A total of 150 patients with presumed aneurysmatic peripheral atherosclerotic disease were included in the study. Patients were first scanned with conventional ultrasound (US), serving as reference technique. An infra-renal abdominal aorta diameter of ≥30 mm was defined as an AAA. Hereafter, the aorta was scanned using the Aortascan BVI 9600. Statistical analyses were performed using SPSS version 15.0 statistical software. Abdominal aortic aneurysms were detected with conventional US in 78 (52%) patients, compared with 74 (49%) AAA's detected with Aortascan BVI 9600. The Aortascan BVI 9600 demonstrated a sensitivity, specificity, positive and negative predictive value of 90, 94, 95, and 89%, respectively, in the detection of AAA's.

The Aortascan BVI 9600 automatically detects the aortic diameter with a 90% sensitivity without the need for a trained operator. Because of these unique capabilities, it can be used for AAA screening outside the hospital.

Twenty-nine patients (56 ± 12 years) with a history of recent acute coronary events (ACE) underwent STE-DSE. Left ventricular images, sampled at frame rates 70–100 Hz, were analysed off-line (Echopac BT 6.0.0). Velocity, strain, and rotational imaging were performed. Twenty patients had LV ejection fraction (EF) >40% (Group 1) whereas nine patients had LVEF <40% (Group 2). Average heart and frame rates were identical during DSE in the two groups (P = ns). Global circumferential strain (%) was significantly lower in Group 2 compared with Group 1 (10.65 ± 5.30 vs. 16.82 ± 6.61; P < 0.05) at rest and during peak stress (14.72 ± 6.51 vs. 21.13 ± 7.2; P < 0.05). The global peak rotation rate (degree/s) was, however, higher at rest in Group 2 (70 ± 97 vs. 19 ± 67; P < 0.05) and 20 µg stress. Peak systolic velocity increased in three of the four LV walls at 20 µg (in Groups 1 and 2). A global rotational rate increased significantly at 20 µg during systole in both the groups, but was unchanged in Group 2 during diastole.

Speckle tracking echocardiography dobutamine stress appears to provide comprehensive information on LV mechanical status in the aftermath of ACE. The modality may help risk stratify such patients.

Transthoracic and transoesophageal data from patients with a variety of cardiac conditions were used for analysis of LV regional function. The focus was on the effects of mechanical asynchrony. Ejection fraction was calculated on the basis of LV end-diastolic volume and end-systolic volume obtained by two different ways: (i) end-systolic volume as a whole; and (ii) the sum of all regional end-systolic volumes (which may occur at different times). The relative difference, D-EF, between EFs obtained by (i) and (ii) was taken as the ‘merit’ of EF. A value of zero is the highest merit. Irrespective of the examination method, we found that D-EF was always higher than zero, and that its value depended on the extent of mechanical asynchrony.

Ejection fraction is not the arithmetic average of regional EFs. An increase of asynchrony increases D-EF, i.e. it reduces the merit of EF as a measure of cardiac function.

Twenty-five patients underwent 2DE and RT3DE. Views of 2DE (RV inflow, RV short axis, and apical four-chamber) were compared with RT3DE views by four readers. RT3DE data sets were sliced from anterior–posterior (apical view) and from base to apex (short axis) to obtain six standardized planes. Readers recorded the RV ejection fraction (RVEF) from 2DE and RT3DE images. RVEF recorded by RT3DE (RVEF_3D) and 2D (RVEF_2D) were compared with RVEF by disc summation (RVEF_DS), which was used as a reference. Interobserver variability among readers of RVEF_3D and RVEF_2D was then compared. Overall, mean RVEF_DS, RVEF_3D, and RVEF_2D were 37 ± 11%, 38 ± 10%, 41 ± 10%, respectively. The mean difference of RVEF_3D – RVEF_DS was significantly less than RVEF_2D–RVEF_DS (3.7 ± 4% vs. 7.1 ± 5%, P = 0.0066, F-test). RVEF_3D correlated better with RVEF_DS (r = 0.875 vs. r = 0.69, P = 0.028, t-test). RVEF_3D was associated with a 39% decrease in interobserver variability when compared with RVEF_2D [standard deviation of mean difference: 3.7 vs. 5.1, (RT3DE vs. 2DE), P = 0.018, t-test].

RT3DE provides improved accuracy of RV function assessment and decreases interobserver variability when compared with 2D views.

We performed aortic arch analysis on all 2000 adult patients (mean age 52, range 18–89) referred to our echocardiography lab for transthoracic echocardiograms between January and December 2007. Adequate study was obtained in 1826 patients (91% of cases). Suprasternal notch views and aortic arch analysis were normal in 1787 patients (98%) and abnormal in 39 patients (2%). Among patients with abnormal findings, 32 patients (82%) had aortic arch plaques, 24 of them (75%) had plaques <4 mm, and 8 patients (25%) had plaques ≥4 mm. Four patients (10%) had aortic arch aneurysms (diameter ≥4.5 cm). Other abnormal findings included one case of coarctation of the aorta, one case of a floating thrombus in a right pulmonary artery branch, one case of severe stenosis of the inominate artery, and one case of type A aortic dissection. Subsequently, 7 patients (18%) underwent surgery, 4 patients (10%) were started on oral anticoagulation therapy, and 28 patients (72%) treated with an antiplatelet and risk factors modification.

Aortic arch analysis showed significant pathology in 2% of the adult population undergoing routine TTE. This led to therapeutic interventions in all patients with abnormal findings, and to curative therapy in more than quarter of them. Aortic arch analysis should be mandatory during a routine exam and part of any standard digital acquisition protocol for TTE in adults.

Forty patients were studied by transthoracic 2D and 3D echocardiography pre- and 3, 6, and 12 months post-surgery. TAPSE (15.5 ± 3, 16.5 ± 3, and 18.5 ± 4 mm at 3, 6, and 12 months, respectively) and PSV (11.9 ± 2, 12 ± 2, and 12.8 ± 3 cm/s at 3, 6, and 12 months, respectively) were significantly (P < 0.001) lower after surgery in comparison with pre-surgical values (TAPSE: 25.3 ± 4 mm; PSV: 17.8 ± 4 cm/s). On the contrary, pre-operative RVEF (58.4 ± 4%) did not change after surgery (56.9 ± 5, 59.5 ± 5, and 58.5 ± 5% at each step).

