Journal of the American Society of Echocardiography

Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

2013-05-01

Estimation of Pulmonary Pressures and Diagnosis of Pulmonary Hypertension by Doppler Echocardiography: A Retrospective Comparison of Routine Echocardiography and Invasive Hemodynamics

2013-03-18

Background: To date, Doppler echocardiography is the most widespread and well-recognized technique for the noninvasive evaluation of systolic pulmonary artery pressure (sPAP). However, recent studies have reported reservations about the relevance of Doppler echocardiography or the tool's reliability in the diagnosis and follow-up of patients with pulmonary hypertension (PH). Thus, the aim of this dedicated retrospective study was to address the questions of Doppler echocardiography's relevance and accuracy for PH diagnosis in the routine activity of a conventional echocardiography department.Methods: Institutional databases were used to extract and analyze the records of 310 patients who underwent both hemodynamic and echocardiographic investigations within a single hospitalization period.Results: Despite an underestimation of absolute Doppler sPAP values compared with measurements on right heart catheterization, data analysis revealed a strong correlation (r = 0.80, P < .00001, n = 310). Targeting a mean pulmonary pressure on right heart catheterization of 25 mm Hg for the definition of PH, receiver operating characteristic curve analysis demonstrated a strong association between sPAP and PH diagnosis (area under the curve, 0.82; n = 155). The cutoff obtained for sPAP was 38 mm Hg, and when applied on a second-test subgroup population (n = 155), sensitivity, specificity, and accuracy were 88%, 83%, and 86%, respectively. When patients with examination intervals of <2 days were selected (n = 115), sensitivity and specificity reached 89% and 89%, respectively. No combination of parameters produced an improvement on the initial results.Conclusions: In the real-world practice of a conventional echocardiography department, Doppler echocardiography is associated with high accuracy, sensitivity, and specificity for PH evaluation, thus confirming its major position as a primary noninvasive tool.

Derivation of Mean Pulmonary Artery Pressure from Noninvasive Parameters

2013-02-13

Background: The assessment of pulmonary pressure is important for the diagnosis and management of patients with pulmonary hypertension. Mean pulmonary artery pressure (MPAP) has been used in the current definition of pulmonary hypertension. However, invasive derivation by Doppler echocardiography provides the peak pulmonary artery systolic pressure (PASP). The aim of this study was to derive a method to predict MPAP from PASP.Methods: Invasive hemodynamic pressures in 307 patients who underwent right heart catheterization were examined. Simple regression techniques were used to determine the relationship between MPAP and PASP in a derivation cohort (n = 198) and a validation sample (n = 109). Bland-Altman analysis was performed to examine predicted versus observed values of MPAP.Results: MPAP and PASP at catheterization were strongly related over a range of pressures (R2 = 0.89, n = 198; SE, 4.04; P < .0001). The relation of MPAP to PASP in the derivation cohort (MPAP = 0.61 × PASP + 1.95 mm Hg) was validated in the test sample, with an R2 value of 0.94 for predicted versus observed MPAP (SE, 2.87; P < .0001). The relationship of predicted versus observed MPAP was constant across different degrees of pressure elevation, as well as different etiologies of pulmonary hypertension. Applying the equation to Doppler-derived pulmonary pressures, there was excellent correlation of predicted MPAP from echocardiography and invasively measured MPAP (R2 = 0.78, P < .0001).Conclusions: MPAP can be accurately predicted from PASP over a wide pressure range for different etiologies of pulmonary hypertension. This finding may help define MPAP noninvasively.

Can Pulmonary Hypertension and Increased Pulmonary Vascular Resistance Be Ruled in and Ruled Out by Echocardiography?

