Background-: Left ventricular outflow tract obstruction is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). The classical quantification of intraventricular obstruction is performed in resting conditions in supine position, but this assessment does not reflect what happens in HCM patients (pts) in their daily activities, neither during effort nor during orthostatic recovery.

Exercise stress echocardiography is the most frequently used stress test in our laboratory. Exercise echocardiography is used mainly in the study of patients with coronary artery disease. However, the technique is increasingly being used to study other diseases.In our centre, we use an original methodology, published by us in 2000, in which we evaluate heart function during exercise in the treadmill. After the exercise, patients are maintained in orthostatic position when appropriate or lying down in left lateral decubitus for further evaluation. Since this method seems to increase the quality and the quantity of information obtained in so many clinical arenas, we now present a detailed review of this methodology and its applications.

BACKGROUND: Stress echocardiography has a 72%-85% sensitivity and an 80%-95% specificity. In this study, we characterized patients who received a false-positive stress echocardiogram result. METHODS: A total of 5,256 patients underwent a stress echocardiogram (induced by exercise, dobutamine, or dipyridamole) between 2009 to 2018, and 405 patients (7.7%) received a positive result. Among the positive patients, 300 underwent coronary angiography within 12 months, and these patients were included in this study (mean age = 64.9 ± 9.4 years, 230 men [76.7%]). Coronary artery disease was diagnosed by stenosis ≥50% in any epicardial coronary artery. Clinical and echocardiographic variables were compared between patients with trueand false-positive stress echocardiogram results. RESULTS: Seventy-two patients (24%) had a false-positive stress echocardiogram, with similar rates across stressor types (p = 0.574). Patients with false positives were less frequently men (63.9% vs. 80.7%, p = 0.003), had lower diabetes mellitus prevalence (15.3% vs. 45.6%, p = 0.001), were similar to true positive patients with regard to body-mass index, arterial hypertension prevalence, hyperlipidemia and smoking, and had lower pre-test probability of coronary artery disease (23% vs. 32%, p = 0.016). The wall motion score index (WMSI) was higher in the true-positive stress group, and wall motion abnormalities were more frequent in the apical segments (70.5% vs. 56.7%, p = 0.034). In a multivariable predictive model, men (odds ratio [OR] = 2.994), diabetes (OR = 5.440), and peak WMSI (OR = 10.690) were associated with a true-positive result. CONCLUSIONS: Twenty-four percent of our study population received a false-positive stress echocardiogram result, with similar rates across stressor types. Patients with true-positive stress echocardiogram results are more likely to be men, diabetic, and have a high peak WMSI.

Candida species can cause clinical manifestations in various organs of the cardiovascular system, i.e., the pericardium, myocardium, and endocardium, with endocarditis being the best-known clinical entity. Endocarditis is seen primarily in intravenous drug users and in individuals with damaged native valves, especially in congenital heart disease or rheumatic valvular diseases, and in prosthetic heart valves. The authors present a case of Pichia ohmeri endocarditis in an intravenous drug user, with an unusual presentation form. This is a case of a 42-year-old man, an intravenous heroin user, who was admitted to our Vascular Surgery Department because of fever and acute serious ischemia of the left inferior limb. He presented with fever (39 degrees C), a pale and cold left limb, absence of the left popliteal pulse, and a pansystolic murmur at the cardiac apex. The transthoracic echocardiogram showed a large vegetation on the anterior leaflet of the mitral valve and severe mitral regurgitation with good left ventricular systolic function. Empirical antibiotic therapy was started. Six days after admission, embolectomy was performed with partial clinical recovery. Three blood cultures and the embolus showed a teleomorphic form of Candida guilliermondii - Pichia ohmeri. Therapy with intravenous liposomal amphotericin B, fluocitosin, imipenem, and aztreonam was started. Two weeks later, his clinical condition deteriorated with acute heart failure refractory to medical therapy, mandating mechanical ventilation and high-dose vasopressor and inotropic amine support. He underwent urgent mitral valve replacement with a biologic prosthetic valve. Rapid stabilization of the cardiac status occurred, but ischemic limb lesions required further vascular interventions.

A 39-year-old woman underwent uneventful percutaneous occlusion of an ostium secundum atrial septal defect (ASD) with a 22 mm Ultrasept ASD Occluder. Transesophageal echocardiography (TEE) performed two years after implantation revealed a de novo residual left-to-right shunt through the correctly implanted device. Three-dimensional transesophageal echocardiography (3D TEE) further clarified this finding by showing a perforation of the device membrane coating. The patient underwent transcatheter closure of the residual shunt with a 20 mm Ultrasept PFO device. The procedure was guided by fluoroscopy and real-time 3D TEE. At the end of the procedure 3D TEE documented correct device deployment with complete defect coverage and absence of residual shunt.