Prognostic value of low-dose dobutamine stress echocardiography in patients with aortic stenosis and impaired left ventricular function.

INTRODUCTION: The aim of this multicenter, prospective study was to evaluate the long-term prognostic value of low-dose dobutamine stress echocardiography (LDDSE) in patients with aortic stenosis (AS) and depressed left ventricular (LV) function. MATERIAL AND METHODS: The study group comprised 39 patients (34 male, mean age 59 +/-13 years) with AS (peak gradient > 25 mm Hg), LV ejection fraction (LVEF) </= 45% and low transaortic gradient (peak gradient </= 45 mm Hg, mean gradient </= 35 mm Hg). The qualification for subsequent therapeutic procedures was based on generally accepted indications. All patients underwent LDDSE and coronary angiography. Twelve months after LDDSE patients underwent control resting echocardiography and clinical evaluation. RESULTS: Twenty-seven (69.2%) patients had preserved contractile reserve. In this subgroup, true-severe AS was diagnosed in 12 patients, whereas pseudo-severe AS was found in 15 patients. Nine patients with true-severe AS, 2 patients with pseudo-severe AS and 7 patients without contractile reserve were referred for surgical treatment. The independent risk factors of death during follow-up were: aortic valve area (AVA) at peak stress < 0.8 cm(2) (OR 1.4; p = 0.003) and LVEF at rest < 35% (OR 6.8; p = 0.05). The independent risk factors of composite end-point (death or myocardial infarctions or pulmonary edema) were: AVA at stress < 0.8 cm(2) (OR 4.0; p = 0.03), absence of AVA increase during LDDSE (OR 5.7; p = 0.005), absence of contractile reserve (OR 4.5; p = 0.01) and presence of significant CAD (OR 6.9; p = 0.02). CONCLUSIONS: In patients with AS and depressed LVEF, LDDSE is a useful tool for long-term risk stratification

Influence of gender on diagnostic accuracy of rapid atrial and ventricular pacing stress echocardiography for the detection of coronary artery disease: a multicenter study (Pol-RAPSE final results).

BACKGROUND: Rapid cardiac pacing using a permanent pacemaker may be used as a nonpharmacologic stress during echocardiographic imaging for diagnosing coronary artery disease (CAD). We presented the final results of a national multicenter study, the Polish study on Rapid Pacing Stress Echocardiography (Pol-RAPSE), aimed at the assessment of the safety and accuracy of rapid cardiac pacing for the noninvasive diagnosis of CAD in women and men. METHODS: We have analyzed 149 tests performed in 100 patients with permanent pacemakers (27% ventricular pacing [VVI], 10% atrial pacing [AAI], 63% dual chamber pacing [DDD]) referred for stress echocardiography. All patients underwent coronary angiography as a reference for assessing the accuracy of rapid cardiac pacing stress echocardiography (RAPSE). Significant CAD was defined as luminal diameter reduction more than 50% in at least 1 major epicardial coronary artery. RESULTS: Peak stress was obtained in 73 patients using physiologic stimulation of right atrium by and mode or in 76 patients by VVI mode. Significant CAD was detected by angiography in 46% of women and 57% of men (P = not significant). The feasibility of the test was 98%. Overall accuracy of the test was slightly lower in women than in men (75% vs 88%, P = .04), although there were no significant differences in sensitivity, specificity, and positive and negative predictive values between the genders. In women (n = 48), the accuracy of RAPSE performed in AAI and VVI mode was 79% and 70% with no significant difference and in men was 89% and 87%, respectively (P = not significant). CONCLUSION: RAPSE is a safe and feasible modality for diagnosing CAD. The method offers slightly higher accuracy in men compared with women. Overall efficacy is satisfactory with both AAI and VVI pacing, although easier interpretation of peak AAI/DDD images results in a trend toward better accuracy

Cardiovascular imaging practice in Europe: a report from the European Association of Cardiovascular Imaging.

