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Open access

Jet van Zalen, Sveeta Badiani, Lesley M Hart, Andrew J Marshall, Louisa Beale, Gary Brickley, Sanjeev Bhattacharyya, Nikhil R Patel and Guy W Lloyd


Mortality dramatically rises with the onset of symptoms in patients with severe aortic stenosis (AS). Surgery is indicated when symptoms become apparent or when there is ventricular decompensation. Cardiopulmonary exercise testing (CPET) in combination with exercise echocardiography can unmask symptoms and provides valuable information regarding contractile reserve. The aim of the present study was to determine the prevalence of reduced exercise tolerance and the parameters predicting adverse cardiovascular events.


Thirty-two patients with asymptomatic severe AS were included in this study. Patients were followed up as part of an enhanced surveillance clinic.


Age was 69 ± 15.7 years, 75% of patients were male. Patients had a raised NT-ProBNP of 301 pg/mL. VO2peak was 19.5 ± 6.2 mL/kg/min. Forty-one percent of patients had a reduced %VO2peak and this predicted unplanned cardiac hospitalisation (P = 0.005). Exercise systolic longitudinal velocity (S′) and age were the strongest independent predictors for VO2peak (R 2 = 0.76; P < 0.0001). Exercise S′ was the strongest independent predictor for NT-ProBNP (R 2 = 0.48; P = 0.001).


A large proportion of patients had a lower than predicted VO2peak. The major determinant of exercise and NT-ProBNP is the ability of the left ventricle (LV) to augment S′ on exercise rather than the severity of aortic valve obstruction or resting structural remodelling of the LV. Reduced exercise tolerance and more adverse remodelling, rather than valve obstruction predicted unplanned hospitalisation. This study demonstrates that for those patients, in whom a watchful waiting is an agreed strategy, a detailed assessment should be undertaken including CPET, exercise echocardiography and biomarkers to ensure those with exercise limitation and risk of decompensation are detected early and treated appropriately.

Open access

Josef Finsterer and Claudia Stöllberger

Open access

Christopher Johnson, Katherine Kuyt, David Oxborough and Martin Stout

Strain imaging provides an accessible, feasible and non-invasive technique to assess cardiac mechanics. Speckle tracking echocardiography (STE) is the primary modality with the utility for detection of subclinical ventricular dysfunction. Investigation and adoption of this technique has increased significantly in both the research and clinical environment. It is therefore important to provide information to guide the sonographer on the production of valid and reproducible data. The focus of this review is to (1) describe cardiac physiology and mechanics relevant to strain imaging, (2) discuss the concepts of strain imaging and STE and (3) provide a practical guide for the investigation and interpretation of cardiac mechanics using STE.

Open access

Sothinathan Gurunathan and Roxy Senior

Open access

Sahrai Saeed, Eva Gerdts, Ulrike Waje-Andreassen, Juha Sinisalo and Jukka Putaala


The incidence of ischemic stroke in young patients is increasing and associated with unfavorable prognosis due to high risk of recurrent cardiovascular events. In many young patients the cause of stroke remains unknown, referred to as cryptogenic stroke. Neuroimaging frequently suggests a proximal source of embolism in these strokes. We developed a comprehensive step-by-step echocardiography protocol for a prospective study with centralized reading to characterize preclinical cardiac changes associated with cryptogenic stroke.

Methods and study design

SECRETO (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome; NCT01934725) is an ongoing multicenter case–control study enrolling patients (target n = 600) aged 18–49 years hospitalized due to first-ever ischemic stroke of undetermined etiology and age- and sex-matched controls (target n = 600). A comprehensive assessment of cardiovascular risk factors and extensive cardiac imaging with transthoracic and transesophageal echocardiography, electrocardiography and neurovascular imaging is performed. Transthoracic and transesophageal echocardiograms will be centrally read, following an extensive protocol particularly emphasizing the characteristics of left atrium, left atrial appendage and interatrial septum.


A detailed assessment of both conventional and unconventional vascular risk factors and cardiac imaging with transthoracic and transesophageal echocardiography are implemented in SECRETO, aiming to establish indirect and direct risk factors and causes for cryptogenic stroke and novel pathophysiological brain–heart pathways. This may ultimately enable more personalized therapeutic options for these patients.

Open access

Hannah Bellsham-Revell, Antigoni Deri, Silvia Caroli, Andrew Durward, Owen Miller, Sujeev Mathur, Jelena Saundankar, David Anderson, B Conal Austin, Caner Salih, Kuberan Pushparajah and John Simpson

Background: The Technical Performance Score (TPS) developed by Boston Children’s Hospital showed surgical outcomes correlate with adequacy of technical repair when implemented on pre-discharge scans. We applied this scoring system to intraoperative imaging in a tertiary UK congenital heart surgical centre to gauge if intraoperative TPS correlated with patient outcome.

Methods: After a period of training, intraoperative TPS (epicardial and/or transesophageal echocardiography) was instituted. TPS was used to inform intraoperative discussions and recorded on a custom-made database using the previously published scoring system. After a year we assessed the relationship between the TPS and mortality and extubation time.

