Stress Echocardiography Study Research Articles

Pulmonary pressure-flow responses to exercise in heart failure treated with angiotensin receptor neprilysin inhibitor

BackgroundThe role of the angiotensin receptor neprilysin inhibitor (ARNI) in cardiac function, particularly its impact on pulmonary circulation, remains underexplored. Recent studies have described abnormal mean pulmonary artery pressure (mPAP)-cardiac output (CO) responses as having the potential to assess the disease state. The aim of this study was to assess the effects of ARNI on pulmonary circulation in heart failure. We measured echocardiographic parameters post 6-min walk (6 MW) and compared the changes with baseline and follow-up. Our hypothesis was that pulmonary pressure-flow relationship of the pulmonary circulation obtained by 6 MW stress echocardiography would be improved with treatment. MethodsWe prospectively enrolled 39 heart failure patients and conducted the 6 MW test indoors. Post-6 MW echocardiography measured echocardiographic variables, and CO was derived from electric cardiometry. Individualized ARNI doses were optimized, with follow-up echocardiographic evaluations after 1 year. ResultsLeft ventricular (LV) volume were significantly reduced (160.7 ± 49.6 mL vs 136.0 ± 54.3 mL, P < 0.001), and LV ejection fraction was significantly improved (37.6 ± 11.3% vs 44.9 ± 11.5%, P < 0.001). Among the 31 patients who underwent 6 MW stress echocardiographic study at baseline and 1 year later, 6 MW distance increased after treatment (380 m vs 430 m, P = 0.003). The ΔmPAP/ΔCO by 6 MW stress decreased with treatment (6.9 mmHg/L/min vs 2.8 mmHg/L/min, P = 0.002). The left atrial volume index was associated with the response group receiving ARNI treatment for pulmonary circulation. ConclusionsInitiation of ARNI was associated with improvement of left ventricular size and LVEF. Additionally, the 6 MW distance increased and the ΔmPAP/ΔCO was improved to within normal range with treatment.

Abstract 14279: Improved Pressure-Flow Relationship With Sacubitril/Valsartan: A 6-min Walk Stress Echocardiographic Study

Background: In the clinical setting, there are various techniques for stress echocardiography, of which the 6-minute walk (6MW) test is a straightforward and utilized one. An abnormal hemodynamic response to exercise is indicated by a ΔmPAP/ΔCO slope of greater than 3 mmHg/L/min between rest and exercise. This response is associated with impaired prognosis in patients with exercise dyspnea and several cardiovascular diseases. Hypothesis: Our hypothesis was that pressure-flow relationship of the pulmonary circulation obtained by 6MW stress echocardiography would be enhanced with treatment. Aims: The aim of this study was to assess the effects of administration of Sacubitril/Valsartan on cardiac function in heart failure. Methods: We prospectively enrolled 39 patients with heart failure. The 6MW test was performed indoors in a flat, straight corridor. The peak tricuspid regurgitation jet, early diastolic transmitral flow velocity and early diastolic mitral motion were obtained by echocardiography post-6MW. We calculated the slope of ΔmPAP/ΔCO as a parameter of pulmonary hypertension. Follow-up echocardiographic studies were performed after 1 year. Results: Left ventricular diameter and volume were significantly reduced (LVDd; 59.3±7.7mm vs 56.0±8.6mm, P&lt;0.001, LVEDV; 160.7±49.6ml vs 136.0±54.3ml, P&lt;0.001), and LVEF was significantly improved (37.6±11.3% vs 44.9±11.5%, P&lt;0.001). Among the 31 patients who underwent 6MW stress echocardiographic study at baseline and 1 year later, 6MW distance increased after treatment (380m vs 430m, P=0.003). The ΔmPAP/ΔCO by 6MW stress decreased with treatment (6.9mmHg/L/min vs 2.8mmHg/L/min, P=0.002). Conclusions: Initiation of Sacubitril/Valsartan was associated with improvement of left ventricular size and LVEF. Additionally, the 6MW distance increased and the ΔmPAP/ΔCO was improved to within normal range with treatment. Sacubitril/Valsartan distinctly improved cardiac reactivity to exercise.

