johann christopher | CARE HOSPITAL THE INSTITUE OF MEDICAL SCIENCES (original) (raw)
Papers by johann christopher
Journal of cardiovascular magnetic resonance, 2024
Journal of Cardiovascular Computed Tomography, Dec 31, 2023
Indian journal of clinical cardiology, Feb 12, 2021
Endomyocardial fibrosis is a rare cardiomyopathy. There has to be a high level of suspicion to ma... more Endomyocardial fibrosis is a rare cardiomyopathy. There has to be a high level of suspicion to make the diagnosis. The treatment is based on symptomatic relief and surgical management is based on the exact pathology found in the left ventricle apex. MRI is a robust investigation which can confirm diagnosis and provide management options and prognosis.
Cardiology and Therapy, Apr 12, 2023
The current recommendations by Indian experts who are focused on the challenges in the management... more The current recommendations by Indian experts who are focused on the challenges in the management of patients with acute coronary syndrome (ACS) in rural areas, due to limited catheterization (CATH) lab facilities and interventional cardiologist coverage across the country, are described. 120 cardiologist experts drafted recommendations during ten advisory board meetings conducted from April to May 2022. Experts framed statements based on experience, collective clinical judgment from practical experience, and available scientific evidence regarding ACS. The consensus positioned fondaparinux as highly useful in non-CATH-lab-based hospitals for patients diagnosed with non-ST elevation acute coronary syndrome (NSTE-ACS) and ST elevation acute coronary syndrome (STE-ACS) patients who cannot be shifted to percutaneous coronary intervention (PCI)-capable centres, or for patients who are thrombolysed at peripheral centres.
Journal of the Indian Academy of Echocardiography & cardiovascular imaging, 2018
Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of p... more Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of prognostic importance in heart failure (HF) diseases. Recently, right ventricular (RV) function is being increasingly recognized as critical parameter in terms of mortality outcomes both in acute and chronic HF. We sought to determine the prognostic significance of PH and RV function in patients of acute and chronic HF from retrospective institutional data. Methodology: We studied 306 patients with HF presentation including acute decompensated HF. Pulmonary artery systolic pressure (PASP) and RV function were determined with the use of Doppler echocardiography, with PH as PASP >50 mmHg and tricuspid annular plane systolic excursion (TAPSE) <1.6 cm along with global RV fractional area change. The primary endpoint was all-cause mortality during 3-year follow-up. Results: PH was present in 134 patients (43.8%) and RV dysfunction in 129 patients (42.2%). The majority of patients with RV dysfunction had PH (58.1%). Patients with normal RV function and PH had an intermediate risk. However, patients with RV dysfunction without PH were not at increased risk for 3-year mortality. Conclusion: Critical echocardiography parameters in the evaluation of HF include PASP for pressure and volume overload status as well as RV function. The incremental prognosis is also determined by PH and RV function. The compounding effect of PH & RV dysfunction is detrimental in terms of high morbidity rates and mortality outcomes.
自律神経 = The Autonomic nervous system, Aug 15, 2002
Journal of cardiovascular disease research, 2021
Cardiovascular imaging Asia, 2018
A 48-year-old female with chest pain was diagnosed with an inferoposterior wall myocardial infarc... more A 48-year-old female with chest pain was diagnosed with an inferoposterior wall myocardial infarction. A moderate pericardial effusion was revealed on two-dimensional echocardiography. Post-thrombolysis, the patient experienced persistent chest pain. In view of the possibility of a sealed myocardial rupture, the patient underwent coronary CT angiography (CTA). The rupture was confirmed via CTA, and the coronary anatomy was delineated. The patient underwent pericardial patch repair with good results.
Cureus, Oct 2, 2022
Ellis-Van Creveld syndrome (EVCS) is an abnormal genetic condition of the EVC2 gene located on ch... more Ellis-Van Creveld syndrome (EVCS) is an abnormal genetic condition of the EVC2 gene located on chromosome 4. In this case, the person presents with bone growth abnormalities, thus having a short stature, short arms and legs (more commonly the forearm and lower leg), a narrow chest with short ribs, polydactyly, spoon-shaped or malformed nails, abnormalities in dentition, and congenital heart defects like atrial septal defects and ventricular septal defects. In this case report, we present a 4.5-year-old female child who presented with cough and cyanosis as signs and tachypnea, tachycardia, facial oedema, cold, and clubbing as symptoms with polydactyly and short stature focuses on a rare presentation of a syndromic disease known as EVCS.
