Archives of Cardiovascular Disease (2010) 103, 115—128 REVIEW Key role of Doppler echocardiography in the emergency management of elderly patients Rôle clé de l’écho Doppler cardiaque dans la prise en charge du sujet âgé dans le contexte de l’urgence Pierre Vladimir Ennezat a,b,∗, Damien Logeart c, Alain Berrebi d, André Vincentelli b,e, Sylvestre Maréchaux a,b a Intensive Cardiology Care Unit, centre hospitalier régional et universitaire, 59037 Lille cedex, France b EA 2693, faculté de médecine, université de Lille-2, 59037 Lille cedex, France c Department of Cardiology, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, Paris, France d Department of Cardiovascular Surgery, hôpital Européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France e Cardiovascular Surgery Department, centre hospitalier régional et universitaire, 59037 Lille cedex, France Received 21 July 2009; accepted 4 November 2009 Available online 6 January 2010 KEYWORDS Ageing; Cardiovascular disease; Doppler echocardiography; Elderly; Emergency Summary Owing to modern epidemiology in Western countries, ageing represents a growing health burden. In general, because of age itself and comorbid conditions, all clinical cardiovascular manifestations have a higher mortality rate and a worse outcome in older people compared with in younger individuals. Diagnosis of the disease in the elderly in an emergency setting is particularly challenging for the practitioner. Age-related cardiovascular changes and comorbid conditions may alter signs, symptoms and adaptation to the disease and response to treatment. Bedside Doppler echocardiography is likely to play a major role in guiding diagnosis, therapeutic strategies and prognosis. The purpose of this review is to appraise the application of echocardiographic examination in helping the clinician facing emergency situations that involve the cardiovascular system in the older population. © 2009 Elsevier Masson SAS. All rights reserved. Abbreviations: A, Late diastolic peak flow velocity; E, Early diastolic peak flow velocity; Ea, Early diastolic mitral and tricuspid annular velocities; HF, Heart failure; HFpEF, Heart failure with preserved ejection fraction; LV, Left ventricular. ∗ Corresponding author. Cardiology Hospital, Intensive Care Unit, boulevard Pr-J.-Leclercq, 59037 Lille cedex, France. Fax: +33 3 20 44 65 04. E-mail address: ennezat@yahoo.com (P.V. Ennezat). 1875-2136/$ — see front matter © 2009 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.acvd.2009.11.002 116 MOTS CLÉS Échocardiography ; Sujet âgé ; Urgences P.V. Ennezat et al. Résumé Du fait de l’épidémiologie moderne des pays occidentaux, le vieillissement représente un problème de santé publique majeur. L’âge avancé et les co-morbidités associées aggravent la mortalité et le pronostic des manifestations cardiovasculaires chez les sujets âgés. Poser le diagnostic d’une maladie chez le sujet âgé dans un contexte d’urgence est particulièrement complexe pour le praticien. Les modifications cardiovasculaires liées à l’âge et aux co-morbidités peuvent modifier les signes diagnostiques, les symptômes, l’adaptation à la maladie et la réponse au traitement. L’écho Doppler cardiaque au lit du patient joue un rôle majeur pour guider le diagnostic, la thérapeutique, les stratégies de prise en charge et ainsi le pronostic. Le but de cet article de synthèse est d’illustrer l’aide apportée par l’écho Doppler cardiaque au clinicien face aux situations urgentes qui impliquent le système cardiovasculaire chez le sujet âgé. © 2009 Elsevier Masson SAS. Tous droits réservés. Background Ageing represents a major public health burden. The proportion of people aged 65 years and older in Western Europe is projected to increase from 17% in 2008 to 30% in 2060. Cardiovascular disease remains the leading cause of morbidity and mortality in the elderly. Conversely, because of the ageassociated alterations in cardiac and vascular properties, ageing remains a major risk factor for cardiovascular morbidity and mortality. Age is indeed one variable in various scores that predict poor outcome in different settings (e.g. the Global Registry of Acute Coronary Events or the Seattle Heart Failure Survival Model) [1,2]. Where age alone results in pre-existing impaired left ventricular (LV) filling capacity and reduced renal function [3], for instance, myocardial infarction associated with minor myocardial damage is more likely to result in pulmonary congestion (Killip class ≥ II) and subsequent worse outcome in the older individual than in the younger individual. Doppler echocardiography is a non-invasive, radiationfree, bedside tool that may be considered as a modern stethoscope. Extremely varied and undiscovered cardiovascular diseases, often at a very late stage of the disease, may be disclosed using Doppler echocardiography imaging in older people. Owing to the conveniences of modern life, sedentary older people may underestimate, ignore or not report their symptoms, or may reduce their level of physical activity to avoid or minimize symptoms. Moreover, diagnosis of an event such as an acute myocardial infarction is usually delayed in older people because of atypical symptoms (dizziness, fatigue, altered mental status, etc.), resulting in increased time to onset of therapy and poorer outcome than in the younger individual [4]. In addition, because cardiovascular diseases are seldom seen in isolation in older people (half have at least two chronic medical conditions), non-specific symptoms such as dyspnoea may be caused by other concomitant diseases such as chronic lung disease or obesity. To this effect, besides other diagnostic procedures including biomarkers, electrocardiogram and chest X-ray, comprehensive bedside Doppler echocardiography appears to be an important tool for diagnosis, therapeutic management and risk stratification in older people presenting in the emergency room. The goal of this report is to review the usefulness of Doppler echocardiography imaging in treating older people in the emergency room. The operating room setting is also addressed. Age-related changes in health (‘normal’ ageing process) Cellular and molecular mechanisms (cardiomyocyte size, number and function, key steps of excitation-contraction coupling, composition and distribution of elastin and collagen, vascular endothelial and smooth muscle cell function and structure, nitric oxide pathway, etc.) that account for changes in the ageing heart and vessels are multiple and complex. The reader can refer to the excellent review articles published previously on this topic [5—7]. Arterial alterations include mainly decreased endothelial-mediated vasodilation, increased central vascular stiffening and aortic pulse wave velocity and faster reflected pulse waves, leading to an age-associated increase in LV wall stress and metabolic demand (Fig. 1) [8,9]. Increased late-systolic reflected waves due to the marked decrease in arterial compliance result in a fall in diastolic blood pressure and a rise in systolic blood pressure, and therefore higher pulse pressure. The marked increase in systolic contribution to total coronary blood flow suggests that systolic blood pressure may have a greater role in myocardial perfusion in the elderly than in the younger individual. Besides the progressive increase in cardiac workload with advancing age, myocardial fibrosis promotes prolonged LV diastolic relaxation. Blunted beta-adrenergic arterial vasodilation [10] and inotropic and heart rate response [11], in addition to the changes mentioned above, contribute to the decreased aerobic capacity in older people. Lastly, decline in renal function and atrial fibrillation also contribute to a decrease in the stress response. Echocardiographic features in normal ageing The structural echocardiographic changes associated with normal ageing include a progressive increase in LV wall thickness that does not exceed the upper limit of normal (≤ 11 mm), with a minor decrease or no change in LV internal dimensions, resulting in a mild increase