Contributions of anemia to exercise intolerance in heart failure with preserved ejection fraction-An exercise stress echocardiographic study.

Anemia is common in patients with heart failure with preserved ejection fraction (HFpEF) and is associated with exercise intolerance. However, there are limited data on how anemia contributes to reduced exercise capacity in patients with HFpEF. We aimed to characterize exercise capacity, cardiovascular and ventilatory reserve, and the oxygen (O2) pathway in anemic patients with HFpEF. A total of 238 patients with HFpEF and 248 dyspneic patients without HF underwent ergometry exercise stress echocardiography with simultaneous expired gas analysis. Patients with HFpEF were classified into two groups based on the presence of anemia (hemoglobin<13.0g/dL in men and<12.0g/dL in women). Anemic HFpEF patients (n=112) had worse nutritional status and renal function, lower iron levels, and greater left ventricular (LV) remodeling and plasma volume expansion than those without anemia (n=126). Exercise capacity, assessed by peak oxygen consumption, exercise intensity, and exercise duration, was lower in the anemic HFpEF group than in the other groups. Despite a similar cardiac output during exercise, anemic patients with HFpEF demonstrated limitations in arterial O2 delivery, lower arteriovenous O2 content difference, and ventilatory inefficiency (higher minute ventilation vs. carbon dioxide production slope) during peak exercise. Anemic HFpEF patients demonstrated unique pathophysiological features with greater LV remodeling and plasma volume expansion, limitations in arterial O2 delivery and peripheral O2 extraction, and ventilatory inefficiency, which may contribute to reduced exercise capacity. Further studies are needed to develop an optimal approach for treating anemia in patients with HFpEF.

Impaired Left Ventricular Contractile Reserve in Patients With Hypertrophic Cardiomyopathy and Abnormal Blood Pressure Response: A Stress Echocardiographic Study.

Abnormal blood pressure response (ABPR) has been reported to be a risk factor for sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). We aimed to elucidate the relationship between ABPR during exercise stress echocardiography (ESE) and impaired left ventricular (LV) contractile reserve based on two-dimensional strain in patients with HCM. Patients with HCM underwent ESE with treadmill exercise. Patients whose blood pressure elevation at maximum workload was lower than 20 mmHg from baseline were classified as having ABPR. Echocardiographic parameters were compared between patients with and without ABPR. Results: Of 26 patients with HCM, nine patients were diagnosed with ABPR. Significant LV outflow tract obstruction (>50 mmHg) was provoked only in one patient with ABPR (baseline to the conclusion of the exercise, 15.2 mmHg to 63.0 mmHg). Change in cardiac output (CO) and the ratio of early diastolic velocity to early annular velocity (E/e') from baseline to just after the conclusion of exercise did not differ between patients with and without ABPR (CO, 102±40% vs. 122±45%, P = 0.19; E/e', 4±22% vs. 2±20%, P = 0.86). Change in systemic vascular resistance change was not significant (patients with vs. without ABPR, -52±10% vs. -46±13%, P = 0.24). Percent change in LV global longitudinal strain was lower in patients with ABPR than patients without ABPR (12±17% vs. 27±15%, P = 0.02). In conclusion, impaired LV contractile reserve during exercise might contribute to ABPR in patients with HCM.