2013-03-18

Background: Several treatment options are available for pulmonary vascular disease, and more patients are considered for right heart catheterization. The aims of this study were to evaluate the diagnostic ability of echocardiography to detect pulmonary hypertension and increased pulmonary vascular resistance (PVR).Methods: This retrospective study comprised 118 patients investigated within 48 hours of right heart catheterization. Echocardiography was used to assess pulmonary artery systolic pressure and pulmonary artery mean pressure, filling pressures, cardiac output, and PVR. To diagnose increased PVR, three echocardiographic variables related to pressure reflection in the pulmonary circulation were used. Separate cutoff values aimed at ruling in (high positive likelihood ratio [PLR]) and ruling out (low negative likelihood ratio) pulmonary hypertension (pulmonary artery mean pressure >25 mm Hg) and increased PVR (>3 Wood units) were determined from a derivation group (n = 59, receiver operating characteristic curve analysis) and evaluated in a test group (n = 59).Results: The linear relations between hemodynamic variables assessed with simultaneous echocardiography and right heart catheterization were moderate to strong (R = 0.55 to 0.95), and there were no significant differences, but the limits of agreement were wide. With Doppler pulmonary artery systolic pressure >39 mm Hg, the PLR for pulmonary artery mean pressure >25 mm Hg was 4.7, and with Doppler pulmonary artery systolic pressure ≤29 mm Hg, the negative likelihood ratio was 0.12. The PLR for pressure reflection variables with ruling-in cutoff values ranged from 4.3 to 6.4. With all three variables positive, the PLR was 9.9. The negative likelihood ratio with ruling-out cutoff values ranged from 0.22 to 0.08.Conclusions: Echocardiography that includes assessment of pressure reflection in the pulmonary circulation can rule in and rule out pulmonary hypertension and increased PVR.

Doppler under Pressure: It's Time to Cease the Folly of Chasing the Peak Right Ventricular Systolic Pressure

Nelson B. Schiller, Bryan Ristow — 2013-05-01

There are three studies in this issue of The Journal that contribute to our understanding of the noninvasive determination of pulmonary hemodynamics. This editorial discusses aspects of each of these studies and places them in context of the contemporary practice of echocardiography. The editorial concludes with a discussion of improving current practice and research, partly based on the model of aortic stenosis (AS).

Ventricular Function and Dyssynchrony Quantified by Speckle-Tracking Echocardiography in Patients with Acute and Chronic Right Ventricular Pressure Overload

2013-03-25

Background: The aim of this study was to noninvasively investigate right ventricular and left ventricular (LV) adaptation to right ventricular pressure overload in patients with acute pulmonary thromboembolism (APTE) and chronic pulmonary artery hypertension (CPAH).Methods: Thirty-seven patients with APTE, 36 patients with CPAH, and 33 controls were retrospectively enrolled. Myocardial deformation and wall motion were analyzed using speckle-tracking strain and displacement imaging echocardiography in the right and left ventricles. The standard deviation of the heart rate–corrected intervals from QRS onset to peak systolic strain and peak systolic displacement (PSD) for the six segments was used to quantify right ventricular and LV mechanical dyssynchrony (peak systolic strain dyssynchrony and PSD dyssynchrony). The myocardial performance index in both ventricles was also evaluated.Results: The APTE and CPAH groups had reduced ventricular performance (LV myocardial performance index, 0.40 ± 0.10, 0.66 ± 0.18 [P < .05 vs controls], and 0.58 ± 0.19 [P < .05 vs controls] in the control, APTE, and CPAH groups, respectively) and large mechanical dyssynchrony (LV longitudinal PSD dyssynchrony, 58 ± 41 msec, 119 ± 49 msec [P < .05 vs controls], and 83 ± 37 msec [P < .05 vs controls and the APTE group] in the control, APTE, and CPAH groups, respectively) in both ventricles. Multiple regression analysis indicated that LV longitudinal PSD dyssynchrony in the APTE group and the LV eccentricity index in the CPAH group were independent determinants of LV myocardial performance index.Conclusions: Pathophysiologic mechanisms that regulate ventricular performance vary depending on whether the ventricles are exposed to acute or chronic right ventricular pressure overload.

