Normal Transthoracic Echocardiography Research Articles

Deep phenotyping of unaffected carriers of pathogenic BMPR2 variants screened for pulmonary arterial hypertension.

Pathogenic variants in the gene encoding for BMPR2 are a major genetic risk factor for heritable pulmonary arterial hypertension. Owing to incomplete penetrance, deep phenotyping of unaffected carriers of a pathogenic BMPR2 variant through multimodality screening may aid in early diagnosis and identify susceptibility traits for future development of pulmonary arterial hypertension. 28 unaffected carriers (44±16 years, 57% female) and 21 healthy controls (44±18 years, 48% female) underwent annual screening, including cardiac magnetic resonance imaging, transthoracic echocardiography, cardiopulmonary exercise testing and right heart catheterisation. Right ventricular pressure-volume loops were constructed to assess load-independent contractility and compared with a healthy control group. A transgenic Bmpr2Δ71Ex1/+ rat model was employed to validate findings from humans. Unaffected carriers had lower indexed right ventricular end-diastolic (79.5±17.6 mL·m-2 versus 62.7±15.3 mL·m-2; p=0.001), end-systolic (34.2±10.5 mL·m-2 versus 27.1±8.3 mL·m-2; p=0.014) and left ventricular end-diastolic (68.9±14.1 mL·m-2 versus 58.5±10.7 mL·m-2; p=0.007) volumes than control subjects. Bmpr2Δ71Ex1/+ rats were also observed to have smaller cardiac volumes than wild-type rats. Pressure-volume loop analysis showed that unaffected carriers had significantly higher afterload (arterial elastance 0.15±0.06 versus 0.27±0.08 mmHg·mL-1; p<0.001) and end-systolic elastance (0.28±0.07 versus 0.35±0.10 mmHg·mL-1; p=0.047) in addition to lower right ventricular pulmonary artery coupling (end-systolic elastance/arterial elastance 2.24±1.03 versus 1.36±0.37; p=0.006). During the 4-year follow-up period, two unaffected carriers developed pulmonary arterial hypertension, with normal N-terminal pro-brain natriuretic peptide and transthoracic echocardiography indices at diagnosis. Unaffected BMPR2 mutation carriers have an altered cardiac phenotype mimicked in Bmpr2Δ71Ex1/+ transgenic rats. Future efforts to establish an effective screening protocol for individuals at risk for developing pulmonary arterial hypertension warrant longer follow-up periods.

Prevalence and prognosis of structural heart disease among athletes with negative T waves and normal transthoracic echocardiography.

The aim of the present study was to evaluate the prevalence and prognosis of structural heart disease (SHD) among competitive athletes with negative T waves without pathological findings at transthoracic echocardiogram. From a prospective register of 450 athletes consecutively evaluated during a second-level cardiological examination, we retrospectively identified all subjects with the following inclusion criteria: (1) not previously known cardiovascular disease; (2) negative T waves in leads other than V1-V2; (3) normal transthoracic echocardiogram. Patients underwent cardiac MRI and CT. The primary endpoint was the diagnosis of definite SHD after multimodality imaging evaluation. A follow-up was collected for a combined end-point of sudden death, resuscitated sudden cardiac death and hospitalization for any cardiovascular causes. A total of 55 competitive athletes were finally enrolled (50 males, 90%) with a mean age of 27.5 ± 14.1 years. Among the population enrolled 16 (29.1%) athletes had a final diagnosis of SHD. At multivariate analysis, only deep negative T waves remained statistically significant [OR (95% CI) 7.81 (1.24-49.08), p = 0.0285]. Contemporary identification of deep negative T waves and complex arrhythmias in the same patients appeared to have an incremental diagnostic value. No events were collected at 49.3 ± 12.3 months of follow-up. In a cohort of athletes with negative T waves at ECG, cardiac MRI (and selected use of cardiac CT) enabled the identification of 16 (29.1%) subjects with SHD despite normal transthoracic echocardiography. Deep negative T waves and complex ventricular arrhythmias were the only clinical characteristic associated with SHD diagnosis.

