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PubMed1997

The new pulmonary artery catheters: continuous venous oximetry, right ventricular ejection fraction, and continuous cardiac output.

OBJECTIVE: To review the literature addressing the new pulmonary artery catheters: continuous venous oximetry, right ventricular ejection fraction, and continuous cardiac output. DATA SOURCE: All pertinent English language literature dealing with new pulmonary artery catheters were retrieved from 1981 through 1996. STUDY SELECTION: Articles were chosen for review if the primary objective of the paper was study or review of technology related to new pulmonary artery catheters. DATA EXTRACTION: From the literature selected, information was obtained about continuous venous oximetry, right ventricular ejection fraction, and continuous cardiac output catheters. DATA SYNTHESIS: When pulmonary artery catheterization is used, continuous venous oximetry catheters may be considered for use when it is anticipated that therapy will be based upon oxygen transport end points. When pulmonary artery catheterization is used, right ventricular ejection fraction catheters may be considered for use when the anticipated therapy will be based upon evaluation of ventricular preload and when central venous pressure and/or pulmonary artery occlusion do not accurately reflect preload. When pulmonary artery catheterization is used, continuous cardiac output catheters may be considered for use in titration of interventions employed to alter stroke volume. CONCLUSION: Clinician misinterpretation and misapplication of the data appear to be the greatest impediment to using pulmonary artery catheterization to alter pathophysiologic processes and improve outcome in critically ill patients. Future research should first document effectiveness or lack of effectiveness of the "standard" pulmonary artery catheter (PAC). Pending these results, outcome and cost/benefit studies should be performed comparing "standard" with new PACs.

Cardiac Output↗
PubMed1980

Postexercise changes in ejection fraction associated with coronary artery disease.

Radionuclide measurement of left ventricular ejection fraction (LVEF) response to exercise has been proposed as a way to help identify patients with coronary artery disease (CAD). Previous studies were done using an exercise bicycle or a treadmill and showed that patients with CAD do not increase ejection fraction (EF) to the same extent as normal (control) subjects. The present studies were done using a coaxial Gamma Cor cardiac probe. Because radiocardiograms (RCG) obtained with the cardiac probe require 1/10 the dose required for a scintillation camera, serial measurements could be made before, during and following exercise. Although 3 of our 9 patients showed an unchanged and 3 showed a decreased EF at the time of maximal exercise, 3 others were able to increase their EF, and in 2 this increase occurred concomitantly with angina. Thus, not all the CAD patients could be identified by failure to increase EF in response to exercise. However, looking at the period just following exercise, one can see that most of our patients with CAD maintain or increase LVEF during the first 6 to 9 min after stopping exercise; normal (control) subjects rapidly return to the preexercise value. The normal pattern is an increase in EF during exercise followed by a prompt return toward normal after cessation of exercise. Changes of this normal pattern of EF increase and decrease occurred in all except 1 patient with CAD, and consequently provided a better indication of the presence of significant disease than the response during exercise alone.

Adult↗
PubMed1983

Determination of cardiac output and ejection fraction with the dual cardiac probe.

Cardiac output and left ventricular ejection fraction were determined noninvasively at the bedside in 26 patients by using a dual scintillation probe. The probe is a nonimaging detector that records a high frequency time-activity curve of the passage of an intravenously injected radioactive bolus through the heart. Results were correlated with ejection fraction measured by biplane cineangiography (r = 0.80) and cardiac output determined by green dye dilution (R = 0.86). It is concluded that the dual probe provides an accurate noninvasive means of measuring these parameters, and that it may be particularly applicable to serial measurements in patients in the intensive care unit.

Journal Article↗
PubMed1987

Comparison of some haemodynamic parameters determined by invasive methods as well as by the noninvasive radionuclide estimation of the left ventricular ejection fraction in conscious and anaesthetized dogs.

An attempt was made to elaborate an optimal method for noninvasive radionuclide determination of left ventricular ejection fraction in conscious and lightly anaesthetized dogs, as well as to assess the value of this procedure in estimating cardiac functional state. Repeated determinations in the same animals have shown that the 45 degree left anterior oblique position (LAO-45) for imaging is optimal, giving the most uniform values of the calculated left ventricular ejection fraction. Neither the latter, nor the haemodynamic parameters (LVSP, LVEDP and dP/dt) determined by invasive methods were changed by light pentobarbital anaesthesia (20 mg/kg i. v.). Results confirm the validity of noninvasive radionuclide determination of left ventricular ejection fraction for estimation of the functional state and of the pharmacological actions on the latter in both conscious and anaesthetized animals.

