J.D. Kasprzak

Stress echocardiography expert consensus statement European Association of Echocardiography (EAE) (a registered branch of the ESC)

Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding - coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operators training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.

Stress Echocardiography Expert Consensus Statement--Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC).

Stress echocardiography is the combination of echocardiography with a physical, pharmacological, or electrical stress. The diagnostic endpoint for the detection of myocardial ischaemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy to radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the possibility of performing coronary flow reserve evaluation of the left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage of the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence on the operators training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of non-invasive diagnosis of coronary artery disease. In 1935, Tennant and Wiggers1 demonstrated that coronary occlusion immediately resulted in instantaneous abnormality of wall motion. A large body of evidence2–5 recognized for the first time that transient dys-synergy was an early, sensitive, specific marker of transient ischaemia, clearly more accurate than ECG changes and pain. In European clinical practice,6–10 stress echo has been embedded in the legal and cultural framework of existing European laws and medical imaging referral guidelines. The …

Stress echocardiography expert consensus statement-executive summary: european association of echocardiography (a registrated branch of the ESC).

Stress echocardiography is the combination of echocardiography with a physical, pharmacological, or electrical stress. The diagnostic endpoint for the detection of myocardial ischaemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy to radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the possibility of performing coronary flow reserve evaluation of the left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage of the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence on the operators training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of non-invasive diagnosis of coronary artery disease. In 1935, Tennant and Wiggers1 demonstrated that coronary occlusion immediately resulted in instantaneous abnormality of wall motion. A large body of evidence2–5 recognized for the first time that transient dys-synergy was an early, sensitive, specific marker of transient ischaemia, clearly more accurate than ECG changes and pain. In European clinical practice,6–10 stress echo has been embedded in the legal and cultural framework of existing European laws and medical imaging referral guidelines. The …

Arterial dysfunction in syndrome X: results of arterial reactivity and pulse wave propagation tests

Objective: To assess arterial distensibility using pulse wave velocity (PWV) measurements and its relation with endothelium dependent vasodilatation (EDV) in patients with cardiological syndrome X. Methods: The study group consisted of 92 patients: 52 with syndrome X (34 women, 18 men, mean (SD) age 45 (3) years) and 40 healthy volunteer controls (27 women, 13 men, mean (SD) age 41 (2) years) without risk factors of atherosclerosis and with negative ECG exercise test and normal proximal coronaries on transoesophageal echocardiography. Patients with arterial hypertension, diabetes mellitus, valvar disease, or cardiomyopathy were excluded. PWV measured by a Complior Colson device was calculated for each patient. EDV was assessed from two dimensional Doppler measurement using an Acuson Sequoia with 8 MHz linear transducer at rest, during postischaemic reactive hyperaemia, and after an oral dose of 400 μg of glyceryl trinitrate. Results: PWV was significantly higher in patients with syndrome X than in healthy subjects (9.3 (0.7) m/s v 8.2 (0.9) m/s, respectively, p < 0.001). Baseline brachial artery diameter was similar in the syndrome X and control groups (4.0 (0.6) mm v 4.08 (0.64) mm, NS). EDV was impaired in patients with syndrome X compared with controls (6.6 (3.0)% v 11.1 (3.9)%, p < 0.001). Endothelium independent vasodilatation was similar in both groups. In patients with syndrome X there was a positive correlation between PWV and the degree of EDV (r = 0.864, p < 0.001). The cut off value for PWV was 8.5 m/s, with a sensitivity of 62% and a specificity of 91%. Conclusions: EDV but not glyceryl trinitrate induced vasodilatation is decreased in patients with syndrome X. There is a strong correlation between PWV and the degree of endothelial dysfunction of peripheral arteries in patients with syndrome X. PWV assessment may be useful to identify abnormal vascular physiology in these patients.

Pocket-size echocardiograph - a valuable tool for non-experts or just a portable device for echocardiographers?

PURPOSE The diagnostic value of examinations performed with the use of pocket-size echocardiograph by medical professionals with different levels of experience remains to be determined. The aim of this study was to assess the diagnostic value of bedside echocardiographic examinations performed with the use of pocket-size echocardiograph by experienced cardiologist and medical students. MATERIAL/METHODS The study group comprised 90 patients (63 men, 27 women; mean age 64±14 years) admitted to the cardiac intensive care unit and 30 patients from an out-patient clinic (21 men, 9 women; mean age 62±17 years). All patients underwent bedside echocardiographic examination performed with pocket-size echocardiograph by two briefly trained medical students (n=90 patients) or cardiologist (n=30 patients). Major findings were recorded using a simplified questionnaire. Within 24 hours standard echocardiographic examination was performed in all patients by another cardiologist using a full sized echocardiograph. The study group was divided into 4 subgroups: A / B - first / second half of in-patients examined by students, group C - inpatients examined by cardiologist, group D- out-patients examined by students. RESULTS The agreement between standard transthoracic echocardiography (sTTE) and major findings on bedside transthoracic echocardiography (bTTE) was fair to moderate (kappa 0.293-0.57) in group A, moderate to very good (kappa 0.535-1.00) in group B, good to very good (kappa 0.734-1.00) in group C and moderate to very good (kappa 0.590-1.00) in group D. CONCLUSIONS Pocket-size echocardiograph enables an expert echocardiographer to perform reliable bedside examinations. When used by briefly trained medical students it provides an acceptable diagnostic value with notable learning curve effect.

