Owing to its ease of application, noninvasive nature, and safety, echocardiography is an essential imaging modality to assess cardiac function in patients affected by ischemic heart disease (IHD). Over the past few decades, we have witnessed a continuous series of evolutions in the ultrasound field that have led to the introduction of innovative echocardiographic modalities which allowed to better understand the morphofunctional abnormalities occurring in cardiovascular diseases. This article offers an overview of some of the newest echocardiographic modalities and their promising application in IHD diagnosis, risk stratification, management, and monitoring after cardiac rehabilitation.

Background: HyperDoppler is a new echocardiographic color Doppler-based technique that can assess intracardiac flow dynamics. The aim of this study was to verify the feasibility and reproducibility of this technique in unselected patients and its capability to differentiate measures of vortex flow within the left ventricle (LV) in normal sedentary subjects, athletes, and patients with heart failure. Methods: Two hundred unselected, consecutive patients presenting at the echocardiographic laboratory, 50 normal subjects, 30 athletes, and 50 patients with chronic heart failure and LV ejection fraction <50% were enrolled. Images were acquired using a MyLab X8 echo-scanner. Area, intensity, depth, length, and kinetic energy dissipation (KED) of vortex flow were measured. Results: The HyperDoppler technique feasibility was 94.5%. According to the intraclass correlation coefficient evaluations, repeatability and reproducibility of vortex flow measures were good for vortex area (0.82, 0.85), length (0.83, 0.82), and depth (0.87, 0.84) and excellent for intensity (0.92, 0.90) and KED (0.98, 0.98). Combining different vortex flow measures, the LV flow profile of healthy sedentary individuals, athletes, and heart failure patients could be differentiated. Conclusions: HyperDoppler is a feasible, reliable, and practical technique for the assessment of LV flow dynamics and may distinguish normal subjects and patients with heart failure.

Background: Cardiovascular diseases in the context of renal and liver transplants remain the leading cause of morbidity and mortality. Physical exercise at a moderate intensity is allowed to contrast the risk profile. Echocardiographic evaluation is essential to stratifying potential cardiotoxicity by the standard and, more recently, the deformation and dynamic study of the intracardiac vortex. This study aims to investigate the vortex echo parameters of solid-organ-transplanted subjects who are physically active compared to a control group of healthy subjects. Methods: A group of 33 transplanted subjects (16 kidneys and 17 livers) was studied via a transthoracic echocardiography exam, comprehending the myocardial deformation parameters of global longitudinal strain (GLS), twisting of the left ventricle (LV) chamber, and HyperDoppler image acquisition. Results: The subjects enrolled in this study were 50 in total: there were 33 transplanted and 17 healthy subjects. The transplanted subjects presented higher values of interventricular septum in diastole (IVSd p = 0.001), posterior wall diastolic (PWd p = 0.05), and left ventricle mass index (LVMI p = 0.029); ejection fraction (EF) was found to be higher in athletes (p < 0.001). Transplanted subjects presented mild diastolic dysfunction, emerging only from septal E values (p = 0.001). The 4DStrain (p = 0.018) and GLS2c (p = 0.017) were significantly better in the athletes. All of the geometrical and energetical vortex data were in the normal range and no significant differences were found. An interesting positive correlation was evident for the diastolic parameter, particularly the E/A ratio (p = 0.023) and E’ septal value (p = 0.049), along with the vorticity fluctuation. This behavior was present for all subjects, particularly those that were transplanted (p = 0.005). Conclusions: In the vortex investigation, especially in cases of normal EF, the positive correlation of some diastolic parameters with the flow dynamic patterns corroborates this hypothesis. The HyperDoppler analysis could be helpful to detecting potential damage earlier in the diastolic time before a systolic deficiency.

Background/Objectives: Solid organ transplant recipients (OTR) have been recently involved in exercise prescription programs in order to reduce the high prevalence of cardiovascular diseases. The normal systolic and diastolic cardiac function is fundamental to personalizing the prescription. Diastolic dysfunction can be associated to a higher risk of cardiovascular events and left atrial (LA) strain is an emerging parameter in the evaluation of diastolic compromising, especially in subjects with preserved ejection fraction. Left atrial (LA) strain has never been explored in this category. The study aimed to evaluate the contribution of the LA strain in the assessment of diastolic function of OTR and its potential contribution in the exercise program. Methods: 54 solid OTR (liver and kidney transplants) regularly trained for at least 12 months in a home-based, partially supervised model at moderate intensity estimated by cardiopulmonary exercise test, underwent a complete echocardiographic analysis. The measured variables included left ventricle systolic function (ejection fraction, EF), diastolic function (E/A and E/E’), LA indexed volumes, LA peak atrial longitudinal strain (PALS) and LA peak atrial contraction strain (PACS). The data were compared to those of 44 healthy subjects (HS). Results: The OTR showed an overweight condition (BMI: 25.79 ± 2.92 vs. 22.25 ± 2.95; p < 0.01). Both groups showed a preserved systolic function (EF: OTR 63.1 ± 3.5% vs. HS 66.9 ± 6.1; p < 0.001), while diastolic standard parameters were significantly different (E/A, 1.01 ± 0.4 vs. 1.96 ± 0.74; p < 0.001; E/E’, 9.2 ± 2.7 vs. 6.9 ± 1.3; p < 0.001, in OTR and HS respectively) despite being normal. LA strain was significantly lower in OTR vs. HS (4C PALS, 33.7 ± 9.7 vs. 45.4 ± 14.19; p < 0.001; 4C PACS, 15.9 ± 6.7 vs. 11.6 ± 7.5; p = 0.006; 2C PALS, 35.3 ± 11.1 vs. 47.6 ± 14.9; p < 0.001; 2C PALS, 17.4 ± 4.9 vs. 13.2 ± 14.97; p = 0.001; in OTR and HS respectively). A specific correlation of two- and four-chamber PACs and PALs with BMI has been observed (R for 4C PALS −0.406 ** and 2C PALS −0.276 *). Conclusions: These findings suggest that the coexistence of increased bodyweight in asymptomatic OTR patients can exacerbate the impairment of LA strains. LA strain detection could be useful in the development of a personalized exercise program for OTRs, especially for asymptomatic subjects and those with elevated cardiovascular risk profile, to potentially manage the exercise program in the long term. Larger studies will confirm the role via an eventual structured clinical score index.