Despite the post-operative reduction of RV performance along the long axis suggested by TAPSE and PSV, the absence of a decrease in 3D RVEF leads to caution in the interpretation of these 2D and Doppler parameters after cardiac surgery, supporting the hypothesis of geometrical rather than functional changes in the right ventricle.

Seventy healthy volunteers, with a good continuous wave Doppler tricuspid regurgitation signal at rest, underwent quantitative Doppler echocardiographic measurements at rest and during semi-supine exercise test. Pulmonary artery systolic pressure was estimated at rest, at low level (25 W), and at peak exercise using four times tricuspid valve regurgitation velocity squared adding a right atrial pressure of 5 mmHg. During exercise, PASP increased from rest (27 ± 4 mmHg) to peak (51 ± 9 mmHg). None of the individuals reached a PASP ≥ 60 mmHg at 25 W. Pulmonary artery systolic pressure at peak was higher in individuals ≥60 years old compared with those from 20 to 59 years old (56 ± 9 vs. 49 ± 7 mmHg, P = 0.02). Pulmonary artery systolic pressure at peak exercise ≥60 mmHg was found in 36% of the individuals aged from 60 to 70 and in 50% after 70. Age, LV mass, and PASP at rest were independent predictors of PASP at peak exercise.

Pulmonary artery systolic pressure at peak exercise can reach values ≥60 mmHg in many healthy individuals older than 60 with good exercise capacity. However, high levels of PASP > 60 mmHg for low level of exercise should be considered abnormal.

Retrospective longitudinal cohort of children (n = 88) after repair of TOF followed by serial echocardiography over 9 years. LV and RV diameters were expressed by z-scores based on normal paediatric reference values. Time courses of LV and RV diameter z-scores, degree of PR, and influence of co-variables were analysed using mixed regression models. LV diameter z-scores were significantly lowered before repair, increased after surgery, but fell again over time; thus, mean LV diameters were significantly lower than normal population means at all times. LV diameter z-scores correlated negatively with RV dilation and degree of PR. Notably, they were significantly higher in patients with previous shunts. After pulmonary valve replacement, LV diameter z-scores recovered to normal, whereas RV diameter z-scores remained abnormal.

Our results confirm progressive adverse RV–LV interaction in the long-term post-operative follow-up of TOF. The use of z-scores facilitated the analysis of time courses of LV and RV diameters.

One hundred and sixty type 2 diabetic patients and 110 non-diabetic controls, all with no evidence of heart disease, were studied. The participants were stratified into four distinct age-groups (A: <46, B: 46–60, C: 61–75, and D: >75 years) and underwent full echocardiographic examination. Conventional systolic and diastolic parameters were similar between the study groups. However, tissue Doppler imaging examination revealed an impaired systolic and diastolic longitudinal myocardial function in diabetic patients vs. controls, although these differences were not noticed within the youngest age-group. Diastolic dysfunction was established concomitantly in both diabetic and control subjects in age-group B. In contrast, diabetic patients showed an earlier induction of myocardial systolic dysfunction, evidenced by significantly lower average systolic longitudinal myocardial velocity in age-group B. Independent predictors of systolic myocardial dysfunction were age, glycated haemoglobin, and systemic blood pressure.

Type 2 diabetic patients demonstrate an early and concomitant induction of systolic and diastolic myocardial dysfunction as a preclinical manifestation of diabetic cardiomyopathy.

We evaluated 70 individuals, consisting of 35 hypertensives and 35 middle-aged volunteers as a control. None had DD based on global indices (deceleration time, isovolumic relaxation time, and E/A). Segmental early and late diastolic Doppler-derived strain rates (SRs) were recorded from 18 segments in the longitudinal axis. The number of segments with SR_E/SR_A<1.1 was represented as segmental DD. Mean relaxation of the basal, mid, and apical regions was also calculated. Septal and mean mitral annular Ea velocities were also recorded. Non-hypertensive, middle-aged individuals had evidence of segmental DD that was mostly distributed at the basal parts of the heart, and in particular at the septal wall. Hypertensive patients had a lower mean relaxation based on SR_E and SR_E/A at the basal, mid, and apical regions, with the basal parts appearing more compromised and with higher segmental DD compared with controls. Segmental DD in that group was more extensive towards the mid and even apical regions, with the septal and basal inferior walls being the most heavily affected areas. The lateral wall appeared to be the region that was most resistant to diastolic abnormalities in both groups. Even individuals with ‘normal’ septal and mean Ea had evidence of segmental DD. However, contrary to global indices of DD, septal Ea could predict the presence of segmental DD.

Abnormal relaxation appears to have a particular distribution over the myocardial walls. Basal parts are generally more heavily affected, particularly the septal and inferior walls. The lateral wall and apical regions are more resistant to diastolic abnormalities. In subjects with normal global DD, strain echocardiography has an incremental value over mitral annular diastolic velocities and global indices of DD for early detection of diastolic abnormalities.

Fifty-one consecutive patients with heart failure underwent exercise Doppler echocardiography before CRT implantation to assess global contractile reserve and local contractile reserve (assessed by two-dimensional speckle tracking) in the region of the LV pacing lead. Responders (30 patients) showed a greater exercise-induced increase in left ventricular ejection fraction (LVEF) compared with non-responders (P < 0.001). Contractile reserve was directly related to the improvement in LVEF and to LV reverse remodelling after 6 months of CRT (P < 0.001). A 6.5% exercise-induced increase in LVEF yielded a sensitivity of 90% and a specificity of 85.7% to predict the response after 6 months of CRT. Baseline myocardial deformation as well as contractile reserve in the LV pacing lead region was greater in responders than in non-responders (P < 0.0001).

Myocardial contractile reserve (global and regional) is a strong predictive factor of LV reverse remodelling after CRT.

