Transthoracic Echocardiographic Study Research Articles

Correlation of echocardiographic parameters in prone and supine positions in normal adults using a novel approach.

Transthoracic echocardiography (TTE) in prone position is challenging. Innovative use of transesophageal echocardiography (TEE) probe to perform TTE for such patients has been described; but reproducibility and correlation of the TTE measurements by this technique with those obtained by the standard supine TTE study are still unknown. We enrolled 30 non-COVID-19 individuals, with a mean (SD) age 35 (10.9) years and 11 females, to study the agreement between the transthoracic measurements of the left ventricular (LV), left atrial (LA), aortic dimensions, and ejection fraction (EF) obtained in prone position using an external TEE probe versus the standard supine position using the conventional TTE probe. There were no significant differences between LV end-diastolic and end-systolic diameters, septal wall thickness, posterior wall thickness, and aortic root dimensions in the prone versus the supine positions, while the mean EF (60.3% vs 63.1%, P=.014) and mean LA dimensions (1.8 vs 1.9cm/m2 , P<.001) were significantly lower in the prone position. The mean time of scans was significantly longer in the prone as compared to the supine position (12.5 vs 4.5minutes, P<.001). All supine studies had good quality while in the prone position four studies were of poor quality, and one was nondiagnostic. Assessment of cardiac dimensions and systolic function in the prone position using transthoracic TEE probe was feasible. LV and aortic dimensions agreed well with the standard TTE in supine position; however, LA dimensions and EF were lower in the prone position.

A deep learning approach for the automatic recognition of prosthetic mitral valve in echocardiographic images

The first step in the automatic evaluation of the cardiac prosthetic valve is the recognition of such valves in echocardiographic images. This research surveyed whether a deep convolutional neural network (DCNN) could improve the recognition of prosthetic mitral valve in conventional 2D echocardiographic images. An efficient intervention to decrease the misreading rate of the prosthetic mitral valve is required for non-expert cardiologists. This intervention could serve as a section of a fully-automated analysis chain, alleviate the cardiologist's workload, and improve precision and time management, especially in an emergent situation. Additionally, it might be suitable for pre-labeling large databases of unclassified images. We, therefore, introduce a large publicly-available annotated dataset for the purpose of prosthetic mitral valve recognition. We utilized 2044 comprehensive non-stress transthoracic echocardiographic studies. Totally, 1597 patients had natural mitral valves and 447 patients had prosthetic valves. Each case contained 1 cycle of echocardiographic images from the apical 4-chamber (A4C) and the parasternal long-axis (PLA) views. Thirteen versions of the state-of-the-art models were independently trained, and the ensemble predictions were performed using those versions. For the recognition of prosthetic mitral valves from natural mitral valves, the area under the receiver-operating characteristic curve (AUC) made by the deep learning algorithm was similar to that made by cardiologists (0.99). In this research, EfficientNetB3 architecture in the A4C view and the EfficientNetB4 architecture in the PLA view were the best models among the other pre-trained DCNN models.

RESISTANT HYPERTENSION AND METABOLIC SYNDROME –A TWO-WAY RELATIONSHIP

Objective: Resistant hypertension is often accompanied by sympathetic hyperactivity, arterial stiffness and metabolic syndrome. Moreover, the idea of metabolic syndrome increasing the effect of resistant hypertension in sympathetic nervous system and vascular wall is under examination. The aim of this study was to appraise the effect of the metabolic syndrome on sympathetic drive, as it was assessed by MSNA estimations, and arterial stiffness in patients with resistant hypertension. Design and method: We studied 34 patients with resistant hypertension (age: 57 ± 11 years, 22 males, office blood pressure (BP): 157/93 ± 13/11 mmHg, 24-hour BP: 138/83 ± 14/10 mmHg, under 3.2 ± 0.5 antihypertensive drugs) who underwent anthropometric measurements, blood examinations and transthoracic echocardiographic study, for assessment of the metabolic profile. In all participants, MSNA was evaluated based on established methodology (microneurography) and arterial stiffness on the basis of carotid to femoral pulse wave velocity (PWV). Metabolic syndrome was defined according to the Adult Treatment Panel III criteria. Results: Patients with resistant hypertension and metabolic syndrome (n = 14), compared to those without metabolic syndrome (n = 20) were characterized by higher levels of office systolic BP (166 ± 15 vs 151 ± 15 mmHg, p &lt; 0.001), fasting glucose (132.7 ± 2.7 vs 94.7 ± 2.2 mg/dl, p &lt; 0.05), waist circumference (109.1 ± 5.3 vs 94.8 ± 9.3 cm, p = 0.002), as well as left ventricular mass index (124.2 ± 16.2 vs 114.4 ± 16.2 g/m2, p = 0.001). Furthermore, metabolic syndrome patients exhibited greater levels of MSNA (84.8 ± 2.5 vs 74.2 ± 2.4 bursts per 100 heart beats, p &lt; 0.001) and greater levels of carotid to femoral PWV (11.5 ± 0.8 vs 9.1 ± 1.3m/sec, p &lt; 0.001). In all participants, sympathetic nerve traffic as assessed by resting MSNA was related to office systolic BP (r = 0.38, p &lt; 0.05) and waist circumference (r = 0.33, p = 0.002), but there was no association with PWV values (p = NS). Conclusions: In patients with resistant hypertension, metabolic syndrome is associated with high MSNA and PWV levels. These results suggest thatthe presence of metabolic syndrome can exacerbate the setting of resistant hypertension, through sympathetic overdrive and vascular abnormalities, conditions that can be the subject of therapeutic interventions.