Introduction: solid organs transplanted recipients (OTR) have been recently involved in exercise prescription programs in order to reduce the high prevalence of cardiovascular diseases. The normal systolic and diastolic cardiac function is fundamental to personalize the prescription. Diastolic dysfunction can be associated to an higher risk of cardiovascular events and left atrial (LA) strain is an emerging parameter in the evaluation of diastolic compromising, especially in subjects with preserved ejection fraction. Left atrial (LA) strain has never been explored in this category. The study aimed to evaluate the contribution of the LA strain in the assessment of diastolic function of OTR and its potential contribution in the exercise program. Materials and Methods: 54 solid OTR (liver and kidney transplanted) regularly trained for at least 12 months in an home based partially supervised model at moderate intensity estimated by cardiopulmonary exercise test, underwent a complete echocardiographic analysis. Measured variables included left ventricle systolic function (ejection fraction: EF), diastolic function (E/A and E/E’), LA indexed volumes, LA peak atrial longitudinal strain (PALS) and LA peak atrial contraction strain (PACS). The data were compared to 44 healthy subjects (HS). Results: OTR showed an overweight condition (BMI: 25.79 ±2.92 vs 22.25±2.95). Both groups showed a preserved systolic function (EF: OTR 63.1±3.5% vs HS 66.9±6.1; p<0,001) while diastolic standard parameters were significantly different (E/A: 1.01±0.4 vs 1.960.74; p<0.001; E/E’: 9.2±2.7 vs 6.91.3; p<0.001, in OTR and HS respectively) despite normal. LA strain was significantly lower in OTR vs HS (4C PALS: 33.7±9.7 vs 45.4; p<0.001 and 4C PACS: 15.9±6.7 vs 11.67.5; p=0.006; 2C PALS: 35.3±11.1 vs 47.614.9; p<0.001; 2C PALS: 17.4±4.9 vs 13.2; p=0.001, in OTR and HS respectively). A specific correlation of 2 and 4 chamber PACs and PALs with BMI has been observed (R for 4C PALS -0.406** and 2C PALS -0.276*). Conclusions: These findings suggest that the coexistence of increased body weight in asymptomatic OTR patients can exacerbate the impairment of LA strains. LA strain detection could be useful in the personalized exercise program for OTR especially if asymptomatic subjects and with elevated cardiovascular risk profile, to potentially manage the exercise program in the long term. Larger studies will confirm the role in an eventual structured clinical score index.

Background: Evaluation of blood flow dynamics within the left atrium (LA) using cardiac imaging techniques, such as four-dimensional (4D) flow magnetic resonance imaging (MRI) and contrast and non-contrast ultrasound, is an area of increasing interest, especially in patients with atrial fibrillation (AF). While 4D flow MRI and contrast ultrasound are limited in their application in routine clinical practice, non-contrast ultrasound techniques have the potential for extensive clinical application. However, there are no studies on LA flow dynamics evaluated using these latter techniques. Here we present the first application of HyperDoppler, a non-contrast color Doppler-based technique, to the assessment of LA flow dynamics in a case series. Methods: The transthoracic color Doppler modified apical 4-chamber view of a normal healthy subject and two patients with AF (one with persistent and the other with permanent AF) were analyzed using HyperDoppler. The resulting velocity vector map was visually examined frame-by-frame to describe LA flow dynamics. Results: In the healthy subject, HyperDoppler showed a LA flow behavior consistent with findings from the literature employing 4D flow MRI. In both patients with AF, HyperDoppler showed alterations of the LA flow dynamics pattern. Conclusions: Our preliminary observations suggest that HyperDoppler may be a valuable tool for characterizing physiological and pathological LA flow dynamics. Further studies are needed to confirm, explain and expand our initial findings.