in cardiac mass and Echocardiography in acute elderly patients 117 Figure 1. Reproduced from McEniery et al., J Am Coll Cardiol 2005, with permission. Regression curves showing the effect of age on variables of wave reflections (augmentation index and pressure, panel A) and arterial stiffness (pulse wave velocity, panel B) for men (circles, solid lines) and women (squares, dashed lines) obtained with the Sphygmocor® system. Open circles and squares represent augmentation pressure and closed circles and squares represent the augmentation index. Note that both variables of arterial stiffness and wave reflections increase with age, thereby increasing the systolic load imposed on the myocardium during the ageing process. Panel C represents the aortic pressure waveform in a 75-year-old woman and panel D represents the aortic pressure waveform in a 50-year-old man, both obtained using the radial function transfer of the Sphygmocor® system. Note the age-related increase in augmentation pressure (AP, arrows), thereby increasing the augmentation index (Alx) pressure (the ratio of AP/pulse pressure [PP], which is identical in these two patients), indicating an increase in wave reflections associated with age. Dp: diastolic pressure; HR: rate; Sp: systolic pressure. concentric LV remodelling [12]. A significant increase in the aortic root dimension occurs with age and predicts incident heart failure (HF), stroke, and cardiovascular and all-cause mortality [13]. Left atrial enlargement, which promotes stroke and atrial fibrillation (frequent illnesses in older people), also occurs with age [14]. Sclerosis due to myxomatous degeneration, collagen infiltration and calcifications of both aortic and mitral valves are observed frequently in the elderly. Changes at the mitral level include from a few spicules of calcium to a large mass located behind the posterior leaflet, forming a half ring that may interfere with annular motion and decrease atrioventricular compliance, serve as a substrate for thromboembolism, heart block, valvular dysfunction or infective endocarditis (Video Loop 1) [15]. There is also a statistically significant decrease in LV outflow tract diameter and velocity that parallels a decrease in aortic valve area and an increase in aortic velocity [16]. Paralleling the increased arterial stiffening and systemic vascular resistance, an aortic flow mid-systolic notch is seen frequently in the elderly population (Fig. 2). Importantly, LV diastolic function declines with ageing, while LV ejection fraction remains preserved. There is a progressive decrease in early diastolic peak flow velocity (E), deceleration and early diastolic peak flow velocity/late diastolic peak flow velocity (E/A) ratio [17]. As a result, 87% of the elderly population exhibit an E/A ratio < 1 (Fig. 3) [18]. Similarly, tissue Doppler early diastolic mitral and tricuspid annular velocities (Ea) are lower in older people than in younger individuals. In addition, Ea is inversely related to late systolic load, which is mediated predominantly by the increased systolic wave reflections brought by age, thereby leading Figure 2. Left ventricular outflow tract pulsed Doppler flow display in a healthy elderly subject. The midsystolic notch suggests increased stiffness of the arterial tree. 118 P.V. Ennezat et al. Figure 3. Pulse wave Doppler recording taken from mitral valve tips showing peak E (early) and A (late) diastolic flows in (A) a 20-year-old man, (B) a 40-year-old man and (C) a non-hypertensive 65-year-old man. The E/A ratio decreases with age while E wave deceleration time increases. to an increased E/Ea ratio [8]. However, it is not known whether other cut-off values for ‘normal’ age-specific E/Ea ratios should be used. In contrast, tissue Doppler late diastolic velocities are not altered with age. It is worth noting that tissue Doppler systolic mitral annular velocity (a measure of longitudinal contractility of the LV myocardium) is also lower in the elderly, demonstrating subclinical LV systolic dysfunction [19]. However, the compensatory increase in radial thickening normalizes LV ejection fraction, which remains stable with age [20]. Systolic pulmonary artery pressure, estimated from the tricuspid regurgitant velocity, increases progressively with age [21,22], probably due to the age-related increase in pulmonary arterial stiffening and/or heightened LV end-diastolic pressure. Both systolic and early diastolic velocities of the tricuspid annulus are lower in older people than in younger individuals [19]. It is worth noting that systemic hypertension, a common condition in older people [23], exacerbates the changes related to ageing, such as LV hypertrophy, alterations in LV diastolic function, longitudinal systolic function and pulmonary pressure [22]. Heart failure setting HF is the most frequent hospital discharge diagnosis among the elderly [24]. The reader can refer to a recently published comprehensive review on the role of echocardiography in the management of HF [25]. Heart failure with preserved left ventricular ejection fraction HF with preserved ejection fraction (HFpEF) increases in prevalence in older populations (about 50% of older peo- ple with HF) [26]. HFpEF is particularly common in elderly women with longstanding hypertension, type 2 diabetes mellitus and obesity [27]. However, before categorizing a patient as having HFpEF, several causes (such as severe cardiac valvular diseases, restrictive, infiltrative or hypertrophic cardiomyopathy, isolated right ventricular failure, pericardial diseases, intracardiac masses, pulmonary vein stenosis, congenital heart diseases, presence of prosthetic heart valve, bradycardia related to atrioventricular or sinoatrial blocks, myocardial ischaemia related to coronary artery disease, high-output HF, dialysis-dependent and end-stage renal failure, liver cirrhosis, nephrotic syndrome, and transient LV systolic dysfunction related to tachyarrhythmia) need to be excluded by thorough clinical and echocardiographic examination, laboratory data and eventually other diagnostic procedures. In HFpEF patients, echocardiography shows the characteristic combination of LV hypertrophy or concentric remodelling and left atrial enlargement, which is a harbinger of chronically elevated LV filling pressure in older people presenting with signs and symptoms of congestive HF (Video Loop 2) [28]. The acute rise in E/Ea ratio and pulmonary pressure is common in the setting of acute HF. Importantly, transmitral inflow recording may, nevertheless, show the pattern of ‘hyperabnormal relaxation’ in decompensated older people [29]; in these cases, heightened LV filling pressure is easily uncovered by calculating the E/Ea ratio (Fig. 4). In steady state, despite vasodilator and diuretic therapy, the averaged levels of the E/Ea ratio and pulmonary pressure remain higher compared with controls [30]. Similarly, right ventricular enlargement and functional mitral regurgitation may be observed transiently in the overloaded state, although this reduces or disappears with cardiac load reduction (Video Loops 3A and 3B) [31]. Importantly, besides severe coronary artery or valve disease, HFpEF may be an unrecognized cause of mechanical ven- Figure 4. Pulse wave mitral valve recording taken at the tips of the mitral leaflets showing an ‘hyperabnormal relaxation’ pattern in a 80-year-old man during the acute phase of a pulmonary oedema. Note the elevated averaged E/Ea ratio at 15, demonstrating increased left ventricular filling pressure. Echocardiography in acute elderly patients 119 Figure 5. Pulsed wave Doppler transmitral flow (left) and pulmonary vein flow (right) tracings from a mechanically-ventilated 71-year-old woman in whom a first attempt to wean mechanical ventilation failed because of heightened left ventricular filling pressure (restrictive pattern of Doppler transmitral flow and predominant pulmonary diastolic vein flow), despite normal ejection fraction. tilatory weaning failure in the intensive care unit. Abrupt and unprepared ventilatory