Results: From 01 September 2015 to 04 July 2016 there were 272 TPS procedures in 251 operations with 208 TPS recorded. Seven patients had surgery with no documented TPS, 3 had operations with no current TPS score template available. Patients left the operating theatre with TPS optimal in 156 (75%), adequate 34 (16%) and inadequate 18 (9%). Of those with an optimal score on leaving theatre, 10 had more than one period of cardiopulmonary bypass. There was a non-significant trend towards patients with optimal/adequate TPS having shorter times to extubation: median (range) of 1(0-26 days) and 2.5(0-11 days) respectively(p=0.05). There were 9 deaths <30days after surgery (3.6%); 4 had TPS recorded (optimal in all cases).

Conclusions: Application of intraoperative TPS is feasible and provides a way of objectively recording intraoperative imaging assessment of surgery. There was no significant difference in extubation times between the groups nor did an ‘inadequate’ TPS score predict mortality.

Open access

Victor Dahl Mathiasen, Christian Alcaraz Frederiksen, Christian Wejse and Steen Hvitfeldt Poulsen

Tuberculous pericarditis is a rare diagnosis seen among as few as 1% of tuberculosis (TB) patients in developed countries. We present a case of a 60‐year‐old male suffering from a transient constrictive pericarditis and subclinical involvement of the myocardium in a clinical case of tuberculous pericarditis with corresponding improvement after the initiation of anti-tuberculous treatment. We suggest monitoring of myocardial function using global longitudinal strain by myocardial speckle tracking strain analysis as supplement to routine left ventricular ejection fraction, to assess clinical improvement in patients at risk of developing constrictive pericarditis.

Open access

Mary Mashicharan, Zein El-Dean, Viktor Zlocha and Jeffrey Khoo

Fibroelastomas are rare, primary cardiac tumours with a predilection for valvular endothelium and a propensity to embolize. We present the case of a 72-year-old male with multiple cerebrovascular events (CVA) despite oral anticoagulation. Transoesophageal echocardiography (TOE) revealed a small mobile left atrial mass with frond like projections attached by a stalk to the orifice of the left atrial appendage(LAA). The mass was surgically excised and confirmed to be a fibroelastoma on histological examination. This case report describes a rare but treatable source of CVAs and highlights the utility of TOE in the assessment of cardiac embolic source.

Open access

Catrin Williams, Anca Mateescu, Emma Rees, Kirstie Truman, Claire Elliott, Bohdana Bahlay, Ailsa Wallis and Adrian Ionescu

Background. Data about the epidemiology of valvular heart disease (VHD) in the elderly is scarce. Hand-held ultrasound devices (HUD) enable point of care ultrasound scanning (POCUS) but their use in an elderly population has not been reported for VHD screening in primary practice.

Methods. One hundred consecutive subjects aged >70y without a VHD diagnosis had 2D and colour Doppler POCUS by an accredited sonographer, using a contemporary HUD (Vscan), in a primary practice setting. Patients with left-sided valve pathology identified by Vscan were referred for formal echo in the local tertiary cardiac centre.

Results. Mean age (SD) was 79.08 (3.74) years, [72-92 years]; 61F. By Vscan, we found 5 patients with >/= moderate aortic stenosis (AS), 8 with >/= moderate mitral regurgitation (MR) and none with >/= mild aortic regurgitation. In the AS and MR groups each, 1 patient had valve intervention following from the initial diagnosis by Vscan, 2 and 1 respectively are under follow-up in the valve clinic, while 2 and 4 respectively refused TTE or follow-up. Two patients with moderate MR by Vscan had mild and mild/moderate MR respectively by TTE and were discharged. Total cost for scanning 100 patients was $18,201 - i.e. $182/patient.

Conclusions. Screening with a hand-held scanner (Vscan) we identified 5/100 elderly subjects who needed valve replacement or follow-up in valve clinic, at a cost of $182/patient. These findings have potential significance for the allocation of resources in the context of an ageing population.

Open access

Karthik Seetharam, Nobuyuki Kagiyama and Partho P Sengupta

The intersection of global broadband technology and miniaturized high-capability computing devices has led to a revolution in the delivery of healthcare and the birth of telemedicine and mobile health (mHealth). Rapid advances in handheld imaging devices with other mHealth devices such as smartphone apps and wearable devices are making great strides in the field of cardiovascular imaging like never before. Although these technologies offer a bright promise in cardiovascular imaging, it is far from straightforward. The massive data influx from telemedicine and mHealth including cardiovascular imaging supersedes the existing capabilities of current healthcare system and statistical software. Artificial intelligence with machine learning is the one and only way to navigate through this complex maze of the data influx through various approaches. Deep learning techniques are further expanding their role by image recognition and automated measurements. Artificial intelligence provides limitless opportunity to rigorously analyze data. As we move forward, the futures of mHealth, telemedicine and artificial intelligence are increasingly becoming intertwined to give rise to precision medicine.