Journal of cardiovascular disease research, 2021
Indian heart journal, 2007
Journal of Family Medicine and Primary Care
Indian Journal of Clinical Cardiology, 2021
Endomyocardial fibrosis is a rare cardiomyopathy. There has to be a high level of suspicion to ma... more Endomyocardial fibrosis is a rare cardiomyopathy. There has to be a high level of suspicion to make the diagnosis. The treatment is based on symptomatic relief and surgical management is based on the exact pathology found in the left ventricle apex. MRI is a robust investigation which can confirm diagnosis and provide management options and prognosis.
Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging, 2018
Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of p... more Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of prognostic importance in heart failure (HF) diseases. Recently, right ventricular (RV) function is being increasingly recognized as critical parameter in terms of mortality outcomes both in acute and chronic HF. We sought to determine the prognostic significance of PH and RV function in patients of acute and chronic HF from retrospective institutional data. Methodology: We studied 306 patients with HF presentation including acute decompensated HF. Pulmonary artery systolic pressure (PASP) and RV function were determined with the use of Doppler echocardiography, with PH as PASP >50 mmHg and tricuspid annular plane systolic excursion (TAPSE) <1.6 cm along with global RV fractional area change. The primary endpoint was all-cause mortality during 3-year follow-up. Results: PH was present in 134 patients (43.8%) and RV dysfunction in 129 patients (42.2%). The majority of patients with RV...
The Journal of the Association of Physicians of India, 2007
Reduction of blood flow to both cerebral hemispheres or the brainstem (reticular activating syste... more Reduction of blood flow to both cerebral hemispheres or the brainstem (reticular activating system), results in acute hypoperfusion. This leads to loss of consciousness and postural tone, with resulting syncope. As syncope is a transient event, it follows that the cause of central nervous system (CNS) dysfunction must also be transient. Persistent causes of significant CNS dysfunction results in altered mental status or even coma (cerebrovascular and metabolic causes).
European Heart Journal, 2013
Purpose: For a long time, enteroviruses have been considered to be the most common cause of acute... more Purpose: For a long time, enteroviruses have been considered to be the most common cause of acute viral myocarditis (MC), with possible transition from MC to dilated cardiomyopathy (DCM). Recent investigations have shown, however, that other viruses are also frequently encountered in MC patients, suggesting that persistence of various virus species may play a pathogenic role in the transition from MC to DCM. The purpose of this study was to screen endomyocardial biopsies (EMBs) from patients with "idiopathic" DCM for the presence of viral genomes by using polymerase chain reaction (PCR) to assess the frequency of cardiac viral infections that may be involved in the pathogenesis of the disease. Methods: EMBs were obtained for PCR analysis from 100 consecutive patients (median left ventricular ejection fraction, 35.0%; range, 9% to 45%). PCR was performed to detect the genomic sequences of enterovirus (EV), adenovirus (ADV), human cytomegalovirus (HCMV), herpes simplex virus, Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), parvovirus B19 (PVB19), influenza A and B viruses and Coxiella burnettii. Myocardial inflammation was assessed by histological and immunohistological analyses. Results: Viral genomes could be amplified from EMBs of 85 (85%) of the 100 DCM patients: EV=25 (29%), ADV=5 (6%), PVB-19=10 (12%), HHV-6/7 =10 (12%), EBV=8 (9%), HCMV=6 (7%), including n= 10 cases (10%) with multiple infections. Active or borderline myocarditis according to the Dallas classification did not exist in any case. Conclusions: Viral genomes were frequently detected in EMBs of patients with systolic left ventricular dysfunction. Our data suggest that myocardial persistence of various viruses, often presenting as multiple infections, play a role in the pathogenesis of DCM far more frequently than suspected so far.
