Recent advances in echocardiography have allowed assessment of flow velocity in the epicardial coronary arteries of patients with ischemic heart disease, using transthoracic color Doppler echocardiography (TTDE). However, few data are available regarding coronary blood flow in patients with hypertrophic cardiomyopathy (HCM).
To assess the epicardial coronary arteries of patients with HCM.
A group of 25 patients with HCM was assessed prospectively (mean age 57 ± 21 years, 11 male) using TTDE; flow velocities in the epicardial coronary arteries were measured and compared with those obtained in 10 age- and gender-matched controls. Analysis of the diastolic spectral waveform included flow velocity integral (VTI), peak velocity, deceleration time, and deceleration slope measurements, while systolic waveform analysis included peak flow measurement and morphology assessment (positive, absent or negative). An analysis of variance (ANOVA) test was used for multiple comparisons for variables with a normal distribution, and a Kruskal–Wallis test was used for variables with non-Gaussian distribution.
Patients with HCM exhibited an increase in diastolic flow velocity with a rapid deceleration slope and a systolic slope which was decreased, absent or reversed, compared to normal subjects. On linear regression analysis there was no correlation with the type of hypertrophy or magnitude of the intraventricular pressure gradient in patients with obstructive HCM.
In patients with HCM, noninvasive assessment with TTDE revealed abnormal findings in the distal flow of the epicardial coronary arteries, very similar to those seen in the no-reflow phenomenon. These findings were independent of the type of hypertrophy and magnitude of the intraventricular pressure gradient in patients with obstructive HCM.
The anomalous mitral arcade is a rare congenital malformation of the mitral valve and its tensor apparatus. It is characterized by enlarged papillary muscles connected to each other and to the free edge of the anterior mitral leaflet by a bridge of fibrous tissue. We report a rare variant of anomalous mitral arcade that was associated with accessory mitral leaflet in subaortic area and accessory chordae. Our patient was asymptomatic till the age of 18 years, when he presented for the first time in acute decompensated heart failure secondary to severe mitral regurgitation and left ventricular dysfunction. The patient had rapid deterioration with fatal outcome.
]]>The aim of our study was to demonstrate that the use of contrast microbubbles during transesophageal echocardiography (TEE) guided cardioversion will improve interpretation of the TEE images.
TEE-guided cardioversion of atrial flutter or fibrillation (AF) is a safe and proven method to restore sinus rhythm. However, artifacts and dense spontaneous echo contrast in the left atrial appendage (LAA) can sometimes decrease the level of confidence in excluding the presence of thrombus.
One hundred patients referred for TEE-guided cardioversion were prospectively enrolled and microbubble contrast agent (DEFINITY) was administered after the clinical decision had been made regarding suitability for cardioversion. Noncontrast and contrast images were compared during subsequent offline analysis.
LAA dimensions and contractility indices were higher, artifacts were significantly differentiated, previously unsuspected LAA filling defects were identified, and the level of confidence in excluding thrombus was enhanced in the contrast images when compared to the noncontrast images. After 4 months follow-up, 1 stroke-associated death occurred in a patient who had LAA thrombus recognized only by contrast. Left atrial appendage visualization is enhanced with microbubble contrast agent use during transesophageal echocardiography guided cardioversion and is useful in identification of intracardiac thrombus.
Cardiac device–related infection caused by Aspergillus species is a rare finding associated with high mortality. Prompt recognition and treatment is imperative, but difficult as blood cultures are often negative and diagnosis requires a high index of suspicion. Live/real time three-dimensional transthoracic echocardiography (3DTTE) provides incremental knowledge in the characterization of valvular vegetations. Here, we provide a detailed description of an invasive cardiac device–related infection caused by Aspergillus fumigatus using 3DTTE. Findings described here highlight the role for 3DTTE in the prompt diagnosis of invasive cardiac Aspergillus infections as well as surgical planning in such cases.
]]>A 29-year-old man was admitted to our outpatient clinic with exertional dyspnea. Transesophageal echocardiography (TEE) revealed a ruptured sinus of Valsalva aneurysm into the right ventricle. Real time three-dimensional (3D) TEE, used to visualize the relationship between the rupture, the aortic valve, and the right ventricle, revealed the precise shape, size, and location of the defect. The defect was closed using a 16/10 mm Amplatzer duct occluder under real time 3DTEE guidance. 3DTEE provided more accurate delineation of the defect location and orientation than other imaging techniques and may aid in the selection of an appropriate device for closure.
Purpose: Although nonobstructive prosthetic valve thrombosis (PVT) does not develop hemodynamic compromise, it carries potential risk for thromboembolism. Real time three-dimensional transesophageal echocardiography (RT-3DTEE), has emerged as a complementary tool in depicting “en face” views of prosthesis compared with two-dimensional transesophageal echocardiography (2DTEE). We aimed to evaluate the utility of RT-3DTEE in assessment of mitral ring-located thrombosis. Method: We present 3 cases of mechanical mitral valve thrombosis complicated by thromboembolism, who were all examined and followed-up by 2D transthoracic echocardiography (TTE), 2DTEE, and RT-3DTEE. Result: The consequencies of thromboembolism in the patients were coronary embolism, transient ischemic attack, and ischemic stroke, respectively. They were all inadequately anticoagulated at the time of admission. 2DTTE and TEE examination was unsatisfactory; RT-3DTEE depicted nonobstructive mitral ring thrombosis in each of the patients. The patients were followed up under effective anticoagulation and antiplatelet therapy. RT-3DTEE was able to demonstrate the evolution of thrombus size in each of the patients. Conclusion: Nonobstructive ring-located PVT which poses risk for thromboembolism, may be diagnosed with certainty and imaged with clarity utilizing RT-3DTEE.
]]>Accurate assessment of intracardiac flows by Doppler echocardiography may add important hemodynamic information in the critically ill patient. Detailed analysis of flow gradients through different sites and their correlation with timing of cardiac events may help us in better understanding the pathophysiology of the underlying disease. We report the clinical case of a 78-year-old patient with septic shock, in whom an A-dip of aortic regurgitation, shortening of diastolic filling, and diastolic mitral regurgitation were detected by Doppler analysis. Pathophysiologic explanation of these phenomena and their evolution after inotropic drug infusion are reported.
]]>Double-chambered ventricle is a rare congenital cardiac abnormality, most commonly affecting the right ventricle. Here, we report a case of an incidental diagnosis of this condition affecting the left ventricle (LV), which is found much less frequently, and the use of contrast echocardiography in its evaluation. The addition of computed tomography (CT), highlighting the blood supply of both chambers by the left anterior descending (LAD) artery allowed us to confirm the diagnosis.
]]>Objective: Three-dimensional (3D) speckle tracking echocardiography (3DSTE) is a novel imaging modality for assessing cardiac function. We aimed to analyze left atrial (LA) function using 3DSTE in patients with atrial fibrillation (AF). Methods: 3DSTE was performed in 20 patients prior to their pulmonary vein isolation for AF. Every patient underwent a complete two-dimensional echocardiographic study at the same time. 3DSTE-derived circumferential (CS), longitudinal (LS), radial (RS), 3D (3DS), and area strain (AS) values were measured in the basal (b), mid (m), and superior (s) regions of the LA. 3DSTE-defined maximal (LAmax) and minimal LA volumes (LAmin) and LA total emptying fraction were calculated automatically. Eleven randomly selected age- and gender-matched healthy volunteers served as controls. Results: Patients with AF had significantly larger LAmax and LAmin and reduced LS, RS and CS.3DS and AS were significantly lower throughout the LA in cases with AF (3DS−b, −m, −s [AF patients vs. controls]: −18 ± 8% vs. −29 ± 8%, P = 0.001; −14 ± 6% vs. −22 ± 7%, P = 0.002; −10 ± 7% vs. −20 ± 9%, P = 0.002; AS−b, −m, −s [AF patients vs. controls]: 35 ± 15% vs. 52 ± 13%, P = 0.004; 50 ± 21% vs. 72 ± 19%, P = 0.009; 31 ± 21% vs. 65 ± 27%, P < 0.0001, respectively). Conclusions: 3DSTE-derived “uni-dimensional” LS, RS, CS, as well as novel strain parameters (3DS, AS) are significantly reduced in patients with AF compared to matched controls. 3DS and AS might be new strain parameters providing further insights into the alterations of LA function in patients developing AF.
]]>Fractional pulse pressure (PPf), is thought to more directly reflect arterial stiffness than pulse pressure. Our aim was to evaluate the relationship between coronary flow reserve (CFR), left ventricular diastolic function (LVDf) and PPf in hypertensive patients with normal coronary arteries. Out of 109 hypertensive patients (aged 52.8 ± 9.4 years), with normal coronary angiography, CFR was calculated successfully in 106 patients. CFR was calculated using transthoracic echo Doppler assessment with hyperemia induced by infusion of dipyridamole at a rate of 0.56 mg/kg over 4 minutes, while diastolic function was evaluated by means of transmitral flow and tissue Doppler imaging. PPf was calculated as pulse pressure divided by mean arterial pressure [Systolic blood pressure − Diastolic blood pressure/Mean arterial pressure (SBP − DBP/MAP)], Hypertensive patients with low CFR (n = 54) compared with those with normal CFR (n = 52) exhibited significantly increased PPf (75.2 ± 11.4 vs. 61.5 ± 6.7 P < 0.001). Moreover, patients with higher PPf had significantly decreased transmitral E/A ratio (P < 0.01), as well as increased E/Em ratio (P < 0.01). In hypertensives with low CFR, PPf was negatively correlated with CFR (r = −0.815, P < 0.0001). After applying multivariate linear regression analysis, PPf turned out to be a powerful independent predictor of CFR. Receiver operating characteristic (ROC) analysis revealed that a PPf of ≥0.63 was the best cutoff value for prediction of CFR <2.0 and E/Em ≥ 8 (AUC = 0.916 and 0.929 respectively; P < 0.001). Increased PPf was associated with impaired CFR and diastolic dysfunction in hypertensive patients with normal coronary arteries. PPf could be used as a simple non-invasive index for assessment of coronary microcirculation in hypertensives with normal coronary arteries.
]]>Transcatheter aortic valve replacement (TAVR) is an effective treatment option for patients with severe aortic stenosis who are at high surgical risk because of multiple comorbidities. Many of these patients have been treated with pacemakers for concomitant conduction disease. The combination of severe aortic stenosis, cardiomyopathy, and conduction abnormalities results in a state of low cardiac output. Here, we report 2 complex TAVR cases where Doppler echocardiography was used to guide adjustment of device settings, leading to improved cardiac hemodynamic profiles.
]]>Echocardiographic image quality in Fontan survivors may be limited by a variety of factors. We sought to describe echocardiographic quality and factors associated with study quality in subjects participating in the Pediatric Heart Network Fontan Cross-Sectional Study. Echocardiograms were obtained at 7 clinical sites using a standard protocol. Quality grading and analysis were performed by a core laboratory. Univariate and multivariable modeling were performed to assess factors associated with quality and ability to obtain images sufficient for prespecified quantitative analysis. A total of 543 echocardiograms were obtained. The quality of echocardiograms improved over the duration of the study. The great arteries, systemic veins, and pulmonary veins were less likely to be adequately imaged than other cardiac structures. Quantitative analysis of ventricular volume was possible in 76% overall, but only 41% of those with mixed ventricular morphology. Factors independently associated with better quality included younger age, levocardia, acquisition of the echocardiogram at a longer time since the beginning of enrollment, absence of a pulmonary artery stent, and clinical site. Patient and center-specific factors are associated with echocardiographic quality after the Fontan procedure. Increased familiarity and experience with a standard imaging protocol is likely to result in improved quality.
A 17-year-old male with a history of newly implanted mechanical valve at the aortic position, presented with fever, rigors, and painful cutaneous abscesses on his lower extremities and was suspected for infective endocarditis. Transthoracic echocardiography (TTE) showed a vegetation-like structure following the movement of the mechanical heart valve (MHV), which eventually proved to be a product of degassing microbubbles (MB).
]]>Postoperative atrial fibrillation (POAF) is common after cardiac surgery and is associated with increased morbidity, mortality, and prolonged hospital stay. Speckle tracking echocardiography (STE) has been applied recently for evaluation of LA function. The purpose of this study was to examine whether left atrial longitudinal strain measured by STE is a predictor for the development of POAF following mitral valve surgery for severe mitral regurgitation. We studied 53 patients undergoing mitral valve surgery in sinus rhythm at the time of surgery. Echocardiography with evaluation of LA strain by STE was performed. Detection of POAF was based on documentation of AF episodes by continuous telemetry throughout hospitalization. Patients who did not develop POAF were taken as group 1 and those who had POAF constituted group 2. The echocardiographic and clinical predictors of POAF were investigated. POAF occurred in 28.3% of subjects. Mean age, LAVi and BNP were found higher in group 2 while peak atrial longitudinal strain (PALS) (13.9 ± 3.8% vs. 24.8 ± 7.3%; P < 0.001), peak atrial contraction strain (PACS) (7.6 ± 1.95% vs. 11.3 ± 3.5%; P < 0.001) were significantly lower. By multivariate logistic regression analysis, PALS and LAVi were independent predictor of POAF development. LA longitudinal strain was found to predict POAF in patients undergoing mitral valve surgery. It could be used to better identify patients at greater risk of developing POAF, and thus to guide in risk stratification and to take appropriate intensive prophylactic therapy.
The survival rate of heart transplant patients is increasing, underlying the need for accurate predictors of adverse events during clinical follow-up. Myocardial performance index (MPI) is a Doppler-derived index of combined systolic and diastolic function: we assessed the prognostic role of MPI in survival of patients >1 year after heart transplantation (HT). A total of 152 consecutive HT patients referred to our institution were enrolled in this prospective study. Primary endpoints were cardiac death and a composite of major adverse cardiac events (MACE). During follow-up (69 ± 22 months), 68 (44.7%) patients had an adverse event and 20 (13.15%) patients died. Patients with MACE during follow-up showed lower EF (57.3 ± 9.3 vs. 63 ± 6.1; P < 0.001) and higher MPI (0.45 ± 0.19 vs. 0.31 ± 0.13; P < 0.001) at enrolment. MPI and EF were independently related to MACE (OR = 2.2; 95% confidence interval [CI] = 1.01–5.1; and OR = 6.6; 95% CI = 3.5–11.2, respectively) and showed strong diagnostic power (MPI: receiver operating characteristic [ROC] area = 79%, with 79% sensitivity and 81% specificity; EF: ROC area = 77%, with 54% sensitivity and 91% specificity) in the subsequent year. Patients with EF > 50% and MPI < 0.45 at enrolment showed 75% event-free survival 5 years after HT. In HT patients, MPI combined with EF was an accurate means of predicting long-term adverse events.