Multimodality imaging for negative T waves among athletes with normal transthoracic echocardiography: prevalence and prognosis of structural heart disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The aim of the present study was to evaluate the prevalence of structural heart disease (SHD) among competitive athletes with negative T waves without pathological findings at transthoracic echocardiogram, evaluated at cardiac MRI and cardiac CT. Methods From a prospective register of 450 athletes consecutively evaluated during a second-level cardiological examination, we retrospectively identified all subjects with the following inclusion criteria: 1)not previously known cardiovascular disease; 2)negative T waves in leads other than V1-V2; 3)normal transthoracic echocardiogram. Patients underwent cardiac MRI and CT. The primary endpoint was the diagnosis of definite SHD after multimodality imaging evaluation. A follow-up was collected for a combined end-point of sudden death, resuscitated sudden cardiac death and hospitalization for any cardiovascular causes. Results A total of 55 competitive athletes were finally enrolled (50 males, 90%) with a mean age of 27.5±14.1 years old. Among the population enrolled 16 (29.1%) athletes had a final diagnosis of SHD. At multivariate analysis, only deep negative T waves remained statistically significant [OR(95%CI) 7.81(1.24–49.08), p=0.0285]. Contemporary identification of deep negative T waves and complex arrhythmias in the same patients appeared to have an incremental diagnostic value. No events were collected at 49.3±12.3 months of follow-up. Conclusion In an unselected cohort of athletes with negative T waves at ECG, cardiac MRI (and selected use of cardiac CT) enabled the identification of 16 (29.1%) subjects with SHD despite normal transthoracic echocardiography. Deep negative T waves and complex ventricular arrhythmias were the only clinical characteristic associated with SHD diagnosis.

Case Report: Right atrial organized thrombus three years after tricuspid annuloplasty

Background: Occurrence of right atrial masses, especially in patients with history of cardiac surgery, is rare. Differential diagnosis between malignant and non-malignant aetiologies might be cumbersome, and surgery is often required to prevent complications or disease evolution. Case: We report the case of a 16-year-old girl from a rural area of Sudan, who underwent surgery for a modified De Vega’s tricuspid annuloplasty, and mitral and aortic valve replacement with mechanical prostheses. The patient was on regular follow-up but demonstrated a poor compliance to anticoagulation therapy with a time in therapeutic range between 52% and 20%. She remained asymptomatic, but a right atrial mass was diagnosed by transthoracic echocardiography during a follow-up visit 41 months after the first operation. Surgical removal of the mass revealed an organized thrombus arising from the point where the Prolene stitches for the tricuspid annuloplasty were previously passed. The patient recovered from surgery, was discharged home on post-operative day 10 and the first follow-up visit at 30 days after discharge confirmed a good clinical status and a normal transthoracic echocardiography (TTE). Conclusions: This case report describes the diagnostic and therapeutic work-out of a thrombus formation on the suture lines of a tricuspid annuloplasty. Moreover, it highlights the importance of a strict and long follow-up after valvular surgery and of the adherence to anticoagulation therapy, especially for patients living in rural areas of developing countries.

1039 CARDIAC MRI EVALUATION FOR ATHLETES WITH NEGATIVE T WAVES AT ECG AND NORMAL TRANSTHORACIC ECHOCARDIOGRAPHY.

Abstract Introduction Negative T waves at ECG represent a common diagnostic dilemma in athletes. These subjects, often asymptomatic, undergo ECG screening every year before practicing competitive sports. The clinical meaning of these ECG abnormalities is often unclear and a comprehensive diagnostic evaluation is needed. Echocardiography is the first step test in all these cases, but the advent of cardiac MRI in the clinical field empowers the diagnostic capability for the identification of cardiovascular disease at a very early stage, even when transthoracic echocardiography is normal. The aim of the present study is to define the prevalence of positive cardiac MRI among athletes with negative T waves at ECG and normal echocardiography and to define the clinical predictors of pathological cardiac MRI or cardiac CT Material and Methods A consecutive cohort of athletes with negative T waves at ECG and normal findings at transthoracic echocardiography were enrolled. All athletes underwent 24h ECG monitoring, ECG exercise test and cardiac MRI; cardiac CT was performed only if clinically indicated and in all subjects with &amp;gt;35 years old of age. The type of sport practiced was recorded and stratified according to intensity into low- mid- and high-intensity. The site of negative T waves was recorded and T waves were defined as “deep” if wider than 2 mm. The presence of any arrhythmias during the 24-ECG monitor or exercise ECG test was recorded as well. The primary end-point of the study was the identification of diagnostic criteria for any structural heart disease at cardiac MRI or cardiac CT Results A total of 55 athletes (50 male, 90%) were enrolled with a mean age of 27 ± 14 years-old. Most of them practiced high-intensity sports activity (47 athletes, 85.4%). Anterior T waves were the most common type (29 athletes, 52.7%) and 8 athletes (14.5%) had more than isolated ventricular ectopic beats at 24-hours ECG monitoring. Among the entire cohort, 16 athletes (29.1%) had cardiac MRI or cardiac CT diagnostic for specific structural heart disease. Of interest, the presence of deep negative t waves (OR 8.1 95%CI 1.4–49.5, p&amp;lt;0.001) and arrhythmias more complex than isolated ventricular ectopic beats (OR 5.5 95%CI 1.1–26.6, p&amp;lt;0.001) were significative associated with structural heart disease even in the presence of normal transthoracic echocardiography. Conclusions Our results identified a prevalence of 29% of structural heart disease among athletes with negative T waves at ECG even when transthoracic echocardiography was normal. Of interest deep negative T waves and arrhythmias more complex than isolated ventricular ectopic beats were significative associated with structural heart disease. Thus, according to our results, advanced cardiovascular imaging techniques (cardiac MRI or cardiac CT) should be considered in athletes with negative T waves at ECG even in the presence of normal transthoracic echocardiography especially if complex ventricular arrhythmias of deep negative T waves are present.