Contractile and chronotropic reserve assessment in stress echocardiography studies negative for myocardial ischemia

Contractile and chronotropic reserve assessment in stress echocardiography studies negative for myocardial ischemia

Contractile and chronotropic reserve assessment in stress echocardiography studies negative for myocardial ischemia

Contractile and chronotropic reserve assessment in stress echocardiography studies negative for myocardial ischemia

Abstract 13684: Comparison Between Men and Women With Severe Obesity for Risk of Adverse Outcomes of Myocardial Ischemia: An Exercise Stress Echocardiographic Study

Background: Obesity and sex have a complex relationship with myocardial ischemia. We explored the association of sex and severe obesity with adverse cardiovascular outcomes in patients with ischemic exercise stress echocardiography (EXE). Methods: We retrospectively studied 142 patients with ischemic ExE [Age: 65±11 years, 70(49%) women, EF: 57±8%, body mass index (BMI): 28±6 kg/m 2 ]. Severe obesity (BMI&gt;35 kg/m 2 ) occured in 48 (34%) patients. Patients were stratified based on obesity and sex (4 groups, women, and men with and without severe obesity), followed for median of 1.5 years, and compared for clinical, exercise variables and occurrence of composite outcomes (death, acute coronary syndrome, cardiac hospitalization and repeat ischemia testing). Results: In our study, 28(20%) women and 20(14%) men had severe obesity, and 42(29%) women and 52(37%) men had no severe obesity. Groups were not different for age, risk factors, exercise characteristics, and resting LV function. Outcomes occurred in 85(60%) patients and were more prevalent in women with severe obesity compared to women without or men with or without severe obesity [21(75%), 17(40%), 11(55%), and 35(67%), p=0.014]. Sex and severe obesity did not predict outcomes in isolation [HR: 1.13 (95%CI:0.74 to 1.73), 1.48 (95%CI:0.95 to 2.3), respectively, figure 1A, B]. Survival analysis showed that women without severe obesity were at lowest risk, men were at similarly elevated risk irrespective of severe obesity, and women with severe obesity were at highest risk for composite outcomes [p=0.037, figure 1C, HR: 2.5 (95% CI: 1.3 to 4.8)]. After adjusting for clinical, exercise, and echocardiographic variables, women with severe obesity remained at high-risk [HR: 2.2, (95% CI: 1.06 to 4.36)]. Conclusion: In patients with ischemic ExE, women with severe obesity are at higher risk for adverse cardiac outcomes. Future studies are needed to understand the pathophysiologic mechanisms underlying this association.

Clinical course and decision-making in heart failure by preload stress echocardiography: a preliminary study.

Abnormal left ventricular diastolic response to preload stress can be an early marker of heart failure (HF). The aim of this study was to assess clinical course in patients with HF with preserved ejection fraction (HFpEF) who underwent preload stress echocardiography. In the subgroup analysis, we assessed the prognosis of patients with unstable signs during preload stress classified by treatment strategies. We prospectively conducted preload stress echocardiographic studies between January 2006 and December 2013 in 211 patients with HFpEF. Fifty-eight patients had abnormal diastolic reserve during preload stress (unstable impaired relaxation: unstable IR). Of 58 patients with unstable IR, 19 patients were assigned to additional therapy by increased or additional therapy and 39 patients were assigned to standard therapy. Composite outcomes were prespecified as the primary endpoint of death and hospitalization for deteriorating HF. During a median period of 6.9years, 19 patients (33%) reached the composite outcome. Unstable group with standard therapy had significantly shorter event-free survival than stable group. Patients with uptitration of therapy had longer event-free survival than those with standard therapy group after adjustment of laboratory data (hazard ratio, 0.20, 95% confidence interval, 0.05-0.90; P=0.036); the 10year event-free survival in patients with and without uptitration of therapy was 93% and 51%, respectively (P=0.023). Patients with unstable sign had significantly shorter event-free survival than patients with stable sign. After additional therapy, the prognosis of patients with unstable signs improved. This technique may impact decision-making for improving their prognosis.

