Prevalence and inter-relationship of different Doppler measures of dyssynchrony in patients with heart failure and prolonged QRS: a report from CARE-HF

Background: Cardiac resynchronisation therapy (CRT) improves mortality and morbidity in heart failure patients with wide QRS. Observational studies suggest that patients having more left ventricular dyssynchrony pre-implantation obtain greater benefit on ventricular function and symptoms with CRT.Aim: To provide an analysis of the prevalence and type of dyssynchrony in patients included in the CARE-HF trial.Methods: 100 patients 67 (58 to 71) years were examined with echocardiography including tissue doppler imaging before receiving a CRT-pacemaker. Atrio-ventricular dyssynchrony (LVFT/RR) was defined as left ventricular filling time <40% of the RR-interval. Inter-ventricular mechanical delay (IVMD) was measured as the difference in onset of Doppler-flow in the pulmonary and aortic outflow tracts >40 ms. Intraventricular (regional) dyssynchrony in a 16-segment model was expressed either as a delayed longitudinal contraction (DLC) during the postsystolic phase or by tissue synchronisation imaging (TSI) with a predefined time-difference in systolic maximal velocities >85 ms.Results: LVFT/RR was present in 34% and IVMD in 60% of patients while intra-ventricular dyssynchrony was present in 85% (DLC) and 86% (TSI) with a high agreement between the measures (Kappascore 0.86-1.00), indicating the methods being interchangeable. Patients with cardiomyopathy (53%) were more likely to have LVFT/RR <40% (45% vs. 21% (p= 0.02)) and more segments affected by intra-ventricular dyssynchrony 4(3, 5) vs. 3(1, 4), p = 0.002, compared to patients with ischemic heart disease.Conclusion: The prevalence of intra-ventricular dyssynchrony is high in patients with heart failure, wide QRS and depressed systolic function. Most important, TSI appears to be a fast and reliable method to identify patients with intra-ventricular dyssynchrony likely to benefit from CRT

Manual on indications and performance of specific echocardiographic applications

The second manual on indications for and performance of echocardiography focusses on specific echocardiographic modalities and special problems in several patient cohorts. Practical aspects are discussed with priority. Established echocardiographic modalities are transesophageal, stress and contrast echocardiography. Modern technologies, such as 3D echocardiography and deformation imaging play an important role in nearly all scenarios of clinical echocardiography. This complete echocardiographic spectrum is incorporated into emergency and intensive care medicine, monitoring interventions of structural heart diseases, cardiac surgery, patients with cardiac assist devices, adult patients with congenital heart diseases and the care of highly infectious patients in pandemics. The diagnostic procedures of conventional and modern echocardiography are highlighted in this manual. The use of 3D echocardiography to characterize cardiac morphology and the application of deformation imaging to objectify cardiac function are already established in clinical practice. Stress echocardiography to detect myocardial ischemia and viability or to diagnose valvular heart diseases, assessment of coronary flow reserve to analyze myocardial perfusion and contrast echocardiography for left ventricular opacification and tumor characterization are increasingly being used to improve diagnostics. As mentioned for conventional echocardiography in the last manual of echocardiography in 2009, the modern features in echocardiography require standardized documentation and acquisition of certain images with optimized ultrasound settings, because conclusive and reproducible data analysis can only be performed if the image quality is sufficient

Enhanced left ventricular endocardial border delineation with an intravenous injection of SonoVue, a new echocardiographic contrast agent : A European multicenter study.

The safety and efficacy of SonoVue (also referred to as BR1), a new contrast agent for delineating endocardial border of the left ventricle after intravenous administration, was assessed. Two hundred and eighteen patients with suspected coronary artery disease undergoing fundamental echocardiography for the assessment of left ventricle were enrolled in a prospective multicenter, single blind, cross-over study with random sequence allocation of four different doses of SonoVue. Endocardial border definition in the apical and parasternal views was scored as 0 = not visible, 1 = barely visible, and 2 = well visualized before and after contrast enhancement. Analysis was performed by two pairs of off-site observers. Safety of SonoVue was also assessed. Results of our study indicated that the mean improvements in the endocardial border visualization score were as follows: 3.1 +/- 7.8 (95% CI, 2.5 and 3.7) for 0.5 ml, 3.4 +/- 8.0 (95% CI, 2.8 and 4.0) for 1 ml, 3.4 +/- 7.9 (95% CI, 2.8 and 4.0) for 2 ml, and 3.7 +/- 8.0 (95% CI, 3.1 and 4.3) for 4 ml (P < 0.05 for all doses from baseline). Changes from baseline in endocardial visualization scores were also seen in the apical views (P < 0.05) and they were dose-dependent (P < 0.001). Similar enhancements of endocardial visualization scores were observed in the apical views in patients with suboptimal baseline echocardiographic images. Diagnostic confidence for assigning a score and image quality also were significantly better following contrast enhancement. No significant changes in the laboratory parameters and vital signs were noted following contrast enhancement, and the side effects were minimal. It was concluded that SonoVue is safe and effective in delineating endocardial border, including in patients with suboptimal baseline images