The study population consisted of 40 non-selected patients (mean age 48 ± 18 year, 20 men) and 50 non-selected healthy volunteers (mean age 34 ± 12 year, 21 men). Feasibility and intra-observer reproducibility of the measurement of LV rotation parameters by STE were assessed for two different methods (Method A: six tracking points placed mid-myocardial and Method B: six tracking points placed endocardial and epicardial forming six myocardial segments). Subsequently, inter-observer and temporal reproducibility of the most robust method were assessed. Complete LV rotation assessment was more feasible with Method A (60 out of 90 subjects, 67% vs. 50 out of 90 subjects, 56%). In the 49 subjects in whom both Methods A and B were feasible, intra-observer reproducibility of LV rotation parameters was better with Method A (variabilities 2 ± 3 to 10 ± 9% vs. 2 ± 4 to 21 ± 18%). With this method, inter-observer variability varied from 4 ± 4 to 13 ± 9% and temporal variability from 4 ± 6 to 19 ± 15%.

The most robust method to assess LV rotation with QLAB software is from the mid-myocardium. This method is feasible in approximately two-thirds of subjects and has good intra-observer, inter-observer, and temporal reproducibility, allowing to study changes over time in LV rotation in an individual patient.

2D speckle tracking and TDI echocardiograms were performed in 79 healthy adult male volunteers (age range: 22–76 years). 2D speckle tracking allowed the determination of myocardial and peak systolic and early diastolic SR in radial, circumferential, and longitudinal planes, whereas TDI provided longitudinal only. Mean circumferential and radial and SR were calculated from data collected at six basal myocardial regions, whereas mean longitudinal and SR derived from both 2D speckle tracking and TDI were calculated from the basal septum and basal lateral walls. Standard 2D echocardiography allowed the assessment of LV morphology including LV length, LV end-diastolic volume, LV end-diastolic diameter, mean wall thickness, and LV mass. The association of myocardial and SR data with relevant LV morphology indices was determined by adoption of the general, non-linear allometric model (y= ax^b). The b exponent ± 95% confidence intervals were reported. The relationships between the measures of LV morphology and myocardial and SR were highly variable and generally weak. Only two relationships displayed at least a moderate effect size (r ≥ 0.30): (i) 2D circumferential peak systolic SR and LV end-diastolic dimension (b = –0.92; –1.35 to 0.5, r = 0.44) and (ii) TDI longitudinal peak systolic SR and LV length (b = –1.39; –2.11 to –0.66, r = 0.41).

The empirical relationships derived in this cohort do not support the need to scale myocardial and SR derived from 2D speckle or TDI for any index of LV morphology.

Echo imaging and invasive LV pressure measurements were performed during right atrial (RA) pacing and dobutamine challenge in eight pigs. LV torsion and torsional rate profiles were analysed from grey scale and tissue Doppler data (apical and basal short axis) at frame rates of 82 ± 17 and 183 ± 14 Hz, respectively. Temporal subsampling of TDI data sets was performed at 82 ± 6 Hz in order to mimic the mean temporal resolution of STI and the LV torsional curves were again extracted. At rest, LV UR values were comparable for both imaging techniques. However, during dobutamine stimulation, TDI estimated peak UR was predominantly higher than UR measured by STI (–112.1 ± 64.5°/s vs. –75.5 ± 31.4°/s, P < 0.05). The similarity of LV UR measurements with respect to the STI/TDI data was examined by a Bland–Altman analysis.

Although both methods regarding LV UR correlated well, these methods cannot be interchanged. STI showed a bias to underestimate UR at high values.

Sixteen patients aged 25.6 ± 3.7 years (eight each after Senning or Mustard repair of complete transposition) were studied. Transoesophageal imaging was performed in the catheterization laboratory under general anaesthesia before and at the end of a 10 min infusion of 5 µg/kg/min of Dobutamine. The BNP levels were measured at rest. Myocardial Doppler data were acquired before and at peak stress in a four-chamber view. The BNP (pg/mL) values of 67.3 ± 47.5 (14–189) were elevated. There was no correlation between BNP and IVA, strain, or systolic and diastolic velocities at rest. Dobutamine stress led to a significant increase in IVA, s-velocity, and strain but no significant change in e-velocity. A correlation was found between increase in IVA under Dobutamine and BNP levels (r = 0.57, P < 0.02).

Elevated BNP levels correlate with response of systolic right ventricular function assessed by IVA to Dobutamine stress.

We evaluated whether peak systolic longitudinal strain (PSLS) of left ventricle using 2D speckle tracking method might be useful for screening of severe CAD. One hundred and eight patients who underwent echocardiography and coronary angiography were evaluated. Patients were grouped according to the coronary angiographic findings as follows; high-risk group with left main or three-vessel CAD (n = 38), low-risk group with one- or two-vessel CAD (n = 28), and control group without CAD (n = 30).

PSLSs of all left ventricular segments were obtained successfully in 96 (89%) patients. None had RWMA at resting echocardiogram. PSLS was significantly reduced, especially in mid- and basal segments, in the high-risk group. Receiver operating characteristic (ROC) curve analysis demonstrated that mid- and basal PSLSs could effectively detect patients with severe CAD (area under ROC curve = 0.83, 95% CI 0.75–0.91). According to ROC curve analysis, –17.9% appears to be a helpful cutoff value for discriminating those with severe CAD (specificity 79% and sensitivity 79%).

PSLS at rest was significantly lower in patients with left main or three-vessel CAD without RWMA, and might be useful for identifying patients with a severe CAD.

Twelve transthoracic RT3DE (Philips) data sets obtained in pigs during transition from no contrast to steady-state enhancement (Definity) were analysed using custom software. Analysis included: (i) semi-automated detection of left ventricular endo- and epicardial surfaces using level-set techniques in one frame to define a 3D myocardial ROI, (ii) rigid 3D registration to reduce translation and rotation, (iii) elastic 3D registration to compensate for deformation, and (iv) quantification of MVI(t) in the 3D ROI from the registered and non-registered data sets to assess the effectiveness of registration. For each MVI(t) curve we computed % variability during steady-state enhancement (100 x SD/mean) and goodness of fit (r²) to the indicator dilution equation MVI(t) = A[1–exp(–βt)]. Analysis of myocardial contrast throughout contrast inflow was feasible in all data sets. Three-dimensional registration improved MVI(t) curves in terms of both % variability (2.8 ± 1.8 to 1.5 ± 0.9%; P < 0.05) and goodness of fit (r² from 0.79 ± 0.2 to 0.90 ± 0.1; P < 0.05).

