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Purpose Echocardiography is a common tool for cardiac and hemodynamic assessments in critical care research. However, interpretation (and applications) of results and between-study comparisons are often difficult due to the lack of certain important details in the studies. PRICES (Preferred Reporting Items for Critical care Echocardiography Studies) is a project endorsed by the European Society of Intensive Care Medicine and conducted by the Echocardiography Working Group, aiming at producing recommendations for standardized reporting of critical care echocardiography (CCE) research studies. Methods The PRICE panel identified lists of clinical and echocardiographic parameters (the “items”) deemed important in four main areas of CCE research: left ventricular systolic and diastolic functions, right ventricular function and fluid management. Each item was graded using a critical index (CI) that combined the relative importance of each item and the fraction of studies that did not report it, also taking experts’ opinion into account. Results A list of items in each area that deemed essential for the proper interpretation and application of research results is recommended. Additional items which aid interpretation were also proposed. Conclusion The PRICES recommendations reported in this document, as a checklist, represent an international consensus of experts as to which parameters and information should be included in the design of echocardiography research studies. PRICES recommendations provide guidance to scientists in the field of CCE with the objective of providing a recommended framework for reporting of CCE methodology and results.

BackgroundWe recently reported that nearly half of patients with heart failure with preserved ejection fraction (HFpEF) did not show echocardiographic diastolic dysfunction (DD), but had normal diastolic function (ND) or indeterminate diastolic function (ID). However, the clinical course and outcomes of patients with HFpEF with ND or ID (ND/ID) remain unknown.MethodsFrom the PURSUIT–HFpEF registry, we extracted 289 patients with HFpEF with ND/ID at discharge who had echocardiographic data at 1-year follow-up. Patients were classified according to the status of progression from ND/ID to DD at 1 year. Primary endpoint was a composite of all-cause death or HF rehospitalization.ResultsMedian age was 81 years, and 138 (47.8%) patients were female. At 1 year, 107 (37%) patients had progressed to DD. The composite endpoint occurred in 90 (31.1%) patients. Compared to patients without progression to DD, those with progression had a significantly higher cumulative rate of the composite endpoint (P < 0.001) and HF rehospitalization (P < 0.001) after discharge and at the 1-year landmark (P = 0.030 and P = 0.001, respectively). Progression to DD was independently associated with the composite endpoint (hazard ratio (HR): 2.014, 95%CI 1.239–3.273, P = 0.005) and HF rehospitalization (HR: 2.362, 95%CI 1.402–3.978) after discharge. Age (odds ratio (OR): 1.043, 95%CI 1.004–1.083, P = 0.031), body mass index (BMI) (OR: 1.110, 95%CI 1.031–1.195, P = 0.006), and albumin (OR: 0.452, 95%CI 0.211–0.969, P = 0.041) were independently associated with progression from ND/ID to DD.ConclusionsMore than one-third of HFpEF patients with ND/ID progressed to DD at 1 year and had poor outcomes. Age, BMI and albumin were independently associated with this progression.UMIN-CTR ID: UMIN000021831.

Delayed LV filling occurs, typically observed at the level of the pulmonary vein Doppler flow (reduced systolic versus diastolic flow velocities) as a left atrial reservoir function [5,6]. Since the introduction of tissue Doppler (TDI), it is clear that no other Doppler tool provides so much information related to the diagnosis of diastolic dysfunction. Diastolic dysfunction is an evolving story and different Doppler patterns of both transmitral flow and TDI could be identified, potentially complicating the diagnosis [7]. Since the guidelines of Nagueh et al., an interplay between 2-D echo, colour Doppler, pulsed wave Doppler and TDI is essential to obtain a clear diagnosis [2]. [...]e’ is at least partially influenced by loading conditions, in particular in those patients with normal systolic function [8], as was the case in the studied population.

Objectives: To establish the prevalence of preserved left ventricular (LV) systolic function (PSF) in 435 consecutive symptomatic patients referred to a heart failure clinic and to examine their ventilatory response to exercise when compared with 134 control volunteers. Methods: 216 (50%) patients had systolic heart failure (SHF) (ejection fraction < 45%). 51 (11%) had an immediately apparent alternative causes of breathlessness and 168 (39%), with no obvious other cause of breathlessness, were divided into those with PSF and diastolic dysfunction (DD) (PSFDD; n  =  113 or 26% of referrals) and those without DD (PSFN; n  =  55 or 13% of referrals). The controls were divided into those with (CDD; n  =  32) and those without (CN; n  =  102) echocardiographic evidence of DD. Results: Patients with SHF had lower peak oxygen consumption (pV̇o2), steeper slope of minute ventilation (V̇e) to carbon dioxide production, lower exercise time and shorter 6 min walk test than PSF patients and controls. PSFDD patients had lower pV̇o2, exercise time and 6 min walk test than CDD, although their echocardiograms were not different. Exercise capacity did not differ between PSFDD and PSFN patients. The slope relating V̇e to symptoms (Borg/V̇e slope) was less steep in those with SHF than in PSFDD (0.17 (0.04) v 0.20 (0.08), p < 0.05) and in PSFN (0.19 (0.10), p < 0.05), implying greater symptoms of breathlessness for a given level of V̇e. Both PSF groups had a steeper slope than CDD (0.14 (0.09), p < 0.05 for both comparisons). Conclusions: Patients with PSF have exercise tolerance intermediate between that of patients with SHF and controls. Exercise tolerance is similar in PSFDD and PSFN. Both groups have worse exercise tolerance than CDD. PSFDD and PSFN patients seem to experience a greater awareness of V̇e than CDD and patients with SHF.