Independent and Incremental Value of Deformation Indices for Prediction of Trastuzumab-Induced Cardiotoxicity

2013-04-05

Background: Assessment of left ventricular systolic function is necessary during trastuzumab-based chemotherapy because of potential cardiotoxicity. Deformation indices have been proposed as an adjunct to clinical risk factors and ejection fraction (EF), but the optimal parameter and optimal cutoffs are undefined. The aim of this study was to determine the best means of early detection of subsequent reduction of EF in patients with breast cancer treated with trastuzumab.Methods: Eighty-one consecutive women (mean age, 50 ± 11 years) receiving trastuzumab were prospectively studied, 37 of whom received concurrent anthracyclines. Conventional echocardiographic indices (mitral annular systolic [s′] and diastolic [e′] velocities) and myocardial deformation indices (global longitudinal peak systolic strain [GLS], global longitudinal peak systolic strain rate [GLSR-S], and global longitudinal early diastolic strain rate [GLSR-E]) were measured at baseline and at 6 and 12 months. Cardiotoxicity was defined as a >10% decline as a percentage of baseline EF in 12 months.Results: In the 24 patients (30%) who later developed cardiotoxicity, myocardial deformation indices decreased at 6 months (GLS, P < .001; GLSR-S, P = .009; GLSR-E, P = .002 vs baseline), but e′ was unchanged. The strongest predictor of cardiotoxicity was ΔGLS (area under the curve, 0.84); an 11% reduction (95% confidence interval, 8.3%–14.6%) was the optimal cutoff, with sensitivity of 65% and specificity of 94%. In sequential models, the clinical model (χ2 = 10.2) was improved by GLSR-S (χ2 = 14.7, P = .03) and even more so by GLSR-E (χ2 = 18.0, P = .005) or GLS (χ2 = 21.3, P = .0008). Discrimination improvement by adding GLS was confirmed by an integrated discrimination improvement of 18.6% (95% confidence interval, 8.6%–28.6%; P = .0003). A net 29% of the patients without events were reclassified into lower risk categories, and a net 48% of the patients with events were reclassified into higher risk categories, resulting in a total continuous net reclassification improvement (>0) of 0.77 (95% confidence interval, 0.33–1.22; P = .036).Conclusions: GLS is an independent early predictor of later reductions in EF, incremental to usual predictors in patients at risk for trastuzumab-induced cardiotoxicity.

Differential Changes of Left Ventricular Myocardial Deformation in Diabetic Patients with Controlled and Uncontrolled Blood Glucose: A Three-Dimensional Speckle-Tracking Echocardiography–Based Study

Xiaoling Zhang, Xin Wei, Yujia Liang, Min Liu, Chunmei Li, Hong Tang — 2013-04-05

Background: Preclinical left ventricular (LV) systolic dysfunction has been documented in patients with diabetes mellitus (DM) with preserved LV ejection fractions (LVEFs). The aims of this study were to investigate whether there is any difference in myocardial deformation between patients with DM with controlled (defined as glycosylated hemoglobin [HbA1c] < 7%) and uncontrolled (HbA1c ≥ 7%) blood glucose using three-dimensional speckle-tracking echocardiography and to explore whether the level of HbA1c is associated with preclinical LV systolic dysfunction.Methods: Thirty-one patients with DM with controlled blood glucose, 37 patients with DM with uncontrolled blood glucose, and 63 matched controls were studied. All subjects had normal LVEFs (≥55%). Global longitudinal strain (GLS), global circumferential strain, global area strain, and global radial strain were assessed using three-dimensional speckle-tracking echocardiography.Results: Despite similar LVEFs, patients with uncontrolled DM had decreased peak systolic strain in all directions compared with the other two groups, as evidenced by GLS, global circumferential strain, global area strain, and global radial strain (all P values <.001). However, the difference between patients with controlled DM and controls was observed only for GLS (P = .038). By multivariate liner regression analysis, the level of HbA1c was independently associated with the values of GLS (β = −0.274, P = .024), global circumferential strain (β = −0.245, P = .042), and global area strain (β = −0.272, P = .024).Conclusions: GLS may be a sensitive indicator of early LV systolic dysfunction in patients with DM despite normal LVEF. Poor blood glucose control, as defined by HbA1c ≥ 7%, leads to reductions of LV systolic strain in all directions that are independently associated with preclinical LV dysfunction.