Fabry disease (FD) is characterized by left ventricular hypertrophy (LVH). Conventional echocardiography is not sensitive enough to perform the preclinical diagnosis To assess whether longitudinal myocardial strain of the left ventricle (LV), using speckle tracking, is useful to detect early myocardial involvement in FD. Forty-four patients with FD who were diagnosed with genetic testing were prospectively included and were compared to a sex-matched control group. They were divided into three groups: 22 with LVH (Group I), 22 without LVH (Group II), and 22 healthy volunteers (Group III). LV longitudinal strain was measured from the apical views. An ANOVA test was used for multiple comparisons for variables with a normal distribution, and a Kruskal–Wallis test was used for variables with non-Gaussian distribution. Longitudinal LV strain was different in the three groups: it was ≥−15% in at least one segment in all Group I patients, in 50% of patients of Group II and in no patient of Group III. Seventy percent of the segments with abnormal strain in Group II were located in the basal regions (32/46). These findings show that the presence of at least one strain value ≥−15% demonstrates subclinical myocardial dysfunction in patients with preclinical FD. Longitudinal myocardial LV strain measured with speckle tracking is a useful tool to detect early myocardial involvement in young patients with FD. This information allows the detection and treatment of myocardial dysfunction at an early stage, which is of high clinical importance.
]]>Left atrial (LA) size is related to cardiovascular morbidity and mortality. The relative role of multiple determinants of LA morphology in healthy subjects remains incompletely defined. The aim of this study is to define normal ranges for LA diameters and volume index (LAVi), and to investigate clinical and echocardiographic correlates. A total of 1480 healthy individuals (mean age 36.1 ± 15.5 years, range 20–80; 61% males) underwent a comprehensive transthoracic echocardiography exam including assessment of LAVi calculated using the biplane area-length method at the apical four-chamber and two-chamber views at ventricular end systole (maximum LA size) and indexed for body surface area (BSA). Mean LAVi in the overall population was 29.5 ± 10.8 mL/m2 (range: 26.1–41.8 mL/m2). Distinct higher values were found in subjects ≥50 years as compared with those <50 years of age (33.4 ± 12.5 vs. 29.1 ± 13.5; P < 0.001). On univariate analysis, LA volume was significantly associated with age (r = 0.48, P < 0.0001), male gender (r = 0.28, P < 0.05), BSA (r = 0.51, P < 0.0001), mitral E/E' (r = 0.47, P < 0.0001), LV end-diastolic volume (r = 0.52, P < 0.0001), and LV mass index (r = 0.31, P < 0.05). Multivariable analysis identified age, BSA, LV end-diastolic volume, and mitral E/E' ratio as the only independent determinants of LA volume (model R2 = 0.54, P < 0.0001). Gender was an independent predictor of most absolute LA volume, but following normalization to BSA, some associations became nonsignificant. In healthy individuals LAVi vary significantly by age, BSA, diastolic function, and LV dimensions, with lesser effects of gender.
]]>Takotsubo cardiomyopathy, described as transient regional contractile abnormalities limited to the apical and mid-segments of the left ventricle (LV), has also been reported to involve basal and/or mid LV segments (inverted Takotsubo); fewer reports, however, have addressed right ventricular (RV) dysfunction.
To assess the distribution of regional abnormalities and RV involvement in Takotsubo cardiomyopathy and compare it to the literature.
We evaluated 23 patients with both classical and inverted presentations (19 female, aged 64 ± 19 years), including 2 recurrences, totaling 25 episodes. Classical Takotsubo was observed in 15 patients, while 10 had the inverted form. LV ejection fraction (EF) was lower for classical compared to inverted presentation (30 ± 7 vs. 45 ± 4%, P < 0.001) with higher troponin values (1.3 ± 1.4 vs. 0.5 ± 0.6, P = 0.034). RV abnormalities were found in 7 patients (28%), mainly with classical presentation (6 patients), presenting with mid and apical RV impairment. One patient with inverted Takotsubo had mid-RV involvement. Patients with RV involvement had lower left ventricular ejection fraction (LVEF) (28 ± 10% vs. 40 ± 10%, P = 0.02), but not when adjusted for presentation type. Overall rate of complications was higher for classical compared to inverted presentation, and not influenced by RV involvement.
RV contractile abnormalities may follow the same LV regional distribution in Takotsubo cardiomyopathy; the type of presentation rather than the presence of RV dysfunction seems to be responsible for an increased risk of complications and severity of functional impairment.
Echocardiography-guided pericardiocentesis is the first choice method for relieving cardiac tamponade, but the exact role of the echocardiography at the moment of the puncture is still controversial. In this report, detailed echocardiographic evaluation was performed in 21 consecutive patients with cardiac tamponade just before the pericardiocentesis. Appropriate needle position was determined according to the probe position using imaginary x, y, and z axes. Pericardiocentesis was performed successfully using this technique without simultaneous echocardiography and no complications were observed. We concluded that bedside echocardiography with detailed evaluation of the puncture site and angle is enough for pericardiocentesis instead of real time guiding.
]]>There is no available published information about the atrial electromechanical coupling time (AEMCT) in patients with atrial septal defect (ASD). The aim of this study was to investigate the relationship between ASD and AEMCT obtained by tissue Doppler imaging (TDI).
A total of 35 patients with ASD and 22 healthy controls were included in the study. The time intervals from the onset of the P-wave on the surface electrocardiogram to the beginning of the late diastolic A-wave (PA) representing AEMCT were obtained from the lateral mitral annulus, septal mitral annulus, and right ventricular (RV) tricuspid annulus, and named PA-lateral, PA-septal, and PA-tricuspid, respectively. The difference between PA-septal and PA-tricuspid, PA-lateral and PA-septal, and PA-lateral and PA-tricuspid were defined as intra-right AEMCT, intra-left AEMCT, and inter- AEMCT, respectively.
PA-tricuspid, PA-septal, and PA-lateral values were longer in patients with ASD when compared with the controls, but did not reach statistical significance (39.9 ± 19.1 vs. 37.2 ± 15.5, P = 0.952; 49.6 ± 14.0 vs. 45.4 ± 11.1, P = 0.826 and 60.3 ± 16.3 vs. 59.7 ± 12.5, P = 0.437, respectively). There were no significant differences between the ASD and control groups in terms of inter-atrial, intra-right atrial, and intra-left AEMCT (21.3 ± 2.3 vs. 20.8 ± 4.6, P = 0.957; 9.7 ± 3.3 vs. 6.9 ± 1.3, P = 0.723 and 13.6 ± 4.7 vs. 10.9 ± 4.5, P = 0.518, respectively). Furthermore, ASD diameter and total septum length did not correlate with AEMCT.
Both intra- and inter-AEMCT were not increased in patients with ASD than control subjects. In addition, we found no association between the ASD diameter and indices of AEMCT in patients with ASD.
Dobutamine stress echocardiography (DSE) is a successful technique for detection of ischemia in patients with suspected coronary artery disease (CAD). There are some data that administration of β-blocker after peak infusion of dobutamine can improve sensitivity. The goal of this manuscript is to review the current literature in regard to the mechanism and accuracy of post–dobutamine β-blocker administration for ischemia detection. In this review, we present 2 case reports followed by detailed review of the literature.
]]>Right coronary artery arising from the pulmonary artery is extremely rare, is generally present without symptoms in childhood. We present a 7-year-old girl with anomalous right coronary artery from the pulmonary artery (ARCAPA), that might easily missed in clinical practice. Anomalous origin of the right coronary artery was noted on echocardiography. Then, catheterization and computed tomography angiography confirmed the diagnosis. Transthoracic echocardiography is still important to detect children who deserve further investigation.
A previously healthy 16-year-old girl presented with history of fever of 3 months duration without any significant clinical finding on examination. Transthoracic echocardiography (TTE) revealed moderate pericardial effusion and later diagnosed as tubercular in etiology. Besides, TTE also showed an incidental finding of large left ventricular (LV) diverticulum in submitral region along the postero-basal segment and left ventricular noncompaction (LVNC). Nonapical LV diverticulum is a rare variant of this uncommon congenital condition and its association with LVNC has not been reported in literature. Patient was discharged on antitubercular therapy for pericardial effusion and advised for 6 monthly follow-up for diverticulum.
]]>Endocarditis is a rare complication of brucellosis, and it is the most common cause of deaths in brucellosis. We report a case of Brucella endocarditis and endoaortitis of the bicuspid aortic valve and ascending aorta (sinotubular junction) diagnosed with real time three-dimensional (3D) transthoracic echocardiography. The vegetation attached to ascending aorta could be delineated with help of 3D transthoracic echocardiography suggestive of Brucella endoaortitis which is seen in fulminant infections like brucellosis. 3D echocardiography helped to understand the pathophysiology of Brucella endo-aorto-carditis which not only infects valvular structures but also the aortic.
Echocardiography is the front-line investigation for assessment of cardiac morphology and function. Assessment of ventricular systolic function has traditionally been defined by the ejection fraction (EF). However, EF is influenced by preload and after load and is inadequate as a sole indicator of systolic performance. Studies have also shown its inability to detect early myocardial dysfunction.
We present images from a patient with pulmonary sarcoidosis referred for echocardiography after developing palpitations. Two-dimensional-echocardiography was unremarkable but speckle tracking echocardiography (STE) revealed significantly abnormal regional myocardial strains. The images highlight the potential of STE to reveal early myocardial involvement in sarcoidosis.
Atrial septal defects (ASD) are often complex in shape and deciding an appropriate device size is important to avoid embolization as well as erosion. Here, we describe a patient with an oval ASD whose percutaneous closure was complicated by device embolization which was caught live by transoesophageal echocardiography.
Ebstein's anomaly comprises a wide spectrum of congenital cardiac abnormalities involving the tricuspid valve (TV) apparatus and the architecture of the morphological right ventricle (RV). We report a case of Ebstein's anomaly in a 3-year-old boy having a unique association with severe subpulmonic obstruction caused by tethered and dysplastic anterior tricuspid leaflet (ATL), and a large ventricular septal defect. In view of poorly functioning RV, the baby was planned for a bidirectional Glenn shunt with subsequent Fontan completion.
]]>Cardiac fibromas represent the second most common benign cardiac mass seen in the pediatric population, but they are rarely seen in adults. Given their large size and unpredictable location within the heart, patients may present with varying symptomatology, and in many cases, the initial presentation is sudden death. Both echocardiography and magnetic resonance imaging are critical to the early diagnosis and prompt treatment of these potentially dangerous primary tumors. We report a 29-year-old woman presenting with syncope and ventricular tachycardia. She was found to have a 5.0 cm inferoapical left ventricular fibroma, which was successfully resected.
]]>Structural mitral valve (MV) abnormalities are common in patients with hypertrophic cardiomyopathy (HCM). This is the first report demonstrating MV abnormalities in very young children as the sole overt clinical feature of a known HCM-causing sarcomere protein gene mutation. Due to MV leaflet elongation, we also noticed a typical fast diastolic swinging motion of the MV in our patients. This novel echocardiographic feature may be used as a clinical marker of HCM disease in the absence of left ventricular hypertrophy.
]]>The aim of this study was to assess left atrial (LA) functional remodeling in lone atrial fibrillation (LAF) patients via two-dimensional speckle tracking echocardiography (2DSTE).
Forty-five paroxysmal LAF patients and 30 healthy controls underwent 2DSTE in sinus rhythm. Longitudinal LA strain/strain rate (LAS/LASR) of booster, reservoir, and conduit function in apical four- and two-chamber views were measured and averages of the 2 views were used.
The 2 groups had similarity in LA volume. LAS and LASR of the 3 phasic functions were reduced in patients. Comparing the 2 groups, LA booster strain (LASa) and strain rate were −12.31 ± 3.15 versus −15.30 ± 2.52% and −1.64 ± 0.51 versus −2.08 ± 0.48 1/sec, respectively, P < 0.05 for both. Multivariate regression confirmed that LAF was an independent determinant of LAS/LASR reduction. LASa was the most accurate parameter for differentiating LAF patients from controls (area under receiver operating characteristic curve, 0.763; cutoff value, −14.3%; sensitivity, 71.1% and specificity, 70.0%). Finally, LASa decrement was found to be the only significant predictor of early atrial fibrillation (AF) recurrence (odds ratio [OR], 1.39 per unit decrement; 95% CI, 1.02–1.89; P = 0.038).
Remodeling of LA booster pump, reservoir, and conduit function in LAF patients can be detected by 2DSTE before structural remodeling. Occurrence of LAF is associated with impairment of LA intrinsic myocardial properties. LASa can differentiate LAF patients and lower LASa is associated with early recurrence of AF after ablation.
A 52-year-old male with a right ventricular mass that filled the entire right ventricle and assumed its shape was evaluated by two-dimensional and real time three-dimensional (3D) echocardiography. Contrast enhanced 3D imaging and quantitative assessments of the size of the mass were performed. The clinical correlation, the imaging characteristics of the mass, and the pattern of vascularity were consistent with metastatic hepatocellular carcinoma. The case illustrates the incremental role of 3D echo in defining the size, shape, spatial relationship, attachments, consistency, and vascularity of the right ventricular mass.
Background: Understanding of right ventricular (RV) function has significantly improved in recent years; however, objective assessment remains problematic. This study sought to demonstrate that a novel speckle tracking method can be used to assess RV global systolic function when compared with traditional echocardiographic measures. Methods: A total of 125 patients (mean age 50 ± 16 years) with a wide range not only of systolic function for both ventricles but also pulmonary pressures and acoustic windows based on patient's body surface areas were studied. Standard parameters of left and RV systolic function were collected and echocardiographic images from four-chamber apical planes were analyzed by conventional manual tracing using a novel General Electric (GE) automated functional imaging (AFI) to measure myocardial strain. Results: Global longitudinal RV strain measurements obtained with manual tracing showed good correlation with traditional parameters of main RV chamber as well as right ventricular outflow tract (RVOT) systolic performance. In a stepwise multiple regression analysis, tricuspid annular systolic motion was the best independent variable that correlated with global AFI RV peak systolic strain followed by RV outflow tract systolic excursion. Receiver operating characteristic analysis showed a global RV AFI peak systolic strain value <−17% to be abnormal (sensitivity 73%, specificity 91%). Discussion: This new automated AFI method provides simultaneous quantitation of global and regional RV function that is angle independent and correlates with standard measures of RV performance without the need for additional derivative measurements, complex calculations, or tedious offline analysis.