Evaluation of Left Atrium/Left Atrial Appendage Function in Cases with Systemic Embolization in the Setting of Normal Transthoracic Echocardiography and Normal Sinus Rhythm

Various left atrium (LA) and left atrial appendage (LAA) anatomies and functions could be associated with embolic events. We aimed to investigate the impact of variation in LAA and LA functions on the occurrence of systemic embolization in normal sinus rhythm and normal echocardiography findings. This cross-sectional study was performed on 22 patients with documented peripheral emboli versus 32 control subjects. LA area, LAA area, ejection fraction (EF) of LA/LAA, LAA velocity and tissue Doppler imaging (TDI) of LA walls, left ventricular diastolic function, and EF were determined. There were statistically significant differences between LAA area, LAA EF, TDI of lateral LA wall, and TDI of anterior LA wall in cases versus controls. Echocardiography findings in LAA and LA functions could help to identify high-risk patients for embolic events in normal sinus rhythm cases.

Contemporary family screening in hypertrophic cardiomyopathy: the role of cardiovascular magnetic resonance.

AimsGenetic testing in relatives of hypertrophic cardiomyopathy (HCM) patients leads to early identification of pathogenic DNA variant carriers (G+), before the onset of left ventricular hypertrophy. Routine phenotyping consists of electrocardiography (ECG) and transthoracic echocardiography (TTE). Cardiovascular magnetic resonance (CMR) has become valuable in the work-up of HCM. In this study, we investigated the value of CMR in phenotyping of G+ family members.Methods and resultsThis study included 91 G+ subjects who underwent ECG, TTE and CMR, with a maximal wall thickness (MWT) <15 mm on TTE. The relative performance of TTE and CMR regarding wall thickness measurements and HCM diagnoses was assessed. HCM was defined as MWT of ≥13 mm. Logistic regression was performed to assess whether ECG and TTE parameters can predict CMR results. Most subjects (75%) had an MWT <13 mm on TTE, of which 23 (34%) were diagnosed with HCM based on CMR. MWT differences (range 1–10 mm) were often caused by an anterobasal hook-shaped thickening of the myocardium not visible on TTE. Two of 23 (9%) subjects with HCM on TTE were reclassified as no HCM on CMR. Normal ECG and TTE results almost excluded reclassifications by CMR. The prevalence of other HCM-related abnormalities on CMR was low.ConclusionCMR reclassified 27% of subjects. Subjects with normal ECG/TTE results were reclassified in a low number of cases, justifying screening with ECG and TTE in G+ relatives. In subjects with abnormal ECGs and/or poor TTE image quality, CMR is indicated.

Cardiac iron overload detection using longitudinal strain in asymptomatic children with beta thalassemia major.