weaning can result in an acute increase in LV wall tension, and increased venous return and thereby LV preload, promoting increased pulmonary capillary wedge pressure and secondary mitral regurgitation, and eventually precipitating pulmonary oedema in HFpEF patients (Fig. 5) [32]. Prior vasodilator and diuretic therapy is likely to help ventilatory weaning in this setting. Of note, after the acute HF episode, exercise echocardiography often unmasks LV abnormal response or induced functional mitral regurgitation [30,33]. Heart failure with reduced LV ejection fraction HF with reduced ejection fraction is also common in elderly populations (Video Loop 4). Coronary artery dis- ease, hypertension, sustained excess tachycardia and cardiac valvular disease, such as aortic stenosis, are the main causes of HF with reduced ejection fraction in older people. Segmental wall motion abnormalities and LV scarring suggest underlying coronary artery disease. Coronary angiography provides the definitive diagnosis. Cardiac valvular diseases Cardiac valvular diseases are common in the general population and increase with age [34]. Aortic valve stenosis affects 2% of patients older than 65 years (mean age 82 years) [35]. The pathophysiological consequences of aortic valve stenosis include LV hypertrophy, elevated LV diastolic pressure and progressive decline in LV systolic function [36]. Aortic valve replacement is warranted in the absence of Figure 6. Left ventricular outflow tract (LVOT) and transaortic pulse wave and continuous Doppler recording in a 78-year-old patient with long-standing hypertension, admitted for syncope and symptoms of heart failure. The left ventricular fractional shortening and concentric hypertrophy are immediately evident (Video Loop 5). The forward stroke volume index is measured at 30 mL/m2 , the mean transaortic pressure gradient (MPG) is 30 mmHg and the calculated aortic effective orifice area is 0.90 cm2 . These findings are consistent with the diagnosis of paradoxical low flow/low gradient aortic stenosis despite a preserved left ventricular ejection fraction. VTI: velocity time integral. 120 severe comorbid conditions when patients develop symptoms or LV systolic dysfunction [37]. It is worth noting that percutaneous procedures in older people need further validation (ongoing REVIVE, REVIVAL and PARTNERS trials) before wide acceptance in routine practice. Lowdose dobutamine is useful for assessing the presence of contractile reserve and differentiating true severe from pseudosevere stenosis in the challenging subset of patients with low LV ejection fraction and low transvalvular gradient [38,39]. Exercise stress echocardiography may be envisioned in patients with aortic valve stenosis and equivocal symptoms and normal ejection fraction [40,41]. In the elderly, the narrowed valvular orifice is often combined with underlying LV systolic and diastolic dysfunction that may be related to other cofactors such as coronary artery disease or longstanding hypertension, thereby adding a level of complexity to the assessment of these patients. In addition, low transvalvular gradients are frequently observed in these elderly patients, despite a calculated aortic valve area below 1.0 cm2 or 0.60 cm2 /m2 , questioning the true severity of the stenosis. In some patients, the discrepancy between relatively low transvalvular gradients and decreased aortic valve area may be explained by the pressure recovery phenomenon [42,43]. A significant rise in static pressure downstream from the orifice occurs (due to reconversion of kinetic energy into potential energy) if the ascending aorta is narrow (diameter of the aortic sinotubular junction < 30 mm) and leads to an overestimation of Doppler-derived transvalvular gradients. The use of the Doppler-derived energy loss index, which takes account of the diameter of the aorta to calculate aortic effective orifice area, helps to reconcile discrepancies between Doppler transvalvular pressure gradient data and effective orifice area obtained by the Doppler continuity equation [42,44]. Recently, Hachicha et al. demonstrated that lowflow (stroke volume index ≤ 35 mL/m2 ), low-gradient but severe aortic valve stenosis despite normal ejection fraction is prevalent in older people, especially in hypertensive women with concentric LV remodelling or hypertrophy and high systemic vascular resistances (Fig. 6, Video Loop 5) [45]. Despite a low transvalvular pressure gradient [46], these patients are indeed at a severe stage of the disease, associated with a high global LV afterload (the sum of arterial and valvular loads) [47]. The low survival observed in patients managed conservatively advocates identification of this challenging subgroup of aortic valve stenosis patients and consideration of aortic valve replacement. Concomitant significant mitral regurgitation or left-to-right shunt related to an atrial septal defect may occasionally cause low transvalvular gradients despite severe aortic valve stenosis and normal ejection fraction [48]. Concomitant mitral regurgitation and HF requires comprehensive assessment. The reader can refer to the review article published previously on this topic [49]. Mitral valve prolapse is a common cause of mitral regurgitation (Video Loops 6A and 6B) and is often combined with mitral annular calcification in older people, which otherwise complicates valve surgery significantly. Large calcific deposits in the posterior mitral annulus may themselves restrict posterior leaflet motion and produce mitral regurgitation (Video Loops 7A and 7B) [15]. In contrast, extensive mitral calcifications that extend onto the base of the mitral leaflets may produce P.V. Ennezat et al. Figure 7. Associated with Video Loop 10. Continuous wave Doppler signal from the left ventricular outflow tract at the site of obstruction. a significant increase in transvalvular velocity-derived gradients, suggesting severe mitral stenosis (Video Loop 8) [15]. Using transoesophageal echocardiography, in contrast to the thickening at the leaflet tips and commissural fusion seen with rheumatic disease, these large calcifications spare the edges of the leaflets and the commissures, often resulting in moderate stenosis and thus allowing conservative management in the elderly. Of note, heightened LV diastolic pressure, related to ageing, hypertension or concomitant aortic valve disease, may result in relatively low transmitral gradient despite severe mitral stenosis. Of note, patients with true severe calcific mitral stenosis are not good candidates for percutaneous valvotomy [37]. In older people with LV systolic dysfunction, functional/ischaemic mitral regurgitation is usually mild or moderate but may be severe, especially in the case of severe posterior leaflet tethering (Video Loop 9). Patients with ischaemic mitral regurgitation associated with a high posterior leaflet angle should not undergo restrictive annuloplasty [50]. Drug-induced valvular disease (with the anti-Parkinson disease dopamine receptor agonist pergolide) has been reported but is uncommon. Intra-left ventricular obstruction The presence of LV obstruction should be ruled out systematically in the setting of HF and normal or supranormal ejection fraction, even in the absence of hypertrophic cardiomyopathy (Fig. 7, Video Loop 10). Dynamic LV outflow tract obstruction affects both systolic and diastolic LV function. Pre-existing LV concentric remodelling, associated with specific conditions such as inappropriate or excessive use of positive inotropic therapy or relative hypovolaemia, may facilitate the occurrence of intra-LV obstruction and produce mitral leaflet systolic anterior motion and hence unexpected (‘paradoxical’) pulmonary oedema. Fluid challenge, discontinuation of inotropic therapy and possibly initiation of beta-blockade therapy are indicated in this situation. Permanent pacing Owing to the increased prevalence of permanent cardiac pacing in elderly people, HF associated with permanent Echocardiography in acute elderly patients 121 Figure 