Echocardiographic assessment of LV filling pressure is feasible and accurate. When combined with clinical data, it leads to a more accurate diagnosis, regardless of LVEF.

AimsExercise intolerance is a hallmark of heart failure with preserved ejection fraction (HFpEF), yet its mechanisms remain unclear. The current study sought to determine whether increases in cardiac output (CO) during exercise are appropriately matched to metabolic demands in HFpEF. Methods and resultsPatients with HFpEF (n ¼ 109) and controls (n ¼ 73) exercised to volitional fatigue with simultaneous invasive (n ¼ 96) or non-invasive (n ¼ 86) haemodynamic assessment and expired gas analysis to determine oxygen consumption (VO 2 ) during upright or supine exercise. At rest, HFpEF patients had higher LV filling pressures but similar heart rate, stroke volume, EF, and CO. During supine and upright exercise, HFpEF patients displayed lower peak VO 2 coupled with blunted increases in heart rate, stroke volume, EF, and CO compared with controls. LV filling pressures increased dramatically in HFpEF patients, with secondary elevation in pulmonary artery pressures. Reduced peak VO 2 in HFpEF patients was predominantly attributable to CO limitation, as the slope of the increase in CO relative to VO 2 was 20% lower in HFpEF patients (5.9 + 2.5 vs. 7.4 + 2.6 L blood/L O 2 , P ¼ 0.0005). While absolute increases in arterial -venous O 2 difference with exercise were similar in HFpEF patients and controls, augmentation in arterial-venous O 2 difference relative to VO 2 was greater in HFpEF patients (8.9 + 3.4 vs. 5.5 + 2.0 min/dL, P , 0.0001). These differences were observed in the total cohort and when upright and supine exercise modalities were examined individually. ConclusionWhile diastolic dysfunction promotes congestion and pulmonary hypertension with stress in HFpEF, reduction in exercise capacity is predominantly related to inadequate CO relative to metabolic needs.--

Background-Quadricuspid aortic valve (QAV) is a rare congenital cardiac defect. This study sought to determine QAV frequency in a large echocardiography database, to characterize associated cardiovascular abnormalities, and to describe long-term outcomes.

The E/e' ratio should not be used to estimate LVFP in subjects with significant MAC. However, mitral E/A ratio and IVRT are useful predictors of LVFP in this patient population. The proposed decision algorithm combining these Doppler parameters is accurate in estimating LVFP in patients with MAC.

Paradoxical coronary artery embolism is a rare, but often an underdiagnosed cause of acute myocardial infarction. It should be considered in patient who presents with chest pain and otherwise having a low risk profile for atherosclerosis coronary artery disease. We describe a case of paradoxical coronary artery embolism causing ST segment elevation myocardial infarction in a patient with upper extremity venous thrombosis. Echocardiography demonstrated a patent foramen ovale (PFO) with bidirectional shunt. In addition to treatment of acute coronary event closure of the PFO should be considered to prevent a recurrence.