This is the first study to describe a new technique for semi-automated volumetric quantification of myocardial contrast from RT3DE images that includes registration and thus provides the basis for 3D measurement of myocardial perfusion.

Two hundred and ninety-eight healthy subjects (M/F = 186/112) underwent Doppler echocardiography and pulsed Tissue Doppler of tricuspid annulus in apical four-chamber view. Tricuspid annular plane systolic excursion (TAPSE), Doppler indexes of RV outflow tract and of tricuspid inflow, right atrial dimension and inferior vena cava size, and collapsibility were measured. Pulsed Tissue Doppler lateral corner of the tricuspid annulus was also recorded and annular systolic (Sa), early diastolic (Ea), and atrial (Aa) peak velocities and Ea/Aa ratio determined. The ratio of tricuspid E peak velocity and Ea (E/Ea ratio) was calculated as an index of right atrial pressure. The population was divided in seven age decades: 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, and >70 years. TAPSE, Sa, Ea, and Ea/Aa ratio were progressively reduced and both Aa and E/Ea ratio increased with the increasing age groups (all P < 0.0001). E/Ea ratio was 4.1 ± 0.9 in the age decade 11–20 years and 5.4 ± 1.5 in subjects >70 years (P < 0.0001). By multi-linear regression analyses, after adjusting for heart rate and body mass index, age was the main independent predictor of average Sa, Ea, and Aa velocities and of E/Ea ratio.

Ageing shows an independent impact on pulsed Tissue Doppler-derived indexes of RV myocardial function in healthy subjects. Our data provide reference values of pulsed Tissue Doppler of the right ventricle for age decades.

Assessment of global longitudinal strain (GLS), global longitudinal strain rate (GLSR), and regional peak systolic strain (PSS) of right ventricle was performed in 33 ASD patients. The data were compared with those from 34 age-matched adults with patent foramen ovale. Before percutaneous closure, mean GLS was significantly increased in comparison to control group, and significantly reduced after closure. Analysis of regional PSS showed significant decrease in the lateral apical, lateral mid, and septal apical segments. GLSR was not influenced by ASD closure.

Two-dimensional strain appears to be helpful also for the assessment of RV function and its response to correction of volume overload.

Eighteen patients with first-time MI and no signs of heart failure at rest underwent upright bicycle exercise at 25, 50, and 75 W, and were compared with 18 age-matched controls. Systolic (S') and early (E') mitral annular velocities and early mitral filling velocity (E) were measured at each stage. LV ejection fraction was lower in the MI group (46 vs. 54%, P < 0.01), while end-diastolic volumes were similar. S' was lower in the MI patients, but increased during exercise in both groups. E' was similar at rest, but increased in the control group only. Early mitral filling (E) increased in both groups, thus the E/E' ratio increased during exercise in the MI group only. Heart rate was similar in both groups.

Upright exercise echocardiography is feasible and can unmask early diastolic dysfunction and increased LV filling pressures in patients with small prior MIs.

A blinded prospective study was conducted in 190 consecutive subjects at risk of HHT who underwent screening for PAVMs, including clinical evaluation, pulse oximetry, standard and CE, and chest multirow CT without contrast medium. A semi-quantitative analysis of the shunt size was performed according to the contrast echo opacification of the left-sided chambers: Grade 0, no bubbles; 1, occasional filling with <20 bubbles; 2, moderate filling; 3, complete opacification. The first 100 patients were compared with 100 controls. A total of 119 (63%) patients had positive CE (32.2% Grade 1, 13.1% Grade 2, 11% Grade 3, 6.3% with patent foramen ovale). The overall diagnostic performance of CE was sensitivity 1.00, specificity 0.49, positive predictive value (PPV) 0.32, negative predictive value (NPV) 1.00. The PPV for the different grades was 0.00 for Grade 1, 0.56 for Grade 2, 1.00 for Grade 3; the NPV of Grade 0 was 1.00. A significant correlation was found between the CE grading and the number of PAVM, and complications (P < 0.0001).

CE is an extremely sensitive procedure for the detection of PAVMs with substantial clinical impact.

We evaluated 70 hypertensive patients and 30 non-hypertensive volunteers. The patients were divided as follows: without global diastolic dysfunction (HTN-N) and with global diastolic dysfunction (HTN-DD). The segmental and global longitudinal strain (S) and strain rate (SR) and early and late diastolic SR were recorded from 18 segments. The number of segments with abnormal relaxation (SR_E/SR_A < 1.1) was calculated as segmental DD. Pulse pressure/SV index was used as a surrogate marker of AS. Arterial stiffness was higher in HTN-N and was more pronounced in the HTN-DD group compared with the control (1.45 ± 0.38 vs. 1.79 ± 0.36 vs.1.21 ± 0.31 mmHg m²/ml, all P < 0.05). HTN-N had increased segmental DD compared to control despite the normal conventional indices of diastolic dysfunction. Global longitudinal deformation of the HTN-N group was similar to the control; HTN-DD also showed evidence of LV hypertrophy (LVH) and had more extensive segmental DD and deteriorated global systolic deformation compared with the control, despite the normal ejection fraction (segmental DD: 11 ± 3 vs. 4 ± 2, P < 0.05 and strain: 17.7 ± 2.8 vs. 21.2 ± 2.3%, P < 0.05). The deterioration of AS in the hypertensive group was accompanied with a particular distribution of segmental DD that was more pronounced at the basal regions compared with apical LV territories. Arterial stiffness and LV mass index are found to be independent predictors of segmental DD, mean Ea, and global systolic deformation.