]]>An elderly man with dyspnea and syncope was found to have severe aortic stenosis (AS) by the continuity equation, despite a transaortic gradient that was only moderately elevated, in the setting of severe left ventricular dysfunction. The transaortic gradient increased during postextrasystolic beats, suggesting that his that his AS was truly severe; this was confirmed by dobutamine echocardiography. He underwent transcatheter aortic-valve replacement (TAVR), with subsequent improvement in left ventricular systolic function. The diagnostic and prognostic significance of postextrasystolic potentiation, with associated increase in aortic stenosis gradient, deserves renewed attention in the TAVR era.
]]>A 68-year-old man underwent echocardiogram with agitated saline for a presumed diagnosis of primary pulmonary hypertension. Surprisingly, the bubbles from the agitated saline enter the left heart before filling the right side, leading to a diagnosis of Eisenmeger's syndrome from a sinus venosus atrial septal defect. Because of high right-sided pressure, the bubbles preferentially travel from the superior vena cava through the defect to the right superior pulmonary vein and left atrium, rather than the right side. This diagnosis was later confirmed on cardiac MRI.
Tricuspid regurgitation (TR) produced by endocavitary leads (EL) from permanent pacemakers and implantable cardiac defibrillators is a well-known complication of this procedure. The EL may damage or interfere with tricuspid valve function causing mechanical interference of the valve leaflets leading to incomplete valve closure. It is important to recognize this mechanical complication because it could be corrected by repositioning the lead. In this case report we demonstrate how three-dimensional transthoracic echocardiography permits to obtaining an en face view, which allows simultaneous visualization of the 3 moving leaflets during the cardiac cycle, their attachment to the tricuspid annulus and the pattern of leaflet coaptation. Thus, we propose three-dimensional transthoracic echocardiography as the tool of choice to evaluate TR related to EL, to evaluate the necessity of repositioning the lead if severe regurgitation or tricuspid valve malfunction are demonstrated.
]]>We describe a rare case of pulmonary valve endocarditis associated with a double-chambered right ventricle in an adolescent male highlighting the two-dimensional and three-dimensional transthoracic echocardiographic findings. He was managed with aggressive antibiotic therapy followed by surgery. The echocardiographic findings were confirmed during surgery.
]]>Guidelines for assessing diastolic function by echocardiography are continually being updated. Our ability to use available guidelines effectively has not been completely investigated. Six trained echocardiographers were asked to interpret 105 echocardiograms using current American Society of Echocardiography (ASE) algorithms for interpretation of diastolic grade and estimation of left atrial (LA) pressure. Diastolic grade was categorized as normal, mild, moderate, or severe dysfunction. The presence or absence of elevated LA pressure was determined using a second ASE algorithm. As a reference comparison for level of agreement, left ventricular ejection fraction was visually determined. By the ASE algorithm, 29 subjects (28%) met all measurement criteria in their assigned grade and 57 subjects (55%) met all or all but one criterion of their assigned grade. Of the 45 subjects (43%) for whom the guidelines disagreed by more than 1 criterion, the readers debated between normal and moderate dysfunction in 22% or mild and moderate diastolic dysfunction in 31%. Percent inter-reader agreement and kappa values were 76% (0.7) for determining diastolic grade, 84% (0.67) for determining elevated LA pressure, and 84% (0.67) for estimation of ejection fraction, the reference standard. For all subjects, if multiple echocardiographic criteria failed to fit into the proposed guidelines, agreement fell to 66% (0.58) for determining diastolic grade and 74% (0.48) for determining LA pressure. There is reasonable agreement estimating diastolic grade and LA pressure using current guidelines. Further refinements in the definition of mild and moderate dysfunction may improve agreement.
]]>Left atrial (LA) size is known to increase with chronically increased left ventricular (LV) filling pressure. We hypothesized that LA volume was predictive of aortic valve replacement (AVR) and cardiovascular events in a large cohort of patients with asymptomatic mild to moderate aortic valve stenosis.
Transthoracic echocardiography was performed in 1,758 patients in the Simvastatin and Ezetemibe in Aortic Stenosis study. LA volume was measured in the apical four-chamber view in 1,503 patients (85%). The relation of LA volume to AVR or a combined endpoint of cardiovascular events (AVR, congestive heart failure due to aortic stenosis or death from cardiovascular causes) was evaluated.
AVR was performed in 415 (28%) patients, whereas 505 (34%) reached the combined endpoint. A significant but weak association of increased LA volume and risk of the combined endpoint was found (log-rank test: P = 0.02), but this relation did not reach any significance in a multivariate model adjusting for age, gender, aortic valve area index, LV ejection fraction, LV hypertrophy, hypertension, and mitral regurgitation. LA volume was not predictive of AVR (log-rank test: P = 0.3).
In asymptomatic patients with mild to moderate Aortic valve stenosis (AS), LA volume was not predictive of the combined endpoint of Aortic valve replacement, development of heart failure or cardiac death. AVA and presence of LV hypertrophy were the only predictors of events in multivariate analysis.
There is no definitive and reliable echocardiographic method for estimating the pulmonary vascular resistance (PVR) to differentiate persistent vascular disease from dynamic pulmonary hypertension. The aim of this study was to analyze the relationship between the pulmonary venous blood flow velocity-time integral (VTIpv) and PVR.
Eighteen patients (10 females; 4 months to 22 years of age) with congenital heart disease and left to right shunt were studied. They underwent complete cardiac catheterization, including measurements of the PVR and Qp:Qs ratio, before and after 100% oxygen inhalation. Simultaneous left inferior pulmonary venous flow VTIpv was obtained by Doppler echocardiography. The PVR decreased significantly from 5.0 ± 2.6 W to 2.8 ± 2.2 W (P = 0.0001) with a significant increase in the Qp:Qs ratio, from 3.2 ± 1.4 to 4.9 ± 2.4 (P = 0.0008), and the VTIpv increased significantly from 22.6 ± 4.7 cm to 28.1 ± 6.2 cm (P = 0.0002) after 100% oxygen inhalation. VTIpv correlated well with the PVR and Qp:Qs ratio (r = −0.74 and 0.72, respectively). Diagnostic indexes indicated a sensitivity of 86%, specificity of 75%, accuracy of 83%, a positive predictive value of 92% and a negative predictive value of 60%.
The VTIpv correlated well with the PVR. The measurement of this index before and after oxygen inhalation may become a useful noninvasive test for differentiating persistent vascular disease from dynamic and flow-related pulmonary hypertension.
In recent years, right ventricular (RV) function has acquired greater relevance as a clinical and prognostic marker in many physiopathological conditions. The study aims to point out the value of real time three-dimensional echocardiography (RT3DE) and tissue Doppler imaging (TDI) in the evaluation of patients affected by pulmonary hypertension (PH), compared with conventional two-dimensional (2D) echocardiography.
We enrolled 44 subjects affected by PH who underwent 2D and Doppler echocardiography, RT 3D Echocardiography and TDI evaluation of the RV, and a healthy control group. PH itself can induce severe functional and structural abnormalities of the RV, such as RV hypertrophy, RV dilation, and RV systolic and diastolic dysfunction.
In this study, RV FAC, and TAPSE showed marked alterations in patients with PH compared to the control group (C): (RVFAC: [PH] 0.29 ± 0.07 vs. [C] 0.49 ± 0.05%, P < 0.0001; TAPSE: [PH] 15.3 ± 3.2 vs. [C] 21.1 ± 2.6 mm, P > 0.0001). The 3D RV end-diastolic volume was significantly higher in PH than in C (PH) (138.7 ± 25.3 vs. [C] 82.8 ± 12.5 mL, P < 0.0001] as well as 3D RV end-systolic volume (PH) (97.6 ± 21.5 vs. [C] 39.3 ± 9.5 mL, P < 0.0001). The 3D RV ejection fraction (EF) was significantly lower in the pulmonary hypertension group than in healthy subjects (31.8 ± 6.8 vs. [C] 52.5 ± 4.7%, P < 0.0001).
In patients with PH, evaluation of the RV diastolic and systolic volume and EF by RT3DE has shown a higher discriminating power in comparison, respectively, with 2DRV diastolic area and the relative fractional area changes.
We assessed the impact of morbid obesity on systolic and diastolic heart function in severely obese, but otherwise healthy subjects and age-matched controls.
Overall, 27 obese patients: 19 female (F) and 8 male (M) mean age 37 ± 9, mean body mass index (BMI) 46 ± 6 and 27 control subjects: mean age 36 ± 10, mean BMI 23 ± 3 were examined by transthoracic echocardiography, including tissue Doppler echocardiographic (TDE) assessment and speckle tracking echocardiography to measure left ventricular longitudinal, circumferential, and radial strain (S) and strain rate (SR) during systolic and early diastolic phase.
Obese patients presented with enlargement of both ventricles and the left atrium, and thicker left ventricular wall. Although left ventricular ejection fraction (EF) as well as amplitude of tricuspid annulus plane systolic excursion (TAPSE) was similar, the amplitude of mitral annulus plane systolic excursion (MAPSE) and ventricular systolic and early diastolic velocities measured by TDE were significantly lower for both ventricles in the obese group. (RV S′ 13 ± 3 cm/sec vs. 15 ± 2 cm/sec, P = 0.0057; LV S′ lat 8.5 ± 1.6 cm/sec vs. 12.1 ± 2.8, P < 0.0001, E′ lat: 12.4 ± 2.9 vs. 16.4 ± 3.5 cm/sec for left ventricular and E′ 12 ± 3 cm/sec vs. 18 ± 4 for right ventricular velocities, P < 0.0001). Among the deformation parameters, systolic and diastolic circumferential and systolic radial strain and SR were decreased in the obese subjects, whereas longitudinal strain did not differ significantly.
TDE parameters documented reduced systolic and diastolic function of both ventricles in obese patients. 2-dimensional speckle tracking analysis revealed that circumferential and radial but not longitudinal strain and SR were impaired in the obese group.
To investigate whether plasma B-type Natriuretic peptide (BNP), a surrogate of left ventricular filling pressure (LVFP), is predictive of left atrial appendage thrombus (LAAT) in patients with nonvalvular atrial fibrillation (AF) independent of known clinical risk predictors.
We conducted a retrospective cohort study of 297 consecutive subjects with AF who underwent a clinically indicated transesophageal echocardiogram (TEE) to evaluate for LAAT and spontaneous echo contrast (SEC). Among those, 136 had a clinically indicated BNP level. Using multivariate logistic regression analysis models, we determined factors independently predictive of the primary endpoint of LAAT and the secondary endpoint of either LAAT or SEC.
Nineteen subjects (6.4%) had LAAT and they were found to have a higher mean CHADS2 score (2.53 vs 1.76, P = 0.01) and mean BNP level [1949 vs. 819 pg/mL, P = 0.001] than those without LAAT. None of the patients with a BNP level ≤500 pg/mL had LAAT. Multivariate logistic regression analysis demonstrated that BNP was predictive of LAAT and the composite of LAAT/SEC independent of the CHADS2 score and warfarin therapy [OR = 1.23 and 1.6 per 500 pg/mL increment in BNP, P-values = 0.03 and 0.001; respectively]. Moreover, adding BNP to the predictive model negated the influence of the CHADS2 score.
These data indicate that BNP is an independent predictor of LAAT in AF and may complement the role of the CHADS2 score in predicting stroke risk.
To evaluate the independent prognostic role of two-dimensional (2D) strain measures reflecting global longitudinal left ventricular (LV) systolic function in outpatients affected by chronic heart failure (CHF).
Global longitudinal LV systolic strain (GLS) was assessed in 308 outpatients affected by CHF, by analyzing standard views with 2D speckle tracking technique. During a mean follow-up of 26 ± 13 months 37 patients died (29 due to cardiovascular causes), 10 patients underwent heart transplantation, and 75 patients experienced at least 1 episode of hospitalization due to acute decompensated heart failure (ADHF). Thirty-one patients without a history of major ventricular arrhythmic events experienced the occurrence of ventricular fibrillation and/or tachycardia or sudden death was observed. Multivariate Cox regression analysis showed that GLS was significantly associated with all-cause mortality (HR: 1.15; 95%CI: 1.02–1.30; P: 0.026), cardiovascular death (HR: 1.20; 95%CI: 1.04–1.39; P: 0.011), cardiovascular death or heart transplantation (HR: 1.24; 95%CI: 1.09–1.41; P: 0.001), ADHF-related hospitalizations (HR: 1.15; 95%CI: 1.05–1.25; P: 0.003), and arrhythmic events (HR: 1.17; 95%CI: 1.03–1.33; P: 0.018).
Quantifying LV longitudinal systolic function in CHF outpatients on the basis of 2D speckle tracking analysis provides a new parameter that independently predicts patient outcome, thus, strengthening its possible role in current clinical practise.
The conventional mid-esophageal observation by three-dimensional transesophageal echocardiography (3DTEE) sometimes fails to visualize the subvalvular apparatus. In this study, we compared the effectiveness of the transgastric approach by 3DTEE in visualizing the mitral valve complex with the conventional mid-esophageal approach.
We studied 10 consecutive patients who underwent mitral valve surgery for functional mitral regurgitation. The anatomy of the mitral complex was interpreted from the 3DTEE data acquired by both the mid-esophageal and the transgastric approach preoperatively. The interpretations of the image of the mid-esophageal approach and the transgastric approach were compared with surgical observations.
In the concordance rate for surgical observation, the interpretation of the number of papillary heads and chordal distribution for the transgastric observation were superior to those for the mid-esophageal observation both for anterior papillary muscle (P < 0.01 and 0.005, respectively) and posterior papillary muscle (P < 0.001 and 0.0005, respectively).
The accuracy of transgastric observations of submitral structure using 3DTEE was superior to that provided by the conventional mid-esophageal approach. Transgastric approach offers a ventricular view and complementary information to conventional mid-esophageal approach in patient with functional mitral regurgitation.
Thirty-six patients with psoriasis and 56 healthy volunteers were included in this study.
Echocardiographic examination included transmitral peak flow velocities of the early phase (E) and late phase (A) of the mitral inflow, left ventricular myocardial velocity measurements, and coronary flow reserve (CFR) measurement.
Baseline coronary diastolic peak flow velocity (DPFV) of left anterior descending artery (LAD) was significantly higher in the psoriasis group. However, hyperemic DPFV was slightly lower and CFR (2.19 ± 0.39 vs. 2.60 ± 0.31, P < 0.0001) was significantly lower in the psoriasis group than in the control group. CFR was significantly and inversely correlated with disease duration, Psoriasis Area and Severity Index (PASI) score, and hsCRP.