Angiocardiography↗
PubMed1992

Spontaneous variability of left ventricular ejection fraction assessed with the Cardioscint.

A miniature, non-imaging caesium iodide nuclear probe optically coupled to a photodiode (the 'Cardioscint') has been developed which, in conjunction with a modified personal computer, is capable of continuous on-line monitoring of left ventricular function and ST-segment level at the bedside. The purpose of this study was to assess the variability in ejection fraction over periods of time and to compare this variability with that of equilibrium gamma camera radionuclide ventriculography. Ten normal volunteers (nine male) of mean (S.D.) age 49 (10) years underwent semisupine radionuclide ventriculography using both gamma camera and Cardioscint in randomized order. The gamma camera recorded four consecutive acquisitions (mean of 7.2 min each) and the Cardioscint, using a 20 s acquisition time, recorded left ventricular function over 35 min per subject. The mean ejection fraction of the group by gamma camera was 52 (7)% and by Cardioscint was 54 (5)%. When the variability in ejection fraction by gamma camera was compared with the Cardioscint averaged over corresponding time periods (i.e. an average of 7.2 min), the mean coefficient of variation of the camera was 5.0% versus 2.9% for the probe system. Individual 20-s probe acquisitions over the total study duration (reflecting the short-term variability of the system) had a coefficient of variation of 5.1%. Thus the Cardioscint provides a stable continuous recording of ejection fraction. These volunteer data provide a basis for interpretation of data acquired in the clinical situation.

Adult↗
PubMed1983

Alterations in left ventricular volumes and ejection fraction during atrial pacing in patients with coronary artery disease: assessment with radionuclide ventriculography.

The present study was performed to determine the utility of radionuclide ventriculography (RNV) in conjunction with atrial pacing in the identification of individuals with coronary artery disease. Accordingly, left ventricular end-diastolic volume index, end-systolic volume index, ejection fraction, and regional wall motion were measured with radionuclide ventriculography before and during atrial pacing in 37 patients: 27 with and 10 without (control subjects) coronary artery disease. In the control subjects, pacing caused a decrease in end-diastolic volume index (77 +/- 19 [mean +/- SD] ml/M2 at rest, 50 +/- 18 ml/M2 at peak pacing; p less than 0.001), a decrease in end-systolic volume index (34 +/- 14 ml/M2 at rest, 19 +/- 9 ml/M2 at peak pacing; p less than 0.001), an increase in ejection fraction (0.61 +/- 0.11 at rest, 0.66 +/- 0.11 at peak pacing; p = 0.006); and no deterioration in wall motion. In 16 patients with coronary artery disease who developed ECG and/or metabolic evidence of ischemia during pacing, end-diastolic volume index decreased (87 +/- 26 ml/M2 at rest, 69 +/- 24 ml/M2 at peak pacing; p less than 0.001), end-systolic volume index was unchanged (43 +/- 20 ml/M2 at rest, 44 +/- 21 ml/M2 at peak pacing; p = NS), ejection fraction decreased (0.55 +/- 0.12 at rest, 0.40 +/- 0.14 at peak pacing; p less than 0.001), and new wall motion abnormalities developed in 14. In 11 patients with coronary artery disease but no ECG or metabolic evidence of ischemia, pacing caused a decrease in end-diastolic volume index (80 +/- 26 ml/M2 to 61 +/- 31 ml/M2; p less than 0.001), a decrease in end-systolic volume index (36 +/- 17 ml/M2 to 28 +/- 20 ml/M2; p = 0.002), no change in ejection fraction (0.60 +/- 0.11 to 0.60 +/- 0.13; p = NS), and new wall motion abnormalities in four. Although the specificity of these scintigraphic measurements for the identification of patients with coronary artery disease was excellent (1.0), the combined sensitivity of all scintigraphic measurements was high only if ECG or metabolic evidence of ischemia was present: 0.94 in patients with evidence of ischemia but only 0.36 in those without ischemia. Thus radionuclide ventriculography during incremental atrial pacing is useful in the identification of patients with coronary artery disease only if ischemia is induced.