Cardiomyopathy mediated by iron disposition in cardiomyocytes is a dreadful cause of morbidity and mortality in patients with beta thalassemia major (BTM). Conventional transthoracic echocardiography (TTE) parameters are preserved at late stages of cardiomyopathy induced by iron overload. Therefore, cardiac imaging modalities based on myocardial deformation such as strain imaging are used for early detection of cardiac iron overload. To demonstrate the contribution of longitudinal strain (LS) in early detection of cardiac iron overload in children with BTM. Sixty children (30 children with BTM and 30 healthy controls) were enrolled in this study. Conventional TTE study was performed in both patient and control groups. LV regional longitudinal strain (RLS) were determined and compared between the two study groups. Mean age was 10.4 ± 5years in BTM group compared to 10.2 ± 5years in control group (p = 0.876). Compared to control group, there was no significant difference in conventional TTE parameters except for indexed left atrium (LA) area and volume. LA was significantly larger in BTM children (27.59 ± 13.1ml/m2 vs. 18.23 ± 4.33ml/m2, p = 0.001). RLS was lower in anterior, septal and inferior walls in basal and middle segments of LV in BTM group while there was no significant difference in RLS in apical segment between the two groups (-27.30 ± 5.1 vs.-28.83 ± 4.33, p = 0.22). In asymptomatic BMT children with normal conventional TTE parameters, LS could be used for the detection of subclinical myocardial dysfunction.

Thrombolytic therapy in conjunction with CPR has managed cardiac arrest caused by extensive of pulmonary embolism and subglottic laryngeal oedema

Extensive Pulmonary embolism led to a patients’ acute deterioration to cardiogenic shock. Thrombolytic therapy had been administered during cardio-pulmonary resuscitation following cardiac arrest. The patient fully recovered and the right ventricle demonstrated normal transthoracic echocardiography (TTE) studies 16 hours after the arrest event.

Diagnostic Yield of TEE in Patients with Cryptogenic Stroke and TIA with Normal TTE: A Systematic Review and Meta-Analysis.

Introduction: The role of transesophageal echocardiography (TEE) in cryptogenic stroke and transient ischemic attack (TIA) with normal transthoracic echocardiography (TTE) remains controversial in the absence of definite guidelines. We aimed to perform a systematic review and meta-analysis to estimate an additional diagnostic yield and clinical impact of TEE in patients with cryptogenic stroke and TIA with normal TTE. Methods: We performed a systematic review of cohort studies on PubMed using the keywords ‘cryptogenic stroke’, cryptogenic TIA’, ‘TEE’, and ‘TTE’ with matching MeSH terms. We included studies with patients who had cryptogenic stroke or TIA and had normal TTE findings, where the study intended to obtain TEE on all patients and reported all TEE abnormalities. The studies containing patients with atrial fibrillation were excluded. All studies were evaluated for internal and external validity. Inverse variance random effects models were used to calculate the effect size, the number needed to diagnose, and the 95% confidence interval. Results: We included 15 studies with 2054 patients and found LA/LAA/aortic thrombus, valvular vegetation, PFO-ASA, valvular abnormalities, and complex aortic plaques on TEE. Of these, 37.5% (29.7%–45.1%) of patients had additional cardiac findings on TEE. Management of 13.6% (8.1%–19.1%) of patients had changed after TEE evaluation. Based on current guidelines, it should change management in 4.1% (2.1%–6.2%) of patients and could potentially change management in 30.4% (21.9%–38.9%) of patients. Sensitivity analysis was also performed with only class II studies to increase internal validity, which showed additional cardiac findings in 38.4% (28.5%–48.3%), changed management in 20.2% (8.7%–31.8%), should change management in 4.7% (1.5%–7.9%), and could potentially change management in 30.4% (17.8%–43.0%) of patients. Conclusions: The diagnostic yield of TEE to find any additional cardiac findings in patients with cryptogenic stroke or TIA is not only high, but it can also change management for certain cardiac abnormalities. TTE in cryptogenic stroke or TIA may mitigate future risks by tailoring the management of these patients.

Comparison between myocardial function assessed by echocardiography during hospitalization for COVID-19 and at 4\xa0months follow-up

In patients hospitalized for corona virus infectious disease 19 (COVID-19) it is currently unknown whether myocardial function changes after recovery and whether this is related to elevated cardiac biomarkers. In this single center, prospective cohort study we consecutively enrolled hospitalized COVID-19 patients between 1 April and 12 May 2020. All patients underwent transthoracic echocardiography (TTE) evaluation during hospitalization and at a median of 131 days (IQR; 116–136) follow-up. Of the 51 patients included at baseline, 40 (age: 62 years (IQR; 54–68), 78% male) were available for follow-up TTE. At baseline, 68% of the patients had a normal TTE, regarding left ventricular (LV) and right ventricular (RV) volumes and function, compared to 83% at follow-up (p = 0.07). Median LV ejection fraction (60% vs. 58%, p = 0.54) and tricuspid annular plane systolic excursion (23 vs 22 mm, p = 0.18) were comparable between hospitalization and follow-up, but a significantly lower RV diameter (39 vs. 34 mm, p = 0.002) and trend towards better global longitudinal strain (GLS) (− 18.5% vs − 19.1%, p = 0.07) was found at follow-up. Subgroup analysis showed no relation between patients with and without elevated TroponinT and/or NT-proBNP during hospitalization and myocardial function at follow-up. Although there were no significant differences in individual myocardial function parameters at 4 months follow-up compared to hospitalisation for COVID-19, there was an overall trend towards normalization in myocardial function, predominantly due to a higher rate of normal GLS at follow-up.