CFR is decreased in patients with psoriasis, and it correlates to disease duration, PASI score, and inflammation.
The choice of the imaging modality (transthoracic [TTE] vs. transesophageal echocardiography [TEE]) for the diagnosis of infective endocarditis (IE) depends on different variables. Aim of the present study is to provide updated data on the diagnostic sensitivity and the clinical usefulness of TTE vs. TEE from the Italian Registry on IE (RIEI).
The RIEI has enrolled consecutive cases of IE in every participating centre, evaluating diagnostic and therapeutic data from a real world practice perspective.
From July 2007 to October 2010, 658 consecutive cases with definite IE according to Duke criteria have been enrolled in the RIEI (483 males). The following diagnostic echocardiographic exams were performed: 616 TTE (94%) and 476 TEE (72%). A positive TTE was recorded in 399 cases (65%), an uncertain TTE in 108 cases (17%), and a negative TTE in 109 cases (18%). For TEE, a positive study was reported in 451 cases (95%), uncertain in 13 cases (2.7%), and negative in 12 cases (2.5%) (P < 0.001). This difference is not evident in patients with tricuspid valve IE or i.v. drug addiction, and in Streptococcus bovis or Streptococcus viridans IE. TTE was significantly more performed before the admission and earlier than TEE during admission (P = 0.000). TTE was mainly responsible for the initial diagnosis in 59%. TEE contributed to changing the therapeutic approach in 42%.
In the real world, TTE is performed earlier and more commonly, and it is the major echocardiographic tool for the initial diagnosis. TEE confirms its superior diagnostic sensitivity in most cases, although it is relatively underused.
The twisting motion of the heart has an important role in the function of the left ventricle. Speckle tracking echocardiography is able to quantify left ventricular (LV) rotation and twist. So far this new technique has not been used in congenital heart disease patients. The aim of our study was to investigate the feasibility and the intra- and inter-observer reproducibility of LV rotation parameters in adult patients with congenital heart disease.
The study population consisted of 66 consecutive patients seen in the outpatient clinic (67% male, mean age 31 ± 7.7 years, NYHA class 1 ± 0.3) with a variety of congenital heart disease. First, feasibility was assessed in all patients. Intra- and inter-observer reproducibility was assessed for the patients in which speckle tracking echocardiography was feasible. Adequate image quality, for performing speckle echocardiography, was found in 80% of patients. The bias for the intra-observer reproducibility of the LV twist was 0.0°, with 95% limits of agreement of −2.5° and 2.5° and for interobserver reproducibility the bias was 0.0°, with 95% limits of agreement of −3.0° and 3.0°. Intra- and inter-observer measurements showed a strong correlation (0.86 and 0.79, respectively). Also a good repeatability was seen. The mean time to complete full analysis per subject for the first and second measurement was 9 and 5 minutes, respectively.
Speckle tracking echocardiography is feasible in 80% of adult patients with congenital heart disease and shows excellent intra- and inter-observer reproducibility.
Only 50% of patients with aortic stenosis (AS) and low ejection fraction (EF) improve their contractility after surgical aortic valve replacement (AVR). Long-term prognosis of these patients is strongly correlated to EF recovery after the surgery. The aim of this study was to compare the postoperative left ventricular function recovery in patients with severe AS and reduced EF after AVR and transcatheter aortic valve implantation (TAVI).
Twenty-one patients undergoing AVR for severe AS (<1 cm²) and reduced EF (<45%) were echocardiographically compared with 31 patients treated with TAVI by conventional and two-dimensional (2D) strain method. TAVI patients were older (83 ± 6 vs. 74 ± 13 years, P < 0.001), had more comorbidities (Euroscore 26 ± 15% vs. 16 ± 12%, P < 0.001) and no differences in ischemic heart disease (16.1% vs. 9.5%, P = 0.39). EF was similar in both groups at baseline. Aortic valve area significantly increased (P = 0.01) while pressure gradient decreased (P = 0.009) after both procedures but TAVI was associated with a better EF recovery compared with AVR at day 7. Regional function assessed by radial 2D strain increased in TAVI group but was transiently deteriorated in AVR patients (P < 0.05). Longitudinal as well as circumferential 2D strain progressively increased at follow-up in both groups (P < 0.05). EF was similar in both groups at 3-month follow-up.
In patients with severe AS and reduced EF, TAVI is associated with faster and better recovery of LV function compared with AVR.
Pulmonary hypertension (PH) is an important complication in the natural history of chronic obstructive pulmonary disease (COPD) and is caused by the remodeling of pulmonary arteries impairing the distensibility and stiffness of the major pulmonary arteries.
To evaluate the pulmonary artery distensibility by transthoracic echocardiography in patients with COPD.
We prospectively investigated COPD male patients and compared with healthy controls. In addition to right ventricle (RV) conventional echocardiographic parameters, right pulmonary artery fractional shortening(RPA-FS) and new pulmonary artery stiffness (PAS) parameters were compared.
Fifty-four COPD patients participated in the study and compared with a control group consisting of 24, all men, healthy, nonsmoking subjects. Six patients were excluded from study due to poor quality of echocardiographic recordings. The distensibility of PA evaluated by the RPA-FS parameter was found to be significantly lower in patients with COPD than it was in normal subjects (13.3 ± 8.1 vs. 27.6 ± 4.9,P :< 0.001) and correlated positively with tricuspid annular systolic excursion (TAPSE) (r = 0.566, P < 0.001) and pulmonary acceleration time (r = 0.607, P < 0.001) and correlated inversely with pulmonary artery systolic pressure (r = −0.587, P < 0.001), PAS(r = −0.479, P < 0.001) and functional capacity (r = −0.586, P < 0.001). Similar to this, PAS found to be impaired in COPD patients (29.5 ± 13.6 vs. 15.7 ± 4.1, P < 0.001) and correlated inversely RPA-FS (r = −0.479, P < 0.001). There were statistically significant difference for pulmonary artery distensibility (RPA-FS) and PAS parameters among the COPD subgroups with regard to NYHA functional capacity (P < 0.001).
In this study, we found that PAS and distensibility were worsened in COPD patients and correlated with decreased functional capacity.
Until now, there is no consensus regarding the definition of a clinical response to cardiac resynchronization therapy (CRT) in patients with chronic heart failure (CHF) and systolic left ventricular (LV) dysfunction. The aim of this study was to evaluate if echocardiography is predictive for an objective improvement in exercise capacity during long-term follow-up of CRT.
Each patient underwent echocardiography and spiroergometry both at baseline and at last follow-up. Left ventricular dyssynchrony (LVD) before CRT was defined by tissue Doppler imaging (TDI) as intra-LV delay ≥40 msec (septal-lateral or anterior-posterior). Clinical response to CRT was defined as increase of peakVO2 or as increase of maximal workload >10% as compared to baseline.
Mean follow-up was 69 ± 37 months. From the 238 consecutive patients included in the study, 141 (59%) were classified as clinical responders and 97 (41%) as nonresponders. Baseline data of responders and nonresponders were comparable. However, clinical responders showed more often LVD (64%) than nonresponders (42%, P = 0.004). On multivariate regression analysis, nonischemic origin of CHF (β-coefficient in the final model 0.1, P = 0.04) and LVD at baseline (β-coefficient in the final model 0.2, P < 0.001) were independently associated with clinical response during long-term follow-up. Patients with LVD at baseline had significant more often an improvement of left ventricular ejection fraction >10% (P = 0.02) and a reduction of left ventricular end-diastolic diameter (LVEDD) >10% (P < 0.01) than patients without LVD at baseline.
LVD at baseline as assessed by a straightforward echocardiographic approach predicts the long-term clinical response to CRT and is associated with a more pronounced reverse LV remodeling.
A 60-year-old hypertensive male with non-ST segment elevation myocardial infarction had a hyperdynamic LV with mild posterior leaflet mitral valve prolapse without significant regurgitation on transthoracic echocardiogram. Two-dimensional (2D) TEE showed severe mitral regurgitation with prolapse of P2 and P3 scallops. Posteromedial papillary muscle rupture was suspected. Three-dimensional (3D) TEE demonstrated severely prolapsing P2 and P3 valve scallops with a clear view of the partially ruptured posteromedial papillary muscle. Patient underwent emergency coronary bypass and mitral valve replacement. Surgical pathology of papillary muscle confirmed coagulative necrosis. 3D TEE was superior in identifying the partial posteromedial papillary muscle rupture.
Reoperation for degenerated mitral bioprosthesis is considered a high risk procedure. Transcatheter mitral valve in valve implantation has emerged as an off-label alternative for patients contra-indicated to surgery. We report a 46-year-old man, with a 29 mm mitral bioprosthesis since 2002, who was admitted for acute heart failure because of a severe intra-prosthetic regurgitation. His recent medical history revealed a fast growing cavum carcinoma. In view of generally poor prognosis, the heart team decided to perform a transcatheter mitral valve in valve implantation by transapical approach. Live three-dimensional TEE was used during the implantation for sizing, device positioning, and hemodynamic assessment.
]]>Primary tumors of the heart are rarely seen. Cardiac angiosarcomas are malignant tumors that almost always have a poor prognosis. Atrium rupture and coronary artery fistula are very rare complications of primary cardiac angiosarcoma. We describe a 57-year-old man suffering from primary cardiac angiosarcoma with spontaneous ruptures of the right atrium and right coronary artery (RCA). Theoretically, either of these ruptures invariably results in pericardial effusion and tamponade that is rare but potentially life threatening. In this instance, however, the patient might have developed fibrous adhesions resulted from previous bloody pericardial effusion. A massive pericardial effusion was localized, which consequently prevented cardiac tamponade and hemodynamic collapse. Echocardiography revealed the tumor progression leading to detectable infiltration of solid mass into the right atrial (RA) wall, which is close to RCA. And color Doppler displayed the flow into the pericardial cavity through a disrupted RA wall and perforated RCA. Echocardiography remains the primary method of choice for evaluation of cardiac masses.
]]>In cardiac arrest survivors, postresuscitation myocardial stunning usually presents as either global left ventricular dysfunction or regional dyssynergy including the various forms of stress cardiomyopathy, in which rare variants may be difficult to diagnose. We present a patient with cardiac arrest during general anesthesia, in whom speckle tracking–derived myocardial strain helped to distinguish between the inverted variant of stress cardiomyopathy and global postresuscitation myocardial stunning.
]]>Latest research shows that the lower resting values of right ventricular (RV) myocardial % strain may represent a physiologic change rather than subclinical myocardial damage. Therefore, we assessed load-independent changes to the RV as a consequence of high intensity training by measuring the Isovolumic acceleration (IVA) of the free wall of the RV in conjunction with NT pro-BNP measured by an electrochemiluminescence assay.
Seventeen controls (mean age 27 ± 4), 24 soccer footballers (mean age 24 ± 4), and 18 elite rowers (mean age 22 ± 4) were studied. Left ventricular (LV) and RV % strain were measured using two-dimensional (2D) speckle based automated functional imaging (AFI) software. RV free wall IVA was measured using pulsed-wave tissue Doppler at the lateral tricuspid annulus. Standard 2D echo were used to measured RV parameters including the Tei index (systolic and diastolic function) and the total annular plane systolic excursion (TAPSE) of the RV annulus. NT pro-BNP was measured by an electrochemiluminescence assay.
The RV diameter was increased in the footballers and elite rowers compared with controls (P < 0.001). RV wall size was greater in the elite rowers compared with controls and footballers (P = 0.002). The peak IVA of the RV was higher in the rowers, compared with the footballers and to controls (P < 0.001). The mean LV and RV % myocardial strain were lower in the elite athletes and the footballers compared with controls (P < 0.001). There was no difference in RV Tei index, levels of BNP, and TAPSE across all subjects.
This study showed a significant increase in IVA of the RV of athletes despite reduced myocardial % strain and normal levels in NT-proBNP. This suggests that the decrease in % strain is not a consequence of myocardial damage, but may represents a part of the physiological response to endurance exercise. Therefore, a reduced IVA in a remodeled RV could herald a pathological response.
We aimed to investigate whether coronary sinus (CS) dilatation develops in patients with mitral stenosis (MS) and to demonstrate its relationship with the global myocardial performance of the right ventricle (RV).
We enrolled 34 patients with MS who underwent echocardiography after exhibiting typical symptoms (31 female; mean age 41 ± 12 years) and 20 age- and sex-matched controls without MS who underwent echocardiography (16 female; mean age 38 ± 13 years). The RV myocardial performance index (MPI) was detected using tissue Doppler echocardiography (TDE), and maximum CS diameter was measured from the posterior atrioventricular groove in the apical four-chamber view during the ventricular systole.
The RV MPI was significantly higher in the MS group compared to the control group (0.60 ± 0.11 vs. 0.41 ± 0.08, P < 0.001). Moreover, the maximum CS dimension was higher in the MS group compared to the control group (8.5 ± 1.1 mm vs. 6.5 ± 1.4 mm, P < 0.001). The maximum CS dilatation was positively correlated with the RV MPI (r = 0.691; P < 0.001).
The RV MPI, which represents both systolic and diastolic functions, is increased in patients with MS and correlates with CS dilatation.
Echocardiography (echo)-quantified LV stroke volume (SV) is widely used to assess systolic performance after acute myocardial infarction (AMI). This study compared 2 common echo approaches – predicated on flow (Doppler) and linear chamber dimensions (Teichholz) – to volumetric SV and global infarct parameters quantified by cardiac magnetic resonance (CMR).
Multimodality imaging was performed as part of a post-AMI registry. For echo, SV was measured by Doppler and Teichholz methods. Cine-CMR was used for volumetric SV and LVEF quantification, and delayed-enhancement (DE) CMR for infarct size.
Overall, 142 patients underwent same day echo and CMR. On echo, mean SV by Teichholz (78 ± 17 mL) was slightly higher than Doppler (75 ± 16 mL; Δ = 3 ± 13 mL; P = 0.02). Compared to SV on CMR (78 ± 18 mL), mean difference by Teichholz (Δ = −0.2 ± 14; P = 0.89) was slightly smaller than Doppler (Δ = −3 ± 14; P = 0.02), but limits of agreement were similar between CMR and echo methods (Teichholz: −28, 27 mL, Doppler: −31, 24 mL). For Teichholz, differences with CMR SV were greatest among patients with anteroseptal or lateral wall hypokinesis (P < 0.05). For Doppler, differences were associated with aortic valve abnormalities or root dilation (P = 0.01). SV by both echo methods decreased stepwise in relation to global LV injury as assessed by CMR-quantified LVEF and infarct size (P < 0.01).