Utility of a Deep-Learning Algorithm to Guide Novices to Acquire Echocardiograms for Limited Diagnostic Use

Artificial intelligence (AI) has been applied to analysis of medical imaging in recent years, but AI to guide the acquisition of ultrasonography images is a novel area of investigation. A novel deep-learning (DL) algorithm, trained on more than 5 million examples of the outcome of ultrasonographic probe movement on image quality, can provide real-time prescriptive guidance for novice operators to obtain limited diagnostic transthoracic echocardiographic images. To test whether novice users could obtain 10-view transthoracic echocardiographic studies of diagnostic quality using this DL-based software. This prospective, multicenter diagnostic study was conducted in 2 academic hospitals. A cohort of 8 nurses who had not previously conducted echocardiograms was recruited and trained with AI. Each nurse scanned 30 patients aged at least 18 years who were scheduled to undergo a clinically indicated echocardiogram at Northwestern Memorial Hospital or Minneapolis Heart Institute between March and May 2019. These scans were compared with those of sonographers using the same echocardiographic hardware but without AI guidance. Each patient underwent paired limited echocardiograms: one from a nurse without prior echocardiography experience using the DL algorithm and the other from a sonographer without the DL algorithm. Five level 3-trained echocardiographers independently and blindly evaluated each acquisition. Four primary end points were sequentially assessed: qualitative judgement about left ventricular size and function, right ventricular size, and the presence of a pericardial effusion. Secondary end points included 6 other clinical parameters and comparison of scans by nurses vs sonographers. A total of 240 patients (mean [SD] age, 61 [16] years old; 139 men [57.9%]; 79 [32.9%] with body mass indexes >30) completed the study. Eight nurses each scanned 30 patients using the DL algorithm, producing studies judged to be of diagnostic quality for left ventricular size, function, and pericardial effusion in 237 of 240 cases (98.8%) and right ventricular size in 222 of 240 cases (92.5%). For the secondary end points, nurse and sonographer scans were not significantly different for most parameters. This DL algorithm allows novices without experience in ultrasonography to obtain diagnostic transthoracic echocardiographic studies for evaluation of left ventricular size and function, right ventricular size, and presence of a nontrivial pericardial effusion, expanding the reach of echocardiography to clinical settings in which immediate interrogation of anatomy and cardiac function is needed and settings with limited resources.

Evaluation of non-invasive imaging parameters in coronary microvascular disease: a systematic review

BackgroundCoronary microvascular dysfunction (CMD) is an important underlying cause of angina pectoris. Currently, no diagnostic tool is available to directly visualize the coronary microvasculature. Invasive microvascular reactivity testing is the diagnostic standard for CMD, but several non-invasive imaging techniques are being evaluated. However, evidence on reported non-invasive parameters and cut-off values is limited. Thus, we aimed to provide an overview of reported non-invasive parameters and corresponding cut-off values for CMD.MethodsPubmed and EMBASE databases were systematically searched for studies enrolling patients with angina pectoris without obstructed coronary arteries, investigating at least one non-invasive imaging technique to quantify CMD. Methodological quality assessment of included studies was performed using QUADAS-2.ResultsThirty-seven studies were included. Ten cardiac magnetic resonance studies reported MPRI and nine positron emission tomography (PET) and transthoracic echocardiography (TTE) studies reported CFR. Mean MPRI ranged from 1.47 ± 0.36 to 2.01 ± 0.41 in patients and from 1.50 ± 0.47 to 2.68 ± 0.49 in controls without CMD. Reported mean CFR in PET and TTE ranged from 1.39 ± 0.31 to 2.85 ± 1.35 and 1.69 ± 0.40 to 2.40 ± 0.40 for patients, and 2.68 ± 0.83 to 4.32 ± 1.78 and 2.65 ± 0.65 to 3.31 ± 1.10 for controls, respectively.ConclusionsThis systematic review summarized current evidence on reported parameters and cut-off values to diagnose CMD for various non-invasive imaging modalities. In current clinical practice, CMD is generally diagnosed with a CFR less than 2.0. However, due to heterogeneity in methodology and reporting of outcome measures, outcomes could not be compared and no definite reference values could be provided.

