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  • Unidimensional Longitudinal Strain: A Simple Approach for the Assessment of Longitudinal Myocardial Deformation by Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-21
    Matthias Aurich, Patrick Fuchs, Matthias Müller-Hennessen, Lorenz Uhlmann, Matthias Niemers, Sebastian Greiner, Tobias Täger, Kristof Hirschberg, Philipp Ehlermann, Benjamin Meder, Lutz Frankenstein, Evangelos Giannitsis, Hugo A. Katus, Derliz Mereles

    Background Impaired left ventricular (LV) longitudinal function (LF) is a known predictor of cardiac events in patients with heart failure, but two-dimensional strain imaging, the reference method to measure myocardial deformation, is not always feasible or available. Therefore, reliable and reproducible alternatives are needed. The aim of the present study was to evaluate unidimensional longitudinal strain (ULS) as a simple echocardiographic parameter for the assessment of LV LF. Methods Two hundred two patients with dilated cardiomyopathy who had their first presentation in the authors' cardiology department, as well as the same number of age- and gender-matched control subjects, were prospectively included in this study. ULS was compared with global longitudinal strain (GLS), the current gold standard for LV LF assessment by echocardiography. Uni- and multivariate Cox regression analyses were conducted to evaluate the prognostic value of ULS. Results LV LF was higher in the control group compared with patients: GLS −19.5 ± 1.7% versus −12.6 ± 4.8% and ULS −16.3 ± 1.5% versus −10.2 ± 3.9% (P < .001 for each). Correlation between ULS and GLS was excellent (r = 0.94), while Bland-Altman plots revealed lower values for ULS (bias −2.76%, limits of agreement ±3.31%). During a mean follow-up time of 39 months, the combined end point of cardiovascular death or hospitalization for acute cardiac decompensation was reached by 28 patients (13.9%). GLS (hazard ratio, 1.21; 95% CI, 1.10–1.34; P < .001) and ULS (hazard ratio, 1.24; 95% CI, 1.12–1.39; P < .001) had comparable prognostic impact on patient outcomes. Conclusions ULS might be an alternative echocardiographic method for the assessment of LV LF, with similar diagnostic and prognostic value compared with GLS.

    更新日期:2018-02-21
  • Morphologic Analysis of the Normal Right Ventricle Using Three-Dimensional Echocardiography–Derived Curvature Indices
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-21
    Karima Addetia, Francesco Maffessanti, Denisa Muraru, Amita Singh, Elena Surkova, Victor Mor-Avi, Luigi P. Badano, Roberto M. Lang

    Background Right ventricular (RV) remodeling involves changes in size, wall thickness, function, and shape. Previous studies have suggested that regional curvature indices (rCI) may be useful for RV shape analysis. The aim of this study was to establish normal three-dimensional echocardiographic values of rCI in a large group of healthy subjects to facilitate future three-dimensional echocardiographic study of adverse RV remodeling. Methods RV endocardial surfaces were reconstructed at end-diastole and end-systole in 245 healthy subjects (mean age, 42 ± 12 years) and analyzed using custom software to calculate mean curvature in six regions: RV inflow tract (RVIT) and RV outflow tract, apex, and body (both divided into free wall and septal regions). Associations with age and gender were studied. Results The apical free wall was convex, while the septum (apex and body) was more concave than the body free wall. Septal curvature did not change significantly from end-diastole to end-systole. The RV outflow tract and RVIT became flatter from end-diastole to end-systole. In keeping with the “bellows-like” action of RV contraction, the body free wall became flatter, while the apex free wall changed to a more convex surface. There were no intergender differences in rCI. In older subjects (≥55 years of age), the RV free wall and RV outflow tract were flatter, and from end-diastole to end-systole, the RVIT became less flattened and the apex less pointed. These changes suggest that the right ventricle is stiffer in older subjects, with less dynamic contraction of the RVIT and less bellows-like movement. Conclusions This study established normal three-dimensional echocardiographic values for RV rCI, which are needed to further study RV diastolic dysfunction and remodeling with disease.