Teichholz and Doppler calculated SV yield similar magnitude of agreement with CMR. Teichholz differences with CMR increase with septal or lateral wall contractile dysfunction, whereas Doppler yields increased offsets in patients with aortic remodeling.
The effects of pulmonary vein (PV) isolation in atrial fibrillation (AF) on left atrial (LA) function or PV flow have not been well documented.
We examined the LA function and PV flow before and 3–6 months after PV isolation in 67 AF patients (34 paroxysmal [PAF] and 33 persistent [CAF]) using transesophageal echocardiography.
AF recurred in 6/34 patients with PAF and in 6/33 patients with CAF 6 months after PV isolation. A larger LA dimension, a lower systolic PV flow velocity, and a lower ratio of systolic to diastolic PV flow velocity were related to a higher incidence of AF recurrence. The increment of left atrial appendage (LAA) flow velocity (55% vs. 22%) and systolic PV flow velocity (57% vs. 20%) after PV isolation tended to be greater in CAF than in PAF. The changes in LAA flow velocity had reverse correlations with the baseline values before PV isolation (PAF: r = −0.73, CAF: r = −0.58). The changes in mitral flow velocity during atrial contraction in PAF had reverse correlations with the baseline values before PV isolation (r = −0.84). The changes in systolic and diastolic PV flow velocity of PAF had reverse correlations with the baseline values before PV isolation (r = −0.56, r = −0.66).
The baseline LA function may affect AF recurrence as well as the improvement of LA function, and the benefit of successful PV isolation might be greater in CAF than in PAF.
To study whether there is any relation between left atrial (LA) size or function and the level of left ventricular dyssynchrony (LV) in patients with heart failure.
Fifty-two patients (male 34, mean age = 65.77 ± 8.69 years) with ejection fraction (EF) <35%, who were candidates for cardiac resynchronization therapy (CRT), underwent conventional transthoracic echocardiography and tissue Doppler imaging (TDI). Intra-ventricular dyssynchrony, inter-ventricular mechanical dyssynchrony (IVMD), and related time intervals were measured. The LA size and function were evaluated by transthoracic echocardiography and deformation imaging using LA lateral wall strain (ST) and strain rate (SR), and the septal wall ST.
The LA volume showed severe dilation in 41 (78.8%) patients. 44 (84.6%) cases had intra-ventricular dyssynchrony and 33 (63.5%) had IVMD. In univariable analysis, the LA lateral wall ST and SR as well as the LA septal wall ST had significant but poor correlation with IVMD. There were also poor to moderate correlation between these parameters and the LV end diastolic diameter and mitral annulus tissue velocity at early and late diastole. However, after adjustment for all the related factors, IVMD remained a significant independent correlate for the LA lateral wall ST and SR. This correlation for the LA septal wall ST was not statistically significant.
IVMD was a significant independent correlate for the LA lateral wall ST and SR. This correlation for the LA septal wall ST was nonsignificant. Future studies are needed to examine whether the correction of inter-ventricular dyssynchrony by CRT in patients with concomitant LA dysfunction can have an independent role in the improvement of the LA function.
Right ventricular (RV) pacing is associated with left ventricular (LV) dysfunction. However, the effects of RV pacing at different sites on both LV and RV function have rarely been studied before. We want to determine whether different RV pacing sites differentially affect LV and RV deformation by using speckle tracking echocardiography (STE).
The subjects were 73 patients who had undergone dual-chamber permanent pacemaker implantation and did not have structural heart diseases. LV and RV global longitudinal strains (GLS) were measured using STE to determine subtle changes in LV function. Twenty-three patients without pacing after pacemaker implantation served as controls; 14 and 36 patients showed apical and septal pacing, respectively.
There were no significant intergroup demographic differences. LV biplane ejection fractions in the septal- and apical-pacing groups were significantly lower than those in the controls. The GLSLV values were similar between the control and septal-pacing groups, but they were lower in the apical-pacing group. Multivariate analysis revealed that cumulative pacing loads and apical pacing were independent factors associated with lower GLSLV values. The GLSRV values were similar between the control and apical-pacing groups; however, they were lower in the septal-pacing group.
We concluded that patients with septal pacing have significantly higher GLSLV and more modest decreases in GLSRV values than patients with apical pacing. Thus, septal pacing may be not necessarily preferable in patients without significant heart disease undergoing dual-chamber permanent pacemaker implantation.
The aim of this study was to evaluate the effect of left ventricular aneurysm (LVA) volume and myocardial strain on left ventricular function in a rabbit model using real time three-dimensional echocardiographic imaging (RT-3DE) combined with two-dimensional speckle tracking imaging (2D-STI).
A rabbit model of LVA was prepared in 30 New Zealand rabbits by ligating the middle segment of the left anterior descending artery and the left circumflex artery (LVA group); 10 control rabbits underwent thoracotomy alone. Four weeks later, RT-3DE was performed to obtain data on left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), and LVA volume. The peak short-axis radial (SrR) and circumferential (SrC) strain rates were measured using 2D-STI technique.
Compared with control rabbits, LVA group rabbits had significant left ventricular enlargement at the end-systolic and end-diastolic phases (both P < 0.05). LVEF, SrR-Systolic, and SrC-Systolic were significantly lower in the LVA group (all P < 0.05). Moreover, there were high correlations between LVEF and SrC-Systolicanterior wall, SrR-Systolicanterior wall, SrC-Systoliclateral wall, and SrR-Systoliclateral wall (r = −0.895, −0.887, −0.890, −0.891, respectively, all P < 0.05). Of note, LVA volume/LVEDV had the tightest inverse relationship with LVEF (r = −0.911, P < 0.01). Specifically, LVA volume/LVEDV >16% corresponded to LVEF <50%, and LVEF decreased 1.1% while LVA volume/LVEDV increased 1%.
LVA volume/LVEDV provided a sensitive indicator reflecting cardiac function with LVA. Measurement of various parameters using RT-3DE might be a useful means to evaluate cardiac function after LVA formation.
Echocardiography-guided optimization of atrioventricular (AV) delay (AVD) improves left ventricular (LV) filling, and optimized interventricular delay (VVD) leads to further improvement in cardiac output in patients with biventricular (Biv) pacing. Investigators use LV filling and ejection to optimize AV and VV delay in patients with Biv pacing. Effect of such optimization on right-sided hemodynamics remains unknown. In our experience, few patients experience worsening of right ventricle (RV) hemodynamics when LV parameters are optimized. We present a series of cases where we observed suboptimal RV filling or ejection at optimal AVD and VVD for LV. This RV-LV discordance may contribute to nonresponder rate to cardiac resynchronization therapy (CRT) and should be evaluated in a consecutive series of CRT nonresponder patients to help improve CRT response.
]]>To evaluate echocardiographic changes after SAPIEN valve implantation in the pulmonary position.
The feasibility of the SAPIEN transcatheter pulmonary valve (TPV) has recently been demonstrated. We evaluated changes in pulmonary valve function and the right ventricle after SAPIEN TPV placement.
We evaluated echocardiograms at baseline, discharge, 1 and 6 months after TPV placement in 33 patients from 4 centers. Pulmonary insufficiency severity was graded 0–4. TPV peak and mean gradients were measured. Right ventricular (RV) size and function were quantified using routine measures derived from color, spectral, and tissue Doppler indices and two-dimensional echocardiography.
At baseline, 94% patients demonstrated pulmonary insufficiency grade 2–4. This decreased to 12% patients at 6 months (P < 0.01). TPV peak (P < 0.01) and mean gradient (P < 0.01) decreased. RV end-diastolic area indexed to body surface area (BSA) (P < 0.01), Tricuspid regurgitation (TR) gradient (P < 0.01), and the ratio of TR jet area to BSA (P < 0.01) decreased. Tricuspid inflow peak E:A, tissue Doppler imaging (TDI): septal E' and A', TDI: tricuspid A' improved between baseline and discharge, but trended back to baseline by 6-month follow-up. Tricuspid valve annulus z-score, RV area change, tricuspid annular plane systolic excursion (TAPSE), RV dP/dt, tricuspid E:E', and TDI: tricuspid annulus E' showed no change.
Improvements in pulmonary insufficiency and stenosis, RV size, and TR gradient and severity are seen after SAPIEN TPV placement. Selected indices of RV diastolic function improve immediately after TPV implantation, but return to baseline by 6 months. RV systolic function is unchanged.
Transesophageal echocardiography is recommended to monitor left ventricular (LV) size and function in various operations. Generally, two-dimensional (2D) methods are applied intraoperatively. The aim of this study was to compare the accuracy and feasibility of 6 commonly used 2D methods to assess LV function during surgery. LV function in 120 consecutive patients was evaluated. Real time three-dimensional transesophageal echocardiograpy (3DTEE) served as reference. End-diastolic and end-systolic volumes and ejection fraction (EF) were analyzed with Simpson's method of discs (monoplane [MP] and biplane [BP]), eyeball method, Teichholz' method, and speckle tracking (ST) methods. Furthermore, fractional area change (FAC) and peak systolic pressure rise (dP/dt) were determined. Each 2D method was evaluated regarding correlation and agreement with 3DE, intra- and interobserver variability and the time required for evaluation. Simpson BP showed the strongest correlation and best agreement with 3DE for EF (limits of agreement 3.7 ± 11.6%) and volumes. Simpson MP showed similar agreement with 3DE compared to ST (2.8 ± 14.5% vs. 2.0 ± 15.3% and 3.8 ± 14.4% vs. 1.9 ± 15.6%, respectively). Both the eyeball method and Teichholz' method showed wide limits of agreement (−1.5 ± 18.2% and 5.2 ± 22.1%, respectively). DP/dt did not correlate with 3DE. FAC and ST FAC showed similar agreement. Application of 3DE (429 ± 108 seconds) took the longest time, and the eyeball method took the shortest time (8 ± 5 seconds) for analysis. Simpson BP is the most accurate intraoperative 2D method to evaluate LV function, followed by long-axis MP evaluations. Short-axis views were less accurate but may be suited for monitoring. We do not recommend using dP/dt.
]]>Left ventricular (LV) systolic strain provides additional prognostic value to LV ejection fraction (LVEF) and wall motion analysis. However, the relationship between myocardial multidirectional strain and LVEF, and the effect of LV hypertrophy on this relationship, are not completely understood especially in unselected populations.
LV global longitudinal (εL) and circumferential (εC) systolic strain analysis was performed by two-dimensional speckle tracking echocardiography in 215 participants from a community-based study. LV radial wall thickening was measured as global radial strain (εR), and LVEF was assessed by biplane Simpson's method.
εR was significantly associated with εC (β = −0.56, P < 0.01) and with εL (β = −0.18, P < 0.01). The contribution of εL to εR was especially evident in subjects with lower εC and in presence of LV hypertrophy (β = −0.30, P < 0.01). εL and εC were significantly associated with LVEF (β = −0.36 and β = −0.49, both P < 0.01) independent of LV mass and other confounders, and their interaction significantly improved the prediction of LVEF (R2-change = 0.14) but not of εR (R2-change = 0.002).
εR is mainly related to εC with a smaller contribution of εL, which becomes especially evident in subjects with lower εC and in presence of LV hypertrophy. Therefore, radial thickening may not detect subclinical LV longitudinal function reduction in normal ventricles and when εC is preserved. While a reduction in εL has a limited impact on εR, it exerts a greater effect on global LVEF, therefore for a more accurate LVEF prediction both εL and εC need to be considered.
Systemic hypertension is a major risk factor for heart disease and stroke. Data regarding temporal relationship of left atrial (LA) remodeling to onset of hypertension are sparse. We aimed to quantitate LA structural and functional remodeling in newly diagnosed hypertensive patients.
We prospectively identified 380 patients with newly diagnosed systemic hypertension naive to drug therapy, and 380 age-matched control subjects without any history or evidence of hypertension. History or evidence of prior cardiovascular events, congenital or valvular heart disease, and renal dysfunction were exclusion criteria. Prevalence of LA enlargement, LA mechanical dysfunction expressed in total emptying fraction, left ventricular (LV) diastolic dysfunction, LV hypertrophy, and their interrelationships were assessed.
Of the 380 newly diagnosed hypertensive patients, 285 (75%) had LA enlargement, 308 (81%) had LA mechanical dysfunction, and 19 (5%) had LVH. Diastolic dysfunction was present in 334 (88%) of the patients. Compared to the controls, the hypertensive group had larger maximal, minimal, and pre-A LA volumes (all P < 0.001). Total and active LA emptying fraction were significantly reduced (both P < 0.001). Total LA emptying fraction was strongly associated with systolic blood pressure [per 10 mmHg, HR 0.94 (0.89–0.98); P < 0.001], with stepwise decrease in LA emptying fraction of 6%, 10%, and 16% from the lowest (141–150 mmHg) to the top tertile of systolic blood pressure (>160 mmHg).
In this drug-naive cohort with newly diagnosed hypertension, LA structural and functional remodeling, and LV diastolic dysfunction were common findings prior to initiation of drug treatment. LVH was uncommon. Impairment of LA mechanical function was evident even in the mildly hypertensive subgroup.
The aim of this study was to examine the impact of metabolic syndrome (MS) on right ventricular (RV) remodeling in different genders.
The study included 341 subjects (216 subjects with MS and 125 controls). MS was defined by the presence of ≥3 ATP-NCEP-III criteria. All subjects underwent complete two-dimensional echocardiography.
RV structure, diastolic, and global function were significantly impaired in MS subjects, in both genders. The multiple regression analysis of MS parameters showed that systolic blood pressure (BP) and waist circumference were independently associated with RV wall thickness in women, whereas the only independent predictor in men was systolic BP. The multivariate logistic regression analysis revealed that increased BP, impaired fasting glucose, and dyslipidemia were a combination of MS risk factors related with RV hypertrophy solely in women. Increased systolic BP, impaired fasting glucose, and abdominal obesity were independently associated with tricuspid E/e′ in women, whereas increased systolic BP was the only independent predictor in men. Impaired fasting glucose, abdominal obesity, and dyslipidemia were a combination of MS criteria, which was independently associated with RV diastolic dysfunction only in women.
Different parameters of MS are responsible for RV remodeling in women and men. The metabolic parameters of MS are more important for RV remodeling in women.
Transthoracic murine echocardiography is a cornerstone of small animal research, but conventional methods cannot detect regional perturbations in cardiac function. Reliable assessment of regional cardiac function would be of value in transgenic models of myocardial disease. Until now automatized algorithms for achieving this suffers from a number of drawbacks. We developed a simple algorithm for rapidly assessing the relative myocardial radial thickening that occurs between end-diastole and end-systole, that is, regional radial transmural end-systolic strain (RTESS).