8. Atrioventricular optimization using Doppler mitral inflow velocities in a 69-year-old woman with atrioventricular conduction delay and an implantable cardioverter defibrillator for a history of syncope and sustained ventricular tachycardia, who had severe shortness of breath despite a normal ejection fraction. Default setting resulted in loss of A wave and prolonged PR interval on the electrocardiogram (left panel). Shortening of the atrioventricular interval improved left ventricular filling with significant contribution of the atrial component (right panel) and thereby relieved heart failure symptoms. cardiac pacing is an important issue. Echocardiography does indeed play an important and evolving role in the care of patients treated with permanent pacing. Right ventricular apical pacing results in LV dyssynchrony and thereby in deterioration of LV systolic and diastolic function, mitral regurgitation, left atrial enlargement, LV remodelling and ultrastructural abnormalities (Video Loop 11). Zhang et al., in a series of 304 patients without a prior history of HF, indicated that permanent right ventricular apical pacing was associated with new-onset HF in 26% of patients [51]. Both older age and underlying coronary artery disease were independent predictors of adverse outcome in these series. Therefore, more attention should be paid to minimizing right ventricular pacing, especially in patients treated with pacemakers for sinus node dysfunction or intermittent atrioventricular block. Pacemaker-induced atrioventricular dyssynchrony (‘pacemaker syndrome’) impairs diastolic LV filling. An atrioventricular delay that is too short interrupts the atrial component of the mitral inflow. An atrioventricular delay that is too long results in E-A fusion and diastolic mitral regurgitation. Therefore, optimization of the atrioventricular delay, using pulsed Doppler interrogation of mitral inflow, may improve the signs and symptoms of congestive HF (Fig. 8). Severe tricuspid regurgitation caused by a permanent pacemaker or implantable cardiac defibrillator lead is an under-recognized cause of severe right HF. Kim et al. found that tricuspid regurgitation worsening was more common with implantable cardiac defibrillators than with pacemakers in patients with baseline mild or trivial tricuspid regurgitation. After lead implantation, abnormal tricuspid regurgitation developed in 21.2% and severe tricuspid regurgitation developed in 3.9% of patients with initial trivial tricuspid regurgitation [52]. Transvenous ventricular pacing leads across the tricuspid valve may cause or exacerbate tricuspid regurgitation (Video Loop 12). Causes of tricuspid regurgitation in this setting most frequently include perforation of the tricuspid valve leaflet but also lead entanglement in the tricuspid valve, lead impingement of the tricuspid valve leaflets and lead adherence to the tricuspid valve [53]. Other causes of heart failure Cardiac amyloidosis in its senile form is an infrequent cause of diastolic HF in the elderly, although it is a frequent postmortem finding in patients aged over 80 years. Extensive ventricular deposition of proteins may result in restrictive cardiomyopathy. The disease is suggested by the presence of enlarged atria, thickened interatrial septum and valves, small ventricles and increased ventricular wall thickness associated with low voltage on electrocardiogram. Reduced LV systolic function may be seen in the late stage of the disease. Radiation exposure to the chest increases particularly in women, due to the increased prevalence of breast cancer in the community. As a result of previous radiation exposure, restrictive cardiomyopathy, constrictive pericarditis, cardiac valvular disease (Video Loops 13 and 14) and, rarely, coronary sinus stenosis that results in turn in increased LV end-diastolic pressure, are considered and evaluated using echocardiography [54]. Diagnosis of post-radiation coronary 122 P.V. Ennezat et al. Figure 9. Pulsed wave Doppler display at the tips of the mitral leaflets and continuous wave Doppler tracing of the mitral regurgitant jet in a 69-year-old patient admitted to the intensive care unit for Killip class III inferior myocardial infarction despite successful reperfusion and normal ejection fraction. Left panel: the atrioventricular dyssynchrony due to a marked prolongation of the PR interval impaired left ventricular filling (inefficient left atrial systole) and produced end-diastolic mitral regurgitation (Video Loop 16). Right panel: two days later, shortening of PR interval concomitant with heart-rate acceleration restored atrioventricular synchrony. Note that the end-diastolic mitral regurgitation disappeared. obstructive disease requires the use of coronary angiography. Acute coronary syndrome setting About 60% of hospital admissions for acute myocardial infarction involve elderly patients [55]. Because acute coronary syndrome is added to the burden of cardiovascular and non-cardiovascular comorbid conditions in the elderly, age is associated with a significant increase in adverse outcomes in patients with an acute coronary syndrome [56,57]. Delayed and severe presentations of myocardial infarction (including mechanical causes of HF) occur more frequently in older people [4]. The reperfusion therapy should not be delayed in patients with ST-segment elevation acute coronary syndrome. In contrast, bedside echocardiography is a useful tool for the management of older people, especially when a rise in cardiac troponin is accompanied by atypical symptoms or a non-diagnostic electrocardiogram because of baseline abnormalities of LV hypertrophy, left bundle branch block or cardiac pacing. Evidence of LV wall motion abnormalities further suggests a diagnosis of acute coronary syndrome. Echocardiography is also essential in guiding the management of patients with signs of acute HF in this setting. Diagnoses of depressed LV systolic function, right ventricular infarction, free wall, interventricular (Video Loop 15) and papillary muscle rupture (Video Loop 16) are established readily by bedside Doppler echocardiography [58]. Of note, pre-existing impaired LV relaxation or atrioventricular dyssynchrony resulting from ischaemiaor drug-induced atrioventricular block may contribute to congestive HF in elderly patients with an acute coronary syndrome (Video Loop 17, Fig. 9). Bedside Doppler echocardiography also provides prognostic information, in addition to major clinical predictors of mortality and routine laboratory testing, in patients presenting with an acute coronary syndrome. Elevated E/Ea ratio, left atrial enlargement and mitral regurgitation, after or before myocardial infarction (findings that are seen more frequently in older people, both in the early and chronic post-myocardial infarction stage) predict subsequent LV remodelling, HF hospitalization and death [59—63]. The key role of bedside Doppler echocardiography is especially obvious in patients with non-ST-segment elevation acute coronary syndrome, where concomitant severe aortic valve stenosis or other severe valvular disease should be detected before cardiac catheterization because their presence requires consideration of cardiac surgery, while immediate percutaneous coronary intervention is likely to complicate cardiac valve disease management. There is an increased awareness among general clinicians of the syndrome of Takotsubo, which primarily affects elderly women; this syndrome, which mimics acute coronary syndrome, is characterized by an onset consequent to acute emotional stress or an acute medical condition, an electrocardiogram showing ST-segment elevation or depression, or T-wave changes, a prolonged QT interval, a mild increase in cardiac troponin, the typical akinesis of the apex together with hypercontraction of the basal walls in the absence of angiographically significant coronary artery Echocardiography in acute elderly patients 123 stenosis, the occasional presence of transient intracavitary pressure gradients and, importantly, complete