Tissue Doppler Is More Sensitive and Reproducible than Spectral Pulsed-Wave Doppler for Fetal Right Ventricle Myocardial Performance Index Determination in Normal and Diabetic Pregnancies

Yen K. Bui, Alaina K. Kipps, Michael M. Brook, Anita J. Moon-Grady — 2013-03-18

Background: The aim of this study was to compare the reproducibility, agreement, and sensitivity of pulsed-wave Doppler tissue imaging (DTI) versus spectral Doppler assessment of right ventricular (RV) myocardial performance index (MPI) in midgestation fetuses in both a normal and a disease state.Methods: RV MPI was calculated using pulsed-wave DTI and spectral Doppler in normal pregnancies (n = 69) and in women with pregestational diabetes (n = 51). Intraobserver and interobserver variability and agreement were evaluated using Bland-Altman analysis. Student's t tests were used for comparisons of differences.Results: In normal fetuses, RV MPI derived by the two methods showed no statistical difference, were interchangeable (DTI, 0.51 ± 0.10; spectral Doppler, 0.50 ± 0.12; P = .686), and were in agreement by Bland-Altman analysis. However, in fetuses of mothers with diabetes, the two methods produced different RV MPI measurements (DTI, 0.56 ± 0.10; spectral Doppler, 0.51 ± 0.12; P < .001). Intraobserver and interobserver bias was lower for DTI.Conclusions: The DTI method of measuring fetal RV MPI is more sensitive, has less variability and more precision, and is better able to demonstrate subtle abnormalities in cardiac function than the spectral Doppler method in diabetic versus normal pregnancies.

Right Ventricular Mechanics in the Fetus with Hypoplastic Left Heart Syndrome

2013-03-07

Background: Right ventricular mechanics influence outcomes in patients with hypoplastic left heart syndrome (HLHS). The aim of this study was to determine whether differences in right ventricular performance have their origins in fetal life and if the architectural character of the hypoplastic left ventricle affects right ventricular mechanics.Methods: The first complete fetal echocardiograms after 17 weeks' gestation were reviewed in 84 fetuses with HLHS and in 115 gestational age-matched normal controls. Inflow, outflow, and myocardial tissue Doppler velocities were measured. E/A and E/e′ ratios and right ventricular myocardial performance index were calculated.Results: In fetuses with HLHS, there were lower tricuspid E/A ratios (mean, 0.6 ± 0.1 vs 0.7 ± 0.1; P < .001), higher E/e′ ratios (mean, 8.1 ± 2.6 vs 7.0 ± 1.3; P = .006), and higher right ventricular myocardial performance indices (mean, 0.47 ± 0.14 vs 0.40 ± 0.10; P < .001) compared with controls. Among fetuses with HLHS grouped according to left ventricular architecture, those with left ventricular endocardial fibroelastosis had the most striking differences in right ventricular mechanics.Conclusions: Right ventricular mechanics are different from normal in fetuses with HLHS and are influenced by the presence of left ventricular endocardial fibroelastosis. These differences precede the imposition of undue loading conditions as a consequence of surgical palliation and may offer clues to the development of later right ventricular failure.