Echocardiographic assessment was performed in mice at baseline (n = 8), 2 hours postintraperitoneal isoprenaline (ISO) injection (n = 8), and 10 days postmyocardial infarction (post-MI) (n = 6). A >1000 frames/sec cine loop was acquired by the ECG-gated Kilohertz visualization technique in the parasternal short-axis projection at 3 mm below the mitral annulus. Endo- and epicardial borders were traced at end-diastole and end-systole and RTESS was calculated for each of n segments by the algorithm. The intra- and inter-observer coefficients of variation for segmental RTESS assessment were 5.11 and 7.32, respectively. At baseline, average segmental RTESS was 56.75% and RTESS was similar in all cardiac segments regardless of how many segments the heart was divided into. In the akinetic myocardium of MI and ISO mice, 47.36% and 26.22% length of the endocardium, respectively, RTESS was near zero and significantly different from the remaining myocardium.
We describe a simple and straightforward approach to quantify regional myocardial deformation in mouse models of cardiovascular disease.
Recently it has been demonstrated that high resolution transthoracic echocardiography (HRTTE) is able to detect differences in the wall thickness of the left anterior descending coronary artery (LAD) between patients with coronary artery disease (CAD) and normal volunteers. We sought to validate this technique, develop a normal range of values and demonstrate the test–retest variability of each measurement. Two hundred forty-two volunteer participants had a HRTTE study to measure their LAD wall thickness, luminal, and external diameters. Thirty of these subjects had these measurements taken on 3 separate occasions by 2 different echosonographers. All subjects were free of clinical CAD, hypertension, hyperlipidemia, and diabetes mellitus. The average anterior wall thickness was 1.1 ± 0.2 mm; posterior wall thickness was 1.1 ± 0.2 mm, luminal diameter 2.2 ± 0.6 mm, and external elastic membrane (EEM) diameter 4.5 ± 0.9 mm. The bias of the measurements within the same operator for LAD wall thickness, luminal diameter, and EEM was 0.042, −0.06, and −0.077 mm, respectively. The bias of the measurements between 2 different operators for LAD wall thickness, luminal diameter, and EEM was 0.082, −0.077, and −0.027 mm, respectively. In conclusion, HRTTE measurement of the LAD vessel is reproducible within and between operators in normal volunteers. This technique therefore warrants further study as a potential screening modality for subclinical coronary atherosclerosis.
]]>Diabetes accelerates the natural process of atherosclerosis and is a predictor for progression of atherosclerotic lesions. To improve clinical outcomes, noninvasive imaging modalities have been proposed to measure and monitor atherosclerosis. Recently, it has been shown that the color M-mode–derived propagation velocity of the descending thoracic aorta (aortic velocity propagation [AVP]) was associated with coronary and carotid atherosclerosis.
Carotid intima-media thickness (CIMT) and AVP were measured in 72 patients with newly diagnosed type 2 diabetes and 44 healthy people. Individuals who had previously used oral hypoglycemic agents or insulin treatment or had a history of hyperlipidemia, cigarette smoking, hypertension, and cardiovascular disease were excluded from this study.
Compared with control group, patients with type 2 diabetes had significantly lower AVP (39.9 ± 6.5 vs. 58.4 ± 6.7 cm/sec, P < 0.001) and higher CIMT (1.1 ± 0.1 vs. 0.95 ± 0.12 mm, P < 0.001) measurements. There were significant correlations between AVP and CIMT (r = −0.835, P < 0.001), AVP and fasting plasma glucose (r = −0.796, P < 0.001)), AVP and HbA1 c (r = −0918 P < 0.001).
Diabetes mellitus may be associated with subclinical atherosclerosis assessed by measurement of AVP and CIMT. These simple methods might improve patient selection for primary prevention atherosclerotic progression.
Late presentation of abnormal origin of coronary artery from the pulmonary artery (ACAPA) is uncommon compared with early presentation, which usually induces extended myocardial necrosis and severe heart failure. The late presentation is characterized by abundant development of intercoronary collaterals resulting in mild and rare symptoms, but nevertheless can cause sudden cardiac death. Our objective was to describe presentation, cardiovascular imaging methods for diagnosis and outcomes of patients with late presentation of ACAP.
The study is a retrospective review of a single-center database to identify all patients diagnosed with ACAPA beyond the first year of life.
From 1976 to 2011, 10 patients were identified with ACAPA at the age of 1.1–64 years: 6 with left coronary artery from the pulmonary artery (ALCAPA) and 4 with right coronary artery from the pulmonary artery (ARCAPA). Echocardiography and Doppler imaging evidenced: (1) direct signs: the abnormal coronary ostium arising from the pulmonary trunk with retrograde coronary artery flow and (2) indirect signs: abundant intercoronary septal collaterals with anterograde flow (ARCAPA) or retrograde flow (ALCAPA) and dilatation of the controlateral normally originated coronary artery. Nine patients underwent surgical implantation of the ACAPA into the ascending aorta. After 7.9 years mean follow-up, all were asymptomatic except one who required a second surgery.
Noninvasive cardiovascular imaging, namely transthoracic echocardiography and Doppler specific parameters, can reach diagnosis of late presentation of ACAPA. Direct aortic implantation is a reliable and effective to establish dual coronary artery circulation and prevent risks due to myocardial ischemia.
Τhe influence of atrial septal occluders in left atrial (LA) function after percutaneous closure of patent foramen ovale (PFO) has not been thoroughly studied.
Twenty-five patients (mean age 40.7 ± 12 years) undergoing percutaneous PFO closure were enrolled in this study. Transthoracic echocardiogram (TTE) was performed 3 and 6 months before the procedure. Volumetric indices (active emptying fraction: LA AEF, expansion index: LA EI, and passive emptying fraction: LA PEF), strain and strain rate (SR), were calculated during the contractile, reservoir, and conduit LA phases for the lateral, anterior, and inferior LA walls with TTE.
After 3 months, a decrease in the SR of the LA anterior wall was observed (from 2.12 ± 0.22 to 1.66 ± 0.26, P < 0.045), while the LA lateral wall strain was found to be increased (from 0.708 ± 0.15 to 0.783 ± 0.159, P < 0.001). Moreover, simultaneously LA AEF was greater compared with baseline (from 31.0 ± 1.6 to 34.0 ± 1.6, P < 0.004). However, all these alterations reversed at 6 months.
Segmental LA function is altered transiently after percutaneous PFO closure with a septal occlude. The LA anterior wall SR decreases, while the lateral wall strain increases. The impact of these alterations needs further clarification.
Rheumatic heart disease (RHD) is common and remains a major cause of morbidity, particularly in developing countries. Its diagnosis relies on expertise-dependent echocardiographic studies. We evaluated the accuracy of briefly trained examiners in identifying RHD utilizing a hand-carried cardiac ultrasound (HCU) device.
Three medical students received 8 hours of training in cardiac ultrasound, focused on assessment of rheumatic valve injury and its complications, using a prototype of HCU device, OptiGo. The students, blinded to the patients' medical condition, performed an auscultation-based physical examination and a focused HCU study on volunteers and patients with known RHD. A standard echocardiography study was used to validate the results.
Each student performed a physical examination followed by an HCU study on 45 subjects (mean age 57 ± 14 years, 52% men), 14 of whom (31%) had rheumatic mitral valve injury. The students' averaged sensitivity for diagnosing RHD by HCU examination was 81%, while specificity was 95%. The interrater agreement (kappa) of the 3 students' HCU study and the standard echocardiography examination were between 0.55 and 0.88 (P < 0.01), and among the students themselves between 0.57 and 0.74 (P < 0.01), as students 1 and 2 had better results than student 3. Auscultation-based physical examination rendered low sensitivity (16%) for diagnosing rheumatic valve complications, namely mitral regurgitation and stenosis; however, it improved by 26% when students based their diagnosis on an HCU study.
The ability to detect rheumatic valve injury using a portable ultrasound device by operators who only received brief echocardiographic training is remarkably high. However, the diagnosis of RHD complications is only modest. This result highlights the utility of portable cardiac ultrasound devices operated by basically trained personnel as a valuable diagnostic tool for RHD.
Even though chronic pulmonary hypertension (cPH) and acute pulmonary embolism (aPE) increase pulmonary vascular resistance and result in right ventricular (RV) dilatation and systolic dysfunction; both conditions operate through drastically different mechanisms. Unfortunately, simple echocardiographic examination might be insufficient to distinguish both entities. This study attempted to determine which objective measures would be useful in differentiating aPE from cPH.
Standard measures of main RV as well as RV outflow tract (RVOT) size and systolic performance calculations were retrospectively measured from 15 patients with confirmed aPE by chest computed tomography and compared with similar data collected from the same number of age-matched patients with moderate (mcPH), severe (scPH), and patients without PH.
Although a positive McConnell sign was seen in 60% of aPE patients and in 17% of the cPH patients, all aPE had a profound reduction in RVOT systolic excursion when compared with cPH patients. Furthermore, maximal tricuspid annular plane systolic excursion, velocity time integral of the RVOT ejection signal, end-systolic or end-diastolic RV to left ventricle (LV) dimension ratio were not useful to distinguish aPE from any of the 2 forms of cPH.
This study demonstrated that measurement of RVOT systolic excursion not only is feasible but also extremely useful in identifying aPE and it is particularly helpful in differentiating it from patients with either mcPH or scPH. This variable might be useful to estimate the global impairment in RV contractility and acute hemodynamic derangement seen in aPE.
Congenital heart diseases (CHD) are responsible for substantial morbidity and mortality in neonates. The preliminary diagnosis often is made by noncardiologists. For this reason, there is a huge demand of training in echocardiography of CHD. This is difficult to achieve due to limited resources of specialized centers.
The goal of this study was to investigate the training effect of the echocardiography simulator EchoCom on trainee's ability to diagnose CHD.
We enrolled 10 residents for simulator-based training in echocardiography of CHD. All participants were instructed on the simulator's basic handling and had one hour to scan the first 9 datasets information (ventricular septal defect, atrial septal defect, atrioventricular septal defect, Tetralogy of Fallot, transposition of great arteries, congenital corrected transposition of great arteries, common arterial trunk, hypoplastic left heart syndrome, normal anatomy) and establish a diagnosis. No help was given except for support regarding simulator related issues. Afterward, 2 rounds of structured simulator based echocardiography training focused on echocardiographic anatomy, spatial orientation, standard views, and echocardiographic anatomy of different CHD followed. All participants completed a standardized questionnaire containing 10 multiple-choice (MC) questions focusing on basic theoretical knowledge in echocardiographic anatomy and common CHD.
Almost all of the residents invited from the affiliated children's hospital had little (20%) or no experience (80%) in echocardiography of CHD. Their Pretest and Posttest scores showed significant improvement for both, MC test and performance test, respectively.
Our study showed that simulator-based training in echocardiography in CHD could be very effective and may assist with training outside the scope of CHD.
Two-dimensional speckle tracking echocardiography (2DSTE) has recently been applied to evaluate left atrial (LA) function in addition to left ventricular (LV) function. However, whether 2DSTE can provide insight into LA-LV interaction related to an increase in LV pressure overload remains unknown.
One hundred five asymptomatic patients with hypertension were studied by conventional, pulsed and tissue Doppler, and 2DSTE. Hypertensive patients were classified into 2 groups according to the ratio of early diastolic to atrial systolic velocity (E/A) of transmitral flow: E/A ≥ 1 (n = 37) and E/A < 1 (n = 68). We used (E/peak early diastolic mitral annular motion velocity [e′])/peak systolic LA strain (S-LAs) and E/e′, as parameters of LA stiffness during ventricular systole and LV diastolic stiffness, respectively.
The peak early diastolic LV longitudinal strain rate, and peak early diastolic LA strain and strain rate were lower in the E/A < 1 group than in the E/A ≥ 1 group. The E/e′/S-LAs and E/e′ were greater in the E/A < 1 group. In the E/A < 1 group, systolic blood pressure (SBP) correlated with LV wall thickness parameters, A, e′, E/e′, peak early diastolic LV longitudinal strain rate, and E/e′/S-LAs. Multivariate regression analysis indicated that A, E/e′, and E/e′/S-LAs were defined as strong predictors related to SBP.
In patients with hypertension, an elevation in SBP leads to increased LA stiffness during ventricular systole and LV diastolic stiffness, in association with continued and further advanced LV diastolic dysfunction. 2DSTE is considered a sensitive tool for detecting abnormal LA-LV coupling related to an increased LV pressure overload.
We aimed to compare three-dimensional (3D) and two-dimensional (2D) echocardiography in the evaluation of patients with recent myocardial infarction (MI), using late-enhancement magnetic resonance imaging (LE-MRI) as a reference method. Echocardiography and LE-MRI were performed approximately 1 month after first-time MI in 58 patients. Echocardiography was also performed on 35 healthy controls. Left ventricular (LV) ejection fraction by 3D echocardiography (3D-LVEF), 3D wall-motion score (WMS), 2D-WMS, 3D speckle tracking–based longitudinal, circumferential, transmural and area strain, and 2D speckle tracking–based longitudinal strain (LS) were measured. The global correlations to infarct size by LE-MRI were significantly higher (P < 0.03) for 3D-WMS and 2D-WMS compared with 3D-LVEF and the 4 different measurements of 3D strain, and 2D global longitudinal strain (GLS) was more closely correlated to LE-MRI than 3D GLS (P < 0.03). The segmental correlations to infarct size by LE-MRI were also significantly higher (P < 0.04) for 3D-WMS, 2D-WMS, and 2D LS compared with the other indices. Three-dimensional WMS showed a sensitivity of 76% and a specificity of 72% for identification of LV infarct size >12%, and a sensitivity of 73% and a specificity of 95% for identification of segments with transmural infarct extension. Three-dimensional WMS and 2D gray-scale echocardiography showed the strongest correlations to LE-MRI. The tested 3D strain method suffers from low temporal and spatial resolution in 3D acquisitions and added diagnostic value could not be proven.
]]>Current guidelines do not recommend routine assessment of right atrial volume due to the lack of standardized data. Three-dimensional wall-motion tracking (3D-WMT) is a new technology that allows us to calculate volumes without any geometric assumptions. The aim of this study was to define the indexed reference values for two-dimensional echocardiography (2D-echo) and 3D-WMT in adult healthy population and to assess the intermethod, intra- and interobserver agreement.