resolution of the apical wall motion abnormality within a few days or weeks [64]. Dyspnoea setting The pathophysiology of dyspnoea in the elderly is often complex to delineate and may be multifactorial [65]. Important contributions may be inherently age-related and include cardiac factors such as decreased LV diastolic compliance or relative chronotropic incompetence, vascular factors such as decreased aortic distensibility or increased peripheral vascular stiffening, but also ventilator abnormalities, skeletal muscle dysfunction, obesity or anaemia. When echocardiographic examination does not disclose significant abnormalities at rest, exercise Doppler echocardiography may play an important role in diagnosis and hence in decision making [41,66]. For example, patients with rheumatic valve disease or not and mild mitral regurgitation at rest may exhibit severe mitral regurgitation during dynamic exercise and a subsequent rise in pulmonary artery systolic pressure [33,67]. Similarly, the severity of functional mitral regurgitation at rest is unrelated to an exercise-induced change in mitral regurgitation in patients with LV systolic dysfunction [68]. The E/Ea ratio, which is a good non-invasive estimator of LV filling pressure, has been validated both at rest and during dynamic exercise. An E/Ea ratio > 15 usually indicates a pulmonary capillary wedge pressure > 20 mmHg when septal Ea is used; and if the ratio is < 8, the LV filling pressure is usually normal [69]. Burgess et al. demonstrated that a post-exercise E/Ea > 13 correlates with elevated LV filling pressure and is highly specific for reduced exercise capacity [70]. Significant isolated pulmonary hypertension (LV ejection fraction > 50% and no left-sided valve disease or congenital heart disease) may be found in elderly patients [71]. Meticulous recording of the velocity of the tricuspid regurgitant jet allows accurate measurement of right ventricular systolic pressure. Pulsed-wave Doppler examination of the right ventricular outflow tract often reveals a mid-systolic notch of the Doppler forward-flow profile in the setting of high pulmonary vascular resistance (Fig. 10). Major and chronically increased right ventricular afterload produces interventricular septal flattening and right ventricular enlargement, hypertrophy and hypokinesis. Further evaluation is needed to rule out pulmonary hypertension associated with recognized causes, such as acute or chronic pulmonary thromboembolic disease, lung disease, sleep apnoea or drug-induced pulmonary hypertension. Moreover, it is necessary to evaluate the elevation of pulmonary capillary wedge pressure as estimated from the E/Ea ratio, as well as increased pulmonary arterial tone or vascular remodelling, to account for the excessive rise in pulmonary pressure at rest or during minimal exercise. Importantly, left-to-right shunt should be ruled out systematically in the presence of right ventricular enlargement. Careful evaluation of the atrial septum with colour flow Doppler and using the ratio of pulsed Doppler cardiac output across the pulmonary and aortic valves may help to detect a previously unknown atrial Figure 10. The tracing of this pulmonary flow discloses a midsystolic notch in an 80-year-old woman, therefore suggesting increased pulmonary vascular resistances. septal defect [48]. Lastly, contrast echocardiography readily allows the detection of a right-to-left shunt through a patent foramen ovale, which may be responsible for refractory profound hypoxaemia, for instance, in the setting of right hemidiaphragmatic paralysis [72,73]. Percutaneous closure of the patent foramen ovale by a catheter-deployed double-umbrella device results in complete normalization of arterial oxygen saturation. Chest pain setting Echocardiography is likely to be a major adjunct (when applied by an expert practitioner) in the assessment of patients with chest pain. Use of echocardiography allows the detection and differentiation of pericardial and pleural effusion (Video Loop 18), direct or indirect signs of pulmonary embolism or acute aortic syndrome. It should be noted that penetrating atherosclerotic ulcers affect the elderly primarily. However, computed tomography or magnetic resonance imaging has a major role to play in the management of patients with aortic disease. Stress echocardiography is recommended in patients with chest pain admitted to the emergency room for risk stratification purposes [74]. Stress dobutamine echocardiography is accurate in detecting coronary artery disease in older people. Nevertheless, subjects older than 75 years experience symptomatic hypotension and ventricular arrhythmias more frequently during dobutamine stress echocardiography [75]. Exercise stress echocardiography may also be envisioned in physically active elderly patients. Syncope setting There are multiple causes of abrupt reduction in brain perfusion in older people. When elucidating the cause of syncope, in addition to the electrocardiogram and clues provided from careful reading of the history (drugs, exertion, pain, arising, etc.), echocardiography may reveal obstruction of LV outflow of any form (aortic valve stenosis, hypertrophic obstructive cardiomyopathy), severe pulmonary hypertension, 124 P.V. Ennezat et al. Figure 11. Reproduced from Maréchaux et al., Eur J Heart 2007, with permission. Transthoracic two-dimensional echocardiography in a 78-year-old-woman demonstrated a myocardial infiltrative mass localized in the septum (Panel A, apical four-chamber view, arrow) and in the left ventricle (LV) inferior wall (Panel B, parasternal short axis, arrow). Pathology allowed diagnosis of a metastasis of a differentiated bronchial carcinoid. RV: right ventricle. left atrial myxoma or ball-valve thrombus. Hence, a normal 12-lead electrocardiogram combined with a lack of structural or functional heart disease discovered on echocardiographic examination in the setting of unexplained syncope is associated with favourable outcome and enables the patient to be discharged. Further diagnostic testing may thereby be envisioned in an outpatient setting in these elderly patients with normal electrocardiogram and bedside echocardiography [76]. The combination of atrioventricular block and aortic valve stenosis should not be misdiagnosed. Owing to the extreme risk of sudden death, thorough evaluation of aortic valve stenosis should be performed after pacemaker implantation. Moreover, before cardiac pacing, both bradycardia and irregular ventricular rate alter transvalvular gradients and load conditions significantly. Ventricular arrhythmias are likely in the presence of LV systolic dysfunction or myocardial scar. Of note, cardiac amyloid infiltration may cause malignant arrhythmias, conduction block, atrial fibrillation or sick sinus syndrome. Cancer setting Patients with cancer may develop complications in the cardiovascular system. While metastases to the myocardium are observed rarely (Fig. 11) [77], direct extension of tumours, such as primary lung tumours and malignant pericardial effusion (Fig. 12), are common. In addition, one third of patients with pericardial involvement will develop cardiac tamponade demanding immediate drainage. Not only pulmonary thromboembolic disease but also severe pulmonary infection, carcinomatous lymphangitis and pulmonary microscopic tumour embolism are suggested by echocardiographic features of cor pulmonale in this setting [78]. Non-bacterial thrombotic endocarditis can also complicate the course of various malignancies. Oedema of neck, face and arms suggests obstruction of the superior vena cava, which is revealed by contrast-enhanced computed tomography. Both acute and chronic HF syndrome due to reduced LV systolic function may be caused by cardiotoxicity of several chemotherapeutic agents, including anthracyclines and/or radiation therapy. Figure 12. Apical four-chamber view showing a large pericardial effusion and a pericardial mass in a 68-year-old man with carcinoma of the lung. Fever setting Owing to the higher incidence