-10 plasma concentration associates with the high risk sources of cardiogenic stroke.

BackgroundEtiological assessment of stroke is essential for accurate treatment decisions and for secondary prevention of recurrence. There is evidence that interleukin-10 (IL-10) associates with ischemic stroke. The aim of this prospective study was to assess the levels of IL-10 in ischemic stroke with unknown or suspected cardiogenic etiology, and evaluate the correlation between IL-10 plasma concentration and the number of diagnosed high risk sources for cardioembolism.MethodsA total of 141 patients (97 males; mean age 61±11 years) with acute ischemic stroke with unknown etiology or suspected cardiogenic etiology other than known atrial fibrillation (AF) underwent imaging investigations to assess high risk sources for cardioembolic stroke established by the European Association of Echocardiography (EAE). IL-10 was measured on admission to the hospital and on a three month follow-up visit.ResultsAcute phase IL-10 concentration was higher in patients with EAE high risk sources, and correlated with their number (p<0.01). In patients with no risk sources (n = 104), the mean IL-10 concentration was 2.7±3.1 ng/L (range 0.3–16.3 ng/L), with one risk source (n = 26) 3.7±5.5 ng/L (0.3–23.6 ng/L), with two risk sources (n = 10) 7.0±10.0 ng/L (1.29–34.8 ng/L) and with three risk sources (n = 1) 37.2 ng/L. IL-10 level was not significantly associated with cerebral infarct volume, presence of previous or recent myocardial infarction, carotid/vertebral artery atherosclerosis, paroxysmal AF registered on 24-hour ECG Holter monitoring or given intravenous thrombolytic treatment.ConclusionIL-10 plasma concentration correlates independently with the number of EAE cardioembolic risk sources in patients with acute stroke. IL-10 may have potential to improve differential diagnostics of stroke with unknown etiology.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging.

Recognizing the critical need for standardization in strain imaging, in 2010, the European Association of Echocardiography (now the European Association of Cardiovascular Imaging, EACVI) and the American Society of Echocardiography (ASE) invited technical representatives from all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. As an initial product of the work of the EACVI/ASE/Industry initiative to standardize deformation imaging, we prepared this technical document which is intended to provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocardiography and thus create a common standard.

Updated standards and processes for accreditation of echocardiographic laboratories from The European Association of Cardiovascular Imaging: an executive summary.

Standards for echocardiographic laboratories were proposed by the European Association of Echocardiography (now the European Association of Cardiovascular Imaging) 7 years ago, to raise standards of practice and improve the quality of care. Criteria and requirements were published at that time for transthoracic, transoesophageal, and stress echocardiography. This paper reassesses and updates the quality standards to take account of experience and the technical developments of modern echocardiographic practice. It also discusses quality control, the incentives for laboratories to apply for accreditation, the re-accreditation criteria, and the current status and future prospects of the laboratory accreditation process.

Updated standards and processes for accreditation of echocardiographic laboratories from The European Association of Cardiovascular Imaging

Standards for echocardiographic laboratories were proposed by the European Association of Echocardiography (now the European Association of Cardiovascular Imaging) 7 years ago in order to raise standards of practice and improve the quality of care. Criteria and requirements were published at that time for transthoracic, transoesophageal, and stress echocardiography. This paper reassesses and updates the quality standards to take account of experience and the technical developments of modern echocardiographic practice. It also discusses quality control, the incentives for laboratories to apply for accreditation, the reaccreditation criteria, and the current status and future prospects of the laboratory accreditation process.

Incremental value of CMR over echocardiography for assessment of LV diastolic function

Background Incidence of heart failure with preserved ejection fraction is increasing and putting the emphases on comprehensive evaluation of diastolic function. Furthermore, diastolic dysfunction even in the absence of heart failure has been shown to have prognostic significance. American Society of Echocardiography and European Association of Echocardiography (ASE/EAE) 2-level decision tree using multi-parametric approach is comprehensive, however discrepancy between the LV filling pressures and LA volume index can lead to discordance and inaccurate assessment of diastolic function. Incremental value of Cardiac Magnetic Resonance (CMR) to Echocardiography in assessment of diastolic function remains unknown. Aim: To assess incremental role of CMR derived LA volume index in classifying diastolic function by Echocardiography.