Arterial stiffness and LVH are independently related to abnormal segmental relaxation and global longitudinal systolic deformation in hypertensive disease.

Three groups (20 athletes with BAV, 20 healthy athletes, and 20 sedentary healthy subjects, all aged 25 ± 3 years) underwent standard echo examination to evaluate LPSS at the basal and medium-apical segments of the lateral wall (LW) and interventricular septum (IVS) of the LV. LPSS was within the normal range; however, in BAV athletes, the LPSS of the basal segments tended to be lower (S%IVS_basal, –17.7 ± 2.7; S%LW_basal, –14.2 ± 2.2; S%IVS_med-apic, –21 ± 3.5; S%LW_med-apic, –18.8 ± 4.2), producing a gradient from basal to apical regions. The EF was normal in all subjects.

Young trained BAV athletes have normal LV performance. Nevertheless, these athletes tend to have lower strain than healthy subjects in the LV basal segments. The clinical implications of this finding are uncertain and require further investigation.

Two hundred and fifty-five subjects with non-invasively and invasively defined aortic valve stenosis (AS) formed the basis of this study. Basis of the nomograms was the correlation analysis between pAv and AVA as estimated by AVA_CE within different LVEF groups. LVEF differed from 65.6 ± 1.8% (Group I, LVEF > 60%) to 34.5 ± 4.3% (Group IV, LVEF ≥ 30%). pAv and AVA varied from 85.6 ± 19.5 mmHg and 0.69 ± 0.16 cm² in Group I to 58.5 ± 15.9 mmHg and 0.73 ± 0.23 cm² in Group IV (pAv: P < 0.001). Mean AVA_CE showed no significant difference between the groups. Correlation between pAv and AVA_CE was statistically significant with P < 0.001 in all subgroups (R² between 0.72 and 0.76). Furthermore, a prospective estimation of AVA using the developed nomograms correlated very well with invasively determined AS using the Gorlin formula (R² = 0.76, SEE = 0.21 cm², bias 0.04 cm²).

The present study has established and confirmed a solid, easy to use nomogram-based method to accurately quantify severe AS.

From 26 September 2005 to 27 October 2005, 112 patients admitted in six hospital wards connected through a 100 Mbit LAN to the echo-lab were scanned within the admission ward by sonographers using a miniaturized echo system. Logistical data were collected and results were compared with those obtained from 194 consecutive patients coming from the same wards and studied in the echo-lab with high-end machines between 8 March 2005 and 15 April 2005. Performing echocardiograms in the admission department avoided long waiting time of the inpatients in the echo-lab before and after the study, increased the percentage of patients studied within 3 and 5 days from request (88 vs. 77% and 100 vs. 95%, respectively; P = 0.03), increased both sonographer (by 33.9%; P < 0.001) and echo-lab productivity (by 41%; P < 0.001), and reduced costs of echocardiograms by 29%.

Implementation of digital echocardiography, certified sonographers, and a miniaturized echo system allowed improvement of the cost-effectiveness of the service provided by the echo-lab for inpatients, and avoided patients' discomfort derived from prolonged waiting time before and after the exam.

Thirteen patients with ostium secundum ASD underwent transcatheter ASD closure. 2D TEE, RT3D TEE, and ICE images were acquired sequentially. RT3D TEE was feasible in all patients. Comparing RT3D TEE and 2D imaging, the mean difference in long-axis dimension was +0.5 mm (P= NS for both), and –1.4 mm in short-axis (2D TEE, P < 0.05; ICE, P = 0.06). BD was greater with 3D TEE vs. ICE (+0.9 mm).

RT3D TEE can be used to guide transcatheter ASD closure with the advantages of lower cost than ICE, and ability to visualize en-face views of the ASD. ASD and BD as measured by RT3D TEE differ when compared with 2D imaging.

We studied 459 patients with Grade I and II essential hypertension who were referred to our outpatient clinic over a period from May 2007 to March 2008. The population was first sorted by waist circumference and then by epicardial fat ≤7 or >7 mm. We measured epicardial fat thickness, waist circumference, carotid artery stiffness, and carotid IMT in all patients. Patients divided according to waist circumference showed no statistical differences in carotid artery stiffness between the two groups. Subjects with epicardial fat >7 mm were older, had higher systolic, diastolic, and pulse pressure, increased left ventricular mass index, carotid IMT, diastolic parameters, and stiffness parameters compared with those with epicardial fat ≤7 mm (P < 0.001). A positive correlation was found between epicardial fat and age, pulse pressure, stiffness parameters, carotid IMT, systolic blood pressure, and duration of hypertension, and a negative correlation was found with diastolic parameters. Age, carotid IMT, and stiffness parameters were independently related to epicardial fat.

Our findings indicate that epicardial fat reflects carotid artery stiffness in hypertension-induced organ damage.

Between January 2004 and April 2008, we prospectively evaluated all patients with known or suspected coronary artery disease (CAD) referred to the echocardiography laboratory for dobutamine stress tests (6061 examinations). Those with abnormal DSE underwent coronary angiogram with a systematic methylergometrine intracoronary injection in the case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients who had spontaneous occlusive coronary spasm or positive methylergometrine test, but no significant stenoses, were ultimately included in this study. About 581 patients had abnormal DSE, among them only 20 (3.4%) fulfilled the inclusion criteria. There were 15 males and 5 females, and mean age was 64.35 years (range 52–85); 8 patients had a known history of CAD and all of them had at least two established cardiovascular risk factors. The culprit vessel was the left anterior descending artery in 10 cases (50%), right coronary artery in 8 cases (40%), and left circumflex in 2 cases (10%). There was a systematic correspondence between the culprit arteries and dobutamine-induced wall motion abnormality territories. No complications occurred during examination or during the provocation test. All the patients were discharged with a calcium channel blocker and were doing well after 13 months of mean follow-up.

Coronary artery spasm can be induced at DSE, but is a rare finding; it could, though, be clinically relevant as it may partly explain some erroneously labelled ‘false-positive’ examinations. Methylergometrine provocation test is a safe and advisable approach in such situations.