Heart failure has reached epidemic proportions, and diastolic heart failure or heart failure with preserved ejection fraction (HFpEF) constitutes about 50% of all heart failure admissions. Long-term prognosis of both reduced ejection fraction heart failure and HFpEF are similarly dismal. No pharmacologic agent has been developed that actually treats or repairs the physiologic deficit(s) responsible for HFpEF. Because the physiology of diastole is both subtle and counterintuitive, its role in heart failure has received insufficient attention. In this review, the focus is on the physiology of diastole in heart failure, the dominant physiologic laws that govern the process in all hearts, how all hearts work as a suction pump, and, therefore, the elucidation and characterization of what actually is meant by “diastolic function”. The intent is for the reader to understand what diastolic function actually is, what it is not, and how to measure it. Proper measurement of diastolic function requires one to go beyond the usual E/A, E/E′, etc. phenomenological metrics and employ more rigorous causality (mathematical modeling) based parameters of diastolic function. The method simultaneously provides new physiologic insight into the meaning of in vivo “equilibrium volume” of the left ventricle (LV), longitudinal versus transverse volume accommodation of the chamber, diastatic “ringing” of the mitral annulus, and the mechanism of L-wave generation, as well as availability of a load-independent index of diastolic function (LIIDF). One important consequence of understanding what diastolic function is, is the recognition that all that current therapies can do is basically alter the load, rather than actually “repair” the functional components (chamber stiffness, chamber relaxation). If beneficial (biological/structural/metabolic) remodeling due to therapy does manifest ultimately as improved diastolic function, it is due to resumption of normal physiology (as in alleviation of ischemia) or activation of compensatory pathways already devised by evolution. In summary, meaningful quantitative characterization of diastolic function in any clinical setting, including heart failure, requires metrics based on physiologic mechanisms that quantify the suction pump attribute of the heart. This requires advancing beyond phenomenological global indexes such as E/A, E/E′, Vp, etc. and employing causality (mathematical modeling) based parameters of diastolic function easily obtained via the parametrized diastolic function (PDF) formalism.

BackgroundThe diagnosis of cardiac amyloidosis (CA) is challenging owing to vague symptomatology and non-specific echocardiographic findings.ObjectiveTo describe regional patterns in longitudinal strain (LS) using two-dimensional speckle-tracking echocardiography in CA and to test the hypothesis that regional differences would help differentiate CA from other causes of increased left ventricular (LV) wall thickness.Methods and results55 consecutive patients with CA were compared with 30 control patients with LV hypertrophy (n=15 with hypertrophic cardiomyopathy, n=15 with aortic stenosis). A relative apical LS of 1.0, defined using the equation (average apical LS/(average basal LS + mid-LS)), was sensitive (93%) and specific (82%) in differentiating CA from controls (area under the curve 0.94). In a logistic regression multivariate analysis, relative apical LS was the only parameter predictive of CA (p=0.004).ConclusionsCA is characterised by regional variations in LS from base to apex. A relative ‘apical sparing’ pattern of LS is an easily recognisable, accurate and reproducible method of differentiating CA from other causes of LV hypertrophy.

Echocardiographic assessment of left ventricular (LV) filling pressures is performed using a multi-parametric algorithm. Left atrial (LA) strain was recently found to accurately classify the degree of diastolic dysfunction. We hypothesized that LA strain could be used as a stand-alone marker and sought to identify and test a cutoff, which would accurately detect elevated LV pressures. We studied 76 patients with a spectrum of LV function who underwent same-day echocardiogram and invasive left-heart catheterization. Speckle tracking was used to measure peak LA strain. The protocol involved a retrospective derivation group (N = 26) and an independent prospective validation cohort (N = 50) to derive and then test a peak LA strain cutoff which would identify pre-A-wave LV diastolic pressure > 15 mmHg. The guidelines-based assessment of filling pressures and peak LA strain were compared side-by-side against invasive hemodynamic data. In the derivation cohort, receiver-operating characteristic analysis showed area under curve of 0.76 and a peak LA strain cutoff < 20% was identified as optimal to detect elevated filling pressure. In the validation cohort, peak LA strain demonstrated better agreement with the invasive reference (81%) than the guidelines algorithm (72%). The improvement in classification using LA strain compared to the guidelines was more pronounced in subjects with normal LV function (91% versus 81%). In summary, the use of a peak LA strain to estimate elevated LV filling pressures is more accurate than the current guidelines. Incorporation of LA strain into the non-invasive assessment of LV diastolic function may improve the detection of elevated filling pressures.