of nosocomial infections with the use of intravascular catheters, prosthetic heart valves and pacemaker leads, infective endocarditis is prevalent in older people and may result in severe valvular disease and/or conduction blocks. Doppler echocardiographic evaluation is key in guiding the surgical approach and timing of intervention. Transoesophageal echocardiography is more sensitive and specific than transthoracic echocardiography in this setting. It should be performed as early as possible to assess the extent of valvular lesions and to detect paravalvular abscess. A history of pulmonary infection in older patients with permanent pacemakers or implantable cardiac defibrillators should be noted and should suggest consideration of lead endocarditis (Video Loop 19). Diagnosis of infective aortitis with the use of transoesophageal echocardiography should be considered in atherosclerotic patients with fever and chest or abdominal pain [79]. Echocardiography in acute elderly patients 125 Operating room setting Figure 13. Transoesophageal view showing the transverse aortic arch in an 82-year-old patient with recent ischaemic stroke. Note the large atherosclerotic plaques of the aortic arch. Stroke setting Ischaemic stroke is a major cause of morbidity and mortality in older people. Both transthoracic and transoesophageal echocardiography are needed to screen multiple sources (such as LV thrombus or left atrial myxoma) that may be involved in cardiogenic embolism in older people, similar to younger individuals. However, atrial fibrillation associated with left atrial enlargement, atherosclerotic intra-aortic debris and large mitral annular calcification may be considered to be more specific to the elderly. Notably, atherosclerotic disease of the aortic arch with large plaques is present in one-third of patients with cryptogenic stroke and accounts for one-third of the population with total ischaemic stroke aged ≥ 60 years who have ≥ 1 vascular risk factor [80]. Cohen et al. found that, among morphological variables such as plaque thickness, surface irregularities, calcifications and hypoechoic plaques, plaque thickness ≥ 4 mm was associated with the highest event rate (Fig. 13) [81]. Falls setting Falls represent a major health problem in the geriatric population. About 40% of persons aged > 65 years will fall at least once each year. Moreover, falling is associated with high mortality and morbidity in elderly people and accounts for 6% of admissions to emergency departments in western countries and 8% of deaths in those aged over 65 years. Maréchaux et al. demonstrated recently that a rise in cardiac troponin occurs frequently in cases of falls [82]. Moreover, elevated cardiac troponin correlates with various heart diseases, including aortic valve stenosis or transient apical ballooning, namely Takotsubo syndrome (Video Loop 20), and with poor outcome [82]. Therefore, echocardiographic examination seems to provide useful information for the appropriate care and prognosis of troponin-positive, older patients referred to the emergency department after being immobilized on the ground after a fall. With age, older people are likely to undergo non-cardiac surgery. However, advanced age is a clinical predictor of increased perioperative cardiovascular risk [83]. Intolerance to cardiac load alterations is common in older people who undergo non-cardiac surgery. Excessive fluid challenge may easily result in pulmonary oedema due to the impaired LV relaxation of the ageing heart. In contrast, because of LV concentric remodelling or hypertrophy associated with ageing, both blood loss and insufficiency of fluid infusion may lead to prompt decrease in cardiac output. Inappropriate inotropic therapy may also provoke LV obstruction and eventually secondary apical ballooning, and thereby paradoxical pulmonary oedema. Underlying coronary artery disease that is prevalent in older people is also a major cause of LV dysfunction and myocardial infarction in the setting of non-cardiac surgery. In contrast to younger individuals, frequent comorbid conditions, functional decline, desired lifestyle and projected lifespan are major factors in evaluating cardiac surgical options. Surgical risk assessment tools may be helpful but have not been developed specifically for older people undergoing cardiac surgery (e.g. euroSCORE [http://www.euroscore.org] and the Cardiac Surgery Risk Models Guideline [http://www.sts.org]). Hence, in a recent study, the operative risk in 282 octogenarians undergoing aortic valve replacement was overestimated by the euroSCORE [84]. A variety of complications may nevertheless occur after cardiac surgery in the elderly. Risk of cerebral ischaemic events increases significantly among these older patients. Dislodgement of aortic atherosclerotic debris during cardiac surgery is favoured by external manipulation of the aorta during palpation, cross-clamping, cardiopulmonary bypass aortic cannula placement or proximal anastomosis of the grafts to the aorta. Transoesophageal echocardiography allows practitioners to discern the presence and severity of atherosclerotic disease of the ascending aorta before reaching or within the operating room. Owing to age-associated cardiovascular features, older people exhibit ‘specific’ complications after surgery on the valves. Small LV cavity and narrowed angle between mitral and aortic valves contribute to the onset of systolic anterior motion after mitral valve repair that may result in intractable severe LV outflow obstruction and accompanying mitral regurgitation, and therefore in serious haemodynamic complications (i.e. inability to wean the patient from cardiopulmonary bypass) (Video Loop 21). Often another pump run (and thereby extended aortic cross-clamp time) is indicated for further procedures to improve systolic anterior motion or mitral prosthetic valve implantation. The onset of LV outflow obstruction may eventually result from mitral bioprosthesis protrusion into the LV due to the disproportionate height of the prosthesis in a small ageing LV. LV obstruction may also develop in the particular setting of a valve-in-valve implantation (Fig. 14, Video Loops 22A and 22B). After aortic valve replacement, LV hypertrophy that is seen more frequently in women with aortic valve stenosis favours intra-LV obstruction. During the weaning of the cardiopulmonary bypass, the use of inotropic drugs at this stage increases the obstruction mediated by LV hypertrophy dramatically and results in a severe low cardiac output. The 126 P.V. Ennezat et al. ciation that subtle cardiac dysfunction can limit ventilatory weaning, advocating wide use of bedside echocardiography in the intensive care unit. Hence, wider echocardiography teaching may be valuable for improving the management of older people in the emergency and operating rooms. However, comprehensive and insightful echocardiographic examination often demands both detective work and in-depth knowledge. Conflict of interest statement None. Appendix A. Supplementary data Figure 14. Associated with Video Loops 22 A and B. The bioprosthetic mitral valve-in-valve implantation resulted in severe systolic anterior motion and a peak outflow tract gradient of 52 mmHg. peroperative transoesophageal echo has highlighted in those patients the value of beta-blockade treatment and an aggressive fluid challenge with complete contraindication of inotropes. Transcatheter aortic valve replacement appears to be an emerging and promising option for high-risk elderly patients. Periprocedural transoesophageal echocardiography plays a major role in guiding transcatheter aortic valve replacement and detecting immediate complications such as pericardial effusion, left ventricular pseudoaneurysm, mitral valve injury, prosthetic valve malpositioning or early migration, severe paravalvular leak and aortic dissection [85]. Heavy mitral annular calcifications predispose patients to left atrial dissection or LV rupture, which is a rare but often lethal complication of mitral valve surgery in the