Risk stratification of women with peripartum cardiomyopathy at initial presentation: A dobutamine stress echocardiography study

Risk stratification of women with peripartum cardiomyopathy at initial presentation: A dobutamine stress echocardiography study

The right ventricular-pulmonary circulation coupling in ischaemic heart disease; a stress echocardiography study

Abstract Objectives This study sought to assess the right ventricular (RV) - pulmonary circulation coupling in patients with coronary artery disease (CAD), preserved echocardiographic indices of right ventricular systolic function and normal pulmonary artery systolic pressure (PASP). Background Patients with CAD are at increased risk for developing left, and ultimately right heart failure. The analysis of underlying mechanisms of worsening RV function has been limited to the hemodynamic sequelae of increased left ventricular (LV) filing pressure leading to pulmonary hypertension. It has been reported that evaluation of RV functional state by using the tricuspid annular plane systolic excursion (TAPSE)/PASP ratio as a surrogate for the RV length-force is of clinical prognostic relevance in patients with known pulmonary hypertension; its role has not been extensively explored in other cardiac conditions including myocardial ischaemia. We hypothesized that the TAPSE/PASP ratio may be able to identify early and subtle changes in RV function in patients with CAD, normal estimated resting PASP, and preserved TAPSE. Methods Data were obtained from a prospectively maintained database, and 223 consecutive patients with preserved right ventricular systolic function (TAPSE≥16mm), and normal resting PASP (≤35mmHg), undergoing stress echocardiography (SE) for suspected coronary artery disease were included. Exclusion criteria: non-ischaemia study, severe valvular disease, poor image quality, resting pulmonary hypertension, reduced right ventricular systolic function. Transthoracic 2-D Doppler echocardiogram was performed by an accredited sonographer at rest and during stress phase and reviewed by two cardiologists unaware of clinical data. Results Fifty-three (24%) SE studies were positive for ischaemia and 170 (76%) negative. Demographic characteristics of both groups are shown in Table 1. All patients had TAPSE≥16mm and a PASP≤35mmHg as per inclusion criteria. The mean TAPSE/PASP ratio was significantly lower in patients with a positive SE suggestive of CAD than controls (0.84±0.22 vs 0.93±0.24, P=0.024). The TAPSE/PASP ratio showed significant correlation with the maximum workload (Watts) achieved (r=0.17, P=0.015) and exercise time (min) (r=0.15, P=0.031), and an inverse correlation with age (r=−0.26, P&amp;lt;0.001) and the development of inducible exertional breathlessness (Exp(B) 0.11, 95% CI 0.028–0.457, P=0.002) on SE. Conclusion Resting TAPSE/PASP was reduced in patients with positive SE, compared to controls. Indexing RV function to RV load, with the use of the TAPSE/PASP ratio identified early changes in RV-pulmonary circulation coupling in CAD patients without resting pulmonary hypertension; this may denote the beginning of subclinical RV dysfunction. Funding Acknowledgement Type of funding sources: None. Table 1

Resting echocardiographic predictors for true-severe aortic stenosis in patients with low-gradient severe aortic stenosis: A dobutamine stress echocardiography study.

Dobutamine stress echocardiography (DSE) is not always feasible in patients with low-gradient severe aortic stenosis (LG-SAS), and there are limited data available on the resting echocardiographic predictors for true-severe aortic stenosis (TSAS). This study investigated resting echocardiographic predictors for TSAS. Clinical data of 106 LG-SAS patients who underwent DSE were retrospectively analyzed. LG-SAS was defined as an aortic valve area index (AVAi)<.6cm2 /m2 , and a mean AV pressure gradient<40mm Hg. The velocity ratio (VR) was calculated as the peak left ventricular outflow tract velocity/peak AV velocity. TSAS was defined as a projected AVAi<.6cm2 /m2 . The mean age was 79.3 ± 7.3 years, and 45 (42.5%) were men. The resting AV data were as follows: AVAi, .50 ± .07 cm2 /m2 ; mean AV pressure gradient, 23.0 ± 7.4mm Hg; and VR, .25 ± .05. The projected AVAi was .58 ± .09 cm2 /m2 , and TSAS was documented in 65 (61.3%) patients. In multivariate analysis, the independent predictors of TSAS were AVAi (p=0.012) and VR (p=0.004) with respective best cut-off values of .52cm2 /m2 and .25 on receiver-operating characteristic curve analysis. According to incremental numbers of the predictors, correct classification percentages of TSAS significantly increased with the Cochran-Armitage trend test (16.2% in no predictors, 65.2% in one predictor, and 95.7 % in two predictors; p<0.001). Resting AVAi and VR were independent predictors of TSAS in LG-SAS patients. The true severity might be predictable using the combination of resting parameters.