Prospective study. Nonselected healthy subjects were enrolled. Every patient underwent a 2D-echo and a 3D-WMT examination. 2D-echo right atrial volume was obtained by using the area-length method (A-L) from four- and two-chamber view. 3D-echo volumes were assessed by 3D-WMT. Values were indexed by the patient's body surface area.
Sixty consecutive healthy subjects were enrolled. Mean age was 57 ± 12-years old and 27 patients (45%) were male. Average indexed right atrial volume obtained by 2D-echo and 3D-echo was 16.76 ± 8.15 mL/m2 and 19.05 ± 6.87 mL/m2, respectively. Univariate linear regression analysis between 2D-echo and 3D-echo right atrial volumes shows a weak correlation between right atrial volume obtained with 2D-echo compared with 3D-WMT (r = 0.29, CI 95% 0.029–0.66, P = 0.033). The agreement analysis shows a similar result (intraclass correlation coefficient [ICC] = 0.28). The intra- and interobserver agreement analysis showed a better agreement when using 3D-WMT.
This is the first study that reports the reference indexed right atrial volume values by means of 2D-echo and 3D-echo in healthy population. 3D-WMT is a feasible and reproducible method to determine right atrial volume.
The aim of our study was to evaluate atrial electromechanical delay (AEMD) and left atrial mechanical functions (LAMF) in the patients with secundum-type atrial septal defect (ASD).
We included 72 patients with secundum type ASD in the study group and 35 gender and age-matched healthy volunteers for the control group. Maximal, minimal, and presystolic LA volumes were measured by modified Simpson method and indexed to the body surface area (BSA). Inter-AEMD, right and left intra-AEMD were measured from the lateral and septal mitral annulus and tricuspid annulus using tissue Doppler imaging (TDI).
The age, gender, systolic and diastolic blood pressure, heart rate (HR), BSA, and body mass index (BMI) parameters were not significantly different between the groups. Left atrial active and total emptying fractions and conduit volumes were significantly lower in the patients with ASD compared with the control group (P = 0.006, P = 0.001, and P = 0.032, respectively). Total emptying volume was increased in patients with ASD (P = 0.021). Passive emptying volume and fraction and active emptying volumes were not different significantly between the groups (P > 0.05). The left intraatrial, right intraatrial, and inter-AEMDs were significantly longer in the ASD group (P = 0.032, P = 0.013, and P = 0.003, respectively).
The left atrial reservoir and contractile pump functions are reduced; the left intraatrial, right intraatrial, and inter-AEMDs are increased in the patients with ASD.
Thoracic aortic disease is a known cause of aortic dilatation and poses significant risk of aortic dissection and rupture. Serial assessment of aortic root dimensions is traditionally performed using echocardiography, which is limited with older age and following surgery, due to poor acoustic windows. Although diastolic measurements are utilized as standard practice in decision making of adult aortopathy, systolic diameters are utilized in pediatric practice. Three-dimensional steady-state free precision (3D-SSFP) has shown promise as an alternate method for providing accurate and reproducible aortic measurements. The agreement between proximal aorta measurements by diastolic 3D-SSFP and echocardiography (both systole and diastole) was examined in 40 subjects. The maximum inner diameters at aortic annulus, root and sinotubular junction demonstrated excellent agreement between 3D-SSFP and echocardiography for all the 3 levels. The best agreement was observed for diastolic root dimensions with a mean difference of +0.01 cm, limits of agreement being −0.26 to +0.28 cm. Three D-SSFP can be used interchangeably with echocardiography in the serial assessment of the aortic root size. Careful attention to obtain an imaging plane utilizing 3D multiplanar reformatting is critical to maximize the agreement between the two imaging modalities.
]]>The inner-half layer of the left ventricular (LV) wall is primarily affected by ischemia and increased LV afterload. We hypothesized that LV wall thickening of inner-half layer and coronary microvascular function are impaired in hypertensive patients, especially in those with electrocardiographic (ECG) strain, which is a marker of LV hypertrophy and adverse prognosis. Therefore, the aim of this study is to investigate the association of the ratio of inner- to outer-half layer of the LV myocardial deformation and coronary microvascular function with ECG strain in hypertensive patients.
We studied 98 hypertensive patients and 13 controls. Hypertensive patients were divided into 2 groups, with (S+) and without (S−) ECG strain. Coronary flow velocity reserve (CFVR) of the left anterior descending artery was evaluated using transthoracic echocardiography. Circumferential and radial strains of the LV wall were analyzed by two-dimensional echocardiographic speckle tracking method, and the inner- to outer-half layer ratio (in/out ratio) was assessed.
Coronary flow velocity reserve of S+ (2.06 ± 0.65) was significantly smaller than those in S− and controls (3.03 ± 0.65 and 3.38 ± 0.51, respectively). In/out ratio in both circumferential and radial strains were decreased as well as in S+ patients. Furthermore, in/out ratio was directly proportional to CFVR.
Hypertensive patients with ECG strain possessed severely impaired CFVR and inner-half myocardial deformation. Moreover, the more severe the LV hypertrophy progresses, the greater is the impairment of coronary microvascular and LV inner-half myocardial deformation. Thus, CFVR and in/out ratio are useful quantitative markers that can render sensitive assessment of physiological changes in hypertensive heart disease.
Congenital aortic stenosis (AS) is the most common obstructive left heart lesion in the young adult population and often complicated by aortic dilatation. Our objective was to evaluate accuracy of aortic imaging with transthoracic echocardiography (TTE) compared with cardiac magnetic resonance (CMR).
Aortic diameters were measured at 4 levels by CMR and TTE. Agreement and concordance were assessed by Pearson's correlation and Bland–Altman analysis.
Fifty-nine patients (age 33 ± 8 years; 66% male) with congenital AS and a bicuspid aortic valve (BAV) were included. Aortic diameters were generally smaller with TTE than with CMR. The best correlation was found at the level of the sinotubular junction (R2 = 0.78) with a bias of 1.46 mm (limits of agreement: −5.47 to +8.39 mm). In patients with an aortic aneurysm >40 mm (n = 29) the correlation and agreement between TTE and CMR were found to be less good when compared with patients with normal aortic diameters, especially at the level of the proximal ascending aorta. The correlation and agreement between both imaging modalities were better in patients with type 1 BAV compared with type 2 BAV. Intra- and interobserver variability was smaller with CMR (1.8–5.9%) compared with TTE (6.9–15.0%).
CMR was found to be superior to TTE for imaging of the aorta in patients with congenital AS, especially at the level of the proximal ascending aorta when an aortic aneurysm is present. Therefore, ideally CMR should be performed at least once to ensure an ascending aortic aneurysm is not missed.
There are conflicting theories regarding the accuracy of echocardiography for determining the value of epicardial fat thickness in cardiovascular risk assessment. The aim of this study was to determine the relationship.
A historical cohort study was conducted on 143 patients, 40 to 87 years old, admitted for coronary angiography. The patients underwent transthoracic echocardiography and measurement of epicardial fat thickness in parasternal long-axis view at end-systole for 3 cardiac cycles. Both procedures were performed within a week before performing coronary angiography.
Epicardial fat thickness was significantly correlated with the existence and severity of coronary artery disease (P-value <0.001). There was also a trend toward lower high-density lipoprotein in males with thicker epicardial fat.
Epicardial fat thickness equal to or more than 7 mm may identify an individual with higher probability of having coronary atherosclerosis.
The HeartMate II is the most frequently used left ventricular assist device (LVAD) in patients with end-stage heart failure. There is a paucity of data regarding its longitudinal cardiac effects, particularly that on diastole.
This retrospective study was an evaluation of echocardiograms preoperatively and at 3, 6, and 12 months postoperatively in patients with a HeartMate II. Measurements included left ventricle (LV) dimensions, ejection fraction (EF), right ventricle (RV) size and function, parameters of diastolic function, and an analysis of mitral regurgitation (MR), tricuspid regurgitation (TR), aortic insufficiency (AI), and aortic valve thickening.
Forty-seven patients were evaluated. LV dimensions decreased but EF, RV size, and RV function were unchanged. Right ventricular systolic pressure (RVSP) and diastolic parameters including mitral inflow E/A, deceleration time (DT), pulmonary vein inflow, left atrial size, and overall diastolic grade improved. LV relaxation measured by tissue Doppler (e') was unchanged and the E/e' ratio was also unchanged. Regarding valve function, MR decreased, TR was unchanged, and the aortic valve became increasingly thickened with increased AI severity.
The HeartMate II unloads the LV as shown by decreased LV size, decreased MR, reduced RVSP, and improved patterns of mitral inflow. However, neither systolic function nor diastolic relaxation improves in this cohort. RV size and function also remain unchanged. The aortic valve shows increased thickening and AI likely from valve leaflet fusion. These results provide detailed functional and hemodynamic information regarding the longitudinal effects of the HeartMate II.
Sickle cell anemia (SCA) is the most common inherited anemia. Although heart involvement in SCA is well-established, there is no data about changes of contraction synchrony in SCA. Therefore, we aimed to study the left ventricular contraction synchrony in SCA patients with narrow QRS and normal ejection fraction (EF).
Thirty-six patients with SCA and 37 age- and gender-matched control subjects were included in the study. Left ventricular dyssynchrony was investigated by color-coded tissue Doppler imaging.
The SCA patients had lower hemoglobin (Hb) and higher ferritin, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left ventricular mass index (LVMI), and pulmonary artery pressure. Peak A velocity, Dt, and E/E′ values were higher in the SCA group however, E/A ratio and average Em were higher in the control group. LV systolic dyssynchrony parameters including Ts-SD-12, Ts-12, Ts-SD-6, and Ts-6 were found to be higher in SCA group when compared with controls. In addition to that, the patients with ventricular dyssynchrony (a Ts-SD-12 > 34.4 msec) were higher in the SCA group than the control group (55.6% vs. 8.1%, P < 0.001). In the correlation analysis, systolic dyssynchrony parameters were found to be correlated with Hb, ferritin, LVMI, E/A, Dt, Em.
Our results revealed that in SCA patients with normal EF and narrow QRS, left ventricular systolic dyssynchrony was an early manifestation of heart involvement and might be coexisted with or preceding diastolic dysfunction.
Resting echocardiographic measures of cardiac function such as left ventricular ejection fraction correlate poorly with exercise capacity. Assessment during exercise using measures less dependent on hemodynamic loading conditions, such as tissue Doppler imaging (TDI), may more accurately characterize the relationship between cardiac function and exercise capacity.
One hundred one subjects with various cardiac diagnoses underwent exercise stress echocardiography with simultaneous cardiopulmonary gas exchange analysis. Standard two-dimensional, Doppler and spectral TDI parameters were assessed at both rest and peak exercise. Across all subjects the strongest relationship with peak oxygen uptake (pVO2) was with peak left ventricular systolic tissue velocity (S′) during exercise (r = 0.84, P < 0.001). The strength of the relationship was greater than that observed with any other common echocardiographic measure of systolic or diastolic cardiac function.
There is a very strong relationship between measurements of S′ during exercise and exercise capacity. The previously observed poor correlation with standard measures of systolic and diastolic cardiac function may be explained both by the load dependence of parameters such as ejection fraction and by reliance on resting as opposed to exercise assessment.
There are limited data on the effects of prolonged acute hypoxia on individual and global measures of biventricular function.
The aim of this study was to assess its effects on conventional and novel measures of biventricular function, including the recently defined E′/(A′×S′) (EAS) index, obtained using pulsed-wave tissue Doppler Imaging (PWTDI) and associated blood brain natriuretic peptide (BNP) levels.
In this study, 14 healthy subjects aged 30.5 years were assessed at baseline and at >150 minutes following hypobaric hypoxia (HH) to the equivalent altitude of 4800 m for a total of 180 minutes. The combined EAS index (E′/(A′ × S′)) was calculated at the mitral and tricuspid annulus using data from the peak systolic (S′) early (E′) and late (A′) diastolic filling.
It was seen that HH increased resting heart rate (63.4 ± 8.4 vs. 85.2 ± 10.2/min; P < 0.0001), cardiac output (4.6 ± 0.7 L/min vs. 6.1 ± 1.2 L/min; P < 0.0001), peak pulmonary artery systolic pressure (PASP) (26.3 ± 2.0 mmHg vs. 37.2 ± 6.3 mmHg; P < 0.0001), and reduced SpO2 (98.5 ± 1.1 vs. 72.9 ± 8.1%; P < 0.0001). There was a significant reduction in mitral (0.19 ± 0.06 vs. 0.11 ± 0.03; P < 0.0001) and tricuspid (0.12 ± 0.04 vs. 0.09 ± 0.03; P = 0.03) EAS indices, but no change in left or right ventricular myocardial performance (Tei) indices, global left ventricular (LV) longitudinal systolic strain, BNP levels, or estimated filling pressures (E/E′). Only reducing SpO2 remained as an independent predictor of PASP on multivariate analysis (overall R2 = 0.77; P < 0.0001). The right and LV EAS indices were significantly correlated (r = 0.45; 95% CI: 0.07–0.7; P = 0.02).
The conclusion from this study was that acute prolonged HH does not adversely affect resting global biventricular function and there is evidence of linked right and LV responses.
While left ventricular (LV) diastolic function (E/e′) is related to functional capacity in patients with atrial fibrillation (AF), the underlying mechanism is unclear. Right ventricular (RV) function is related to prognosis in various diseases, however, its relationship with LV diastolic function is not well-studied. We sought to examine the reliability of echocardiographic indices of RV function in AF, the relationship between LV diastolic function and RV function, and the relationship between RV function and 6MWT distance in ambulatory patients with AF.
We designed a retrospective study evaluating 52 veterans with AF and preserved LV ejection fraction (LVEF) who underwent echocardiography and 6MWT at scheduled visits throughout 1 year. We performed pairwise correlation to evaluate reproducibility of echocardiographic indices of RV function measured 1 week apart. Multiple regression was used to assess the association of indices of RV function to LV diastolic function and functional capacity.
Most RV function indices had good to excellent correlation between 2 visits 1 week apart (coefficient 0.50–0.81) with test-retest variations of <6%, except for tricuspid annular plane systolic excursion (TAPSE), which had a significant variation in 9%. TAPSE, RV S′ and RV e′ were significantly related to LV diastolic function after adjusting for RV systolic pressure. After further adjustment for comorbidities, only RV S′ and RV e′ remained significantly related to 6MWT.
RV tissue Doppler measurements (S′ and e′) had good reproducibility and were independently related to LV diastolic function and 6MWT in men with AF and preserved LVEF.