Clinical Cardiology, 2011
Background: Congenital left ventricular aneurysm (LVA) and diverticulum (LVD) are rare cardiac an... more Background: Congenital left ventricular aneurysm (LVA) and diverticulum (LVD) are rare cardiac anomalies and frequently associated with other cardiac anomalies. The objective of our study was to investigate the prevalence and the spectrum of coronary anomalies in such patients. Hypothesis: The incidence of coronary anomalies is increased in patients with LVA or LVD. Methods: We assessed 117 patients with isolated LVA or LVD for the prevalence of coronary anomalies and compared the findings with an age-and sex-matched control group (n = 117) without the diagnosis of LVA or LVD. Results: Coronary anomalies were present in 58.1% of the study population (68 of 117). The median age of affected patients was 64 years, and 45 (38.5%) were male. Coronary anomalies were more prevalent in patients with LVA or LVD (58.1% vs 6.8%, P < 0.001), male patients (89% vs 57%, P = 0.0002), and in patients with nonapical location of LVA or LVD (24% vs 45%, P = 0.02) compared with control, whereas age and type (LVA vs LVD) had no influence (57% vs 57.6%, P = 0.4; and 58.8% vs 57.6%, P = 0.87, respectively). The number of adverse cardiac events was similar in both groups during a 4.2-year follow-up period (29% vs 19%, P = 0.09). None of the patients in our series had major coronary anomalies with potential lethal consequences. Conclusions: This large single-center study suggests that the prevalence of abnormal coronary-artery anatomy in patients with isolated LVA or LVD is as high as 58.1%. However, we did not identify major coronary anomalies with potential lethal consequences, and the clinical course during follow-up was not influenced by the presence or absence of coronary anomalies. Methods Definition The diagnosis of LVA or LVD in our series was established after angiographic exclusion of coronary artery disease,
Journal of the American College of Cardiology, 2022
BACKGROUND Detection of ≥50% diameter stenosis left main coronary artery disease (LMD) has progno... more BACKGROUND Detection of ≥50% diameter stenosis left main coronary artery disease (LMD) has prognostic and therapeutic implications. Noninvasive stress imaging or an exercise tolerance test (ETT) are the most common methods to detect obstructive coronary artery disease, though stress test markers of LMD remain ill-defined. OBJECTIVES The authors sought to identify markers of LMD as detected on coronary computed tomography angiography (CTA), using clinical and stress testing parameters. METHODS This was a post hoc analysis of ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), including randomized and nonrandomized participants who had locally determined moderate or severe ischemia on nonimaging ETT, stress nuclear myocardial perfusion imaging, or stress echocardiography followed by CTA to exclude LMD. Stress tests were read by core laboratories. Prior coronary artery bypass grafting was an exclusion. In a stepped multivariate model, the authors identified predictors of LMD, first without and then with stress testing parameters. RESULTS Among 5,146 participants (mean age 63 years, 74% male), 414 (8%) had LMD. Predictors of LMD were older age (P < 0.001), male sex (P < 0.01), absence of prior myocardial infarction (P < 0.009), transient ischemic dilation of the left ventricle on stress echocardiography (P = 0.05), magnitude of ST-segment depression on ETT (P = 0.004), and peak metabolic equivalents achieved on ETT (P = 0.001). The models were weakly predictive of LMD (C-index 0.643 and 0.684). CONCLUSIONS In patients with moderate or severe ischemia, clinical and stress testing parameters were weakly predictive of LMD on CTA. For most patients with moderate or severe ischemia, anatomical imaging is needed to rule out LMD. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
Indian Journal of Cardiovascular Disease in Women WINCARS, 2016
The left ventricular ejection fraction (LVEF) assessed by trans-thoracic Echocardiogram (TTE) rem... more The left ventricular ejection fraction (LVEF) assessed by trans-thoracic Echocardiogram (TTE) remains the most common parameter of LV performance that is used in clinical practice. Three-dimensional / volumetric methods are more accurate, but are cumbersome to be performed in every case. The measures of myocardial contractility are more sensitive, reliable and with lesser inter observer variability but their place in daily practice is limited. Two-dimensional echocardiogram has the advantages of easy availability, low cost, portability, lack of radiation and non-invasive nature. Radionuclide studies, SPECT, cardiac CT and cardiac MRI are available only in a few centers and have more specific indication to be performed. The choice of a modality depends on the information sought by the clinician and the availability of expertise. Additional cost, radiation and limited access are important limitations of these special imaging modalities. The invasive methods which were popular a few de...