elderly. The abrupt discontinuity between LV and left atrium appears as a major peroperative bleed or postoperative tamponade. The diagnosis is confirmed by transoesophageal echocardiography, which delineates at best colour flow Doppler entering into the false lumen and often associated paraprosthetic valve regurgitation. LV false aneurysm is a seldom-delayed presentation of the latter complication. These potential complications advocate careful quantitation of mitral valve disease and appropriate indication for cardiac surgery. Conclusion Cardiovascular comorbid conditions reach epidemic proportions among older people. Bedside Dopplerechocardiography readily provides information that is crucial for guiding the therapeutic management of older patients in the operating room or presenting in the emergency room. The evaluation of these patients should integrate clinical, laboratory and echocardiography data to achieve a comprehensive assessment. Underuse of echocardiography in older patients with new HF onset is likely to result in poorer survival [86]. Complications related to myocardial infarction are detected readily using bedside echocardiography. Unexpected Takotsubo syndrome may be revealed in troponin-positive elderly women presenting after a fall or emotional trigger. There is increasing appre- Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.acvd.2009. 11.002. References [1] Granger CB, Goldberg RJ, Dabbous O, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 2003;163:2345—53. [2] Levy WC, Mozaffarian D, Linker DT, et al. The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation 2006;113:1424—33. [3] Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31—41. [4] Popitean L, Barthez O, Rioufol G, et al. Factors affecting the management of outcome in elderly patients with acute myocardial infarction particularly with regard to reperfusion. Data from the French regional RICO survey. Gerontology 2005;51:409—15. [5] Lakatta EG. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part III: cellular and molecular clues to heart and arterial aging. Circulation 2003;107:490—7. [6] Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part I: aging arteries: a ‘‘set up’’ for vascular disease. Circulation 2003;107:139—46. [7] Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part II: the aging heart in health: links to heart disease. Circulation 2003;107:346—54. [8] Borlaug BA, Melenovsky V, Redfield MM, et al. Impact of arterial load and loading sequence on left ventricular tissue velocities in humans. J Am Coll Cardiol 2007;50:1570—7. [9] McEniery CM, Yasmin, Hall IR, et al. Normal vascular aging: differential effects on wave reflection and aortic pulse wave velocity: the Anglo-Cardiff Collaborative Trial (ACCT). J Am Coll Cardiol 2005;46:1753—60. [10] Celermajer DS, Sorensen KE, Bull C, et al. Endothelium-dependent dilation in the systemic arteries of asymptomatic subjects relates to coronary risk factors and their interaction. J Am Coll Cardiol 1994;24:1468—74. [11] Fleg JL, O’Connor F, Gerstenblith G, et al. Impact of age on the cardiovascular response to dynamic upright exercise in healthy men and women. J Appl Physiol 1995;78:890—900. [12] Dannenberg AL, Levy D, Garrison RJ. Impact of age on echocardiographic left ventricular mass in a healthy population (the Framingham Study). Am J Cardiol 1989;64:1066—8. Echocardiography in acute elderly patients [13] Gardin JM, Arnold AM, Polak J, et al. Usefulness of aortic root dimension in persons ≥ 65 years of age in predicting heart failure, stroke, cardiovascular mortality, all-cause mortality and acute myocardial infarction (from the Cardiovascular Health Study). Am J Cardiol 2006;97:270—5. [14] Gardin JM, Henry WL, Savage DD, et al. Echocardiographic measurements in normal subjects: evaluation of an adult population without clinically apparent heart disease. J Clin Ultrasound 1979;7:439—47. [15] Aronow WS. Mitral annular calcification: significant and worth acting upon. Geriatrics 1991;46:73—5, p. 79—80, 85—86. [16] Lindroos M, Kupari M, Heikkila J, et al. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol 1993;21:1220—5. [17] Gardin JM, Arnold AM, Bild DE, et al. Left ventricular diastolic filling in the elderly: the cardiovascular health study. Am J Cardiol 1998;82:345—51. [18] Sagie A, Benjamin EJ, Galderisi M, et al. Reference values for Doppler indexes of left ventricular diastolic filling in the elderly. J Am Soc Echocardiogr 1993;6:570—6. [19] Tretjak M, Kozelj M. Tissue Doppler annular velocities. NT-proBNP and exercise capacity in healthy elderly. Age Ageing 2008;37:336—9. [20] Aurigemma GP, Silver KH, Priest MA, et al. Geometric changes allow normal ejection fraction despite depressed myocardial shortening in hypertensive left ventricular hypertrophy. J Am Coll Cardiol 1995;26:195—202. [21] Dib JC, Abergel E, Rovani C, et al. The age of the patient should be taken into account when interpreting Doppler assessed pulmonary artery pressures. J Am Soc Echocardiogr 1997;10: 72—3. [22] Lam CS, Borlaug BA, Kane GC, et al. Age-associated increases in pulmonary artery systolic pressure in the general population. Circulation 2009;119:2663—70. [23] Lloyd-Jones DM, Evans JC, Levy D. Hypertension in adults across the age spectrum: current outcomes and control in the community. JAMA 2005;294:466—72. [24] Ni H. Prevalence of self-reported heart failure among US adults: results from the 1999 National Health Interview Survey. Am Heart J 2003;146:121—8. [25] Logeart D. Echocardiographic examination: a major role in the management of heart failure. Arch Cardiovasc Dis 2008;101:431—3. [26] Ceia F, Fonseca C, Mota T, et al. Prevalence of chronic heart failure in Southwestern Europe: the EPICA study. Eur J Heart Fail 2002;4:531—9. [27] Klapholz M, Maurer M, Lowe AM, et al. Hospitalization for heart failure in the presence of a normal left ventricular ejection fraction: results of the New York Heart Failure Registry. J Am Coll Cardiol 2004;43:1432—8. [28] Melenovsky V, Borlaug BA, Rosen B, et al. Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction. J Am Coll Cardiol 2007;49:198—207. [29] Bogaty P, Mure P, Dumesnil JG. New insights into diastolic dysfunction as the cause of acute left-sided heart failure associated with systemic hypertension and/or coronary artery disease. Am J Cardiol 2002;89:341—5. [30] Ennezat PV, Lefetz Y, Marechaux S, et al. Left ventricular abnormal response during dynamic exercise in patients with heart failure and preserved left ventricular ejection fraction at rest. J Card Fail 2008;14:475—80. [31] Maréchaux S, Pinçon C, Poueymidanette M, et al. Elevated left atrial pressure estimated by Doppler echocardiography is a key determinant of mitral valve tenting in functional mitral regurgitation. Heart 2009; in press. 127 [32] Pinsky MR. Cardiovascular issues in respiratory care. Chest 2005;128:592S—7S. [33] Maréchaux S, Terrade J, Biausque F, et al. Exercise induced functional mitral regurgitation in heart failure and preserved ejection fraction: a new entity. Eur J Echocardiogr 2009; in press. [34] Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet 2006;368:1005—11. [35] Aronow WS, Kronzon I. Prevalence and severity of valvular aortic stenosis determined by Doppler echocardiography and its association with echocardiographic and electrocardiographic left ventricular hypertrophy and physical signs of aortic stenosis in elderly patients. Am J Cardiol 1991;67:776—7. [36] Freeman RV, Otto CM. Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies. Circulation 2005;111:3316—26. [37] Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 2007;28:230—68. [38] Blais C, Burwash IG, Mundigler G, et al. Projected valve area at normal flow rate improves the assessment of stenosis severity in patients with low-flow, low-gradient aortic stenosis: the multicenter TOPAS (Truly or Pseudo-Severe Aortic Stenosis) study. Circulation 2006;113:711—21. [39] Monin JL, Quere JP, Monchi M, et al. Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation 2003;108:319—24. [40] Ennezat PV, Marechaux S, Iung B, et al. Exercise testing and exercise stress echocardiography in asymptomatic aortic valve stenosis. Heart 2009;95:877—84. [41] Marechaux S, Bellouin A, Polge AS, et al. Clinical value of exercise Doppler echocardiography in patients with cardiac-valvular disease. Arch Cardiovasc Dis 2008;101: 351—60. [42] Dumesnil JG, Pibarot P, Akins C. New approaches to quantifying aortic stenosis severity. Curr Cardiol Rep 2008;10:91—7. [43] Garcia D, Dumesnil JG, Durand LG, et al. Discrepancies between catheter and Doppler estimates of valve effective orifice area can be predicted from the pressure recovery phenomenon: practical implications with regard to quantification of aortic stenosis severity. J Am Coll Cardiol 2003;41: 435—42. [44] Richardson-Lobbedez M, Ennezat PV, Marechaux S. Critical impact of pressure recovery on assessment of aortic valve stenosis. Arch Cardiovasc Dis 2009;102:669—70. [45] Hachicha Z, Dumesnil JG, Bogaty P, et al. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 2007;115:2856—64. [46] Pibarot P, Dumesnil JG, Clavel MA. Clinical vignette: paradoxical low flow, low gradient aortic stenosis despite preserved LV ejection fraction. Arch Cardiovasc Dis 2008;101:595—6. [47] Briand M, Dumesnil JG, Kadem L, et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment. J Am Coll Cardiol 2005;46:291—8. [48] Ennezat PV, Juthier F, Vincentelli A, et al. An unusual cause of low-flow, low-gradient severe aortic stenosis: left-to-right shunt due to atrial septal defect. Cardiology 2009;113:146—8. [49] Ennezat PV, Bellouin A, Marechaux S, et al. Pivotal role of bedside Doppler echocardiography in the assessment of patients with acute heart failure and mitral regurgitation. Cardiology 2009;113:249—59. [50] Magne J, Pibarot P, Dagenais F, et al. Preoperative posterior leaflet angle accurately predicts outcome after restrictive 128 [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] P.V. Ennezat et al. mitral valve annuloplasty for ischemic mitral regurgitation. Circulation 2007;115:782—91. Zhang XH, Chen H, Siu CW, et al. New-onset heart failure after permanent right ventricular apical pacing in patients with acquired high-grade atrioventricular block and normal left ventricular function. J Cardiovasc Electrophysiol 2008;19:136—41. Kim JB, Spevack DM, Tunick PA, et al. The effect of transvenous pacemaker and implantable cardioverter defibrillator lead placement on tricuspid valve function: an observational study. J Am Soc Echocardiogr 2008;21:284—7. Lin G, Nishimura RA, Connolly HM, et al. Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol 2005;45:1672—5. Oh JK. Echocardiography in heart failure: beyond diagnosis. Eur J Echocardiogr 2007;8:4—14. Libby P, Bonow R, Zipes D, et al. ardiovascular disease in the elderly. Braunwald’s heart disease. 8th ed. EL Saunders: Elsevier; 2007. Ennezat PV, Lamblin N, Mouquet F, et al. The effect of ageing on cardiac remodelling and hospitalization for heart failure after an inaugural anterior myocardial infarction. Eur Heart J 2008;29:1992—9. Huerre C, Guiot A, Maréchaux S, et al. Functional decline in elderly patients presenting with acute coronary syndromes: impact on midterm outcome. Arch Cardiovascular Dis 2009; in press. Gueret P, Khalife K, Jobic Y, et al. Echocardiographic assessment of the incidence of mechanical complications during the early phase of myocardial infarction in the reperfusion era: a French multicentre prospective registry. Arch Cardiovasc Dis 2008;101:41—7. Amigoni M, Meris A, Thune JJ, et al. Mitral regurgitation in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: prognostic significance and relation to ventricular size and function. Eur Heart J 2007;28:326—33. Ennezat PV, Darchis J, Lamblin N, et al. Left ventricular remodeling is associated with the severity of mitral regurgitation after inaugural anterior myocardial infarction: optimal timing for echocardiographic imaging. Am Heart J 2008;155:959—65. Moller JE, Pellikka PA, Hillis GS, et al. Prognostic importance of diastolic function and filling pressure in patients with acute myocardial infarction. Circulation 2006;114:438—44. Perez de Isla L, Zamorano J, Quezada M, et al. Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome. Eur Heart J 2006;27:2655—60. Richardson-Lobbedez M, Marechaux S, Bauters C, et al. Prognostic importance of tissue Doppler-derived diastolic function in patients presenting with acute coronary syndrome: a bedside echocardiographic study. Eur J Echocardiogr 2008;9:594—8. Sealove BA, Tiyyagura S, Fuster V. Takotsubo cardiomyopathy. J Gen Intern Med 2008;23:1904—8. Kitzman DW. Exercise intolerance. Prog Cardiovasc Dis 2005;47:367—79. Wissocq L, Ennezat PV, Mouquet F. Exercise-induced high-degree atrioventricular block. Arch Cardiovasc Dis 2009; 102:733—5. Tischler MD, Battle RW, Saha M, et al. Observations suggesting a high incidence of exercise-induced severe mitral regurgitation in patients with mild rheumatic mitral valve disease at rest. J Am Coll Cardiol 1995;25:128—33. Ennezat PV, Marechaux S, Le Tourneau T, et al. Myocardial asynchronism is a determinant of changes in functional mitral regurgitation severity during dynamic exercise in patients with [69] [70] [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85] [86] chronic heart failure due to severe left ventricular systolic dysfunction. Eur Heart J 2006;27:679—83. Ommen SR, Nishimura RA, Appleton CP, et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation 2000;102:1788—94. Burgess MI, Jenkins C, Sharman JE, et al. Diastolic stress echocardiography: hemodynamic validation and clinical significance of estimation of ventricular filling pressure with exercise. J Am Coll Cardiol 2006;47:1891—900. Shapiro BP, McGoon MD, Redfield MM. Unexplained pulmonary hypertension in elderly patients. Chest 2007;131: 94—100. Charbonnel C, Ennezat PV, Darchis J, et al. Pulmonary embolism and right diaphragmatic paralysis: ‘‘one train can hide another’’. Arch Mal Coeur Vaiss 2007;100:61—3. Darchis JS, Ennezat PV, Charbonnel C, et al. Hemidiaphragmatic paralysis: an underestimated etiology of right-to-left shunt through patent foramen ovale? Eur J Echocardiogr 2007;8:259—64. Sicari R, Nihoyannopoulos P, Evangelista A, et al. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 2008;9:415—37. Hiro J, Hiro T, Reid CL, et al. Safety and results of dobutamine stress echocardiography in women versus men and in patients older and younger than 75 years of age. Am J Cardiol 1997;80:1014—20. Brignole M, Alboni P, Benditt DG, et al. Guidelines on management (diagnosis and treatment) of syncope-update 2004. Executive Summary. Eur Heart J 2004;25:2054—72. Marechaux S, Dagorn J, Gaxotte V, et al. Myocardial metastasis of a bronchial carcinoid. Eur Heart J 2007;28:391. Roberts KE, Hamele-Bena D, Saqi A, et al. Pulmonary tumor embolism: a review of the literature. Am J Med 2003;115:228—32. Verbrugge E, Ennezat PV, Marechaux S, et al. Staphylococcal aortitis. Eur Heart J 2006;27:2068. Cohen A. Atherosclerosis of the thoracic aorta further characterization for higher risk of vascular events. J Am Coll Cardiol 2008;52:862—4. Cohen A, Tzourio C, Bertrand B, et al. Aortic plaque morphology and vascular events: a follow-up study in patients with ischemic stroke. FAPS Investigators. French Study of Aortic Plaques in Stroke. Circulation 1997;96:3838—41. Maréchaux S, Lubret R, Delsart P, et al. Clinical significance of unsuspected rise in cardiac troponin in the setting of fall in older people. Emerg Med J 2009: in press. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg 2007;104:15—26. Leontyev S, Walther T, Borger MA, et al. Aortic valve replacement in octogenarians: utility of risk stratification with EuroSCORE. Ann Thorac Surg 2009;87:1440—5. Singh IM, Shishehbor MH, Christofferson RD, et al. Percutaneous treatment of aortic valve stenosis. Cleve Clin J Med 2008;75:805—12. Senni M, Rodeheffer RJ, Tribouilloy CM, et al. Use of echocardiography in the management of congestive heart failure in the community. J Am Coll Cardiol 1999;33:164—70.