Patients with mitral stenosis have usually blunted pulmonary venous (PV) flow, because of decreased mitral valve area and diastolic dysfunction. The authors compared changes in Doppler PV velocities ...by using transesophageal echocardiography (TEE) against hemodynamics parameters before and after mitral balloon valvotomy to observe relevance of PV velocities and endsystolic left atrial (LA) pressure-volume relationship. In 25 patients (aged 35 +/- 17 years) with mitral stenosis in sinus rhythm, changes in LA pressure and volumes were compared with PV velocities before and after valvotomy. Mitral valve area, mitral gradients, and deceleration time were obtained. Mitral valve area and mitral gradients changed from 1 +/- 0.2 cm2 and 14.6 +/- 5.4 mmHg to 1.9 +/- 0.3 cm2 and 6.3 +/- 1.7 mmHg, respectively (p<0.001). AR peak reverse flow velocity and AR duration decreased from 29 +/- 13 cm/s and 110 =/- 30 msec to 19 +/- 6 cm/s and 80 +/- 29 msec respectively (p<0.001). Transmitral Doppler E wave deceleration time decreased from 327 +/- 85 to 209 +/- 61 s and cardiac output increased from 4.2 +/- 1.0 to 5.2 +/- 1.1 L/minute (p<0.001). The changes in LA pressure were correlated with changes in S/D (r=0.57, p<0.05). The changes in endsystolic LA pressure-volume relationship were also correlated with changes in S/D (r=0.52, p<0.05). Endsystolic LA pressure-volume relationship decreased after mitral balloon valvotomy, as a result of a large decrease in pressure. PV systolic/diastolic (S/D) waves ratio reflects endsystolic LA pressure-volume relationship and may be used as another indicator of successful valvotomy.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
The updated second edition of the "Curriculum cardiology", first edition 2013, aims to show which competences a cardiologist should nowadays master. It is very pleasing that in this second edition ...representatives of the Young German Cardiac Society (Young DGK) have contributed as authors. The increasing specialization within cardiology should, however, only represent one side of the coin: there must also still be a common foundation of cardiology, embedded in the discipline "internal medicine". This foundation includes the basis of theoretical knowledge, practical skills (competence levels I-III) and an occupational and professional attitude of the (prospective) cardiologist. New additions to the advanced training since the first edition of the curriculum in 2013 are, for example a chapter on digital cardiology, the further training in psychocardiology, which was newly introduced into the model further training regulations and finally also the explicit formulation of shared decision making in the interests of cardiac patients. The curriculum should give the prospective cardiologist the possibility to structure the further training as efficiently as possible and ultimately to retain and expand that which has been learned in the sense of a "professional lifelong" qualification. The curriculum also aims to reach the trainers and the Medical Councils and demonstrate which contents and skills should be mediated in the further training to become a cardiologist from the perspective of the German Cardiac Society (DGK).
Background and hypothesis: Myocardial contrast echocardiography using second‐generation agents has been proposed to study myocardial perfusion. A placebo‐controlled, multi‐center trial was conducted ...to evaluate the safety, optimal dose, and imaging mode for NC100100, a novel intravenous second‐generation echo contrast agent, and to compare this technique with technetium ‐ 99m sestamibi (MIBI) single‐photon emission computed tomography (SPECT).
Methods: In a placebo‐controlled, multicenter trial, 203 patients with myocardial infarction > 5 days and < 1 year previously underwent rest SPECT and MCE. Fundamental and harmonic imaging modes combined with continuous and electrocardiogram‐ (ECG) triggered intermittent imaging were used. Six dose groups (0.030, 0.100, and 0.300 μl particles/kg body weight for fundamental imaging; and 0.006, 0.030, and 0.150 μl particles/kg body weight for harmonic imaging) were tested. A saline group was also included. Safety was followed for 72 h after contrast injection. Myocardial perfusion by MCE was compared with myocardial rest perfusion imaging using MIBI as a tracer.
Results: NC100100 was well tolerated. No serious adverse events or deaths occurred. No clinically relevant changes in vital signs, laboratory parameters, and ECG recordings were noted. There was no significant difference between adverse events in the NC100100 (25.7%) and in the placebo group (17.9%, p=0.3). Intermittent harmonic imaging using the intermediate dose was superior to all other modalities, allowing the assessment of perfusion in 76% of all segments. Eighty segments (96%) with normal perfusion by SPECT imaging also showed myocardial perfusion with MCE. However, a substantial percentage of segments (61–80%) with perfusion defects by SPECT imaging also showed opacification by MCE. This resulted in an overall agreement of 66–81% and a high specificity (80–96%), but in low sensitivity (20–39%) of MCE for the detection of perfusion defects.