    更新日期:2018-02-21
  • Relationship Between Proximal Aorta Morphology and Progression Rate of Aortic Stenosis
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-16
    Romain Capoulade, Jonathan G. Teoh, Philipp E. Bartko, Eliza Teo, Jan-Erik Scholtz, Lionel Tastet, Mylene Shen, Christos G. Mihos, Yong H. Park, Julio Garcia, Eric Larose, Eric M. Isselbacher, Thoralf M. Sundt, Thomas E. MacGillivray, Serguei Melnitchouk, Brian B. Ghoshhajra, Philippe Pibarot, Judy Hung

    Background The aim of this study was to examine the association between abnormal morphology of the proximal aorta and aortic stenosis (AS) progression rate. The main hypothesis was that morphologic changes of the proximal aorta, such as effacement of the sinotubular junction (STJ), result in increased biomechanical stresses and contribute to calcification and progression of AS. Methods Between 2010 and 2012, 426 patients with mild to moderate AS were included in this study. Proximal aortic dimensions were measured at three different levels (i.e., sinus of Valsalva, STJ, and ascending aorta), and sinuses of Valsalva/STJ and ascending aorta/STJ ratios were used to determine degree of aortic deformity. AS progression rate was assessed by annualized increase in mean gradient (median follow-up time, 3.1 years; interquartile range, 2.6–3.9 years). The degree of aortic flow turbulence was examined in 18 matched patients with and without STJ effacement using cardiac magnetic resonance phase-contrast imaging. Results Patients' mean age was 71 ± 13 years, and 64% were men. Patients with low ratios had greater AS progression (P < .05). After comprehensive adjustment, sinuses of Valsalva/STJ (P = .025) and ascending aorta/STJ (P = .027) ratios were independently associated with greater AS progression rate. Compared with patients without STJ effacement, those with effacement of the STJ had higher degrees of aortic flow turbulence (24.4% vs 17.2%, P = .038). Conclusions Effacement of the STJ is independently associated with greater AS progression, regardless of arterial hemodynamics, aortic valve phenotype, or baseline AS severity. Patients with abnormal proximal aortic geometry had disturbed aortic flow patterns. These findings suggest an interrelation between proximal aorta morphology and stenosis progression.

    更新日期:2018-02-16
  • Utility of Left Atrial Expansion Index and Stroke Volume in Management of Chronic Systolic Heart Failure
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-14
    Shih-Hung Hsiao, Shih-Kai Lin, Yi-Ran Chiou, Chin-Chang Cheng, Hwong-Ru Hwang, Kuan-Rau Chiou

    Background Titration of evidence-based medications, important for treating heart failure (HF), is often underdosed by symptom-guided treatment. The aim of this study was to investigate, using echocardiographic parameters, stroke volume and left ventricular (LV) filling pressure to guide up-titration of medications, increasing prognostic benefits. Methods A total of 765 patients with chronic HF and severely reduced LV ejection fractions (<35%), referred from 2008 to 2016, were prospectively studied. Echocardiographic guidance was performed in 149 patients. LV filling pressure was assessed by left atrial expansion index, and stroke volume was estimated from diameter and time-velocity integral in the LV outflow tract. Up-titration of evidence-based medications and adjustment for side effects or worsening clinical conditions according to those parameters were performed. Propensity score matching was used to match pairs of patients with (n = 110) or without (n = 110) echocardiographic guidance. End points were 4-year frequencies of HF hospitalization and all-cause mortality. Results During a mean follow-up time of 4.1 years, rates of adverse events were 58 (52.7%) with no echocardiographic guidance and 36 (32.7%) with echocardiographic guidance (P < .0001). Echocardiography provided effective guidance to reduce prescribing frequency and dose of diuretics and to promote evidence-based medication prescription. It reduced HF rehospitalization and all-cause mortality. By multivariate analysis, prognostic improvement was associated with up-titration of medications with echocardiographic guidance. Conclusions There was a statistically significant difference in long-term prognosis between propensity score–matched pairs of patients with chronic severe HF with and without echocardiographic guidance. These findings need further validation in large prospective clinical trials.

    更新日期:2018-02-14
  • Rest and Stress Longitudinal Systolic Left Ventricular Mechanics in Hypertrophic Cardiomyopathy: Implications for Prognostication
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-14
    Iraklis Pozios, Aurelio Pinheiro, Celia Corona-Villalobos, Lars L. Sorensen, Zeina Dardari, Hong-yun Liu, Kenneth Cresswell, Susan Phillip, David A. Bluemke, Stefan L. Zimmerman, M. Roselle Abraham, Theodore P. Abraham