Doppler Flow Patterns in the Right Ventricle–to–Pulmonary Artery Shunt and Neo-Aorta in Infants with Single Right Ventricle Anomalies: Impact on Outcome after Initial Staged Palliations

2013-03-28

Background: A Pediatric Heart Network trial compared outcomes in infants with single right ventricle anomalies undergoing Norwood procedures randomized to modified Blalock-Taussig shunt (MBTS) or right ventricle–to–pulmonary artery shunt (RVPAS). Doppler patterns in the neo-aorta and RVPAS may characterize physiologic changes after staged palliations that affect outcomes and right ventricular (RV) function.Methods: Neo-aortic cardiac index (CI), retrograde fraction (RF) in the descending aorta and RVPAS conduit, RVPAS/neo-aortic systolic ejection time ratio, and systolic/diastolic (S/D) ratio were measured early after Norwood, before stage II palliation, and at 14 months. These parameters were compared with transplantation-free survival, length of hospital stay, and RV functional indices.Results: In 529 subjects (mean follow-up period, 3.0 ± 2.1 years), neo-aortic CI and descending aortic RF were significantly higher in the MBTS cohort after Norwood. The RVPAS RF averaged <25% at both interstage intervals. Higher pre–stage II descending aortic RF was correlated with lower RV ejection fraction (R = −0.24; P = .032) at 14 months for the MBTS cohort. Higher post-Norwood CI (5.6 vs 4.4 L/min/m2, P = .04) and lower S/D ratio (1.40 vs 1.68, P = .01) were correlated with better interstage transplantation-free survival for the RVPAS cohort. No other Doppler flow patterns were correlated with outcomes.Conclusions: After the Norwood procedure, infants tolerated significant descending aortic RF (MBTS) and conduit RF (RVPAS), with little correlation with clinical outcomes or RV function. Neo-aortic CI, ejection time, and S/D ratios also had limited correlations with outcomes or RV function, but higher post-Norwood neo-aortic CI and lower S/D ratio were correlated with better interstage survival in those with RVPAS.

Twenty-Five Years of Fetal Echocardiography in Conjoined Twins: Lessons Learned

2013-04-05

Background: The aim of this study was to determine the accuracy of prenatal echocardiography in the diagnosis of intracardiac malformations and the degree of cardiac fusion in conjoined twins presenting to a single center over a 25-year period.Methods: The study group included 53 sets of conjoined twins from 1987 to 2012, including 38 thoracopagus, six parapagus, six omphalo-ischiopagus, two omphalopagus, and one cephalopagus. Twins were classified according to the degree of cardiac fusion: separate hearts and pericardium (group A, n = 10), separated hearts and common pericardium (group B, n = 2), fused atria and separated ventricles (group C, n = 2), and fused atria and ventricles (group D, n = 39). Postmortem examination was possible in 68 individual cases (98 deaths [69.3%]).Results: Cardiac defects were diagnosed in 47 sets of twins (88.6%). In 10 (18.8%), only one fetus was affected, and in 37 (69.8%), both fetuses were affected (n = 84/106 [79.2%]). There was a high predominance of right-sided lesions (63.0% [53 fetuses in 84 affected]) including pulmonary atresia or stenosis (35.7%), tricuspid atresia (11.9%), and hypoplastic or small right ventricle (21.4%). Autopsy findings added information to fetal echocardiographic findings in nine sets of twins (25.7%). Three pairs classified antenatally in groups A, B, and D were confirmed by autopsy in groups B, C, and C, respectively.Conclusions: This study demonstrates that specialized fetal echocardiography is not a perfect diagnostic tool but is sensitive enough to establish prognosis in the counseling process. Because of complexity, such evaluations should be performed only at tertiary centers by specialists who are familiar with the peculiarities of this rare malformation. The predominance of right-sided lesions is not only an interesting finding, but this information has essential importance in terms of shortening examination times, allowing a more focused analysis of the fetal heart.