Cardiac reserve by 6-minute walk stress echocardiography in systemic sclerosis

ObjectivesThere is a high prevalence of left ventricular diastolic dysfunction (LVDD) in systemic sclerosis (SSc) which is associated with high mortality. Thus, early detection of LVDD could be important in...

Abstract 13566: Clinical Utility of Noninvasive Assessment of Flow-pressure Relationship in Scleroderma

Introduction: Cardiac involvement in Systemic sclerosis (SSc), especially left ventricular diastolic dysfunction (DD), is high prevalence and associated with high mortality. Thus, the early detection of left ventricular DD might be important to manage SSc. Recent study has shown that exercise stress test may evaluate an early stage of heart failure in patients with normal resting echocardiogram. Hypothesis: We hypothesized that SSc patients with normal resting hemodynamics may present early phase of left ventricular DD by exercise echocardiogram, leading to the model of predicting long-term outcomes. Methods: Between January 2014 and December 2018, we prospectively enrolled 140 SSc patients who underwent 6-minute walk (6MW) stress echocardiographic studies with normal range of estimated mean pulmonary arterial pressure (mPAP) (&lt;25mmHg) and mean pulmonary artery wedge pressure (mPAWP) (&lt;15mmHg) at rest. We used ΔmPAP/Δcardiac output (CO) to assess pulmonary vascular reserve and ΔmPAWP/ΔCO to assess left ventricular (LV) reserve between resting and post-6MW point. Results: During a median period of 3.6 years, 25 patients (18%) reached the composite outcome. Both ΔmPAP/ΔCO and ΔmPAWP/ΔCO in patients with events were significantly higher than in ones without events (8.9±3.8mmHg/l/min vs. 3.0±1.7mmHg/l/min; p=0.002, and 2.2±0.9mmHg/l/min vs. 0.9±0.5mmHg/l/min; p&lt;0.001, respectively). In addition, ΔmPAWP/ΔCO is strongly associated with events (p=0.04) in patients with normal ΔmPAP/ΔCO (≤median value), although ΔmPAWP/ΔCO had weak impact in patients with abnormal ΔmPAP/ΔCO (&gt;median value) (p=0.23). Conclusions: Exercise echocardiography revealed impaired LV functional reserve in SSc patients with normal resting hemodynamics. Furthermore, in the group of normal pulmonary vascular function, the patients with impaired LV functional reserve had significantly shorter event-free survival than the ones with non-impaired LV function. Thus, the evaluation of early left ventricular DD with 6MW may detect high-risk group in SSc patients.

Using deep learning to extract novel and quantitative imaging features from perfluoropropane contrast, sulphur hexafluoride contrast and non-contrast stress echocardiography images