Cardiac Output↗
PubMed1982

Effect of age on cardiac index, stroke index and left ventricular ejection fraction at rest and during exercise as studied by radiocardiography.

Radiocardiography was used to measure cardiac output, stroke volume and left ventricular ejection fraction at rest and during muscular exercise in relation with age in 148 healthy subjects (age range: 6-78 years). A clear dependence of these parameters on age was found. The mean annual decrease at rest was 22 +/- 9 ml/min/m2 for cardiac index, 0.22 +/- 0.04 ml/m2 for stroke index and 0.0017 +/- 0.0003 for left ventricular ejection fraction. Male subjects had significantly (p less than 0.001) greater cardiac (9 +/- 4%) and stroke indices (11 +/- 3%) than females. During submaximal exercise cardiac index increased from 3.5 +/- 0.7 l/min/m2 to 8.1 +/- 1.6 l/min/m2 in male subjects (mean age: 32 years) and from 3.1 +/- 0.4 l/min/m2 to 7.2 +/- 1.2 l/min/m2 in female subjects (mean age: 29 years). The corresponding increases in stroke index and left ventricular ejection fraction were: from 52 +/- 7 ml/m2 to 62 +/- 9 ml/m2, from 46 +/- 7 ml/m2 to 51 +/- 9 ml/m2 and from 0.66 +/- 0.08 to 0.79 +/- 0.05 and from 0.64 +/- 0.10 to 0.72 +/- 0.10. In subjects who were 60 years and older the increases of these parameters during exercise were considerably smaller.

Adolescent↗
PubMed2002

Quantitative gated SPECT: the effect of reconstruction filter on calculated left ventricular ejection fractions and volumes.

Gated SPECT (GSPECT) offers the possibility of obtaining additional functional information from perfusion studies, including calculation of left ventricular ejection fraction (LVEF). The calculation of LVEF relies upon the identification of the endocardial surface, which will be affected by the spatial resolution and statistical noise in the reconstructed images. The aim of this study was to compare LVEFs and ventricular volumes calculated from GSPECT using six reconstruction filters. GSPECT and radionuclide ventriculography (RNVG) were performed on 40 patients; filtered back projection was used to reconstruct the datasets with each filter. LVEFs and volumes were calculated using the Cedars-Sinai QGS package. The correlation coefficient between RNVG and GSPECT ranged from 0.81 to 0.86 with higher correlations for smoother filters. The narrowest prediction interval was 111 +/- 2%. There was a trend towards higher LVEF values with smoother filters, the ramp filter yielding LVEFs 2.55 +/- 3.10% (p < 0.001) lower than the Hann filter. There was an overall fall in ventricular volumes with smoother filters with a mean difference of 13.98 +/- 10.15 ml (p < 0.001) in EDV between the Butterworth-0.5 and Butterworth-0.3 filters. In conclusion, smoother reconstruction filters lead to lower volumes and higher ejection fractions with the QGS algorithm, with the Butterworth-0.4 filter giving the highest correlation with LVEFs from RNVG. Even if the optimal filter is chosen the uncertainty in the measured ejection fractions is still too great to be clinically acceptable.

Algorithms↗
PubMedDate not supplied

The relation between viable segments and left ventricular ejection fraction improvement.

For patients with coronary artery disease and left ventricular dysfunction who undergo revascularization, it is important to estimate the left ventricular ejection fraction (LVEF) improvement after revascularization, as this is a strong indicator of the long-term outcome. Identification of viable segments from echocardiography has been considered a predictive sign of LVEF improvement. However, a quantitative relation between segmental function recovery and global ejection fraction improvement has not been established. There is a clinical need to determine parameters that are predictive to LVEF improvement. A cylindrical left ventricular model is proposed to establish the relation between segmental myocardial function and LVEF based on a 12-segment echocardiograph model. Model results show that LVEF improvement is directly related to the contraction ratio in normal segments and a weighted sum of the number of viable segments that recover to normal or hypokinetic, which is equal to a weighted sum of the change in wall motion scores. This new combined parameter is a better predictor of the amount of LVEF improvement than the total number of viable segments or preoperative ejection fraction. The predictive value of the model was illustrated in a group of four patients with coronary artery disease who underwent revascularization.