Comprehensive assessment of the aortic valve in critically ill patients for the non-cardiologist. Part I: Aortic stenosis of the native valve.

Aortic stenosis (AS) causes left ventricular outflow obstruction. Severe AS has major haemodynamic implications in critically ill patients, in whom increased cardiac output and oxygen delivery are often required. Transthoracic echocardiography (TTE) plays akey role in the AS severity grading. In this review, we will give an overview of how to use the simplified Bernoulli equation to convert the echo Doppler measured velocities (cm s-1) to AS peak and mean gra-dient (mm Hg) and how to calculate the aortic valve area (AVA), using the continuity equation, based on the principle of preservation of flow. TTE allows quantification of compensatory left ventricular (LV) hypertrophy, assessment of LV systolic function, and determination of LV diastolic function and LV loading. Subsequently, the obtained results from the TTE study need to be integrated to establish the AS severity grading. The pitfalls of echocardiographic AS severity assessment are explained, and how to deal with inconsistency between AVA and mean gradient. The contribution of transoesophageal echocardiography, low-dose dobutamine stress echo (in case of low-flow low-gradient AS), echocardiography strain imaging, cardiac magnetic resonance imaging, cardiac multidetector computed tomography and the relatively new concept of Flow Pressure Gradient Classification to the work-up for aortic stenosis is discussed. Finally, the treatment of AS is overviewed. Elective aortic valve replacement is indicated in patients with severe symptomatic AS. In the ICU, afterload reduction by vasodilator therapy and treatment of pulmonary and venous congestion by diuretics could be considered.

“A Logical Reasoning of Spongy Myocardium”- A Case of LV Non Compaction Cardiomyopathy

Left ventricular noncompaction cardiomyopathy (LVNC) or spongy myocardium is a rare congenital disorder prominently distinguished by deep abnormal trabeculations and intertrabecular recesses which communicate with the ventricular cavity that can be detected on Transthoracic Echocardiography (TTE) or cardiac MRI (CMR) studies. LVNC can occur in isolation or coexists with other cardiac and/or systemic anomalies and the common clinical complications are heart failure, arrhythmias, and cardio embolism. The American Heart Association classified it as a primary genetic cardiomyopathy. We described the case of a 28years old young adult who presented with heart failure for the first time. Transthoracic echocardiography showed a trabeculated, sponge-like appearance of the ventricular apical and inferolateral segments. Following evaluation with CMR imaging revealed non compaction of the left ventricle. Here we discussed the diagnosis of this case and reviewed the medical literature that concerned to LVNC.

Is Less More? Rationalising the Use of Transthoracic and Transoesophageal Echocardiography in the Investigation of Suspected Endocarditis

It is well-established that the sensitivity of transthoracic echocardiography (TTE) in comparison to transoesophageal echocardiography (TOE) in the diagnosis of endocarditis is suboptimal. Our aim was to analyse how much benefit was gained with a guideline-based TTE-first approach. A retrospective analysis was performed of all referrals for TOE at Waikato Hospital containing “?endocarditis” (or similar phrases) received between 1 January 2019–31 December 2019 for patients aged 18 years or older. Diagnostic performance of TOE and TTE were compared with respect to detection of endocarditis. All studies were also evaluated for agreement between TOE and TTE regarding non-valvular findings, specifically left and right ventricular (LV and RV) size and function. Out of 251 TOEs performed in 2019, there were 84 referrals for suspected endocarditis— all of whom received a TTE. In diagnosing endocarditis, compared to TOE, the sensitivity of TTE was 35.3% (12/32), specificity was 94.2% (49/52), positive predictive value (PPV) was 80.0% (12/15) and negative predictive value (NPV) was 69.0% (49/71). In 88.1% (74/84) of cases, there was reasonable inter-investigation agreement (within 5%) for LV and RV function. Our analysis reaffirms that TTE is insensitive in the diagnosis of endocarditis and the majority of TTEs done reveal grossly similar non-valvular findings. Although our analysis is limited by its size, it does raise the question of whether a direct to TOE strategy might provide an earlier definitive diagnosis and avoid unnecessary TTE studies in patients at high risk for endocarditis.Tabled 1Diagnostic Performance of TTE Sensitivity35.3% Specificity94.2% PPV80.0% NPV69.0%Sensitivity by Valve/Site Aortic (n=16)31.3% Mitral (n=18)61.1% Tricuspid (n=2)50.0% Device (n=1)0.0%Sensitivity by Organism S. aureus (n=19)42.1% Viridans Strep (n=5)80.0% Other (n=8)25.0% Open table in a new tab