Abstract Background Stress echocardiography has become established as the most widely applied non-invasive imaging test for diagnosis of coronary artery disease within the UK. However, stress echocardiography has been substantially qualitative, rather than quantitative, based on visual wall motion assessment. For the first time, we have identified and validated quantitative descriptors of cardiac geometry and motion, extracted from ultrasound images acquired using contrast agents in an automated way. Purpose To establish whether these novel imaging features can be generated in an automated, quantifiable and reproducible way from images acquired with perfluoropropane contrast, as well as investigating how these extracted measures compare to those extracted from sulphur hexafluoride contrast and non-contrast studies. Methods 100 patients who received perfluoropropane contrast during their stress echocardiogram were recruited. Their stress echocardiography images were processed through a deep learning algorithm. Novel feature values were recorded and a subset of 10 studies were repeated. The automated measures of global longitudinal strain (GLS) and ejection fraction (EF) extracted from these images were compared to values previously extracted from sulphur hexafluoride contrast and non-contrast images using the same software. Results A full set of 31 novel imaging features were successfully extracted from 79 studies acquired using the perfluoropropane contrast agent with a dropout rate of 14% (n=92, 8 incomplete image sets). Repeated analysis in a subset of 10 perfluoropropane cases demonstrated excellent reproducibility of the extracted feature values (R2=1). Automated values of GLS and EF, at both rest (GLS = −16.4±4.8%, EF = 63±13%) and stress stages (GLS = −17.7±5.8%, EF = 68±11%), were extracted from 83 perfluoropropane studies, with a dropout rate of 16% (n=99, fewer incomplete sets as short axis view not required). The ranges of GLS and EF measures extracted from the perfluoropropane images were comparable to the other contrast studies (n=222) (Rest GLS = −16.8±5.8%, Rest EF = 63±10%; Stress GLS = −19.1±6.7%, Stress EF = 71±9%) and non-contrast studies (n=86) (Rest GLS = −15.7±5.3%, Rest EF = 57±10%; Stress GLS = −17.3±6.4%, Stress EF = 61±14%). Conclusions Novel features and clinically relevant measures were extracted from images acquired using perfluoropropane contrast for the first time in a fully automated and reproducible way using a deep learning algorithm. The analysis failure rate and generated measures are comparable to those extracted from images using other commonly used sulphur hexafluoride contrast agents and non-contrast stress echocardiography studies. These findings demonstrate that deep learning algorithms can be used for automated quantitative analysis of stress echocardiograms acquired using various contrast agents and in non-contrast studies to improve stress echocardiography practice. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Lantheus Medical Imaging, Inc.

Early Detection of Left Ventricular Subclinical Systolic Dysfunction in Hypertensive Patients: Speckle Tracking at Rest and after Dobutamine Stress Echocardiography Study

Abstract Background: Hypertension is one of the major cardiovascular risk factor that may result in heart failure. Two-D transthoracic echocardiography (2-D TTE) recognizes reduction in left ventricular systolic function in late stages of the disease course, so early detection is of paramount importance. Objective: Our study intended to evaluate feasibility of speckle-tracking echocardiography (STE) to provide additional perceptions for early detection of hypertension induced left ventricular systolic dysfunction. Patient and Methods: We enrolled 40 hypertensive patients, 21 women (52.5%) their mean age was 54.55±9 years and 20 normotensive age and gender matched control individuals (10 women, their mean age was 53.20±12.06 years). All had normal left ventricular systolic function by 2-D TTE. STE performed at rest and low dose dobutamine. Patients with significant ischemic or valvular heart disease as well as atrial fibrillation, conduction abnormalities and diabetes excluded. Results: Systolic blood pressure was significantly higher in the hypertensive group patients (138.50±10.27 mmHg vs. 120.50±7.76 mmHg, respectively; P = <0.001). Compared to control group, hypertensive patients experienced significantly impaired global longitudinal STE at rest (-18.08±1.63% versus 20.50±1.52% respectively; P<0.001) and at low-dose dobutamine (-19.11±1.75% versus 22.61±1.88% respectively; P<0.008). Conclusion: Speckle tracking echocardiography increases the sensitivity in detecting subclinical cardiac involvement in early stages of hypertension compared to conventional 2-D echocardiography.

The Coronary ARteriogenesis with combined Heparin and EXercise therapy in chronic refractory Angina (CARHEXA) trial: A double-blind, randomized, placebo-controlled stress echocardiographic study.

