S. Moir

Transthoracic Echocardiography Is Still Useful in the Initial Evaluation of Patients With Suspected Infective Endocarditis: Evaluation of a Large Cohort at a Tertiary Referral Center

OBJECTIVES To examine the sensitivity of contemporary transthoracic echocardiography (TTE) for the detection of vegetation, abscess cavity, or prosthetic valve dehiscence (Vg) in patients with suspected infective endocarditis (IE) and to identify whether a relatively normal initial TTE finding can be effectively used as a rule out test, obviating the need for transesophageal echocardiography (TEE). PATIENTS AND METHODS We evaluated clinical, microbiological, and echocardiographic data for all patients with suspected IE referred for both TTE and TEE between January 1, 2005, and December 31, 2010. Patients were stratified into 3 groups by baseline TTE findings: negative TTE (native valves with less than or equal to mild regurgitation and no Vg), equivocal TTE (no Vg but prosthetic valve or greater than mild native valvular regurgitation), and positive TTE (Vg detected). RESULTS We studied 622 consecutive patients (68% male; mean ± SD age, 62 ± 17 years), including 256 with Staphylococcus aureus bacteremia (SAB). The presence of Vg was confirmed by TEE in 141 patients (23%). The TTE had low sensitivity for the detection of Vg (58%). A total of 271 patients (44%) had an initial negative TTE. Of these, TEE demonstrated Vg in only 8 patients (negative predictive value [NPV] of negative TTE, 97%). The negative TTE group included 132 patients with SAB, only 6 of whom had Vg (NPV, 95%). Of 265 patients with equivocal TTE, Vg was demonstrated in 51 (19%). CONCLUSION In a hospital population with clinically suspected IE, TTE had low sensitivity for the detection of Vg; however, a negative initial TTE was a common finding, with a high NPV, even in the setting of SAB. A TEE may be avoided in many patients with suspected IE.

IS EXERCISE STRESS ECHOCARDIOGRAPHY USEFUL IN PATIENTS WITH SUSPECTED OBSTRUCTIVE CORONARY ARTERY DISEASE WHO HAVE RESTING LEFT BUNDLE BRANCH BLOCK

Exercise stress echocardiography (ESE) is frequently used for the evaluation of suspected obstructive coronary artery disease (OCAD) in ambulant patients with left bundle branch block (LBBB). Current American College of Cardiology and American Society of Echocardiography guidelines support this

Is exercise stress echocardiography useful in patients with suspected obstructive coronary artery disease who have resting left bundle branch block

Current guidelines support exercise stress echocardiography (ESE) for evaluation of suspected obstructive coronary artery disease (OCAD) in ambulant patients with left bundle branch block (LBBB). Data regarding the diagnostic utility of ESE in patients with LBBB are limited.

Echocardiographic quantification of left ventricular systolic function.

Assessment of left ventricular (LV) systolic function is the most common indication for performing an echocardiogram and, correspondingly, the detection and quantification of systolic dysfunction hold major implications for patient diagnosis and management. However, no perfect measure of ‘systolic function’ exists and there are fundamental limitations inherent to all currently available surrogates. In this clinically focussed editorial, we examine what can actually be measured by echocardiography, identify the techniques with established practical utility and consider their current and potential roles in guiding clinical practice. What can be measured by echocardiography? The physiological parameter that most accurately represents systolic function is contractility - the ability of myocardium to contract against a specific load for any given preload. Assessment of contractility requires simultaneous and continuous measurement of LV pressure and volume over multiple cardiac cycles with manipulation of preload to generate pressure-volume loops across a range of loading conditions. At present, this can only be achieved accurately by invasive methods using conductance catheters. In contrast, all of the commonly utilised echocardiographic (and other non-invasive imaging) techniques for assessing systolic function measure contraction ‐ essentially the degree of myocardial fibre shortening that occurs during systole. This is dictated by the degree of preceding myocardial stretch (preload) and the pressure against which it contracts (afterload) as well as intrinsic contractile function. Consequently, all techniques based on assessment of contraction provide ‘load-dependent’ measurements of systolic function. Nonetheless, a comprehensive echo study provides important insight into the prevailing loading conditions and integration of this information with the indices of LV contraction informs the overall evaluation of systolic function. It should also be borne in mind that our aim, ultimately, is not to quantify systolic function as a physiological parameter but to detect and grade clinically meaningful systolic dysfunction. It is therefore preferable to evaluate echo-based indices of systolic function against a clinical standard rather than a pure physiological one. Clinically useful measures should ideally correlate with symptoms of heart failure, predict the subsequent development of adverse events and, most importantly, provide a proven basis for therapeutic decision making.

TCT-509 Utilisation of 320-Slice Multidetector CT in Assessing the Aortic Root Geometry in Bicuspid Aortic Valves and its Implications for Transcatheter Aortic Valve Replacement

METHODS Between 2012and201593 patients with stable coronary artery disease scheduled for PCI of bifurcation were randomized 1:1 to planning of the procedure based on coronary CTA and angiography (CTAgroup) or angiography alone (CA group). Primary efficacy endpoint was immediate angiographic result measured as a) minimal lumen diameters in main branch (MB) and side branch (SB); b) SB compromise defined as >50% angiographic stenosis; c) SB occlusion defined as TIMI flow grade <2. Secondary efficacy endpoints were: a) procedural characteristics and b) postprocedural FFR in side branch (SB) in a subgroup of patients. Safety outcomes were: a) periprocedural myocardial infarction, b) contrast use and c) radiation dose. Follow-up was obtained by telephone interview 6 months after last patient inclusion.

Feasibility of exercise stress echocardiography for cardiac risk assessment in chronic kidney disease patients prior to renal transplantation

Pharmacologic stress testing is utilized in preference to exercise stress echocardiography (ESE) for cardiac risk evaluation in potential renal transplant recipients due to the perceived lower feasibility of ESE for achieving adequate workload and target heart rate (THR) in this population.

The Impact of Increased Pulmonary Velocity on Estimated Pulmonary Artery Pressure During Exercise Stress Echocardiography

Background: Assessing pulmonary artery pressure (PAP) during stress echocardiography (ESE) is recommended for patients with dyspnoea and valvular heart disease. Right ventricular systolic pressure (RVSP) equals PAP in the absence of significant right ventricular outflow tract gradient/obstruction. When reporting resting transthoracic echocardiograms, the antegrade pulmonary gradient is routinely subtracted from RVSP when the pulmonary velocity (PV)≥ 1.5m/s (9mmHg), however this correction has not been applied during ESE despite increased pulmonary flow associated with exercise. We evaluated the impact of increased PV with exercise on estimated PAP. Methods: We prospectively evaluated 114 consecutive patients referred for ESE (mean age 55, female 47%). Peak pulmonary and tricuspid velocities (TV) were obtained pre and post-exercise. RVSPwas calculatedwhere an adequate TR Doppler envelope was obtained. Results: PV was obtained in all patients preand post-exercise. PV increased from 1.03± 0.46m/s to 1.57± 1.0m/s post-exercise (p 1.5m/s, mean peak corrected PAP was significantly lower than if uncorrected (31.2± 9.3mmHg vs 43.6± 9.7mmHg, p 40mmHg (15% vs 60%, p= 0.003) and PAP>50mmHg (5% vs 25%, p= 0.07). Conclusions: In a cohort of patients undergoing ESE, a significant proportion of patients had a PV>1.5m/s postexercise.Correcting for PV resulted in a significantly lower calculatedPAPpost-exercise suggesting that current practise may overestimate PAP with exercise.