Quantification of mitral regurgitation using transthoracic echocardiography and cardiac magnetic resonance imaging

Both Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) have well-established role in mitral regurgitation (MR) quantification for optimal management strategy. We assessed the correlation between TTE and CMR in the quantification of MR. Participants with isolated MR and echocardiographic mitral regurgitant volume (RVol) ≥ 30 mL/beat were included. A consecutive sample of 30 participants (Mean age 52.7 ± 19.3 years, 50% males) was selected and referred for indirect and direct CMR quantification of mitral RVol. There was a statistically significant strong positive correlation between the echocardiographic and indirect CMR quantification of the mitral RVol (r = 0.753, P < 0.001) and a statistically significant moderate positive correlation between the echocardiographic and direct CMR quantification of the mitral RVol (r = 0.530, P < 0.003). The inter-observer reliability of the MR grade between TTE and CMR showed a statistically significant moderate agreement (κ = 0.502, P = 0.0001) when the observers used the echocardiographic mitral RVol for grading of MR. On the other hand, the inter-observer reliability of the MR grade between TTE and CMR showed a statistically significant faint agreement (κ = 0.251, P = 0.024) when the observers used the echocardiographic regurgitant fraction (RF) for grading of MR. The positive reciprocal relationship between the CMR and the TTE highlights the potential role of the CMR as a concomitant imaging tool for quantification of the mitral RVol and grading of isolated MR, especially with limited or inconclusive TTE studies. This will enhance the management strategy and improve outcomes.

Vascular inflammation and cardiovascular burden in metastatic breast cancer female patients receiving hormonal treatment and CDK 4/6 inhibitors or everolimus

Abstract Background Chemotherapy regimens for breast cancer treatment can promote vascular dysfunction and lead to high cardiovascular risk. Purpose The aim of this study was to investigate the cardiovascular burden and vascular inflammation in metastatic breast cancer patients receiving either CDK 4/6 inhibitors and hormonal treatment or standard everolimus and hormonal treatment. Methods 22 consecutive female patients with metastatic breast cancer that expressed estrogen and /or progesteron receptor and were HER2-negative were enrolled. Patients with active infection, chronic autoimmune disease and history of chemotherapy for the metastatic disease and/or adjuvant chemotherapy during the past 3 years were excluded. All subjects received hormonal treatment and of those, 10 received everolimus and 12 received therapy with CDK 4/6 inhibitors. The two groups were matched for age, history of hypertension, diabetes, dyslipidemia, smoking and all were free of major cardiovascular events for the past 6 months. Regional wall thickness (RWT) and left ventricle mass (LVM) measurements by transthoracic echocardiographic study were obtained followed by 24 hour ambulatory blood pressure monitoring, and 18F-fluorodeoxyglucose positron-emission tomography/computed tomography imaging. Radiotracer uptake in the aortic wall (ascending, arch, descending, abdominal), was quantified as tissue-to-background ratio (TBR).Each patient was assessed for the aforementioned parameters before the initiation and after 6 months of treatment. Results At follow up, patients assigned to CDK4/6 treatment demonstrated increased measurements of 24 hour systolic blood pressure (SBP) (p=0.004), daytime SBP(p=0.004) and night time SBP (p=0.012) (Group effect). The 24 hour mean arterial pressure measurements were also higher in CDK 4/6 population, in comparison to everolimus that displayed firm values. (Group effect- p=0.035, Interaction effect-p=0.023).Additionally, 24 hour diastolic blood pressure recordings in CDK 4/6 therapy were higher opposed to everolimus that remained consistent (Interaction effect- p=0.010). In CDK 4/6 group, TBR aorta measurements also increased significantly, whereas TBR values in everolimus remained stable. (Interaction effect-p=0.049). Both therapeutic regimens displayed statistically significant damaging effect with regards to the following variables: Night-time SBP (p=0.032), RWT (p&amp;lt;0.001), and LVM (p&amp;lt;0.001). Conclusion Chemotherapy with novel CDK 4/6 inhibitors and hormonal treatment can lead to increased vascular inflammation, and higher blood pressure values compared to the combination of everolimus and hormonal treatment in female patients with HR-positive HER2-negative metastatic breast cancer. Moreover, both treatment strategies promote remodelling of the left ventricle by means of increased RWT and mass. Further research and longitudinal studies in this field are required to validate the above findings. Funding Acknowledgement Type of funding source: None