Subclinical chronic left ventricular systolic dysfunction resulting from phosphine poisoning

We present a case of a 32-year-old male crew member of a cargo ship, accidentally exposed to phosphine, a fumigating substance. He and other crew members developed increasing fatigue and digestive disorders 24 h later; two died from acute pulmonary oedema. The patient was admitted to hospital, where bilateral pneumonia, acute nephritis, hepatopathy, electrolyte imbalance and leucopenia were diagnosed. He was discharged from hospital 3 weeks later. He was examined 4 months later for possible chronic consequences of acute phosphine poisoning, which included echocardiography showing normal heart size and cardiac function. However, on advanced quantitative analysis, using two-dimensional speckle tracking echocardiography, depressed global longitudinal strain was found. Our report extends previously published findings of phosphine-induced left ventricular (LV) dysfunction by demonstrating that subclinical myocardial dysfunction resulting from acute phosphine exposure may persist several months after the exposure in an otherwise asymptomatic patient, and potentially may not be entirely reversible. The persistence of subclinical abnormalities of LV longitudinal function can be diagnosed using the advanced quantitative echocardiographic analysis we describe.

1008 Comparison of diagnostic value of stress real-time myocardial contrast echocardiography and gated single-photon emission computed tomography in patients with suspected coronary artery disease

Background: Real time 3D echocardiography provides fast recording of a complete cardiac volume data set and allows new insights into the heart. However, reduced spatial resolution of the 3D matrix transducers led to impaired assessment of left ventricular wall motion (WM). We compaired 3D stress echocardiography combined with contrast application (CA) for improved endocardial border detection to conventional 2D echo in order to detect significant coronary artery disease. Methods: 17 patients with suspected coronary disease underwent dobutamine stress echo. 3D echo was performed in apical view using a 4S transducer (Sonos 7500, Philips) at low mechanical index (0.5-0.6) with bolus injection of 1.0 ml CA (SonoVue©) at rest and during stress. For 2D echo we used also CA and the conventional mode of 4S transducer. WM of 3D echo was evaluated in off-line mode and c-scan analysis (1 mm slices) and compared to conventional WM analysis in 2D echo. Following echo exam, all patients underwent coronary angiography and stenosis (< or ≥70%) as well as perfusion territory were determined by an experienced examiner. Results: Dobutamine stress increased heart rate (69±12 vs 131±21/min, p<0.001) but not blood pressure (RRsys 126±15 vs 149±37 mm Hg, ns). All 272 segments could be sufficiently evaluated by CA 3D stress echo. Specificity of CA 3D echo was comparable to 2D (97.4% vs 98.7%). However, positive (77.8% vs 70.0%, p<0.001) and negative predictive values were higher in CA 3D stress echo (90.6% vs 85.9%, ns). In particular, detection of ≥70% stenoses in the right and circumflex coronary supplying the inferior and posterior wall could be improved (36.4% abs.). Conclusion: Contrast agent supported real time 3D stress echo improves detection of coronary heart disease especially of the right and circumflex coronary artery supplying the inferior and posterior segments. However, less sensitivity of 2D echo supposes reduced echogenicity of the 4S transducer used in conventional mode and limits the technique.