Background: Numerous studies have reported predictors of new-onset postoperative atrial fibrillation (POAF) following cardiac surgery, which is associated with increased length of stay, cost of care, morbidity, and mortality. The purpose of this study was to examine the association between preoperative diastolic function and occurrence of new-onset POAF in patients undergoing a variety of cardiac surgeries at a single institution. Methods: Using data from a prospective study from November 2007 to January 2010, a retrospective review was conducted. The diastolic function of each patient was determined from preoperative transthoracic echocardiograms. Occurrence of new-onset POAF was prospectively noted for each patient in the original study. Demographic and operative characteristics of the study population were analyzed to determine predictors of POAF. Results: Of 223 patients, 91 (40.8%) experienced new-onset POAF. Univariate predictors of POAF included increasing age, male gender, operations involving mitral valve repair/replacement, nonsmoking, hypertension, increased intraoperative pulmonary artery pressure, grade I diastolic dysfunction, abnormal diastolic function of any grade, decreased medial e', elevated medial E/e', and increased left atrial volume. Multivariate predictors of POAF included increasing age, increased left atrial volume, and elevated initial intraoperative pulmonary artery pressure. Even after exclusion of patients with hypertrophic obstructive cardiomyopathy or those undergoing mitral valve operations, diastolic dysfunction was not a multivariate predictor of POAF. Conclusions: In the patient population studied here, preoperative diastolic dysfunction was not predictive of POAF. In addition to increasing age, initial intraoperative pulmonary artery systolic pressure and left atrial volume were both significant multivariate predictors of POAF.

Despite significant advancements in the management of thalassemia, cardiac complications still represent a leading cause of disability and death. Heart dysfunction, although mainly related to myocardial iron overload (IO), might already manifest when the homeostasis of circulating iron species is altered. This study aimed to investigate the presence of heart function changes in relation to scheduled blood transfusions (BT) in transfusion-dependent thalassemic patients, to identify alterations in cardiac function early after BT or within a 7-10 days interval. Twenty patients (8 females; average age 41.65 years), followed at the Center for Hereditary Anemias, University Hospital of Modena, were enrolled to perform an echocardiographic evaluation (ECE) before scheduled BT (T 0 ), a targeted ECE immediately after the transfusion (T early ), and a targeted ECE 7-10 days thereafter (T late ). Medical history, biochemical data, and parameters related to iron status including serum levels of labile plasma iron (LPI), non-transferrin-bound iron (NTBI), and 3 year-average serum ferritin, were collected to assess predictors of transfusion-related cardiac changes. Global longitudinal strain (GLS) at baseline was worse, on average, in patients with higher ferritin or lower serum calcium; early post-transfusion GLS improved significantly in patients with ferritin>1500 ng/mL or albumin-corrected calcium mg/dL, whereas it remained stable in control groups. Notably, several early post-transfusion changes could be consistently predicted by variables related to iron homeostasis or transfusion status. Cardiac MRI T2* showed moderate IO in only one patient. In conclusion, -thalassemic patients with hyperferritinemia or hypocalcemia are likely those who benefit most from BT in terms of systolic function. Even in the absence of overt myocardial IO, alterations in circulating iron status predict early dysfunctions in cardiac response after scheduled blood transfusion.

Aims/hypothesis The aim of this work was to assess the association of advanced glycation end-products (AGEs), measured by skin autofluorescence (SAF), with prevalent heart failure, and with systolic and diastolic cardiac function, in a large population-based cohort study. Methods We assessed the cross-sectional association between SAF and prevalent heart failure among 2426 participants from the population-based Rotterdam Study, using logistic regression. Next, among individuals free of heart failure ( N =2362), we examined the link between SAF (on a continuous scale) and echocardiographic parameters of left ventricular (LV) systolic and diastolic function using linear regressions. Analyses were adjusted for traditional cardiovascular risk factors. Results Higher levels of SAF were associated with higher odds of prevalent heart failure (multivariable adjusted OR 2.90 [95% CI 1.80, 4.62] for one unit higher SAF value). Among individuals without heart failure, one unit increase in SAF was associated with 0.98% lower LV ejection fraction (mean difference [β] −0.98% [95% CI −1.45%, −0.50%]). The association was stronger among participants with diabetes (β −1.84% [95% CI −3.10%, −0.58%] and β −0.78% [95% CI −1.29%, −0.27%] among participants with and without diabetes, respectively). Associations of SAF with diastolic function parameters were not apparent, except in men with diabetes. Conclusions/interpretation AGE accumulation was independently associated with prevalent heart failure. Among individuals free of heart failure, AGEs were associated with cardiac function, in particular systolic function. This association was present in participants with and without diabetes and was more prominent in those with diabetes. Graphical abstract