Coronary collateral circulation exerts protective effects on myocardial ischaemia due to coronary artery disease and can be promoted by exercise with heparin co-administration. Whether this arteriogenetic effect is accompanied by functional improvement of left ventricle during stress and lessening of angina symptoms remains unknown. To evaluate the anti-ischaemic efficacy of heparin plus exercise in coronary artery disease. In a prospective, single-centre, randomized, double-blind study we recruited 32 'no-option' patients (27 males; mean age 61 ± 8 years) with stable angina, exercise-induced ischaemia and coronary artery disease not suitable for revascularization. All underwent a two-week cycle of exercise (two exercise sessions per day, five days per week) and were randomized (n = 16 per group) to intravenous placebo (0.9% saline) versus unfractionated heparin (5.000 IU intravenously), 10 min prior to exercise. We assessed Canadian Cardiovascular Society angina class, stress electrocardiogram and echo parameters (wall motion score index) and computed tomography angiography for collaterals. After two-week cycle, Canadian Cardiovascular Society class statistically decreased in both groups (heparin plus exercise group: 2.6 ± 0.7 to 1.9 ± 0.7, p < 0.001, exercise group: 2.4 ± 0.7 to 2.1 ± 0.9, p = 0.046). Only the heparin plus exercise group improved time-to-ST segment depression (before 270, 228-327 s vs. after 339, 280-360 s, p = 0.012) and wall motion score index (before 1.38 ± 0.25 vs. after 1.28 ± 0.18, p = 0.005). By multi-slice computed tomography angiography, collaterals improved in 12/15 (80%) in the heparin plus exercise group versus 2/16 (12.5%) in the exercise group (p < 0.001). A two-week, 10-test cycle of heparin plus exercise is better than exercise in improving angina class, myocardial ischaemia and collaterals by computed tomography angiography.

P1508The Coronary Arteriogenesis with combined Heparin and Exercise therapy in chronic refractory Angina (CARHEXA) trial: a double-blind randomized placebo-controlled stress echocardiographic study

Abstract Background Coronary collateral circulation exerts protective effects on myocardial ischemia due to coronary artery disease (CAD) and can be promoted by exercise (E) with heparin (H) co-administration. Whether this arteriogenetic effects is accompanied by functional improvement of left ventricle (LV) during stress remains unknown. Purpose To establish the stress-induced functional effects on LV regional and global function of 2-week cycle of H+E in patients with “no-option” CAD. Methods In a prospective, single-center, double-blind, randomized, parallel-group study we recruited 32 “no-option” patients (27 males; mean age of 61±8 years), with stable angina and CTO, refractory to OMT, not suitable for revascularization and with E-induced ischemia. All underwent 2-week cycle of E (2 E test per day, 5 days a week) and were pre-treated with i.v. 0.9% saline or unfractionated H (100 IU/kg up to maximum of 5.000IU, 10 min prior to E). Canadian Class Score (CCS) and 12-lead E-ECG for time-to-1 mm ST-segment depression were assessed at entry and after treatment. LV function was evaluated during treadmill exercise with conventional and advanced imaging indices: Wall Motion Score Index (WMSI); Ejection Fraction (EF); Force (systolic blood pressure/end-systolic volume); Global Longitudinal Strain (GLS). Results Post-treatment exercise-time and CCS improved in both groups. In H+E patients exercise-time improved from 369.8±107.8 sec to 475.3±114.6 sec (p=0.001) while in E patients improved from 384±152.7 sec to 464.8±134.1 sec (p=0.019). CCS score changed in H+E from 2.6±0.7 to 1.9±0.7 (p=0.000), and in E group from 2.4±0.7 to 2.1±0.9 (p=0.046). At peak exercise, H+E was different from E group for EF and GLS (see Table). Effects of H+E on SE parameters H+E p P+E p *H+E vs P+E STRESS Time 0 vs Time 1 Time 0 vs Time 1 Time 0 Time 1 WMSI 1.377 vs 1.279 0.005 1.404 vs 1.376 0.290 0.626 0.255 EF (%) 60.9 vs 64.8 0.016 61.2 vs 57.8 0.284 0.943 0.016 Force (mmHg/mL) 6.36 vs 6.5 0.158 5.82 vs 4.68 0.209 0.760 0.098 GLS (%) −16.96 vs −18.50 0.001 −15.79 vs −15.60 0.380 0.325 0.027 SE = stress echocardiography; H+E = heparin+exercise; P+E = placebo+exercise; Time 0 = before randomization; Time 1 = after 2-week therapy cycle. *p values. Conclusion A 2-week, H+E cycle is associated with improvement in regional and global LV function during exercise, concordantly shown by conventional (WMSI, EF) and advanced (GLS) echocardiographic indices of LV function. This integrates and supplements the classical objective index based on ST-segment depression, unable to localize and quantify the functional consequences of therapy on myocardial ischemia.