752 Aortic wall thickness and pulsatility - do they represent the same aspect of atherosclerosis?

diastole. Study group consisted of 38 consecutive patients referred for the routine TEE. Thoracic aorta was scanned by rotational 3-D TEE. Reformatted datasets were reviewed and the lumen-intima and media-adventitia interfaces were determined. Serial volumetric calculations of 2 cm segments at three levels of the thoracic aorta were performed. The volume of lumen of two-centimeter segments measured at three levels of the thoracic aorta (30 cm, 35 cm and 40 cm from incisors) varied from 7.3 to 17.6 cm 3 (mean 12.0±3.2, 11.5±3.1 and 10.9±2.5 cm3 respectively). The volume of intimamedia complex varied from 0.5 to 5.0 cm 3 (mean 1.8±1.0, 1.6±1.0 and 1.7±1.1 cm3 respectively). Aortic pulsation defined as the difference between the largest and the smallest lumen volume of the same aortic segment varied from 0.0 to 2.8 cm3 (mean 1.3±0.5, 1.1±0.7 and 1.1±0.6 cm3 respectively). The intima-media complex volume was correlated with the aortic lumen volume (R2=0.55, p<0.001), but not with the aortic pulsation (R2=0.02, p=NS). The differences in the measurements of aortic lumen volume, aortic pulsation and intima-media complex volume by the same observer were 0.22±0.10 cm3, 0.07±0.08 cm3 and 0.21±0.06 cm3 respectively, whereas by two observers 0.23±0.15 cm3 ,0 .14 ±0.13 cm3 and 0.17±0.03 cm3 respectively. Following risk factors were independently related to the intima-media complex volume: hypertension (p<0.001), hyperlipidemia (p=0.032) and cigarette smoking (p=0.045). Age (p<0.001), diabetes (p=0.002), masculine gender (p=0.014) and family history (p=0.014) were related to the aortic pulsation. Conclusions: Aortic intima-media complex volume and aortic pulsation represent different aspects of aortic properties and are related to different clinical risk factors of atherosclerosis.

124 Utility of new Doppler parameters connected with elevated left ventricle end-diastolic pressure for identification of mitral inflow pseudonormalization

Purpose: We compared E/Ep and E/E’ ratios and other echocardiographic parameters between patients (pts) with normal (N) and pseudonormal (PN) mitral inflow, performed ROC analysis for detection of optimal cut-off values and assessed diagnostic value of this parameters for detection of pseudonormalization. Methods: Among 120 pts with coronary artery disease and 60 healthy persons examined by transthoracic echocardiography with assessment of diastolic function we selected the subgroup with E/A ratio between 1 and 2, and divided them into N and PN mitral inflow group according to E wave deceleration time. Propagation velocity was measured by color M-mode and tissue Doppler parameters were assessed in lateral segment of mitral annulus. Than we compared 15 pts with PN (mean age 57±11, male) and 54 persons with N pattern (mean age 55±9, male). Results: In N group E/Ep and E/E’ ratios were lower than in PN group (1,7+0,4 vs 3,5±1,3 for E/Ep and 6,3±2,1 vs 9±3,7 for E/E’; p<0,001). For cut-off values of Ev/Ep above 2,3 and of E/E’ above 8,2, sensitivity, specificity, positive predictive value, negative predictive value and accuracy for detection of PN were respectively: 87, 91, 72, 96, 90% and 60, 81, 47, 88, 77%. Area under ROC curve (AUC) for Ev/Ep= 0,921 was comparable with this for left atrium (LA) diameter (0,963) and was higher than AUC for parameters of pulmonary vein flow (0,814 for atrial reversal time and 0,779 for the difference of atrial reversal time and atrial wave duration of mitral inflow). Conclusions: Both Ev/Ep and E/E’ ratios are useful for differentiation of PN and N pattern. In our group of pts diagnostic value of E/Ep ratio was highly significant, greater than E/E’ ratio, comparable with enlarged LA diameter and slightly better than value of pulmonary flow parameters.

333 Prognostic value of systolic and diastolic echocardiographic parameters in patients after myocardial infarction after 18-months follow-up

Purpose: Our aim was to assess role of wide spectrum of echocardiographic parameters in prediction of combined cardiac events (death, myocardial infarction or exacerbation of heart failure) and cardiac deaths in 18-months follow-up in 60 subjects after myocardial infarction. Methods: We assessed classic two-dimensional and Doppler parameters, pulmonary vein flow, propagation of mitral waves and mitral annulus motion by pulsed tissue Doppler. After follow-up period combined endpoints and deaths were registered and on basis of cut-off values found by ROC analysis Kaplan-Meier survival curves were compared. Results: The greatest accuracy for detection of patients with combined endpoint showed: left atrium (LA)>44 mm, area under curve (AUC) 0,909, ejection fraction (EF) below or equal 34%, AUC 0,784, left ventricle diastolic (LVd)>51 mm, AUC 0,811 and systolic dimensions (LVs)>43 mm, AUC 0,798, early wave deceleration time (Edt) below or equal 130 ms, AUC 0,798 and difference of atrial reversal and atrial wave of mitral inflow duration (delta At) >23, AUC 0,781. For all above cutoff values comparison of survival curves revealed highly significant difference with p<0,001. Relative risk and 95% confidence intervals for combined endpoint are shown in table 1. For Edt below 130 ms and delta At above 23 ms all patients experienced combined endpoint. Multivariate analysis revealed only one independent predictor of both combined endpoint and deaths: LA dimension with cutoff values above 44 mm for combined endpoint (p=0,001) and above 46 mm for deaths, (p=0,004).