Algorithms↗
PubMed1990

[Changes in right ventricular ejection fraction in right coronary angioplasty].

In order to analyse the response of the right ventricule (RV) to transient myocardial ischaemia, the RV ejection fraction was measured using a new rapid response thermodilution catheter in 15 patients (14 men and 1 woman: average age 58 +/- 7 years) referred for percutaneous transluminal coronary angioplasty of a dominant right coronary artery. Only patients with single vessel disease with a proximal stenosis of the right coronary without a visible collateral circulation who had no previous history of myocardial infarction were included. Right heart catheterisation was performed with a rapid-response thermodilution catheter which enabled measurement of heart rate, cardiac index, RV end-diastolic and end-systolic volumes and RV ejection fraction. Angioplasty was carried out with the usual steerable balloon catheters. During balloon inflation, there was a slight increase in RV end-diastolic volume (from 78 +/- 11 ml/m2 to 85 +/- 13 ml/m2 at 60 seconds; p less than 0.01) and a large increase in RV end-systolic volume (from 29 +/- 8 ml/m2 to 35 +/- 8 ml/m2 at 30 seconds and 43 +/- 11 ml/m2 at 60 seconds, p less than 0.001) leading to a significant decrease in RV ejection fraction (from 62 +/- 8% to 56 +/- 6% at 30 seconds and 51 +/- 7% at 60 seconds; p less than 0.001). All parameters returned to basal values two minutes after the dilatation. Acute occlusion of the proximal segment of the right coronary artery is therefore associated with a marked change in right ventricular function which rapidly returns to normal after the coronary circulation is restored.

Aged↗
PubMed1990

Marked spontaneous improvement in ejection fraction in patients with congestive heart failure.

PURPOSE: The overall prognosis for patients with congestive heart failure is poor. Defining specific populations that might demonstrate improved survival has been difficult. We therefore examined our patient database for patients with congestive heart failure who demonstrated sustained improvement in left ventricular function and associated resolution of signs and symptoms of congestive heart failure. PATIENTS AND METHODS: We identified 11 patients with severe congestive heart failure (average ejection fraction 21.9 +/- 4.23% (+/- SD) who developed spontaneous, marked improvement over a period of follow-up lasting 4.25 +/- 1.49 years. All 11 patients were initially symptomatic with exertional dyspnea and fatigue for a minimum duration of 3 months. They form a subset of a larger group of 97 patients with chronic congestive heart failure that we have followed with sequential ejection fraction measurements. All 11 patients were treated with digitalis diuretics, and either converting-enzyme inhibitors or a combination of isosorbide dinitrate and hydralazine. Ten of the 11 patients had a history consistent with chronic alcoholism, and each reportedly abstained from alcohol during follow-up. RESULTS: During the follow-up period, the average ejection fraction improved in 11 patients from 21.9 +/- 4.23% to 56.64 +/- 10.22%. Late follow-up indicates an average ejection fraction of 52.6 +/- 8.55% for the group. Congestive heart failure resolved in each case. CONCLUSIONS: We conclude that selected patients with severe congestive heart failure can markedly improve their left ventricular function in association with complete resolution of heart failure. This appears to be particularly evident in those patients with chronic alcoholism who subsequently abstain.

Aged↗
PubMed1985

Effect of oral alcohol on left ventricular ejection fraction, volumes, and segmental wall motion in normals and in patients with recent myocardial infarction.

A first-pass nuclear angiogram and a multiple-gated acquisition study were obtained in 10 normal physicians and in 10 patients with a 7-to-10 day old transmural myocardial infarction. After the scan the subjects drank 2 oz. of whiskey. After 60 minutes, the multiple-gated acquisition study was repeated. In the normal group the left ventricular ejection fraction was 68% before and 72% after alcohol. The left ventricular end-diastolic volume increased from 89 to 97 ml while the left ventricular end-systolic volume decreased from 29 to 27 ml. The stroke volume rose from 61 to 70 ml/beat (p less than 0.05). The cardiac output increased from 4.0 to 5.0 l/min (p less than 0.05). In the infarction group, the left ventricular ejection fraction was 58% before and 56% after alcohol administration. The left ventricular end-diastolic volume fell from 111 to 96 ml, while the left ventricular end-systolic volume declined from 50 to 44 ml. The stroke volume fell from 61 to 52 ml/beat, while the cardiac output fell from 4.5 to 3.8 l/min. In the left ventricular infarction zones, alcohol produced in 9 of the 10 cardiac patients a decline in the left ventricular regional ejection fraction. In the normal group, alcohol produced no significant changes in the regional ejection fraction. The normal and the postinfarction patients responded differently to alcohol.