Echocardiograms were obtained in 378 patients with chronic systolic HF [ejection fraction (EF) ≤ 45%] in sinus rhythm. Restrictive mitral flow was defined by an E wave deceleration time (EDT) ≤ 140 ms. Tissue Doppler imaging early (E_m) diastolic and systolic (S_m) velocities were measured at the mitral annulus. Patients were followed-up for a median of 32 months. Endpoints were all-cause mortality and the combination of death or HF hospitalization. Mean left ventricular EF was 32 ± 8%. Restrictive mitral flow and TDI annular velocities were all univariate predictors of the endpoints. Ejection fraction <25% was the only multivariate predictor of all-cause mortality. E wave deceleration time and E_m < 8 cm/s were independently associated with the combined endpoint of death or HF hospitalization. At 48 months, survival was 61% in patients with RMF and 82% in patients with non-RMF (log-rank: 21.6; P < 0.0001). When patients were stratified according to E_m at or above 8 cm/s or below 8 cm/s, those with RMF and E_m < 8 cm/s exhibited the worst survival (log-rank: 27.16; P < 0.0001). Patients with S_m ≤ 6 cm/s had a 58% survival rate, whereas it was 82% in patients with S_m > 6 cm/s (log-rank: 12.73; P = 0.0004).

Doppler annular velocities provided useful information for prognostication of patients with systolic HF. Particularly, categorization of patients according to E_m velocities allowed us to further stratify patients with RMF and non-RMF.

In nine open-chest pigs, the heart was exposed while preserving the pericardium. Early-stage pericardial adhesions were simulated by instilling tissue glue to pericardial space. Using VVI, LV rotational mechanics was quantitatively assessed endocardially and epicardially along with haemodynamic data at baseline and following the experimental intervention. End-diastolic volume, ejection fraction, stroke volume, late diastolic filling velocity, and LV endocardial torsion decreased significantly. LV epicardial torsion showed only a trend towards decrease (P = 0.141). Endocardial twist and torsion decreased significantly (P = 0.007) from 8.6 ± 2.2 degree and 1.497 ± 0.397 degree/cm to 5.3 ± 1.8 degree and 0.97 ± 0.38 degree/cm, respectively; epicardial twist showed a trend towards a decrease in its magnitude. Gradients of endocardial/epicardial twist and torsion did not significantly change.

The model suggests that early-stage pericardial adhesions reduce both epicardial and endocardial LV twist and torsion without a significant alteration in their transmural gradient. Selective endocardial/epicardial analysis of LV twisting mechanics may have a diagnostic role in detection of early formation of pericardial adhesions.

We studied 141 patients referred for transoesophageal echocardiogram (TEE); 48 were in AF. We obtained TEE and TTE LAA A_M velocities from the LAA apex on the parasternal short-axis and apical two-chamber views. Adequate traces were obtained in 118 patients (84%). In these patients, we measured 5382 LAA A_M velocity tracings. There was a strong correlation between LAA A_M on TEE and TTE parasternal short-axis (r = 0.741; P < 0.0001) and apical two-chamber views (r = 0.729; P < 0.0001). Patients in AF had lower LAA A_M than those with sinus rhythm on parasternal short-axis (12 ± 5 vs. 23 ± 7 cm/s, P < 0.0001) and apical two-chamber (14 ± 5 vs. 23 ± 8 cm/s, P < 0.0001) views. On parasternal short axis, LAA A_M velocities were lower in patients with spontaneous echo contrast, 11 ± 4 vs. 22 ± 8 cm/s (P < 0.0001), and in those with thrombus, 8 ± 2 cm/s (P < 0.0001). On apical two-chamber, LAA A_M velocities were also lower with spontaneous echo contrast, 12 ± 4 vs. 22 ± 7 cm/s (P < 0.0001), and with thrombus, 10 ± 4 cm/s (P < 0.0001). In patients with AF and TTE LAA A_M ≤11 cm/s, we found that nearly one-third had LAA thrombus. In patients with AF and a history of stroke or transient ischaemic attack (TIA), LAA A_M velocities were lower compared with those without history of stroke or TIA in the parasternal short-axis (9 ± 3 vs. 13 ± 5 cm/s, P = 0.02) and apical two-chamber views (11 ± 3 vs. 15 ± 6 cm/s, P = 0.008).

Acquiring and quantifying LAA A_M contraction velocity is feasible on TTE in a high percentage of patients and correlates with TEE. LAA A_M was lower in AF compared with sinus rhythm, with spontaneous echo contrast compared to without spontaneous echo contrast, and in AF patients with a history of stroke or TIA. Those with LAA thrombus had the lowest LAA A_M velocities. LAA A_M is a novel functional parameter that may prove useful for risk stratification of AF.

Tissue Doppler imaging peak systolic velocity (S'), peak early diastolic annular velocity (e'), and timing difference between mitral early flow and early annular movement were measured in 14 patients with constrictive pericarditis, 10 with restrictive cardiomyopathy, and 17 normal subjects using the apical four-chamber view lateral and medial mitral annulus. In controls, mitral lateral e' velocity was 25% higher than medial e' velocity (13.0 ± 3.1 vs. 10.7 ± 2.8 cm/s; P = 0.02), whereas with constrictive pericarditis, averaged lateral e' velocity was 2% lower than medial e' velocity (10.7 ± 2.5 vs. 11.2 ± 3.1 cm/s; P > 0.05). This relationship represented a reversal of lateral and medial e' velocities compared with normal subjects (P = 0.004). Differences in S', E/e', and timing intervals between normal subjects and patients with constrictive pericarditis were not statistically significant; however, restrictive cardiomyopathy could be distinguished from constrictive pericarditis and controls with all other parameters (S', E/e', medial and lateral e' velocities, and timing interval differences; all P < 0.05).

Practical applications of tissue Doppler imaging for evaluation of possible constrictive pericarditis include reversal of the relationship between lateral and medial e' velocities (i.e. ‘annulus reversus’).