The diagnostic yield of transthoracic echocardiography in the intensive care unit: A retrospective observational analysis

Transthoracic echocardiography (TTE) is a commonly requested ICU investigation. Despite this, limited data exist regarding the diagnostic yield of unselected TTEs in a heterogenous ICU population. A retrospective, cross-sectional, single-center study was performed. All ICU patients admitted from January 2018 to February 2019 were included. The primary aim was to define the indications for, and diagnostic yield of, TTEs performed in the ICU. We also investigated the association between major abnormalities identified on TTE and mortality. There were 358 patients admitted to the ICU during the study period. Of these patients, 115 (32%) had a TTE performed during their ICU stay. The primary indication was to assess left ventricular function. Just under two-thirds of TTEs (65%) were normal or had minor abnormalities. Compared to the rest of the ICU population in our study (including both patients without a TTE performed and patients with a normal TTE), patients with an abnormal TTE had higher ICU (35.9% vs 21.3%, Odds Ratio [OR], 2.06; 95% CI, 1.02-4.19, P=.04) and in-hospital (43.6% vs 30.3%, OR, 2.64; 95% CI, 1.33-5.25, P=.01) mortality. A formal TTE was performed in one-third of patients during their ICU admission. Major abnormalities were identified in over one-third of these TTEs. ICU and in-hospital mortality were higher in patients with an abnormal TTE.

Incremental value of cardiovascular magnetic resonance imaging in family screening for hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Genetic testing in relatives of hypertrophic cardiomyopathy (HCM) patients can lead to early identification of carriers of pathogenic DNA variants (G+), before onset of left ventricular hypertrophy (LVH). Repeated evaluation by electrocardiography (ECG) and transthoracic echocardiography (TTE) is recommended to detect HCM during follow-up. Cardiovascular magnetic resonance (CMR) imaging has become valuable in the work-up of HCM, although its role in G+ subjects has not been extensively evaluated. In this study, we investigated the value of CMR in the G+/LVH- population. We included 55 G+ subjects who underwent CMR in addition to ECG and TTE, with a maximal wall thickness (MWT) &amp;lt;15mm on TTE. The CMR imaging protocol consisted at least of steady state free procession imaging and 2-dimensional late gadolinium enhancement (LGE) images. ECGs were considered abnormal in case of pathologic Q waves, T wave inversion or signs of LVH (by voltage criteria including Sokolow-Lyon and a Romhilt-Estes score ≥4). TTEs were abnormal in case of LVH (defined as MWT≥10mm). For both modalities, the diagnosis of HCM was based on a MWT≥13mm. The yield of CMR relative to ECG/TTE was assessed by comparing the proportion of HCM diagnoses and the presence of other phenotypic features. Forward step logistic regression was used to assess whether the presence of TTE/ECG abnormalities could predict reclassifications or abnormalities (crypts and LGE) on CMR. An overview of ECG/TTE and CMR findings is shown in the Figure. Two of 16 (13%) subjects diagnosed with HCM on TTE were reclassified as having no HCM on CMR, and 8 of 39 (21%) subjects without HCM on TTE were reclassified as HCM on CMR. These 8 subjects had a mean MWT of 15.4 ± 2.6 mm on CMR and a mean MWT difference of 4.5 ± 2.9 mm (range 1.7-9.4) compared to TTE, which in 3 cases was explained by a hook-shaped thickening of the basal anterior wall in the 2 chamber view, not visible on TTE. Compared to subjects without HCM on both modalities, the reclassified group had a significantly higher QRS duration (104 ± 14 vs 93 ± 11 ms, p = 0.03) and anterior mitral valve leaflet length (30 ± 4 vs 26 ± 3 mm, p = 0.01). Of the 13 subjects with normal ECG/TTE results, none were reclassified as HCM using CMR. The proportion of additional CMR abnormalities was large in subjects with and without abnormal ECG/TTE results (57% vs 38%, p = 0.24). Subjects with poor TTE image quality were equally likely to be reclassified compared to those with sufficient image quality (10% vs 24%, p = 0.19). Logistic regression demonstrated that the presence of TTE/ECG abnormalities (odds ratio [OR] 8.7 [1.3-59.0], p = 0.03) and age (OR 1.1 [1.0-1.2], p &amp;lt; 0.01) independently predicted reclassifications or presence of abnormalities using CMR. Additional CMR imaging reclassifies 18% of subjects. Subjects with normal ECG and TTE results are not diagnosed as HCM on CMR, but the prevalence of HCM-related abnormalities on CMR was high in subjects with and without ECG/TTE abnormalities. Abstract Figure. Diagnostic approach and CMR findings