Journal of cardiovascular magnetic resonance, 2024
Journal of Cardiovascular Computed Tomography, Dec 31, 2023
Indian journal of clinical cardiology, Feb 12, 2021
Endomyocardial fibrosis is a rare cardiomyopathy. There has to be a high level of suspicion to ma... more Endomyocardial fibrosis is a rare cardiomyopathy. There has to be a high level of suspicion to make the diagnosis. The treatment is based on symptomatic relief and surgical management is based on the exact pathology found in the left ventricle apex. MRI is a robust investigation which can confirm diagnosis and provide management options and prognosis.
Cardiology and Therapy, Apr 12, 2023
The current recommendations by Indian experts who are focused on the challenges in the management... more The current recommendations by Indian experts who are focused on the challenges in the management of patients with acute coronary syndrome (ACS) in rural areas, due to limited catheterization (CATH) lab facilities and interventional cardiologist coverage across the country, are described. 120 cardiologist experts drafted recommendations during ten advisory board meetings conducted from April to May 2022. Experts framed statements based on experience, collective clinical judgment from practical experience, and available scientific evidence regarding ACS. The consensus positioned fondaparinux as highly useful in non-CATH-lab-based hospitals for patients diagnosed with non-ST elevation acute coronary syndrome (NSTE-ACS) and ST elevation acute coronary syndrome (STE-ACS) patients who cannot be shifted to percutaneous coronary intervention (PCI)-capable centres, or for patients who are thrombolysed at peripheral centres.
Journal of the Indian Academy of Echocardiography & cardiovascular imaging, 2018
Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of p... more Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of prognostic importance in heart failure (HF) diseases. Recently, right ventricular (RV) function is being increasingly recognized as critical parameter in terms of mortality outcomes both in acute and chronic HF. We sought to determine the prognostic significance of PH and RV function in patients of acute and chronic HF from retrospective institutional data. Methodology: We studied 306 patients with HF presentation including acute decompensated HF. Pulmonary artery systolic pressure (PASP) and RV function were determined with the use of Doppler echocardiography, with PH as PASP >50 mmHg and tricuspid annular plane systolic excursion (TAPSE) <1.6 cm along with global RV fractional area change. The primary endpoint was all-cause mortality during 3-year follow-up. Results: PH was present in 134 patients (43.8%) and RV dysfunction in 129 patients (42.2%). The majority of patients with RV dysfunction had PH (58.1%). Patients with normal RV function and PH had an intermediate risk. However, patients with RV dysfunction without PH were not at increased risk for 3-year mortality. Conclusion: Critical echocardiography parameters in the evaluation of HF include PASP for pressure and volume overload status as well as RV function. The incremental prognosis is also determined by PH and RV function. The compounding effect of PH & RV dysfunction is detrimental in terms of high morbidity rates and mortality outcomes.
自律神経 = The Autonomic nervous system, Aug 15, 2002
Journal of cardiovascular disease research, 2021
Cardiovascular imaging Asia, 2018
A 48-year-old female with chest pain was diagnosed with an inferoposterior wall myocardial infarc... more A 48-year-old female with chest pain was diagnosed with an inferoposterior wall myocardial infarction. A moderate pericardial effusion was revealed on two-dimensional echocardiography. Post-thrombolysis, the patient experienced persistent chest pain. In view of the possibility of a sealed myocardial rupture, the patient underwent coronary CT angiography (CTA). The rupture was confirmed via CTA, and the coronary anatomy was delineated. The patient underwent pericardial patch repair with good results.
Cureus, Oct 2, 2022
Ellis-Van Creveld syndrome (EVCS) is an abnormal genetic condition of the EVC2 gene located on ch... more Ellis-Van Creveld syndrome (EVCS) is an abnormal genetic condition of the EVC2 gene located on chromosome 4. In this case, the person presents with bone growth abnormalities, thus having a short stature, short arms and legs (more commonly the forearm and lower leg), a narrow chest with short ribs, polydactyly, spoon-shaped or malformed nails, abnormalities in dentition, and congenital heart defects like atrial septal defects and ventricular septal defects. In this case report, we present a 4.5-year-old female child who presented with cough and cyanosis as signs and tachypnea, tachycardia, facial oedema, cold, and clubbing as symptoms with polydactyly and short stature focuses on a rare presentation of a syndromic disease known as EVCS.