Little remains known about the role of overweight to promote progressive atrial and ventricular myocardial dysfunction. Aim of this study was to investigate the potential influence of overweight on left ventricular (LV) and atrial (LA) function, as assessed by speckle tracking strain analysis, in patients at low-to-moderate global cardiovascular risk.
Seventy patients presenting 1 or more cardiovascular risk factor, with preserved ejection fraction, were enrolled. Peak atrial longitudinal strain (PALS) and Peak ventricular longitudinal strain (PVLS) were calculated by averaging values observed in all LV or LA segments, in four- and two-chamber views (global PALS and global PVLS), using a commercially available semiautomated two-dimensional (2D) strain software.
Global PALS was similar in the 2 groups, while global PVLS was significantly lower in the overweight group as compared to normal weight (−17.2 ± 3.3 vs. −18.7 ± 2.8, P < 0.05). Univariate analysis of correlation showed a significantly correlation between global PALS and PVLS (r = −0.43, P < 0.01), as well as with E/A ratio (r = 0.40, P < 0.01) and with LV mass index (r = −0.34, P < 0.05). In multivariate linear regression analysis, these parameters were confirmed as independent predictors of PALS.
In subjects at low-to-moderate cardiovascular risk, overweight is a key determinant of the reduction of global LV longitudinal function as assessed by 2D strain.
Tissue Doppler imaging (TDI) of the mitral annulus has been proposed as an alternative for the identification of hypertrophic cardiomyopathy (HCM) genetically affected subjects without left ventricular hypertrophy (G+/LVH−). Unfortunately, conflicting results have been described in the literature, potentially caused by the angle-dependency of TDI. This study sought to assess abnormalities in mitral annular velocities in G+/LVH− subjects as detected by speckle tracking echocardiography (STE).
The study population consisted of 23 consecutive genotyped family members without major or minor criteria for the diagnosis of HCM (mean age 37 ± 13 years, 9 men) and 23 healthy volunteers (age 38 ± 12 years, 12 men) who prospectively underwent STE.
There were no significant differences in global peak systolic annular velocity (7.4 ± 1.2 vs. 7.1 ± 1.0 cm/sec) and early diastolic annular velocity (10.2 ± 2.5 vs. 11.3 ± 2.2 cm/sec) between G+/LVH− and control subjects. Global peak late diastolic annular velocity was higher in G+/LVH− subjects (8.1 ± 1.7 vs. 5.7 ± 1.1 cm/sec, P < 0.001). Regionally, this difference was seen in all 6 studied LV walls.
This STE study confirms our previous TDI observations on increased peak late diastolic annular velocities in G+/LVH− subjects. Because of the complete overlap in early diastolic annular velocities this parameter cannot be used in the genotypes we studied to differentiate genotype (+) from genotype (−) individuals.
Percutaneous transluminal septal myocardial ablation (PTSMA) is an alternative therapy for patients with hypertrophic obstructive cardiomyopathy (HOCM) that results in sustained improvement in the global diastolic dysfunction. Regional diastolic abnormalities and diastolic asynchrony are very common and closely related to global diastolic dysfunction. The aim of this study was to examine the effect of PTSMA on regional diastolic dysfunction and diastolic asynchrony in HOCM patients using speckle tracking echocardiography.
Strain rate curves were obtained for 18 different segments of the left ventricular (LV) myocardium in 30 HOCM patients 24 hours before and 1 year after PTSMA. The peak strain rate during the isovolumic relaxation period (SRIVR), the peak early diastolic strain rate (SRE), and the time from the onset of the QRS-wave to SRE (TSRE) were measured for each segment. The left atrial volume indexed to the body surface area (LAVI) was measured as a global diastolic index.
At 1 year after PTSMA, there was significant improvement of the global SRIVR (0.14 ± 0.06–0.22 ± 0.07%/sec, P < 0.001) and SRE (0.67 ± 0.24–0.82 ± 0.23%/sec, P = 0.001). The coefficient of variation in TSRE (CVTSRE) decreased significantly. The changes in the regional myocardial diastolic deformation and CVTSRE correlated well with the reduction in the LAVI.
Percutaneous transluminal septal myocardial ablation has a favorable effect on regional diastolic abnormalities and diastolic asynchrony, which may partly account for the persistent improvement in global LV diastolic function in HOCM patients after PTSMA.
The aim of this study was to evaluate left atrial deformations using speckle tracking echocardiography for predicting left atrial appendage (LAA) thrombus in patients with suspected cardioembolic stroke who were in normal sinus rhythm. A total of 153 ischemic stroke patients (89 males, 64 females) in sinus rhythm who were suspected of having cardioembolism were included in the study. The patients underwent conventional two-dimensional (2D) echocardiogram and 2D speckle tracking echocardiogram of the left atrium. Left atrial peak strain (LA-4C-RES) and left atrial precontraction strain (LA-4C-PUMP) were measured. Patients were divided into 2 groups according to the presence of thrombus in the LAA in transesophageal echocardiography. Both LA-4C-RES and LA-4C-PUMP values were found to be significantly lower in patients with LAA thrombus (11.8 ± 1.4% vs. 33 ± 12%, P < 0.001 and 5.8 ± 1.3% vs. 14.2 ± 5.3%, P < 0.001, respectively). A good inverse correlation was present between LA-4C-RES values and LAA morphologic parameters (with LAA area: r = −0.70, P < 0.001, with LAA length: r = −0.60, P < 0.001), and a good positive correlation was present with LAA emptying velocity with pulse Doppler (r = 0.74, P < 0.001). The area under the receiver-operating characteristic curve of the LA-4C-RES was 0.94 (0.90–0.98, P < 0.001), for the LA-4C-PUMP, the area was 0.92 (0.87–0.96, P < 0.001) to predict LAA thrombus. Left atrial deformation parameters measured by 2D speckle tracking method was found to predict impaired LAA functions and the presence of LAA thrombus in ischemic stroke patients with suspected cardioembolism, but who are in sinus rhythm.
]]>There is a suggestion that increased aortic stiffness can be the early manifestations of the atherosclerosis process and is related to decrease coronary flow after coronary stenting. We aimed to evaluate whether aortic stiffness could predict occurrence of in-stent restenosis (ISR) and its relation to coronary flow reserve (CFR) after coronary artery stenting.
The study population included 126 patients with single vessel coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) with bare-metal stenting and at least 12 months of follow-up. All patients underwent noninvasive aortic stiffness index (ASI) assessment before stenting and coronary flow assessment 1 month after stenting. Clinical ISR was observed in 29 (23%) patients, whereas 97 patients remained free of signs or symptoms of recurrent ischemia. ASI was significantly higher in patients with coronary artery disease versus control subjects, and it is significantly increased in patients with restenosis versus those without restenosis (P < 0.0001 and P < 0.001, respectively). There was a significant negative correlation between ASI and CFR (P = 0.0001). The ASI was significantly correlated with C-reactive protein (r = 0.395, P < 0.03). On univariate and multivariate analysis, ASI was the strongest predictor of restenosis (OR 6.8, 95% CI 2.6–13.5).
Increased aortic stiffness was an independent predictor of poststenting impaired coronary flow and occurrence of ISR in patients undergoing PCI. Evaluation of aortic stiffness may represent a useful screening tool to stratify patients according to future risk of restenosis.
Various left ventricular (LV) vortex parameters obtained during contrast echocardiography (CE) have been recently described. The aim of this study was to investigate their determinants and associations with conventional hemodynamic variables.
CE was performed and LV pressure was simultaneously measured during pharmacologic inotropic modulation in 8 mongrel dogs. Customized software was used to assess both vortex geometric parameters (vortex depth [VD], length [VL], width [VW], transverse position, and sphericity index [SI]) and pulsatility parameters (relative strength [RS], vortex relative strength [VRS], and vortex pulsation correlation [VPC]). The associations between each of these parameters and conventional indices representing LV systolic and diastolic function were analyzed.
VD and VW did not change significantly during pharmacologic modulation, whereas VL (P = 0.0034) and SI (P = 0.001) showed significant and progressive linear decreases from baseline during dobutamine infusion. Significant linear changes during positive and negative inotropic modulation were observed in all pulsatiliy parameters (P < 0.01 each). Geometric parameters were critically dependent on LV volume, with pulsatility parameters showing significant positive correlations with heart rate, systolic and diastolic blood pressure (DBP), dp/dtmax, early and late mitral inflow velocities, and peak systolic and diastolic annular velocities. In multivariate analysis, LV end-diastolic volume was a main determinant for VL (r = 0.29, P < 0.001) and VW (r = 0.65, P < 0.001), whereas dp/dtmax for pulsatility parameters (RS [r = 0.61, P < 0.001], VRS [r = 0.46, P < 0.001] and VPC [r = 0.62, P < 0.001]).
Geometric and pulsatility parameters differed in their association with LV geometry and conventional physiologic indices representing LV function. These differences should be considered in interpreting these variables.
Aortic stenosis (AS) is the most frequent valvular heart disease encountered in our daily practice. Although there are clear guidelines for severe AS management, cardiologists often have few treatment options for patients with moderate AS; however, there is higher mortality in this patient subgroup versus an age-matched population. The authors reviewed all of the studies on moderate AS, summarized the factors that increase disease progression and discussed an ideal trial design to prospectively evaluate AS progression factors using modern cardiology tools such as strain and magnetic resonance imaging.
]]>Patients presenting with acute chest pain and suspected acute coronary syndrome (ACS) who have nonobstructive coronary disease on angiography, but new regional wall motion abnormalities are often diagnosed with takotsubo cardiomyopathy (TTC). The cause of TTC is often physical or emotional stress, and this clinical syndrome occurs more often in women than men. When hemodynamically significant mitral regurgitation (MR) accompanies TTC, the mechanism must be carefully elucidated, as systolic anterior motion (SAM) of the mitral valve can cause significant MR and left ventricular outflow tract (LVOT) obstruction. These patients can be conservatively managed, with SAM-associated MR and LVOT obstruction resolving with medical therapy as TTC-associated left ventricular (LV) dysfunction resolves, as opposed to true ACS where further intervention for MR is often necessary. This case report describes 2 cases of TTC presenting with severe MR, who were initially thought to have ACS-associated MR caused by ischemia, but on further echocardiographic interrogation were found to have SAM-associated MR which resolved along with resolution of LV wall motion abnormalities on medical therapy by follow-up echocardiography.
]]>Takotsubo cardiomyopathy is a clinical disorder characterized by a transient dilatation and akynesis or dyskinesis of the left ventricular (LV) apex, mimicking an anterior wall acute myocardial infarction in the absence of significant coronary artery disease (CAD). It typically occurs during an episode of severe emotional or physical stress. Recent reports suggested the potential of dobutamine stress echocardiography (DSE) in inducing the aforementioned syndrome. The transient dysfunction of the LV does not fit any known coronary distribution. Furthermore, there is no obstructive CAD demonstrated at angiography to account for the observed dysfunction. Consequently, the pathophysiology of this syndrome is still undetermined. Here, we report a case of DSE-induced Takotsubo cardiomyopathy in which high-resolution intracoronary imaging was utilized to exclude possible vessel alterations to help provide potential mechanistic explanations for the development of this condition.
]]>A young patient underwent a screening electrocardiogram (EKG) that suggested apical hypertrophic cardiomyopathy. Serial investigation with echocardiography showed a well-defined hyperechogenic mass involving the interventricular septal. To better define the lesion extension three-dimensional (3D) echocardiography was done and it demonstrated a mass invading the septal myocardium, involving the major part of the muscular portion. The findings were highly suggestive of a cardiac fibroma. A cardiac magetic resonance image (MRI) was also compatible with this diagnosis. In our case, 3D echo showed a high accuracy, proving to be a useful tool to determine the anatomy of the lesion, complementary to MRI, guiding best management strategy.
]]>Isolated tricuspid valve disease is rare. We report the case of a 65-year-old female patient who presented with right heart failure. Initial echocardiographic evaluation revealed a giant right atrium (RA) with severe tricuspid inflow obstruction with regurgitation. A comprehensive two- and three-dimensional echocardiographic evaluation revealed a dysplastic tricuspid valve resulting in the inflow obstruction and regurgitation. Rheumatic and carcinoid etiologies were ruled out by relevant tests. It is very rare for dysplastic tricuspid valve to present in late adulthood. The classic echocardiographic findings are discussed followed by a brief review of the literature.
]]>Pulmonary agenesis is characterized by undeveloped pulmonary vessels, bronchi as well as lung parenchyma and is a rare congenital anomaly with unknown etiology. It is usually diagnosed during childhood. Nearly, one third of these patients have concomitant congenital heart diseases. While more than 50% of these patients die before the age of 5 years, some other patients may be asymptomatic throughout their life. On the other hand, common atrium, another rare congenital anomaly, is characterized by complete absence of the atrial septum and is usually accompanied by atrioventricular valve malformations. An 18-year-old male presented with concomitant pulmonary agenesis and common atrium and had not undergone surgery due to high risk for mortality.
]]>Congenital diaphragmatic hernia (CDH) diagnosed in adulthood is very uncommon. In this case report, we describe a case of postprandial syncope in a patient with CDH compressing right heart chambers.
Caseous calcification of the mitral annulus (caseoma) is a rare variant of mitral periannular calcification that should be included in the differential diagnosis of myocardial masses. We present a case of huge mitral annular caseoma. This case illustrates the complementary role of different imaging modalities.
We report the case of a 64-year-old woman with myasthenia gravis, dyspnea, and pericardial effusion. Echocardiography showed a paraaortic mass, confirmed at computed tomography scan, which was later diagnosed as a thymoma after surgical excision.
We report a case of acute mitral regurgitation due to a temporary distortion of the mitral valve apparatus during apical transcatheter aortic valve implantation (TAVI). A few minutes after penetrating the apex, the patient developed severe hypotension and cardiac arrest. A hemodynamic support with femoral–femoral extracorporeal circulation was immediately installed. Transesophageal echocardiography (TEE) revealed that the guidewire interfered with the subvalvular mitral apparatus generating severe acute mitral regurgitation. The patient's condition improved immediately after guidewire removal and there was no residual mitral regurgitation. This case clearly shows the importance and the usefulness of performing a thorough and complete TEE monitoring to prevent and identify complications.
We herein report a case of large right atrial thrombus at the junction of inferior vena cava and right atrium using multimodality imaging. When a right-sided cardiac mass is encountered, it is important to clarify the type of the mass. Atrial myxoma, thrombus, vegetation, metastatic tumors, and primary benign or malignant tumors should be considered in the differential diagnoses of intraatrial masses. However, it is usually hard to make an accurate diagnosis before surgery.