Reducing Unnecessary Noninvasive Testing for Inpatients With Unstable Angina: The RUNIT Protocol

BackgroundRoutine inpatient transthoracic echocardiography (TTE) for patients with unstable angina is common, but it anecdotally adds little value to clinical care. A practice audit at our academic hospital demonstrated that 61.5% of patients with troponin-negative chest pain (TNCP) had normal left ventriculography (LVG) during coronary angiography and normal TTE on the same admission (duplicate testing). MethodsWe developed the Reducing Non-Invasive Testing (RUNIT) protocol, a clinical algorithm applied by clinical nurses to patient with TNCP. We performed a prospective assessment of rate of duplicate testing before and after intervention. If patients met certain simple clinical criteria, their TTE was cancelled (RUNIT positive). Patients then proceeded to have either coronary angiography with LVG or noninvasive risk stratification. We aimed to reduce duplicate testing by 25% over a 1-year period. Balancing measures included pathology on ordered TTEs, 30-day readmission, length of stay, and number of LVG. ResultsAmong 254 patients admitted with TNCP over 12 months, we reduced duplicate testing from 61.5% (before intervention) to 34% (P = 0.001). There was no clinical difference in 30-day readmission (0.9% vs 0.7%), and length of stay was significantly shorter in RUNIT positive (3.48 vs 4.16 days, P = 0.02). The majority of duplicate TTEs did not reveal any management-informing pathology. RUNIT-positive patients underwent more LVG than RUNIT-negative patients (78.3% vs 62.8%, P = 0.008). ConclusionWe achieved a sustained reduction in reflexive TTE ordering in patients with TNCP, and we discuss the potential of nursing-led interventions to address other areas of low value care in cardiology.

Normative Reference Values of Cardiac Output by Pulsed-Wave Doppler Echocardiography in Adults

Cardiac output (CO) is routinely assessed by pulsed-wave Doppler echocardiography, yet reference values in adults are lacking. We aim to establish normative values of CO and cardiac index (CI) by pulsed-wave Doppler-echocardiography and to analyze their relation with gender and age in nonobese and obese adults. We included 4,040 adults (mean age: 55 years, 53% women, 950 obese [body mass index ≥30 kg/m²]) with normal blood pressure, no history of cardiovascular disease, and normal transthoracic echocardiography. Normative reference CO and CI values for were calculated in 3,090 nonobese patients by quantile regression. CO normal limits were lower in females than in males (lower limit: 3.3 vs 3.5 L/min, upper limit: 7.3 vs 8.2 L/min). CI normal limits were identical for both genders (lower limit: 1.9 L/min/m², upper limit: 4.3 L/min/m²). Although the relation of CO to age was weak and observed only in women, CI of both genders was not influenced by age. CO of obese patients was significantly greater than that of their nonobese counterparts. CI of obese patients was not influenced by age and gender and was not significantly different than that of nonobese patients (lower limit 1.8 L/min/m², upper limit 4.1 L/min/m² for both genders). In conclusion, in a large adult population we establish normative reference values for CO and CI measured by Doppler-echocardiography. CI is a remarkably stable parameter that is not influenced by age, gender, and body size and should be used to define low- and high-output states.

Transhepatic echocardiography: a novel approach for imaging in left ventricle assist device patients with difficult acoustic windows.