Adult↗
PubMed2002

Calculation of the left ventricular ejection fraction without edge detection: application to small hearts.

UNLABELLED: Quantitative gated SPECT (QGS) software has been reported to overestimate the left ventricular ejection fraction (LVEF) in patients with small hearts. This finding is caused by the inaccurate detection of the endocardial surface of the left ventricle (LV) due to low resolution and partial-volume effects. In this article we develop a method to calculate the LVEF from gated SPECT data without edge detection and compare it with the QGS method of calculating the LVEF. METHODS: The short-axis images were transformed to the prolate spheroid coordinate system, and detection of the layer of maximum counts (a surface area of maximum counts) was made. First, the volume enclosed by the layer of maximum counts (V(max)) was calculated; then the corresponding ejection fraction [(LVEF)(max)] was calculated. The LVEF was calculated by multiplying the (LVEF)(max) by a constant factor, which was determined from a series of calculations made using QGS on larger hearts. In computer simulations the end-diastolic left ventricular volume (EDV) and the targeted LVEF (tLVEF) were varied to produce LVs of different sizes. The LVs were modeled by 2 confocal hemiellipsoids with 7 different EDVs. The tLVEF was increased from 25% to 75%, in 5% step-size increments, for a total of 11 different ejection fractions. These datasets were then smoothed, creating a total of 77 smoothed sets. The smoothed images were processed by the QGS method and by our method. In patient studies, 58 patient datasets were processed by the QGS method and by our method. No attenuation correction was performed on these datasets. The patients were divided into 2 groups: 44 patients with large hearts (EDV > or = 80 mL) and 14 patients with small hearts (EDV < 80 mL). RESULTS: In computer simulations, the QGS method and our method performed well when imaging large EDVs (EDV > or = 80 mL). Our method derived better results than did the QGS method for small EDVs. In patient studies the LVEF calculated by our method matched well with the QGS LVEF in the 44 patients with large hearts. The correlation coefficient between them was found to be 0.957. Of the 14 patients with small hearts, the LVEFs of 5 patients were severely overestimated by the QGS method compared with the results obtained with our method. CONCLUSION: It is possible to calculate the LVEF without edge detection. Compared with QGS LVEF, our method gave better results for small LVs in computer simulations.

Algorithms↗
PubMed2001

Comparative effects of carvedilol and metoprolol on left ventricular ejection fraction in heart failure: results of a meta-analysis.

BACKGROUND: Both metoprolol and carvedilol improve cardiac function and prolong survival in patients with heart failure. Carvedilol has broader antiadrenergic effects than metoprolol, but it is not clear whether this characteristic is associated with greater benefits on cardiac function during long-term treatment. STUDY DESIGN: We performed a meta-analysis of all 19 randomized controlled trials of carvedilol or metoprolol that measured left ventricular ejection fraction before and after an average of 8.3 +/- 0.1 months of treatment in 2184 patients with chronic heart failure. The mean daily doses were 58 +/- 1 mg of carvedilol and the equivalent of 162 +/- 1 mg of extended-release metoprolol. In the 15 placebo-controlled trials, the mean ejection fraction increased more in the trials of carvedilol than in the trials of metoprolol (placebo-corrected increases of +0.065 and +0.038, respectively), P = .0002. In the 4 active-controlled trials that compared metoprolol directly with carvedilol, the mean ejection fraction also increased more in the carvedilol groups than in the metoprolol groups (+0.084 on carvedilol and +0.057 on metoprolol, respectively), P = .009. The difference in favor of carvedilol in the active-controlled trials was nearly identical to the difference observed in the placebo-controlled trials and was apparent in patients with and without coronary artery disease. CONCLUSION: Long-term treatment with carvedilol produces greater effects on left ventricular ejection fraction than metoprolol when both drugs are prescribed in doses similar to those that have been shown to prolong life.

Adrenergic beta-Antagonists↗
PubMed1993

Survival predictors in patients with a left ventricular ejection fraction of 10-30% receiving a coronary bypass: analysis of preoperative variables.