Journal of cardiovascular disease research, 2021
Indian heart journal, 2007
Journal of Family Medicine and Primary Care
Indian Journal of Clinical Cardiology, 2021
Endomyocardial fibrosis is a rare cardiomyopathy. There has to be a high level of suspicion to ma... more Endomyocardial fibrosis is a rare cardiomyopathy. There has to be a high level of suspicion to make the diagnosis. The treatment is based on symptomatic relief and surgical management is based on the exact pathology found in the left ventricle apex. MRI is a robust investigation which can confirm diagnosis and provide management options and prognosis.
Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging, 2018
Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of p... more Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of prognostic importance in heart failure (HF) diseases. Recently, right ventricular (RV) function is being increasingly recognized as critical parameter in terms of mortality outcomes both in acute and chronic HF. We sought to determine the prognostic significance of PH and RV function in patients of acute and chronic HF from retrospective institutional data. Methodology: We studied 306 patients with HF presentation including acute decompensated HF. Pulmonary artery systolic pressure (PASP) and RV function were determined with the use of Doppler echocardiography, with PH as PASP >50 mmHg and tricuspid annular plane systolic excursion (TAPSE) <1.6 cm along with global RV fractional area change. The primary endpoint was all-cause mortality during 3-year follow-up. Results: PH was present in 134 patients (43.8%) and RV dysfunction in 129 patients (42.2%). The majority of patients with RV...
The Journal of the Association of Physicians of India, 2007
Reduction of blood flow to both cerebral hemispheres or the brainstem (reticular activating syste... more Reduction of blood flow to both cerebral hemispheres or the brainstem (reticular activating system), results in acute hypoperfusion. This leads to loss of consciousness and postural tone, with resulting syncope. As syncope is a transient event, it follows that the cause of central nervous system (CNS) dysfunction must also be transient. Persistent causes of significant CNS dysfunction results in altered mental status or even coma (cerebrovascular and metabolic causes).
European Heart Journal, 2013
Purpose: For a long time, enteroviruses have been considered to be the most common cause of acute... more Purpose: For a long time, enteroviruses have been considered to be the most common cause of acute viral myocarditis (MC), with possible transition from MC to dilated cardiomyopathy (DCM). Recent investigations have shown, however, that other viruses are also frequently encountered in MC patients, suggesting that persistence of various virus species may play a pathogenic role in the transition from MC to DCM. The purpose of this study was to screen endomyocardial biopsies (EMBs) from patients with "idiopathic" DCM for the presence of viral genomes by using polymerase chain reaction (PCR) to assess the frequency of cardiac viral infections that may be involved in the pathogenesis of the disease. Methods: EMBs were obtained for PCR analysis from 100 consecutive patients (median left ventricular ejection fraction, 35.0%; range, 9% to 45%). PCR was performed to detect the genomic sequences of enterovirus (EV), adenovirus (ADV), human cytomegalovirus (HCMV), herpes simplex virus, Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), parvovirus B19 (PVB19), influenza A and B viruses and Coxiella burnettii. Myocardial inflammation was assessed by histological and immunohistological analyses. Results: Viral genomes could be amplified from EMBs of 85 (85%) of the 100 DCM patients: EV=25 (29%), ADV=5 (6%), PVB-19=10 (12%), HHV-6/7 =10 (12%), EBV=8 (9%), HCMV=6 (7%), including n= 10 cases (10%) with multiple infections. Active or borderline myocarditis according to the Dallas classification did not exist in any case. Conclusions: Viral genomes were frequently detected in EMBs of patients with systolic left ventricular dysfunction. Our data suggest that myocardial persistence of various viruses, often presenting as multiple infections, play a role in the pathogenesis of DCM far more frequently than suspected so far.