Prognostic Value of Qualitative and Quantitative Vasodilator Stress Myocardial Perfusion Echocardiography in Patients with Known or Suspected Coronary Artery Disease

2013-02-28

Background: Quantification of myocardial blood flow reserve in patients with coronary artery disease using real-time myocardial perfusion echocardiography (RTMPE) has been demonstrated to further improve accuracy over the analysis of wall motion and qualitative analysis of myocardial perfusion. The aim of this study was to determine the prognostic value of qualitative and quantitative analyses obtained by RTMPE in patients with known or suspected coronary artery disease.Methods: From March 2003 to December 2008, 227 consecutive patients with normal left ventricular function who underwent RTMPE were prospectively studied. Replenishment velocity reserve (β) and myocardial blood flow reserve were derived from RTMPE. Primary outcomes were cardiac death, myocardial infarction and unstable angina with need for urgent coronary revascularization, and secondary outcomes were coronary bypass graft surgery or angioplasty.Results: During a median follow-up period of 32 months (range, 5 days to 6.9 years), 19 major events (two deaths, six myocardial infarctions, and 11 episodes of unstable angina) and 46 total events occurred. Wall motion (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.4–5.6; P = .003) and qualitative myocardial perfusion analysis (HR, 4.3; 95% CI, 2.1–8.5; P < .001) were predictors of total events but not primary events. Abnormal myocardial blood flow reserve and abnormal β reserve were predictors of total events (HR, 8.1; 95% CI, 3–21; P < .001; and HR, 16.5; 95% CI, 5.5–49; P < .001) and primary events (HR, 3.8; 95% CI, 1–15; P = .048; and HR, 8.7; 95% CI, 1.8–40; P = .005). On multivariate analysis, only abnormal β reserve was an independent predictor of total (HR, 10.6; 95% CI, 2.5–43; P = .001) and primary (HR, 10.5; 95% CI, 1.5–6; P = .015) events. Abnormal β reserve added incremental value in predicting primary events (χ2 = 2.0–13.2; P = .014).Conclusions: Quantitative adenosine stress RTMPE added independent and additional prognostic information over wall motion and qualitative myocardial perfusion analysis in patients with known or suspected coronary artery disease and normal left ventricular function.

Carotid Artery Plaque and Progression of Coronary Artery Calcium: The Multi-Ethnic Study of Atherosclerosis

2013-03-25

Background: Carotid and coronary atherosclerosis are associated with each other in imaging and autopsy studies. The aim of this study was to evaluate whether carotid artery plaque seen on carotid ultrasound can predict incident coronary artery calcification (CAC).Methods: Agatston calcium score measurements were repeated in 5,445 participants of the Multi-Ethnic Study of Atherosclerosis (MESA; mean age, 57.9 years; 62.9% women). Internal carotid artery lesions were graded as 0%, 1% to 24%, or >25% diameter narrowing, and intima-media thickness (IMT) was measured. Plaque was present for any stenosis >0%. CAC progression was evaluated with multivariate relative risk regression for CAC scores of 0 at baseline and with multivariate linear regression for CAC score > 0, adjusting for cardiovascular risk factors, body mass index, ethnicity, and common carotid IMT.Results: CAC was positive at baseline in 2,708 of 5,445 participants (49.7%) and became positive in 458 of 2,837 (16.1%) at a mean interval of 2.4 years between repeat examinations. Plaque and internal carotid artery IMT were both strongly associated with the presence of CAC. After statistical adjustment, the presence of carotid artery plaque significantly predicted incident CAC with a relative risk of 1.37 (95% confidence interval, 1.12–1.67). Incident CAC was associated with internal carotid artery IMT, with a relative risk of 1.13 (95% confidence interval, 1.03–1.25) for each 1-mm increase. Progression of CAC was also significantly associated (P < .001) with plaque and internal carotid artery IMT.Conclusions: In individuals free of cardiovascular disease, subjective and quantitative measures of carotid artery plaques by ultrasound imaging are associated with CAC incidence and progression.