Risk stratification of women with peripartum cardiomyopathy at initial presentation: A dobutamine stress echocardiography study

Risk stratification of women with peripartum cardiomyopathy at initial presentation: A dobutamine stress echocardiography study

Crowdsourcing consensus: proposal of a novel method for assessing accuracy in echocardiography interpretation.

Quality in stress echocardiography interpretation is often gauged against coronary angiography (CA) data but anatomic obstructive coronary disease on CA is an imperfect gold standard for a stress induced wall motion abnormality. We examined the utility of crowd-sourcing a "majority-vote" consensus as an alternative 'gold standard' against which to evaluate the accuracy of an individual echocardiographer's interpretation of stress echocardiography studies. Participants independently interpreted baseline and post-exercise stress echocardiographic images of cases that had undergone follow up CA within 3months of the stress echo in two surveys, 2years apart. We examined the agreement of consensus on survey (survey participant response (> 60%) for one decision) with the stress echocardiography clinical read and with CA results. In the first survey, 29 participants reviewed and independently interpreted 14 stress echo cases. Consensus was reached in all 14 cases. There was good agreement between clinical and consensus (kappa = 0.57), survey participant response and consensus (kappa = 0.68) and consensus and CA results (kappa = 0.40). In the validation survey, the agreement between clinical reads and consensus (kappa = 0.75) and survey participant response and consensus (kappa = 0.81) remained excellent. Independent consensus is achievable and offers a fair comparison for stress echocardiographic interpretation. Future validation work, in other laboratories, and against hard outcomes, is necessary to test the feasibility and effectiveness of this approach.

Pulmonary arterial pressure detects functional mitral stenosis after annuloplasty for primary mitral regurgitation: An exercise stress echocardiographic study.

The restrictive mitral valve annuloplasty (RMA) is the treatment of choice for degenerative mitral regurgitation (MR), but postoperative functional mitral stenosis remains a matter of debate. In this study, we sought to determine the impact of mitral stenosis on the functional capacity of patients. In a cross-sectional study, 32 patients with degenerative MR who underwent RMA using a complete ring were evaluated. All participants performed treadmill exercise test and underwent echocardiographic examinations before and after exercise. The patients' mean age was 50.1±12.5years. After a mean follow-up of 14.1±5.9months (6-32months), the number of patients with a mitral valve peak gradient >7.5mmHg, a mitral valve mean gradient >3mmHg, and a pulmonary arterial pressure (PAP) ≥25mmHg at rest were 50%, 40.6%, and 62.5%, respectively. 13 patients (40.6%) had incomplete treadmill exercise test. All hemodynamic parameters were higher at peak exercise compared with at rest levels (all P<.05). The PAP at rest and at peak exercise as well as peak transmitral gradient at peak exercise were higher in patients with incomplete exercise compared with complete exercise test (all P<.05). The PAP at rest (a sensitivity and a specificity of 84.6% and 52.6%, respectively; area under the curve [AUC]=.755) and at peak exercise (a sensitivity and a specificity of 100% and 47.4%, respectively; AUC=.755) discriminated incomplete exercise test. The RMA for degenerative MR was associated with a functional stenosis and the PAP at rest and at peak exercise discriminated low exercise capacity.