The benefit of atrial septal defect closure in the elderly patients

Abstract Objective Closure of the atrial septal defect in the elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in elderly patients. Methods From a total of 650 pts with ASD who underwent transcatheter closure 120 pts over 60 years (70 F, 50 M) with a mean age of 66.7±18.1 (60–78) were analyzed. All patients had an isolated secundum ASD with a mean Qp:Qs: 2.79±1.8 (1.5–3.9). A symptom-limited treadmill exercise tests with respiratory gas exchange analysis and transthoracic color Doppler echocardiographic study as well as Quality of life (QoL) measured using the SF36 questionnaire (SF36q) were repeated in all pts before procedure and after 12 months of follow-up. Results The device was successfully implanted in all pts (procedure time 30.1±9.9 (10–59) minutes, fluoroscopy time 10.1±7.2 (6–40) minutes). There were no major complications. The defect echo diameter was 19.5±15.4 (12 - 34) mm. The mean balloon stretched diameter of ASD was 22.0±7.8 (14 - 36) mm. The diameter of the implanted devices ranged 16 - 38 mm. After 12 months of ASD closure, all the pts showed a significant improvement of exercise capacity parameters. Seven QoL parameters (except mental health) improved at 12 months follow up compared to their baseline data. The mean SF36q scale increased significantly in 96 (80.2%) pts of mean 41.6±26.1 (4–71). The right ventricular dimension decreased in 101 pts (84.2%) (Table 1). Conclusions Closure of ASD in elderly patients caused a significant clinical and hemodynamic improvement after percutaneous treatment, which is maintained to long-term follow-up what justified this procedure in old age. Funding Acknowledgement Type of funding source: None

Electrocardiographic and echocardiographic abnormalities associated with mitral valve prolapse in patients with Marfan syndrome

Abstract Introduction Marfan syndrome (MFS) is responsible for cardiovascular disorders such as aortic aneurism and mitral valve prolapse (MVP). A malignant MVP phenotype combining clinical, electrical and morphological features has been described in symptomatic patients who have experienced sudden cardiac death or complex ventricular arrhythmias. We have taken advantage of the high prevalence of MVP in MFS patient to study the clinical, electrical and echocardiographic abnormalities associated with MVP. Purpose The aim of this study is to describe the clinical, electrical and morphological cardiac abnormalities associated with MVP in a cohort of MFS patients with FBN1 mutations with a high prevalence of MVP and who did not suffer from severe ventricular arrhythmias. Methods All consecutive patients coming to the National Reference Center for Marfan syndrome were evaluated prospectively i.e. clinical examination, 12-lead electrocardiogram, standard transthoracic echocardiography study and molecular genetic screening. Results 352 consecutive patients were included from April 2015 to October 2016 [250 FBN1 mutation carriers (MFS) and 102 healthy relatives (HR)]. None of the patients had a history of sudden cardiac death or complex ventricular arrhythmia. MFS vs HR: MFS patients were younger (33 vs 41yo p&amp;lt;0.001) and 2/3 were women in both groups. In the MFS group, abnormal T waves repolarization in lateral leads were more common [172 MFS (70.2%) vs. 87 HR (86.14%) p&amp;lt;0,0012], as was MVP [38.37% vs 1.96%; p&amp;lt;0,0001], and diastolic hypertrophy of the basal segment of the inferolateral wall (thickness &amp;gt;11mm) [22.31% vs. 9.18%; p&amp;lt;0.0001]. In MFS, MVP affected either one valve (21.22%), or both (17.14%), and was not associated with electric abnormalities. However, diastolic basal inferolateral wall hypertrophy was associated with mitral valve prolapse (p&amp;lt;0,0001), QTc interval prolongation (p&amp;lt;0.0229), abnormal T waves repolarization in the inferior leads (p=0.004), and higher aortic Z-Score (p=0.274). Conclusion In MFS patients, the prevalence of MVP is high and no significant association between MVP and electrical abnormalities was found. In contrast, basal inferolateral wall hypertrophy is associated with MVP and repolarization disorders in inferior leads and QTc interval prolongation, i.e, electrocardiographic abnormalities described in malignant MVP. QTc and basal inferolateral hypertrophy Funding Acknowledgement Type of funding source: None