Symptomatic Exercise-Induced Left Ventricular Outflow Tract Obstruction without Left Ventricular Hypertrophy

2013-03-26

Background: Left ventricular (LV) outflow tract obstruction (LVOTO) is most commonly seen in patients with hypertrophic cardiomyopathy. Postexercise dynamic LVOTO (DLVOTO) has been infrequently identified in symptomatic patients without LV hypertrophy, and its pathophysiology is not well established. The aim of this study was to identify echocardiographic abnormalities that might explain the dynamic development of systolic anterior motion, mitral-septal contact, and LVOTO in these patients.Methods: Patients with DLVOTO and normal wall thickness were compared with 20 age-matched and gender-matched controls with normal stress echocardiographic findings. Two other groups were also compared: patients with DLVOTO and mild segmental hypertrophy (segmental wall thickness ≤15 mm) and patients with normal left ventricles but DLVOTO after dobutamine stress.Results: Six symptomatic patients were identified (mean age, 48 ± 9 years; range, 37–60 years; five men) with normal wall thickness who developed DLVOTO after exercise during a 6-year period. Five had been hospitalized for cardiac symptoms. The mean postexercise LV outflow tract gradient caused by systolic anterior motion mitral-septal contact was 107 ± 55 mm Hg (range, 64–200 mm Hg). All patients had echocardiographic LV wall thicknesses in the normal range (≤12 mm). Structural abnormalities of the mitral valve were identified in all six patients. These were elongated posterior leaflets (2.0 vs 1.5 cm, P < .0005), elongated anterior leaflets (3.2 vs 2.6 cm, P = .015), increased protrusion height of the mitral valve beyond the mitral annular plane (2.6 vs 0.6 cm, P < .00001), and residual protruding portions of the mitral valve leaflets (0.85 vs 0.24 cm, P < .005). There was anterior positioning of the papillary muscles in the LV cavity, with a greater distance from the plane of the papillary muscles to the posterior wall (1.8 vs 1.3 cm, P = .03). In two patients, potentially provoking medications were stopped; two patients received β-blockers, with reductions of angina. Medium-term prognosis was good; no patient had died after 3.5 years. The mitral valve abnormalities in the 10 patients with DLVOTO and mild segmental hypertrophy were qualitatively and quantitatively very similar to those in patients with DLVOTO without hypertrophy. In contrast, the valves of patients with dobutamine stress DLVOTO were not elongated, but 50% had residual mitral leaflets that protruded past the coaptation point by ≥5 mm.Conclusions: DLVOTO after exercise can occur in the absence of LV hypertrophy and may be associated with high gradients and cardiac symptoms. Elongated, redundant mitral valve leaflets with anterior position of the papillary muscles appear to cause the postexercise obstruction.

2013-05-01

Editorial Board

2013-05-01

Information for Authors

2013-05-01

Information for Readers

2013-05-01

Accountable!

2013-05-01

I have read Dr. Marty Makary's book, Unaccountable, a disturbing, but probably not surprising account of deficiencies in the provision of healthcare in the United States. Dr. Makary, a pancreas surgeon at Johns Hopkins University Hospital and Associate Professor of Health Policy, received his medical training at some of the most prestigious medical institutions in our country. Yet, he provides a scathing insider's critique of the actual practices at these institutions and others nationwide. He reports on the broad variation in care within a given hospital, with physicians' recommendations for treatment, including surgery, radiation therapy, or chemotherapy, biased by their personal financial gain; popular but incompetent or even dangerous physicians retained by hospitals because of financial benefit to the institution from their surgeries, and in some cases, additional revenue brought in by complications from their poorly performed work. Makary describes unnecessary surgery endangering patients and the failure of the physicians to provide honest assessments of the risk and benefit of treatment. He criticizes the egregious fundraising practices of hospitals where CEOs earn massive salaries and lavish benefits, “40-50 times more than what they pay their nurses”, and the false advertising claims such as designations of specialty centers, when little expertise actually exists. The book is peppered with specific examples of adverse consequences experienced by completely unsuspecting patients. Dr. Makary calls for transparency and accountability in our medical systems.