Conclusion: NC100100 is safe in patients with myocardial infarction. Intermittent harmonic imaging with a dose of 0.03 μl particles/kg body weight can be proposed as the best imaging protocol. Myocardial contrast echocardiography with NC 100100 provides perfusion information in approximately 76% of segments and results in myocardial opacification in the vast majority of segments with normal perfusion as assessed by SPECT. Although the discrepancies between MCE and SPECT with regard to the definition of perfusion defects requires further investigation, MCE with NC 100100 is a promising technique for the noninvasive assessment of myocardial perfusion.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
We sought to assess the feasibility and accuracy of myocardial contrast echocardiography (MCE) using standard imaging approaches for the detection of perfusion defects in patients who had a ...myocardial infarction (MI).
Myocardial contrast echocardiography may be more versatile than perfusion scintigraphy for identifying the presence and extent of perfusion defects after MI. However, its reliability in routine practice is unclear.
Fundamental or harmonic MCE was performed with continuous or triggered imaging in 203 patients with a previous MI using bolus doses of a perfluorocarbon-filled contrast agent (NC100100). All patients underwent single-photon emission computed tomography (SPECT) after the injection of technetium-99m (Tc-99m) sestamibi at rest. Quantitative and semiquantitative SPECT, wall motion and digitized echocardiographic data were interpreted independently. The accuracy of MCE was assessed for detection of segments and patients with moderate and severe sestamibi-SPECT defects, as well as for detection of patients with extensive perfusion defects (>12% of left ventricle).
In segments with diagnostic MCE, the segmental sensitivity ranged from 14% to 65%, and the specificity varied from 78% to 95%, depending on the dose of contrast agent. Using both segment- and patient-based analysis, the greatest accuracy and proportion of interpretable images were obtained using harmonic imaging in the triggered mode. For the detection of extensive defects, the sensitivity varied from 13% to 48%, with specificity from 63% to 100%. Harmonic imaging remained the most accurate approach. Time since MI and SPECT defect location and intensity were all determinants of the MCE response. The extent of defects on MCE was less than the extent of either abnormal wall motion or SPECT abnormalities. The combination of wall motion and MCE assessment gave the best balance of sensitivity (46% to 55%) and specificity (82% to 83%).
Although MCE is specific, it has limited sensitivity for detection of moderate or severe perfusion defects, and it underestimates the extent of SPECT defects. The best results are obtained by integration with wall motion. More sophisticated methods of acquisition and interpretation are needed to enhance the feasibility of this technique in routine practice.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
A lumped parameter mathematical model of left ventricular filling applicable to analysis of Doppler mitral velocity inflow patterns has been developed. As originally formulated, the model utilizes ...user-provided chamber compliance and mitral impedance parameters and returns the time course of chamber pressure and mitral velocity and flow. The authors describe their initial experience with an algorithm to invert the model, i.e. to analyze observed pressure and flow data and extract the compliance and impedance parameters underlying the observed curves. This algorithm repeatedly solves the forward model, adjusting the physiologic parameters using the Marquardt method until the fit to the observed pressure and flow data is optimized. This algorithm was tested against computer-generated data with up to 10% Gaussian noise. It has also been validated with data from an in vitro analog of the left heart and from a canine model of mitral stenosis. Other possible inversion schemes, such as those which utilize only noninvasive data, are also discussed.< >
Every perioperative transoesophageal echo (TEE) study should generate a written report. A verbal report may be given at the time of the study. Important findings must be included in the written ...report. Where the perioperative TEE findings are new, or have led to a change in operative surgery, postoperative care or in prognosis, it is essential that this information should be reported in writing and available as soon as possible after surgery. The ultrasound technology and methodology used to assess valve pathology, ventricular performance and any other derived information should be included to support any conclusions. This is particularly important in the case of new or unexpected findings. Particular attention should be attached to the echo findings following the completion of surgery. Every written report should include a written conclusion, which should be comprehensible to physicians who are not experts in echocardiography.
In view of the European Association of Echocardiography (EAE) mission statement “To promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular ...ultrasound in Europe” and the increasing demand for standardization and quality control, the EAE have established recommendations and guidelines for standardization of echocardiography performance, data acquisition (images, measurements and morphologic descriptors), digital storage and reporting of echocardiographic studies. The aim of these recommendations is to provide a European consensus document on the minimum acceptable requirements for the clinical practice of echocardiography today and thus improve the quality and consistency of echocardiographic practice in Europe.
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