Clinical Cardiology, 2011
Background: Congenital left ventricular aneurysm (LVA) and diverticulum (LVD) are rare cardiac an... more Background: Congenital left ventricular aneurysm (LVA) and diverticulum (LVD) are rare cardiac anomalies and frequently associated with other cardiac anomalies. The objective of our study was to investigate the prevalence and the spectrum of coronary anomalies in such patients. Hypothesis: The incidence of coronary anomalies is increased in patients with LVA or LVD. Methods: We assessed 117 patients with isolated LVA or LVD for the prevalence of coronary anomalies and compared the findings with an age-and sex-matched control group (n = 117) without the diagnosis of LVA or LVD. Results: Coronary anomalies were present in 58.1% of the study population (68 of 117). The median age of affected patients was 64 years, and 45 (38.5%) were male. Coronary anomalies were more prevalent in patients with LVA or LVD (58.1% vs 6.8%, P < 0.001), male patients (89% vs 57%, P = 0.0002), and in patients with nonapical location of LVA or LVD (24% vs 45%, P = 0.02) compared with control, whereas age and type (LVA vs LVD) had no influence (57% vs 57.6%, P = 0.4; and 58.8% vs 57.6%, P = 0.87, respectively). The number of adverse cardiac events was similar in both groups during a 4.2-year follow-up period (29% vs 19%, P = 0.09). None of the patients in our series had major coronary anomalies with potential lethal consequences. Conclusions: This large single-center study suggests that the prevalence of abnormal coronary-artery anatomy in patients with isolated LVA or LVD is as high as 58.1%. However, we did not identify major coronary anomalies with potential lethal consequences, and the clinical course during follow-up was not influenced by the presence or absence of coronary anomalies. Methods Definition The diagnosis of LVA or LVD in our series was established after angiographic exclusion of coronary artery disease,
Journal of the American College of Cardiology, 2022
BACKGROUND Detection of ≥50% diameter stenosis left main coronary artery disease (LMD) has progno... more BACKGROUND Detection of ≥50% diameter stenosis left main coronary artery disease (LMD) has prognostic and therapeutic implications. Noninvasive stress imaging or an exercise tolerance test (ETT) are the most common methods to detect obstructive coronary artery disease, though stress test markers of LMD remain ill-defined. OBJECTIVES The authors sought to identify markers of LMD as detected on coronary computed tomography angiography (CTA), using clinical and stress testing parameters. METHODS This was a post hoc analysis of ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), including randomized and nonrandomized participants who had locally determined moderate or severe ischemia on nonimaging ETT, stress nuclear myocardial perfusion imaging, or stress echocardiography followed by CTA to exclude LMD. Stress tests were read by core laboratories. Prior coronary artery bypass grafting was an exclusion. In a stepped multivariate model, the authors identified predictors of LMD, first without and then with stress testing parameters. RESULTS Among 5,146 participants (mean age 63 years, 74% male), 414 (8%) had LMD. Predictors of LMD were older age (P < 0.001), male sex (P < 0.01), absence of prior myocardial infarction (P < 0.009), transient ischemic dilation of the left ventricle on stress echocardiography (P = 0.05), magnitude of ST-segment depression on ETT (P = 0.004), and peak metabolic equivalents achieved on ETT (P = 0.001). The models were weakly predictive of LMD (C-index 0.643 and 0.684). CONCLUSIONS In patients with moderate or severe ischemia, clinical and stress testing parameters were weakly predictive of LMD on CTA. For most patients with moderate or severe ischemia, anatomical imaging is needed to rule out LMD. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
Indian Journal of Cardiovascular Disease in Women WINCARS, 2016
The left ventricular ejection fraction (LVEF) assessed by trans-thoracic Echocardiogram (TTE) rem... more The left ventricular ejection fraction (LVEF) assessed by trans-thoracic Echocardiogram (TTE) remains the most common parameter of LV performance that is used in clinical practice. Three-dimensional / volumetric methods are more accurate, but are cumbersome to be performed in every case. The measures of myocardial contractility are more sensitive, reliable and with lesser inter observer variability but their place in daily practice is limited. Two-dimensional echocardiogram has the advantages of easy availability, low cost, portability, lack of radiation and non-invasive nature. Radionuclide studies, SPECT, cardiac CT and cardiac MRI are available only in a few centers and have more specific indication to be performed. The choice of a modality depends on the information sought by the clinician and the availability of expertise. Additional cost, radiation and limited access are important limitations of these special imaging modalities. The invasive methods which were popular a few de...