Continuing Education and Meeting Calendar

2013-05-01

The American Society of Echocardiography is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASE recognizes courses as supplements to formal training in an established echocardiographic laboratory. For more information about a course, please call the number listed. To list a course in the Continuing Education and Meeting Calendar, send the date(s), title, location, sponsor, course director(s), and contact information to ASE, Attn: Cheryl Williams, 2100 Gateway Centre Boulevard, Suite 310, Morrisville, NC 27560; Tel: 919-861-5574 x7160; E-mail: cwilliams@asecho.org.

Minnesota, Eh?

2013-05-01

Yes! Minneapolis, nicknamed “City of Lakes,” will be the stage for the 2013 Scientific Sessions. It truly is a beautiful city and with the sessions taking place in late June, we should have beautiful weather as well. Minneapolis lies on the banks of the Mississippi River, and adjoins Saint Paul, the state's capital. Known as the Twin Cities, Minneapolis–Saint Paul is the 16th largest metropolitan area in the United States, with an abundance of natural and cultural activities. The convention center is relatively new, and although it is quite large, the layout and event space is well organized.

Noninvasive Vascular Appropriateness Criteria—Review and Comments on the American College of Cardiology (ACC) Guidelines

2013-05-01

Appropriateness criteria are becoming increasingly important in US health care. Not only do they allow for improved patient care and health outcomes in a cost-effective manner; they also act as useful and practical guidelines for the treating physician. These criteria are becoming a benchmark against which insurers will reimburse noninvasive testing. Unlike cardiac ultrasound indications, for which separate appropriateness criteria exist, the indications for arterial vascular ultrasound of all major vessels in the body are much broader and there is an even greater need for appropriateness criteria for peripheral vascular testing.

Journal of the American Society of Echocardiography

Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Estimation of Pulmonary Pressures and Diagnosis of Pulmonary Hypertension by Doppler Echocardiography: A Retrospective Comparison of Routine Echocardiography and Invasive Hemodynamics

Derivation of Mean Pulmonary Artery Pressure from Noninvasive Parameters

Can Pulmonary Hypertension and Increased Pulmonary Vascular Resistance Be Ruled in and Ruled Out by Echocardiography?

Doppler under Pressure: It's Time to Cease the Folly of Chasing the Peak Right Ventricular Systolic Pressure

Ventricular Function and Dyssynchrony Quantified by Speckle-Tracking Echocardiography in Patients with Acute and Chronic Right Ventricular Pressure Overload

Independent and Incremental Value of Deformation Indices for Prediction of Trastuzumab-Induced Cardiotoxicity

Differential Changes of Left Ventricular Myocardial Deformation in Diabetic Patients with Controlled and Uncontrolled Blood Glucose: A Three-Dimensional Speckle-Tracking Echocardiography–Based Study

Tissue Doppler Is More Sensitive and Reproducible than Spectral Pulsed-Wave Doppler for Fetal Right Ventricle Myocardial Performance Index Determination in Normal and Diabetic Pregnancies

Right Ventricular Mechanics in the Fetus with Hypoplastic Left Heart Syndrome

Doppler Flow Patterns in the Right Ventricle–to–Pulmonary Artery Shunt and Neo-Aorta in Infants with Single Right Ventricle Anomalies: Impact on Outcome after Initial Staged Palliations

Twenty-Five Years of Fetal Echocardiography in Conjoined Twins: Lessons Learned

Prognostic Value of Qualitative and Quantitative Vasodilator Stress Myocardial Perfusion Echocardiography in Patients with Known or Suspected Coronary Artery Disease

Carotid Artery Plaque and Progression of Coronary Artery Calcium: The Multi-Ethnic Study of Atherosclerosis

Symptomatic Exercise-Induced Left Ventricular Outflow Tract Obstruction without Left Ventricular Hypertrophy

Table of Contents

Editorial Board

Information for Authors

Information for Readers

Accountable!

Continuing Education and Meeting Calendar

Minnesota, Eh?

Noninvasive Vascular Appropriateness Criteria—Review and Comments on the American College of Cardiology (ACC) Guidelines