Hemodynamic Impact and Outcome of Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) frequently requires postprocedural permanent pacemaker (PPM) implantation. We evaluated clinical and hemodynamic impact of PPM after TAVI. Clinical and echocardiographic data were retrospectively analyzed in 230 consecutive patients who underwent TAVI and echocardiography at baseline and after 6 months. Echocardiographic parameters included left ventricular ejection fraction (LVEF), left ventricular (LV) stroke volume, early mitral velocity/annulus velocity ratio (E/e'), right ventricular index of myocardial performance, systolic pulmonary artery pressure (SPAP), and aortic, mitral, and tricuspid regurgitation grades. Clinical outcomes included 2-year survival and cardiovascular and PPM-related event-free survival. The Medtronic CoreValve and Edwards Sapien prosthesis were used in 201 and 29 patients, respectively. PPM was required in 58 patients (25.4%). Two-year and event-free survival rates were similar between patients with and without PPM. At 6 months, patients with PPM demonstrated attenuated improvement in LVEF (-0.9 ± 8.7% vs 2.3 ± 10.8%, respectively, p = 0.03) and LV stroke volume (-2 ± 16 vs 4 ± 10 ml/m(2), respectively, p = 0.015), a trend toward smaller reduction in systolic pulmonary artery pressure (-1 ± 12 vs -6 ± 10 mm Hg, respectively, p = 0.09), and deterioration of right ventricular index of myocardial performance (-3 ± 17% vs 5 ± 26%, respectively, p = 0.05). The differences in post-TAVI aortic, mitral, and tricuspid regurgitation grades were insignificant. In conclusion, PPM implantation after TAVI is associated with reduced LVEF and impaired LV unloading. However, this unfavorable hemodynamic response does not affect the 2-year clinical outcome. The maintenance of clinical benefit appears to be driven by TAVI-related recovery of LV and right ventricular performance that mitigates unfavorable impact of PPM.

Decreasing Tropomyosin Phosphorylation Rescues Tropomyosin-induced Familial Hypertrophic Cardiomyopathy

Studies indicate that tropomyosin (Tm) phosphorylation status varies in different mouse models of cardiac disease. Investigation of basal and acute cardiac function utilizing a mouse model expressing an α-Tm protein that cannot be phosphorylated (S283A) shows a compensated hypertrophic phenotype with significant increases in SERCA2a expression and phosphorylation of phospholamban Ser-16 (Schulz, E. M., Correll, R. N., Sheikh, H. N., Lofrano-Alves, M. S., Engel, P. L., Newman, G., Schultz Jel, J., Molkentin, J. D., Wolska, B. M., Solaro, R. J., and Wieczorek, D. F. (2012) J. Biol. Chem. 287, 44478-44489). With these results, we hypothesized that decreasing α-Tm phosphorylation may be beneficial in the context of a chronic, intrinsic stressor. To test this hypothesis, we utilized the familial hypertrophic cardiomyopathy (FHC) α-Tm E180G model (Prabhakar, R., Boivin, G. P., Grupp, I. L., Hoit, B., Arteaga, G., Solaro, R. J., and Wieczorek, D. F. (2001) J. Mol. Cell. Cardiol. 33, 1815-1828). These FHC hearts are characterized by increased heart:body weight ratios, fibrosis, increased myofilament Ca(2+) sensitivity, and contractile defects. The FHC mice die by 6-8 months of age. We generated mice expressing both the E180G and S283A mutations and found that the hypertrophic phenotype was rescued in the α-Tm E180G/S283A double mutant transgenic animals; these mice exhibited no signs of cardiac hypertrophy and displayed improved cardiac function. These double mutant transgenic hearts showed increased phosphorylation of phospholamban Ser-16 and Thr-17 compared with the α-Tm E180G mice. This is the first study to demonstrate that decreasing phosphorylation of tropomyosin can rescue a hypertrophic cardiomyopathic phenotype.

2013 European Association Cardiovascular Imaging Research Grants

Since its beginning, the European Association of Cardiovascular Imaging (formerly European Association of Echocardiography) Research Programme has funded eight grants and allowed the awardees to expand their research interests in outstanding centres in the field of echocardiography in Europe outside their home institution (for a full report, see: Eur Heart J Cardiovasc Imaging 2012; 13 :47–50). The success of the initiative induced the Board to invest more money and four grants have been funded for the year 2013. The increment of funding with the possibility of higher chances of success increased significantly the applications with the record number of 25. A few changes have been made as regards the application format (which was prepared in a pre-specified format in order …