AimsA significant proportion of left ventricle assist device (LVAD) patients have very difficult transthoracic echocardiographic images. The aim of this study was to find an echocardiographic window which would provide better visualization of the heart in LVAD patients with limited acoustic windows.Methods and resultsBased on the anatomic relationships in LVAD patients, a right intercostal transhepatic approach was proposed. By using a computer simulator, we searched for the appropriate probe orientation. Further, 15 ambulatory LVAD patients (age 56 ± 15 years, 73% males) underwent two echocardiographic studies: one normal transthoracic echocardiography following the institutional protocol (Echo 1) and a second study which included the transhepatic approach (Echo 2). The two exams were performed by two different sonographers and the results validated by a third observer for agreement. The transhepatic intercostal window was feasible in all patients, with an image quality allowing good visualization of structures in 93%. Precise quantification of the left ventricular (LV) and right ventricular (RV) function was achieved more often in the Echo 2 (10 vs. 3 patients for LV, P = 0.03 and 14 vs. 8 patients for RV, P = 0.04). A significant difference existed also in the quantification of the LVAD inflow cannula flow by pulsed Doppler (11 patients in Echo 2 vs. 3 patients in Echo 1, P = 0.009).ConclusionThis is the first study describing a new echocardiographic window in LVAD patients. The transhepatic window may provide better quantification of left and RV dimensions and function and improvement in Doppler interrogation of the inflow cannula.

P1267 Negative baseline diagnostic imaging does not exclude pulmonary embolism in patients with reccurrent syncope

Abstract INTRODUCTION In patients who are admitted to a hospital due to episode of syncope, acute pulmonary embolism (PE) is rarely considered as a possible cause. This report presents two cases illustrating PE as a cause of syncope with elevated cardiac troponin (cTn) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels despite normal echocardiographic examination and negative Doppler ultrasound imaging. Case 1: An 83-year-old woman admitted to the ER due to episodes of recurrent syncopes. According to her anamnesis, she had four episodes of syncopes during last three weeks without chest pain, dyspnea, palpitation or hemoptysis. ECG revealed a normal sinus rhythm with a heart rate of 70 bpm without ischemic changes. Laboratory tests revealed raised levels of cTn and NT-proBNP. Transthoracic echocardiography (TTE) demonstrated preserved left and right ventricular systolic functions without any cardiac chamber enlargement and mild tricuspid regurgitation with a PAP of 35 mmHg. Patient’s pre-test probability for pulmonary embolism was low (Wells’ score &amp;lt; 2) but D-dimer level was elevated. Doppler imaging for detection of deep vein thrombosis was negative. Computed tomography pulmonary angiography (CTPA) showed filling defects in the pulmonary arteries consistent with pulmonary embolism (Panel A). The patient was discharged with rivaroxaban therapy without any complication. Case 2: A 69- year-old woman presented to ER with symptoms of chest pain and recurrent episodes of syncope for the last 2 days. Her medical history revealed hypertension and hyperlipidemia. On admission ECG showed a normal sinus rhythm with a heart rate of 105 bpm and T-wave inversions in inferior leads. Laboratory tests showed elevated levels of cTn and NT-proBNP. TTE demonstrated normal left ventricular systolic function with an ejection fraction of 55% and normal right ventricular function and chamber size with a tricuspid annular plane systolic excursion of 22 mm. Diagnostic coronary angiography was performed to exclude acute ischemia revealed non-significant coronary artery stenosis. Doppler ultrasound imaging for detection of deep vein thrombosis was negative. CTPA showed filling defects in the bilateral main pulmonary arteries consistent with acute bilateral pulmonary embolism (Panel B-C). The patient was discharged with rivaroxaban therapy after four days of hospitalization period without any complication. CONCLUSION Elevated cTn and NT-proBNP leves on admission strongly suggest transient hemodynamic impairment causing cardiac injury and syncope. Normal admission ECG and TTE can exclude most possible acute cardiac causes of syncope. Although acute right ventricular dsyfunction is the most frequent finding of acute massive PE causing hemodymanic impairment resulting with syncope, diagnosis of acute PE should only be excluded with CTPA in patients with similar clinical characteristics despite normal TTE and negative venous Doppler ultrasound imaging. Abstract P1267 Figure

Abstract 123: Diagnostic Yield of TEE in Patients With Cryptogenic Stroke and TIA With Normal TTE: A Systematic Review and Meta-Analysis