    Background Exercise intolerance is the most common symptom in hypertrophic cardiomyopathy (HCM). We examined whether inability to augment myocardial mechanics during exercise would influence functional performance and clinical outcomes in HCM. Methods Ninety-five HCM patients (32 nonobstructive, 32 labile-obstructive, 31 obstructive) and 26 controls of similar age and gender distribution were recruited prospectively. They underwent rest and treadmill stress strain echocardiography, and 61 of them underwent magnetic resonance imaging. Mechanical reserve (MRES) was defined as percent change in systolic strain rate (SR) immediately postexercise. Results Global strain and SR were significantly lower in HCM patients at rest (strain: nonobstructive, −15.6 ± 3.0; labile-obstructive, −15.9 ± 3.0; obstructive, −13.8 ± 2.9; control, −17.7% ± 2.1%, P < .001; SR: nonobstructive, −0.92 ± 0.20; labile−obstructive, −0.94 ± 0.17; obstructive, −0.85 ± 0.18; control, −1.04 ± 0.14 s−1, P = .002); and immediately postexercise (strain: nonobstructive, −15.6 ± 3.0; labile-obstructive, −17.6 ± 3.6; obstructive, −15.6 ± 3.6; control, −19.2 ± 3.1%; P = .001; SR: nonobstructive, −1.41 ± 0.37; labile-obstructive, −1.64 ± 0.38; obstructive, −1.32 ± 0.29; control, −1.82 ± 0.29 s−1, P < .001). MRES was lower in nonobstructive and obstructive compared with labile-obstructive and controls (51% ± 29%, 54% ± 31%, 78% ± 38%, 77% ± 30%, P = .001, respectively). Postexercise SR and MRES were associated with exercise capacity (r = 0.47 and 0.42, P < .001 both, respectively). When adjusted for age, gender, body mass index, E/e’, and resting peak instantaneous systolic gradient, postexercise SR best predicted exercise capacity (r = 0.74, P = .003). Postexercise SR was correlated with extent of late gadolinium enhancement (r = 0.34, P = .03). By Cox regression, exercise SR and MRES predicted ventricular tachycardia/ventricular fibrillation (VT/VF) even after adjustment for age, gender, family history of sudden cardiac death, septum ≥ 3 cm and abnormal blood pressure response (P = .04 and P = .046, respectively). Conclusions Nonobstructive and obstructive patients have reduced MRES compared with labile-obstructive and controls. Postexercise SR correlates with LGE and exercise capacity. Exercise SR and MRES predict VT/VF.

    更新日期:2018-02-14
  • Contrast-Enhanced Echocardiography Has the Greatest Impact in Patients with Reduced Ejection Fractions
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-10-27
    Hang Zhao, Rupal O'Quinn, Marietta Ambrose, Dinesh Jagasia, Bonnie Ky, Joyce Wald, Victor A. Ferrari, James N. Kirkpatrick, Yuchi Han

    Background Contrast-enhanced echocardiography (CE) helps to improve image quality in patients with suboptimal acoustic windows. Despite current recommendations, contrast use remains low. The aim of this study was to identify populations that would benefit more from contrast use. Methods A total of 176 subjects (137 men; mean age, 60.8 ± 13.7 years) with technically difficult transthoracic echocardiographic studies who received clinically indicated intravenous contrast were prospectively studied. The impact on clinical decision making (including alterations in medical therapy, referral, imaging, or clinical procedures) was evaluated. Results The use of CE enabled biplane left ventricular (LV) ejection fraction measurement in 97.2% of studies and the interpretation of regional wall motion in 95% of studies. CE allowed definitive assessment of the presence or absence of LV thrombus in 99% of the cases. In the 174 patients whose ordering physicians could be reached at the time of image interpretation, changes in management occurred in 51% of subjects. There was no difference in the proportion of management changes between inpatients and outpatients (60.0% vs 48.1%, P = .225). Subjects with heart failure, cardiomyopathy, and arrhythmia had a higher proportion of changes (61.4% vs 44.2% [P = .031], 62.5% vs 45.0% [P = .028], and 72.0% vs 47.7% [P = .030], respectively). The proportion of management change after CE increased as pre-CE estimated ejection fraction decreased. Logistic regression showed that pre-CE estimated LV ejection fraction < 50% was the only significant predictor of change of management after contrast (P = .004). Conclusions The use of CE has a significant impact on clinical decision making in patients with suboptimal acoustic windows, especially in those with depressed pre-CE LV ejection fractions.