Aortic Acceleration Time and the Intraoperative Assessment of Aortic Stenosis

Aortic acceleration time (AAT) and the ratio of AAT to ejection time (AAT/ET) are relatively new echocardiographic measures of the severity of aortic stenosis (AS). This study investigated the utility of transesophageal echocardiography (TEE) measurements of AAT and AAT/ET to predict the severity of AS under intraoperative conditions. Retrospective diagnostic accuracy study. St. Vincent's Hospital, Melbourne, Australia, from July 2007 to February 2017. The study comprised 199 patients who underwent aortic valve replacement (AVR) and whose aortic valves were evaluated with spectral Doppler analysis in both preoperative transthoracic echocardiography (TTE) and intraoperative TEE studies fewer than three months apart. Exclusion criteria included AVR for only aortic regurgitation, AVR of prosthetic aortic valves, and known left ventricular outflow tract obstruction. Standard echocardiography assessment of AS and the AAT and AAT/ET measurements was performed using preoperative TTE and intraoperative TEE. The intraoperative AAT and AAT/ET were increased significantly in patients with both high- and low-gradient severe AS compared with patients without severe AS (p < 0.01). Comparing preoperative TTE and intraoperative TEE measurements showed that the AAT was significantly prolonged during general anesthesia (mean difference 9.67 msec [95% confidence interval -13.54 to -5.81]), whereas the AAT/ET was preserved (mean difference -0.0018 [95% confidence interval -0.013 to 0.0091]). An intraoperative TEE cutoff of 109 msec for AAT and 0.35 for AAT/ET had a 74% and 67% sensitivity and 72% and 78% specificity, respectively, to differentiate severe from non-severe AS. The AAT and AAT/ET may be useful adjuncts for the intraoperative measurement of AS. The agreement between intraoperative TEE and preoperative TTE was better with AAT/ET compared with AAT alone.

Transthoracic Echocardiographic Hemodynamic Assessment in Patients under Spinal Anesthesia in Lower Limb Surgery

Background: Spinal anesthesia is often associated with significant hypotension due to a sympathetic blockand can increase the risk of perioperative cardiac complications. Transthoracic echocardiography (TTE) is widely used throughout medicine as a clinical, diagnostic and research tool. Portability, accuracy, ease of use and a variety of training courses have encouraged its use. Aim: The present study was designed to evaluate the hemodynamic changes of spinal anesthesia by Transthoracic Echocardiography and test its efficacy as a monitoring tool in lower limb surgery. Methods: The study included50 patients, who were scheduled for lower limb surgery under spinal anesthesia. Two serial TTE studies were performed. One immediately before spinal anesthesia after giving the preload, then at 10 mins after spinal anesthesia. Changes of heart rate (HR), mean arterial blood pressure (MAP), the total doses of ephedrine and atropine, and data regarding highest sensory level and bromage scale were recorded. Results: Echocardiographic monitoring the heart variables have showed marked decrease when MAP was < 70% of basal values. Conclusion: Transthoracic echocardiography has proved its efficacy as a monitoring tool in assessment and guiding the management of hemodynamic changes after spinal anesthesia.

Normative values of cardiac chamber dimensions and global longitudinal strain in Indians: the Indian Normative Data of Echocardiography Analyzed (INDEA) study.

Ethnic-specific normal reference ranges for various echocardiographic measurements are essential for accurate diagnostic interpretation and clinical decision-making. Unfortunately, such normative data for Indians is lacking. A total of 880 healthy volunteers (mean age 39.7 ± 12.3 years, 63.8% men) from six centers across different regions of India were enrolled in this study. Comprehensive transthoracic echocardiographic study was performed in all subjects, in accordance with the existing guideline recommendations. Cardiac chamber dimensions [Left ventricular (LV) end-diastolic diameter and volume; right ventricular (RV) basal diameter, left atrial volume] were obtained and indexed to body surface area. LV ejection fraction, LV global longitudinal strain (LVGLS) and measures of RV systolic function were also obtained. The subjects were divided into 3 age groups (35years or less, 36-55years and 56years or above) for analysis. Age- and gender-specific reference values for various clinically relevant echocardiographic parameters were derived. Compared with women, men had larger cardiac chamber dimensions and volumes, but not when indexed. In contrast, the women had higher LV systolic function, but right ventricular systolic function was not different. The indexed LV volumes in our study were much smaller than those recommended in the American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) 2015 chamber quantification guidelines but were similar to those reported in the Indian patients included in the recent World Alliance Societies of Echocardiography (WASE) Normal Values Study. LVGLS was also comparable with the WASE data. INDEA study is the first, multi-centric study to provide normal echocardiographic references values for Indian adults. Our findings underscore the need to follow India-specific reference values, instead of those recommended by the ASE/EACVI, which are largely applicable to the western populations.