Background: The diagnostic utility of Transesophageal echocardiography (TEE) in cryptogenic stroke or TIA remains controversial. Objective: To perform a systematic review and meta-analysis to estimate an additional diagnostic yield and clinical impact of TEE in patients with cryptogenic stroke and TIA with normal Transthoracic Echocardiography (TTE) results. Methods: A PubMed literature review was performed of cohort studies. The studies were excluded if routine stroke work-up was not documented, TTE was not performed on all patients or clear TTE data not available, separate analysis for patients with normal TTE results were not available, did not report all cardiac TEE findings, and included patients with Afib or did not have a separate analysis for patients without Afib. Results: Fifteen studies met the criteria, with total of 2054 patients with cryptogenic stroke or TIA with normal TTE results and underwent TEE. All studies were evaluated for internal validity and indirectness. Following TEE findings were noted across different studies: LA/LAA/Aortic thrombus, valvular vegetation, intracardiac tumor, spontaneous echo contrast, PFO, ASA, PFO -ASA combination, valvular abnormalities and complex aortic plaques. 37.5% (29.7% - 45.1%) of patients had additional cardiac findings on TEE. PFO was the second most common abnormality noted after complex aortic plaque. 13.6% (8.1% - 19.1%) of patients required changes in the management after TEE evaluation. Based on the current guidelines, it should change management in 4.1% (2.1% - 6.2%) of patients. It could potentially change management in 30.4% (21.9% - 38.9%) of patients. Analysis was also performed with only class II studies to increase internal validity, which showed additional cardiac findings in 38.4% (28.5% - 48.3%), changed management in 20.2 % (8.7% - 31.8%), should change management in 4.7% (1.5% - 7.9%) and could potentially change management in 30.4% (17.8% - 43.0%) of patients. Conclusions: The diagnostic yield of TEE to find any additional cardiac findings in patients with cryptogenic stroke or TIA is approximately 38%. Based on this analysis, number needed to diagnose one additional abnormality with TEE that can change management per current guidelines is approximately 21.

Subclinical Pulmonary Hypertension in Childhood Systemic Lupus Erythematosus Associated with Minor Disease Manifestations.

The aim of this study was to evaluate pulmonary hypertension (PH) in 852 childhood-onset systemic lupus erythematosus (cSLE) patients. This was a large multicenter study conducted in 10 Pediatric Rheumatology Services of São Paulo state, Brazil. PH was defined as systolic pulmonary artery pressure >35mmHg and/or measurement of the mean pulmonary artery pressure >25mmHg and/or diastolic pressure >15mmHg by transthoracic echocardiogram. Demographic data, clinical manifestations, disease activity score (SLEDAI-2K), disease damage score (SLICC/ACR-DI) and treatments were also evaluated. Statistical analysis was performed using Bonferroni correction (p<0.002). PH was observed in 17/852 (2%) cSLE patients. Effort dyspnea occurred in 3/17, chest pain in 1/17 and right ventricle dysfunction in 3/17 cSLE patients. None had pulmonary thromboembolism or antiphospholipid syndrome. Further comparison between 17 cSLE with PH and 85 cSLE control patients without PH with similar disease duration [15 (0-151) vs. 15 (0-153) months, p=0.448], evaluated at the last visit, revealed higher frequencies of fever (47 vs. 9%, p<0.001), reticuloendothelial manifestations (41 vs. 7%, p<0.001) and serositis (35 vs. 5%, p=0.001) in the former group. Frequencies of renal and neuropsychiatric involvements and antiphospholipid syndrome, as well as the median of SLEDAI-2K and SLICC/ACR-DI scores, were comparable in both groups (p>0.002). Normal transthoracic echocardiography was evidenced in 9/17 (53%), with median cSLE duration of 17.5months (1-40) after PH standard treatment. PH was a rare manifestation of cSLE occurring in the first two years of disease. The majority of patients were asymptomatic with mild lupus manifestations. The underlying mechanism seemed not to be related to pulmonary thromboembolism and/or antiphospholipid syndrome.

Reversed takotsubo cardiomyopathy in a patient with new-onset multiple sclerosis: Cause, link, or just coincidence?

A 29-year-old man with no prior medical history presented to the emergency department with acute chest pain and sudden onset of severe headache. He was alert and oriented. Physical examination revealed hypertension (192/100 mmHg). The patient underwent an urgent computed tomography (CT) scan of the head, which demonstrated a hypodense lesion in the right frontal lobe of the brain, which was later confirmed to be a demyelination lesion related to multiple sclerosis (MS) (Supplementary Fig. 1). The ECG showed no significant abnormalities (Fig. 1A). Patient laboratory findings demonstrated elevated troponin T levels (0.082 μg/L, reference < 0.014 μg/L) and normal CK–MB. Transthoracic echocardiography (TTE) displayed normal left ventricular function with no wall motion abnormalities (Supplementary Video 1). The combination of normal ECG and TTE, and his young age, the subtle rise in troponin was suspected to be related to hypertension. After pharmacological treatment of hypertension, his chest pain resolved, and after 10 days the patient was discharged in good clinical condition.