    更新日期:2018-02-07
  • ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-10-20
    , John U. Doherty, Smadar Kort, Roxana Mehran, Paul Schoenhagen, Prem Soman, , Greg J. Dehmer, John U. Doherty, Paul Schoenhagen, Zahid Amin, Thomas M. Bashore, Andrew Boyle, Dennis A. Calnon, Blase Carabello, Manuel D. Cerqueira, John Conte, Milind Desai, Joseph M. Allen

    Abstract This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

    更新日期:2018-02-07
  • Transcatheter Tricuspid Valve-in-Valve Intervention for Degenerative Bioprosthetic Tricuspid Valve Disease
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-08-23
    Fabien Praz, Isaac George, Susheel Kodali, Konstantinos P. Koulogiannis, Linda D. Gillam, Mary Z. Bechis, David Rubenson, Wei Li, Alison Duncan

    Isolated reoperative tricuspid valve replacement is one of the highest risk operations classified in the Society of Thoracic Surgeons registry, particularly in the setting of preexisting right ventricular dysfunction. Transcatheter tricuspid valve-in-valve implantation represents an attractive alternative to redo surgery in patients with tricuspid bioprosthetic valve degeneration who are considered high-risk or unsuitable surgical candidates. In this review article, the authors discuss the emergence of transcatheter tricuspid valve-in-valve therapy, preprocedural echocardiographic assessment of tricuspid bioprosthetic valve dysfunction, periprocedural imaging required for tricuspid valve-in-valve implantation, and postprocedural assessment of tricuspid transcatheter device function.

    更新日期:2018-02-07
  • Mitral Effective Regurgitant Orifice Area Predicts Pulmonary Artery Pressure Level in Patients with Aortic Valve Stenosis
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-01
    Giovanni Benfari, Stefano Nistri, Pompilio Faggiano, Marie-Annick Clavel, Caterina Maffeis, Maurice Enriquez-Sarano, Corrado Vassanelli, Andrea Rossi

    Background Mitral regurgitation (MR) and elevated pulmonary artery pressure are common findings in patients with aortic valve stenosis (AS). The pathophysiologic role of quantitatively defined MR as a determinant of pulmonary hypertension (PH) is incompletely characterized across the whole spectrum of AS degrees. The purpose of the study was to investigate whether the quantification of MR reveals a link to PH in patients with AS. Methods Consecutive patients undergoing comprehensive echocardiography and presenting peak aortic velocity ≥ 2.5 m/sec were prospectively enrolled. Effective regurgitant orifice area (ERO) and regurgitant volume were obtained using the proximal isovelocity surface area method. Systolic pulmonary artery pressure was calculated by adding right atrial pressure to the tricuspid regurgitation pressure gradient. Results A total of 642 patients were enrolled between 2008 and 2013 (mean age, 79 ± 11 years; mean ejection fraction, 62 ± 10%; mean aortic valve area, 1.09 ± 0.39 cm2); MR was present in 187 (29%). Of note, 154 of 187 patients (82%) showed ERO < 0.20 cm2. ERO and regurgitant volume had the most significant associations with systolic pulmonary artery pressure (R2 = 0.30 and R2 = 0.35, respectively, P < .0001). This relationship persisted after multivariate adjustment and in the subgroups of patients with severe AS or reduced ejection fraction (P < .0001). For each 0.10-cm2 increase, the odds ratio for PH was 3.56 (95% CI, 2.65–4.86; P < .0001). Conclusions In patients with MR and a wide range of AS severity, ERO is independently associated with PH. Also, the role of MR quantification appears stronger than other continuous variables commonly associated with left ventricular diastolic dysfunction, such as E/e′ ratio and left atrial volume.

    更新日期:2018-02-02
  • Echocardiography Core Laboratory Reproducibility of Cardiac Safety Assessments in Cardio-Oncology
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-02
    Michel G. Khouri, Bonnie Ky, Gary Dunn, Ted Plappert, Virginia Englefield, Dawn Rabineau, Eric Yow, Huiman X. Barnhart, Martin St. John Sutton, Pamela S. Douglas

    Background As the potential for cancer therapy–related cardiac dysfunction is increasingly recognized, there is a need for the standardization of echocardiographic measurements and cut points to guide treatment. The aim of this study was to determine the reproducibility of cardiac safety assessments across two academic echocardiography core laboratories (ECLs) at the University of Pennsylvania and the Duke Clinical Research Institute. Methods To harmonize the application of guideline-recommended measurement conventions, the ECLs conducted multiple training sessions to align measurement practices for traditional and emerging assessments of left ventricular (LV) function. Subsequently, 25 echocardiograms taken from patients with breast cancer treated with doxorubicin with or without trastuzumab were independently analyzed by each laboratory. Agreement was determined by the proportion (coverage probability [CP]) of all pairwise comparisons between readers that were within a prespecified minimum acceptable difference. Persistent differences in measurement techniques between laboratories triggered retraining and reassessment of reproducibility. Results There was robust reproducibility within each ECL but differences between ECLs on calculated LV ejection fraction and mitral inflow velocities (all CPs < 0.80); four-chamber global longitudinal strain bordered acceptable reproducibility (CP = 0.805). Calculated LV ejection fraction and four-chamber global longitudinal strain were sensitive to small but systematic interlaboratory differences in endocardial border definition that influenced measured LV volumes and the speckle-tracking region of interest, respectively. On repeat analyses, reproducibility for mitral velocities (CP = 0.940–0.990) was improved after incorporating multiple-beat measurements and homogeneous image selection. Reproducibility for four-chamber global longitudinal strain was unchanged after efforts to develop consensus between ECLs on endocardial border determinations were limited primarily by a lack of established reference standards. Conclusions High-quality quantitative echocardiographic research is feasible but requires a commitment to reproducibility, adherence to guideline recommendations, and the time, care, and attention to detail to establish agreement on measurement conventions. These findings have important implications for research design and clinical care.