Coronary microcirculation and left ventricular diastolic function: comparison between patients on hemodialysis and peritoneal dialysis.

End-stage renal disease is considered to influence coronary microcirculation and left ventricular (LV) diastolic function. We investigated whether differences exist in LV diastolic function indices and coronary flow reserve (CFR) between patients on hemodialysis (HD) and peritoneal dialysis (PD). A complete transthoracic echocardiographic study was performed on 21 HD and 22 PD patients and LV diastolic function was evaluated. CFR was estimated using transthoracic Doppler echocardiography on the left anterior descending artery, during high-dose dypiridamole infusion. HD and PD groups did not differ regarding Doppler-derived diastolic indices, but they significantly differed in the frequency of severe LV hypertrophy (38.1% in HD vs 4.5% in PD group, p = 0.009) and grade II diastolic dysfunction (42.9% in HD vs 4.5% in PD group, p = 0.004). No patient had restrictive filling pattern. There was no difference in the prevalence of arterial hypertension and diabetes mellitus in patients with grade II vs less than grade II dysfunction. Mean CFR was similar in the HD and PD groups (2.25 ± 0.65 vs 2.36 ± 0.76, p = 0.635) and lower in patients with grade II diastolic dysfunction (1.87 ± 0.43 vs 2.44 ± 0.72, p = 0.023) and diabetes (1.70 ± 0.59 vs 2.39 ± 0.68, p = 0.04). LV mass index was negatively associated with CFR (r = -0.308, p = 0.045). Patients on HD had more advanced diastolic dysfunction compared to PD, independently of the presence of hypertension and diabetes. CFR did not differ between HD and PD patients, but it was significantly lower in diabetics and in patients with more advanced diastolic dysfunction.

Evaluation of the preoperative administration of sildenafil on operative and early postoperative outcome after mitral valve replacement in patients with pulmonary hypertension

Background: Mitral valve diseases are commonly associated with pulmonary hypertension. The aim of this study was to evaluate the effect of preoperative administration of sildenafil on the outcome after mitral valve replacement in patients with pulmonary hypertension.&#x0D; Methods: This prospective randomized study was carried out on 67 patients who had a mitral valve replacement and associated high systolic pulmonary artery pressure more than 50 mmHg. Patients were randomized into three groups: group A (n= 20) received preoperative sildenafil for one week, group B (n=22) received sildenafil for one month, and group C (n= 25) did not receive sildenafil. All patients had transthoracic echocardiography preoperatively, one week and one month postoperatively.&#x0D; Results: There was no difference in preoperative and operative variables among groups. Dobutamine support was required in 15 patients (60%) in group C vs. 6 patients (30%) in group A and 5 patients (22.5%) in group B (p= 0.012). Duration of mechanical ventilation was significantly longer in group C (389.2 ± 48.79 minutes) compared to group A and B (295.5 ± 17.01 and 281.4 ± 39.44 minutes, respectively, p&lt;0.001). ICU stay was longer in group C (61.72 ± 13.69 hours) compared to groups A and B (53.55 ± 14.49 and 45.64 ± 13.43 hours, respectively, p=0001). The hospital stay was longer in group C (8.0 ± 1.80 days) compared to group A and B (6.05 ± 0.94 and 6.27 ± 1.24 days, respectively; p&lt; 0.001). The transthoracic echocardiographic study one month after the operation showed that pulmonary artery systolic pressure significantly lower in groups A and B (28.30 ± 3.3 and 28.2 ± 4.98 mmHg, respectively) compared to group C (43.12 ± 4.99 mmHg) (p &lt;0.001). There was no statistically significant difference between groups A and B regarding PASP after five days (p= 0.287) or one month (p= 0.939).&#x0D; Conclusion: We found that preoperative administration of oral sildenafil in patients with pulmonary hypertension undergoing mitral valve replacement may reduce pulmonary hypertension postoperatively. We could not find a difference in the administration of sildenafil for either one week or one month preoperatively.

Cavitation phenomenon in mechanical prosthetic valves: Not only microbubbles.