A total of 224 patients with angina pectoris and a left ventricular ejection fraction in the range of 10-30% (mean 24.2%) underwent coronary artery bypass grafting between April 1986 and August 1991. These patients received a mean (s.d.) of 2.9 (0.3) aortocoronary vein grafts. The overall operative mortality rate was 8.9%. The 1-, 2- and 3-year survival rates were 87.7%, 86.7% and 85.2%, respectively. Analysis of operative risk factors showed that patients with an end-diastolic left ventricular pressure > 24 mmHg were significantly more at risk (mortality rate 20.0%, P < 0.05) than those with an end-diastolic left ventricular pressure < or = 24 mmHg (mortality rate 6.2%). Patients with a perioperative cardiac index < 2.5 l min-1m-2 had higher mortality (25.4%) than those with a cardiac index > or = 2.5 l min-1m-2 (mortality 1.9%, P < 0.001). The operative mortality rate of patients with a cardiac index < 2.5 l min-1m-2 and an end-diastolic left ventricular pressure > 24 mmHg was 40.5%. Patients with a left ventricular ejection fraction of 10-20% were not significantly more at risk (P > 0.05) than those with a left ventricular ejection fraction of 21-30%.

Adult↗
PubMed2002

Effects of resynchronization therapy on sympathetic activity in patients with depressed ejection fraction and intraventricular conduction delay due to ischemic or idiopathic dilated cardiomyopathy.

This study assesses the effect of biventricular pacing on sympathetic nerve activity (SNA) in patients with depressed ejection fraction and intraventricular conduction delay (IVCD). Biventricular pacing has been shown to result in hemodynamic improvement in patients with depressed ejection fraction and IVCD. The effect of biventricular pacing on SNA, however, remains unclear. A total of 15 men with a mean ejection fraction of 25 +/- 4% were enrolled. Arterial pressure, central venous pressure and SNA were recorded during 3 minutes of right atrial (RA) pacing and RA-biventricular pacing. Pacing was performed at a rate 5 to 10 beats faster than sinus rhythm, with an atrioventricular interval equal to 100 ms during RA-biventricular pacing. RA-biventricular pacing resulted in greater arterial pressures (p <0.05) than RA pacing (146 +/- 15/83 +/- 11 vs 141 +/- 15/80 +/- 10 mm Hg). There were no differences in central venous pressures between the 2 pacing modes (p = 0.76). SNA was significantly less during RA-biventricular pacing (727 +/- 242 U) than during RA pacing (833 +/- 332 U) (p <0.02). Furthermore, there was a positive correlation between baseline QRS duration and the decrease in SNA noted with RA-biventricular pacing (r = 0.58, p = 0.03). Biventricular pacing results in improved hemodynamics and a decrease in SNA compared with intrinsic conduction in patients with left ventricular dysfunction and IVCD. If the current findings are also present with chronic biventricular pacing, then this form of therapy may have a positive impact on mortality.

Aged↗
PubMed1995

[Mechanism of overshoot elevation of left ventricular ejection fraction during recovery after exercise in normal subjects and patients with coronary artery disease, assessed by 99mTc exercise radionuclide ventriculography].

An "overshoot" (OS) elevation of ejection fraction above resting levels has been demonstrated during recovery after exercise. To characterize the hemodynamic changes during recovery after bicycle exercise, we used radionuclide ventriculography under the Swan-Ganz catheter insertion in 16 normal subjects and 15 patients with coronary artery disease (CAD) at rest, during bicycle exercise and after exercise periods. In normal subjects, the ejection fraction increased from resting value during peak exercise, and showed overshoot elevation in the early recovery period. In patients with CAD, the ejection fraction decreased from resting value during peak exercise, then showed overshoot elevation in the early recovery period. In normal subjects, the end-diastolic volume (EDV) and the end-systolic volume (ESV) decreased from resting value during OS. In patients with CAD, the EDV at OS was not different from that at rest, the ESV decreased from resting value during OS. The systemic vascular resistance increased from resting value during OS. The systolic blood pressure/ESV, index for ventricular contractility, increased from resting value during OS in both groups. Thus, the decreased systemic vascular resistance does not playing a major role during recovery after exercise, whereas enhanced contractility is evident in both normal subjects and patients with CAD.

Coronary Disease↗