The need for cardiovascular imaging (CVI) is expected to increase over the coming years due to the changes in CV disease epidemiology and ageing of the population. However, reliable statistics on CVI practice in Europe are lacking. Establishing the current status of the use of CVI across Europe has become the first comprehensive project of the European Association of Cardiovascular Imaging and the European Society of Cardiology Taskforce on CVI. In 2013, a survey with relevant information regarding CVI was sent to all National Imaging/Echocardiography Societies and Working Groups. Representatives from 41 countries returned the questionnaire. The present report provides key results of the survey, relating to existing education, training, certification and national accreditation programmes, healthcare organizations, and reimbursement systems

Clinical value of stress transaortic flow rate during dobutamine echocardiography in reduced left ventricular ejection fraction, low-gradient aortic stenosis : a multicenter study

BACKGROUND: Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality. METHODS: This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm2 and mean gradient <40 mmHg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality. RESULTS: Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94–0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05–2.82]; P=0.03). Furthermore aortic valve area <1cm2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality. CONCLUSIONS: Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention

Primož Ramovš\u27s Miniatures for piano

Primož Ramovš (1921-1999) je klavirske Miniature napisal jeseni 1945. Po končanem študiju pri Slavku Ostercu v Ljubljani (1941) ter izpopolnjevanju pri Alfredu Caselli v Rimu (1941-1943) so bile njegovo drugo obsežno poštudijsko delo. Zasnoval jih je kot variacije na koral, s katerim je bil uvedel sklepni stavek Druge simfonije (1943-1944). Sprva jih je želel imenovati variacije brez teme. V desetih odstavkih nastopa izhodiščna misel razdeljena v dve ne zelo kontrastni temi, ki sta vsakokrat obravnavani bodisi zaporedoma bodisi le enav prvotni melodični dikciji se avgmentirani oglasita le v srednjem delu zadnjega odstavka. Delo potemtakem niso variacije brez teme, temveč z utajeno temo, zaradi (morda različnih) zunanjih okoliščin pa jih je avtor slednjič in ne najbolj primerno imenoval Miniature. Bile so natisnjene 1955. leta, kot celota pa prvič javno izvedene šele jeseni 1963 in samó v radijskem programu. Ciklus kaže skladatelja na začetku samostojne poti. V njem so prepleteni idiomi splošnega neoklasicizma med obema vojnama, enako druga modernistična načela, ki jih je pri Slovencih uvajal Osterc, z ostanki starejšega kompozicijskega repertorija, ki ga je bil Ramovš spoznaval na koncertih in med pianističnim študijem. Oboje govori o potezah neoklasicizma na Slovenskem do 1945. leta, predvsem pa razkriva ustvarjalca z izrazitim novatorskim pogumom ter improvizacijsko domišljijo, širokopoteznega v zasnovah in usmerjenega k skrajnim območjem (klavirske) zvočnosti.Primož Ramovš (1921-1999) wrote his piano Miniature (Miniatures) during the autumn of 1945. After finishing his studies with Slavko Osterc in Ljubljana (1941) and taking advanced courses with Alfredo Casella in Rome (1941-1943), these pieces were his second major works. He conceived them as variations on the chorale that introduced the final movement of his Second Symphony (1943-1944). At first, he wanted to name them variations without a theme. Throughout the ten parts, the introductory musical thought unfolds in the formof two contrasting themes, both included either successively or singlyin the original melodic diction they appear augmented only in the middle section of the final part. Thus the piece is not, in fact, a set of variations without a theme, but rather has a "concealed" theme. Due to (possibly various) external circumstances the composer eventually entitled them, perhaps not the most conveniently: Miniature (Miniatures). They were published in 1955 but were not performed as a whole until the autumn of 1963, and even then only were only performed within the context of a broadcast programme. The cycle represents the beginnings of Ramovšćs autonomous artisticpath. Various idioms of ĆcommonĆ neoclassicism from the period betweenthe wars are intertwined with other modernist principles introduced by Osterc, along with the older compositional repertoire that Ramovš was familiar with from concerts and his piano studies. Both bear witness to the features of neoclassicism in Slovenia before 1945, but above all reveal a composer with distinctive innovative courage and an "improvisational" imagination, liberal in design and oriented towards extreme regions of (piano) sonorities

Cardiovascular multimodality imaging in women. A scientific statement of the European Association of Cardiovascular Imaging (EACVI) of the ESC

International audienceCardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been underrepresented in most CVD imaging studies and trials regarding diagnosis, prognosis and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making and monitoring of therapeutics and interventions. However, multimodality imaging (MMI) in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy, menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on cardiovascular multimodality in women, an initiative of the EACVI of the ESC reviews the role of multimodality CV imaging in the diagnosis, management and risk-stratification of CVD, as well as highlighting important gaps in our knowledge that require further investigation

2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC)Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM).

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