We studied 28 new diagnosed moderate and severe OSAS patients (apnoea–hypopnoea index >15) and 18 control group. Exclusion criteria were the presence of structural heart disease, pulmonary disease, diabetes mellitus, dyslipidaemia, alcoholism, neuromuscular disease, renal failure, or malignancy. They were not previously considered or treated for OSA and were all free of drugs. Left ventricular lateral and septal wall early myocardial peak velocity (Em), late myocardial peak velocity (Am), Em to Am ratio, myocardial relaxation time (RTm), myocardial systolic wave (Sm) velocity, isovolumic acceleration (IVA), myocardial pre-contraction time (PCTm), contraction time (CTm), and PCTm to CTm ratio were measured. All echocardiographic parameters were calculated 6 months after CPAP therapy. No statistically significant difference was detected between the groups according to age, gender, body mass index, systolic and diastolic blood pressure, heart rate, fasting blood glucose, and serum lipid parameters. Left ventricular systolic parameters, such as LV septal and lateral wall IVA, CTm, and PCTm to CTm ratio, were significantly lower and Sm was similar in patients with the OSAS group compared with the controls. Left ventricular diastolic parameters, such as LV septal and lateral wall Em velocity and Em to Am ratio, were significantly lower; RTm was significantly prolonged; and Am velocity was similar in patients with OSAS compared with the controls. At the end of the treatment, 20 of 28 patients were compliant with CPAP therapy. Left ventricular septal and lateral wall Em velocity, Em to Am ratio, IVA and CTm, and PCTm to CTm increased significantly, PCTm, PCTm to CTm ratio, and RTm decreased significantly after the therapy, whereas Sm velocity and Am velocity did not change after CPAP therapy in compliant patients.

Left ventricular systolic and diastolic dysfunctions were determined in patients with OSAS, and it was demonstrated that LV systolic and diastolic dysfunctions improved with 6 month CPAP therapy.

A total of 295 consecutive patients with non-valvular AF and a CHADS₂ score of 0 or 1 from the prospective single-centre registry ANTIK, who underwent transoesophageal echocardiography before cardioversion, were included in the study. Median follow-up was 5 years. LA thrombus was present in 3% and dense SEC in 8% of patients. Independent predictors for the presence of thrombus or dense SEC were ejection fraction (EF) <40% and LA diameter ≥50 mm. In anticoagulated patients, thrombus and dense SEC were not independently associated with an increased risk for stroke or death during the 5 year follow-up (OR 1.55, 95% CI 0.50–4.83).

Despite a low CHADS₂ score of 0/1, 3% of patients have LA thrombus and 8% of patients have dense SEC. Independent predictors for the presence of thrombus and dense SEC were EF <40% and LA dimension ≥50 mm. Thus, echocardiography might be a useful tool for further risk stratification in patients with low CHADS₂ score.

The study comprised a one-time test of 676 transducers from 7 manufacturers which were in daily use in clinical departments at 32 hospitals. They were tested with the Sonora FirstCall Test System; 39.8% exhibited a transducer error. Delamination was detected in 26.5% and break in the cable was detected in 8.4% of the tested transducers. Errors originating from the piezoelectrical elements were unusual. Delamination and short circuit occurred without significant differences between transducers from all tested manufacturers, but the errors break in the cable, weak and dead element showed a statistically significant higher frequency in transducers from certain manufacturers.

The high error frequency and the risk for incorrect medical decisions when using a defective transducer indicate an urgent need for increased testing of the transducers in clinical departments.

Takotsubo cardiomyopathy, or transient apical ballooning syndrome, is a recently described form of left ventricular (LV) dysfunction induced by stress. Clinically it can mimic acute coronary syndrome in its presentation. It is characterized by an atypical distribution of LV dysynergy with apical ballooning and compensatory basal hyperkinesis. Coronary angiography is normal. It has preponderance in females.

Although the aetiology of Takotsubo syndrome remains obscure catecholamine release appears to be the principal trigger.

We report a case of dobutamine-induced transient LV apical ballooning in a woman without coronary disease, during a dobutamine stress echocardiogram. There was evidence of ventricular recovery by 72 h.

To our knowledge, only three other case reports describe dobutamine-induced Takotsubo cardiomyopathy.

Dobutamine stress echocardiography is a widely performed diagnostic test, however, it can rarely result in presumed catecholamine-induced transient apical ballooning syndrome.

A total of 32 patients with biventricular EMF (29 women, 55.3 ± 11.4 years) were studied by echocardiography and ergoespirometry. The relationship between the echocardiographic indexes and the percentage of predicted VO_2p (%VO_2p) was investigated by the ‘stepwise’ linear regression analysis. The median VO_2p was 11 ± 3 mL/kg/min and the %VO_2p was 53 ± 9%. There was a correlation of %VO_2p with an average of A' at four sites of the mitral annulus (A' peak, r = 0.471, P = 0.023), E'/A' of the inferior mitral annulus (r = –0.433, P = 0.044), and myocardial performance index (r = –0.352, P = 0.048). On multiple regression analysis, only A' peak was an independent predictor of %VO_2p (%VO_2p= 26.34 + 332.44 x A' peak). EMF patients with %VO_2p< 53% had an increased mortality rate with a relative risk of 8.47.

In EMF patients, diastolic function plays an important role in determining the limitations to exercise and %VO_2p has a prognostic value.

In 57 patients, 2D data and left ventricular velocity profiles were acquired using spectral and colour TD for a subsequent offline analysis. Longitudinal myocardial velocities were measured at unsaturated, 50%-saturated and fully saturated gain, and before and after temporal smoothing using 30, 50, and 70 ms filters, respectively. Gain level and filter width altered significantly the measured velocities. Peak systolic and early diastolic velocities were significantly higher (P < 0.001) and E/E' ratio was significantly lower (P < 0.001) with spectral TD than with colour TD, although there was a good correlation between the results of both TD modalities. The differences between the methods increased at increasing filter width and gain level.

Despite good correlation of the results, spectral TD produces significantly higher myocardial velocity values and lower E/E' ratio than colour TD modality. Increasing gain and temporal smoothing alter significantly the results of velocity measurements and accentuate the difference between the two TD methods.

