Eihab Ghantous

Advancements in congenital heart disease (CHD) care have significantly improved survival, leading to a growing population of adults with congenital heart disease (ACHDs). Many of these patients require ongoing interventions for residual defects, conduit or valve dysfunction, and arrhythmia management, often performed using transcatheter techniques. Imaging plays a critical role in ensuring procedural success and safety. Intracardiac echocardiography (ICE) has emerged as an essential imaging modality in ACHD interventions. With continuous technological advancements, ICE offers several advantages over transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE), including superior visualization, real-time guidance, and the ability to avoid general anesthesia. These benefits have made ICE the preferred imaging tool for many transcatheter procedures. This review explores the expanding role of ICE in ACHD interventions, highlighting its applications in structural and electrophysiological procedures. By enhancing procedural precision and reducing complications, ICE is transforming the management of ACHD patients, optimizing outcomes, and improving long-term care for this complex and growing population.

Significant advances in the diagnosis and treatment of congenital heart disease have transformed patient outcomes, leading to an expanding adult congenital heart disease population. Many of these adults require lifelong procedural interventions, frequently performed in catheterization labs under the guidance of echocardiography. This review explores the transesophageal echocardiographic aspect in key catheterization-based procedures.

Aim: We used a combined stress echocardiography and cardiopulmonary exercise test (CPET) to explore effort intolerance in peripheral arterial disease (PAD) patients. Methods: Twenty-three patients who had both PAD and coronary artery disease (CAD) were compared with twenty-four sex- and age-matched CAD patients and fifteen normal controls using a symptom-limited ramp bicycle CPET on a tilting dedicated ergometer. Echocardiographic images were obtained concurrently with gas exchange measurements along predefined stages of exercise. Oxygen extraction was calculated using the Fick equation at each activity level. Results: Along the stages of exercise (unloaded; anaerobic threshold; peak), in PAD + CAD patients compared with CAD or controls, diastolic function worsened (p = 0.051 and p = 0.013, respectively), and oxygen consumption (p < 0.001 and p < 0.001, respectively) and oxygen pulse (p = 0.0024 and p = 0.0027, respectively) were reduced. Notably, oxygen pulse was blunted due to an insufficient increase in both stroke volume (p = 0.025 and p = 0.028, respectively) and peripheral oxygen extraction (p = 0.031 and p = 0.038, respectively). Chronotropic incompetence was more prevalent in PAD patients and persisted after correction for beta-blocker use (62% vs. 42% and 11%, respectively). Conclusions: In PAD patients, exercise limitation is associated with diastolic dysfunction, chronotropic incompetence and peripheral factors.

Background Data to delineate exercise intolerance in patients with peripheral arterial disease (PAD) are scarce. We used a combined stress echocardiography and cardiopulmonary exercise test (CPET) to explore effort intolerance in PAD. Methods Twenty-eight patients who had both PAD and coronary artery disease (CAD) were compared with sex and age-matched 31 CAD patients and 15 normal controls using a symptom-limited ramp bicycle CPET on a tilting dedicated ergometer. Echocardiographic images were obtained concurrently with gas exchange measurements along predefined stages of exercise. Oxygen extraction was calculated using the Fick equation: (VO2)/(echocardiography-calculated cardiac output) at each activity level. Results Along stages of exercise (unloaded; anaerobic threshold; peak), in PAD+CADF patients compared with CAD or controls: diastolic function worsened (E/e’ 13.2±3.1 vs 9.3±2.4 vs 9.6±4; 16.6±4.3 vs 10.4±2.5 vs 9.1±3.8; 15.8±4 vs 11.9±2.9 vs 9.1±4.1), and oxygen consumption (6.1±1.4 vs 5.8±1.9 vs 6.5±2.5;14.2±1.8 vs 17.1±2.9 vs 18.1±3.3; 14.9±2 vs 19.3±2.5 vs 22±3.6 ml/kg/min) and oxygen pulse (6.5±1.9 vs 6.5±2 vs 6.6±2.3; 8.2±1.8 vs 10±2.4 vs 8.1±2.3; 8.1±2.2 vs 11.1±2 vs 11.7±2.6ml/beat) were reduced. Notably, oxygen pulse was blunted due to an insufficient increase in both stroke volume (89±11 vs 92±11 vs 92±13; 95±10 vs 104±9 vs 103±11; 86±10 vs 97±10 vs 98±11ml) and oxygen extraction (0.06±0.03 vs 0.07±0.03 vs 0.07±0.03; 0.09±0.03 vs 0.12±0.03 vs 0.12±0.03; 0.09±0.03 vs 0.13±0.03 vs 0.13±0.03l/l). Chronotropic incompetence was more prevalent in PAD patients and persisted after correction for beta-blockers use (62% vs 42% and 11% respectively). Reduced ventilatory efficiency (peak VE/VCO2 36.8±4.9 vs 31.5±4 vs 30.5±5l/l) and reduced mechanical efficiency (slope of oxygen consumption/work rate 8.96±0.42 vs 10.37±0.41 vs 10.8±0.49l/W) were found. Conclusion Exercise limitation is affected by diastolic dysfunction, chronotropic incompetence and peripheral factors in PAD patients. Clinical perspectives Peripheral arterial disease (PAD) is characterized by exercise intolerance. Yet, the mechanism behind this limitation is not well characterized. We show here that effort limitation in PAD is caused by a combination of central and peripheral cardiovascular factors including diastolic dysfunction, chronotropic incompetence and insufficient peripheral muscle oxygen extraction. These data may assist targeting future therapeutic measures.