Microbubbles (MBs) or cavitation is high-velocity, echo-bright findings present during the closing or opening of a mechanical valve (MVP). Cavitation bubble growth or gas emboli are less frequently described. We evaluated the hemodynamic parameters involved in the formation of gas emboli and the impact of gas emboli on requests for additional investigations. Transthoracic echocardiographic studies (TTE) of 57 patients (31 males, mean age 46.8±13.8years) with gas emboli were evaluated after heart valve replacement surgery. The majority (72%, n=42) had a mitral or combined mitral/aortic MVP, with 28% (n=16) an aortic MVP. The last TTE with and without gas emboli were considered for the same patient and the no emboli group was the control group (42 patients). The patient's blood pressure (BP) and heart rate (HR) were available for each TTE. Comparing the two TTEs, the systolic and diastolic BP, transmitral and aortic gradients, and left ventricular ejection fraction were similar but the HR (80.9±18.7 vs 72.5±13.9bpm, P=.02) was significantly higher in the group with gas emboli. A TEE was performed 52 times in 27 patients, due to gas emboli, with one case positive for thrombus/vegetation. For 19 patients, a brain CT was requested. In two patients, the indication for the brain CT was gas emboli but the result was negative. Gas emboli are frequently present and associated to an increased HR. They can cause the misdiagnosis of endocarditis or thrombus formation with significant additional requests for diagnostic examinations.

Bone mineral density and hip fracture analysis in patients with heart failure

Objective: Osteoporosis defined by low Bone Mineral Density (BMD), is a progressive disease affecting especially older adults. Hip fracture is the important result of osteoporosis. For the older adults, heart failure (HF) and osteoporosis are two common chronic conditions that are gaining importance for healthcare. The aim of this study is to evaluate bone mineral density and hip fractures in patients with heart failure Method: The study population consisted of 157 patients with heart failure and 155 control subjects without any cardiovascular disease and risk factors. All subjects underwent transthoracic echocardiography, biochemical analysis, and bone DEXA study. Osteoporotic fracture history and operation for fracture, list of current and prior use of medications were obtained from each center’s medical recordings. Results: Among the 157 patients, 45 (29%) had normal BMD, 14 (9%) had osteopenia, and 98 (62%) had osteoporosis. In 155 control subjects, 68 (44%) had normal BMD, 12 (8%) had osteopenia, and 75 (46%) had osteoporosis (P=0.019). Sixteen subjects (10.2%) in heart failure group and 6 subjects (3.9%) in controls had hip fracture (p=0.029). Level of 25-hydroxyvitamin D was significantly lower in heart failure than in controls (15.1±10.2 vs. 29.1±20.4 ng/ml; p<0.001). Conclusions: Patients with heart failure have a lower bone mineral density, low vitamin D level and an increased rate of hip fractures. These findings can be explained by shared risk factors and pathogenetic mechanisms. Further prospective studies should be performed for evaluating the role of heart failure in osteoporotic hip fractures.

Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review.

Introduction: Percutaneous closure of patent foramen ovale (PFO) in selected patients with cryptogenic cerebrovascular ischemic events (CEs) decreases the risk of recurrent stroke; however, optimal patient selection criteria are still under investigation. Candidates for PFO closure are usually selected from the pool of CE patients with a high risk of Paradoxical Embolism (RoPE) score. The RoPE score calculates the probability that PFO is causally related to stroke, based on PFO prevalence in patients with CE compared with that in healthy subjects. The latter has been set at 25% based on the average of autopsy and transesophageal echocardiography (TEE) studies.Methods: We conducted a comprehensive review of studies investigating PFO prevalence in general population and in patients with CE and non-CE using autopsy, TEE, transcranial Doppler (TCD) or transthoracic echocardiography (TTE). Studies were excluded if they (1) reported data from referred subjects with underlying cerebrovascular disease or (2) did not specify etiologically the events.Results: In healthy/control subjects, PFO prevalence was 24.2% (1,872/7,747) in autopsy studies, 23.7% (325/1,369) in TEE, 31.3% (111/355) in TCD, and 14.7% (186/1,267) in TTE studies. All diagnostic modalities included PFO prevalence was higher in CE compared with healthy/control population [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 2.5–3.8] and compared with non-CE (OR = 2.3, 95% CI = 2.0–2.6). In patients with CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (48.9 vs. 27.3%, p < 0.0001, OR = 2.6 with 95% CI = 2.0–3.3) or TCD (58.1 vs. 41%, OR = 1.9, 95% CI = 1.6–2.5), but not TTE (53.3 vs. 37.5%, p = 0.16). Regarding non-CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (20 vs. 12.9%, OR = 1.7, 95% CI = 1.0–2.8) but not TTE (10.4 vs. 7.8%, p = 0.75) or TCD (22.8 vs. 20.1%, p = 0.56).Conclusions: Given the limitations of autopsy and TEE studies, there is good reason not to take a fixed 25% PFO prevalence for granted. The estimation of degree of causality may be underestimated or overestimated in populations with PFO prevalence significantly lower or higher than the established. Given the high sensitivity, non-invasive nature, low cost, and repeatability of TCD, future large-scale TCD-based studies should investigate potential heterogeneity in PFO prevalence in different healthy racial/ethnic populations.