Sixty-five asymptomatic patients with severe AS (aortic valve area <1 cm²) were studied by echocardiography and exercise treadmill and were compared with controls. Conventional echographic parameters as well as longitudinal, radial, and circumferential deformations by 2D strain were measured at rest. During exercise treadmill, maximum tolerated workload, maximum heart rate, blood pressure, and EKG ST variations were recorded. Patients were then followed during 12 months. Compared with controls, despite similar ejection fractions, AS patients presented with a significantly lower global longitudinal strain (GLS) (–17.8 ± 3.5 vs. –21.1 ± 1.8%, P < 0.05) more pronounced in the basal segments (BLS) (–12.4 ± 2.9 vs. –18.4 ± 2.5%, P < 0.05). No difference was observed in terms of radial or circumferential strains. In a subgroup of AS patients with abnormal response to exercise, GLS and BLS were significantly lower (–14.7 ± 5.1 vs. –19.3 ± 4.0% and –10.7 ± 2.5 vs. –14.4 ± 2.1%, P < 0.05). With cut-offs of –18 and –13%, GLS and BLS were able to determine an inadequate exercise response with a sensitivity and specificity of 68 and 75% (AUC 0.77), and 77 and 83% (AUC 0.81), respectively. Finally, patients with a basal strain below –13% presented with more cardiac events in the follow-up.

In asymptomatic patients with severe AS, impaired longitudinal contraction assessed by 2D strain is associated with abnormal exercise response and with an increased risk of cardiac events during follow-up.

We prospectively evaluated MPG and AVA using the 2D-CWD (apical view) and the NI-CWD (right parasternal view) in 100 patients (78 ± 5 years, 65% male) consecutively enrolled in an ongoing prospective study. Aortic stenosis severity was graded as mild (AVA ≥ 1.5 cm²), moderate (1–1.5 cm²), or severe (AVA < 1 cm²). Misclassification was defined as at least a one grade difference and AVA > 0.15 cm² (twice the intra-observer variability). Feasibility of the 2D-CWD was 100%, MPG 20 ± 13 mmHg, and AVA 1.52 ± 0.45 cm². Fifty-three per cent had a mild AS, 34% a moderate AS, and 13% a severe AS. Using the NI-CWD, feasibility was 85%, MPG 25 ± 16 mmHg, AVA 1.33 ± 0.41 cm² (both P < 0.005 compared with 2D-CWD). Thirty-five per cent (n = 30) had a mild AS, 46% (n = 39) a moderate AS, and 19% (n = 16) a severe AS. Using only the 2D-CWD and the apical view, 21 patients (21%) would have been misclassified: 17 as mild instead of moderate AS and 4 as moderate instead of severe AS. In those misclassified patients, MPG was 9 ± 6 mmHg higher with the NI-CWD and 33% had an MPG difference >10 mmHg.

The use of the NI-CWD and the right parasternal view must be performed to evaluate AS severity, especially in case of discrepancy between symptoms and AS severity or for precise evaluation of AS progression.

We examined 60 patients (52.1 ± 12, 8 years) with non-ischaemic dilated cardiomyopathy (NIDC), New York Heart Association II–III, in sinus rhythm, left ventricular ejection fraction 30.1 ± 8.6%, and 44 normals. All subjects underwent an echocardiographic study and a cardiopulmonary exercise test. We evaluated the segmental proximal aorta (AO) pulse wave velocity (PWV) in the region of aortic arch with a new echo-method: from the suprasternal view, the distance between ascending and descending AO was measured with two-dimensional ultrasound, and the aortic flow wave transit time (TT) was measured with pulsed-wave Doppler. Pulse wave velocity was calculated as aortic distance/TT. Patients showed increased PWV (7.4 ± 2.9 vs. 4.8 ± 1.1 m/s, P < 0.001), compared with controls. Patients with advanced left ventricular (LV) (restrictive or pseudo-normal filling pattern) diastolic dysfunction showed increased PWV (8.6 ± 2.6 vs. 6.6 ± 2.9 m/s, P = 0.01) and reduced peak and predicted (for age, sex, and body mass) VO₂ (both P < 0.001), compared with those with mild diastolic dysfunction (delayed relaxation filling pattern). Pulse wave velocity was significantly correlated with the LV mass (r = 0.32, P = 0.01), the peak spectral tissue Doppler imaging systolic wave (r = –0.34, P = 0.006), the LV diastolic filling pattern (r = 0.42, P = 0.001), and the peak (r = –0.47, P < 0.001) and predicted VO₂ (r = –0.579, P < 0.001).

Patients with NIDC showed increased proximal aortic stiffness, which relates to LV systolic and diastolic function and exercise capacity. The echocardiographic assessment of the regional aorta PWV seems to be clinically important.

Eighteen PH patients (age 57, range 35–79 years, 33% male) received bosentan. Six minute walk distance (6-MWD) and echocardiography were performed at baseline and after 1 year follow-up. After 1 year of treatment, 6-MWD increased (mean 60 ± 41 m) in 67% of patients (responders). Baseline RV contraction duration was longer in responders, compared with non-responders (612 ± 66 vs. 514 ± 23 ms; P < 0.01). A baseline RV contraction duration >550 ms was associated with improved 6-MWD (sensitivity 83%, specificity 83%; P < 0.01).

An improvement of 6-MWD during bosentan treatment was associated with a decrease in RV contraction duration and could be predicted by a baseline RV contraction duration >550 ms.

We studied 65 patients with patent foramen ovale or atrial septal defect who received an atrial septal closure device. Transoesophageal echocardiography was used to guide the procedure, and was repeated <1 h after the end of the procedure, at 30 day and 6 month follow-up visits. Transoesophageal echocardiography <1 h after procedure revealed a left-sided thrombus attached to the device in three patients. All cases were successfully treated by thrombolytic therapy with full-dose tenecteplase (0.53 mg/kg in 5–10 s) with disappearance of thrombus in 15–60 min. No cerebrovascular event was recorded during a follow-up of 311 ± 235 days.

Thrombus formation on interatrial closure devices can occur soon after device implantation and can be timely detected by postprocedural TEE.