    更新日期:2018-02-02
  • Clinical Significance of Ejection Dynamics Parameters in Patients with Aortic Stenosis: An Outcome Study
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-01-04
    Anne Ringle Griguer, Christophe Tribouilloy, Ariane Truffier, Anne-Laure Castel, François Delelis, Franck Levy, André Vincentelli, Yohann Bohbot, Sylvestre Maréchaux

    Background Ejection dynamics parameters are useful in assessing prosthetic valve obstruction, but very limited data are available in the setting of native aortic stenosis (AS). The aim of this study was to evaluate and compare the prognostic value of acceleration time (AT) and the ratio of AT to ejection time (ET) in patients with AS. Methods AT and AT/ET were prospectively measured in 456 patients with AS (aortic valve area < 1.3 cm2; mean aortic valve area, 0.85 ± 0.24 cm2). The relationships between AT/ET, AT, and mortality during follow-up were studied. Results During a median follow-up period of 35 months (interquartile range, 33–37 months), 124 patients died. After adjustment for variables of prognostic importance, including mean pressure gradient, stroke volume index, and aortic valve replacement as a time-dependent covariate, patients in the highest tertiles of both AT/ET (>0.36) and AT (>112 msec) were at high risk for overall mortality (adjusted hazard ratios, 2.44 [95% CI, 1.46–4.08; P = .001] and 1.78 [95% CI, 1.06–2.98; P = .029], respectively) compared with those in the lowest tertiles of AT/ET and AT, while survival was similar for the other tertiles (P = NS for all). Compared with patients with AT/ET ≤ 0.36, an increased risk for overall mortality was observed in patients with AT/ET > 0.36 (adjusted hazard ratio, 2.51; 95% CI, 1.66–3.78; P < .0001), while the risk for mortality was not significantly increased in patients with AT > 112 msec compared with those with AT ≤ 112 msec. Adding AT/ET > 0.36 to a multivariate model including classical variables of prognostic importance, including mean pressure gradient and stroke volume index, improved predictive performance in terms of overall mortality, with improved global model fit, reclassification, and better discrimination. Conclusions Among ejection dynamics parameters in patients with AS, AT/ET is strongly associated with excess risk for death during follow-up. AT/ET should be considered in the multiparametric echocardiographic prognostic assessment of patients with AS in clinical practice.

    更新日期:2018-01-04
  • Altered Left Ventricular Geometry and Torsional Mechanics in High Altitude-Induced Pulmonary Hypertension: A Three-Dimensional Echocardiographic Study
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-01-04
    Bart W. De Boeck, Aurel Toma, Stephanie Kiencke, Christoph Dehnert, Stefanie Zügel, Christoph Siebenmann, Katja Auinger, Peter T. Buser, Marco Maggiorini, Beat A. Kaufmann

    Background Changes in left ventricular (LV) torsion have been related to LV geometry in patients with concomitant long-standing myocardial disease or pulmonary hypertension (PH). We evaluated the effect of acute high altitude-induced isolated PH on LV geometry, volumes, systolic function, and torsional mechanics. Methods Twenty-three volunteers were prospectively studied at low altitude and after the second (D3) and third night (D4) at high altitude (4,559 m). LV ejection fraction, multidirectional strains and torsion, LV volumes, sphericity, and eccentricity were derived by speckle-tracking on three-dimensional echocardiographic data sets. Pulmonary pressure was estimated from the transtricuspid pressure gradient (TRPG), LV preload from end-diastolic LV volume, and transmitral over mitral annular E velocity (E/e′). Results At high altitude, oxygen saturation decreased by 15%–20%, heart rate and cardiac index increased by 15%–20%, and TRPG increased from 21 ± 2 to 37 ± 9 mm Hg (P < .01). LV volumes, preload, ejection fraction, multidirectional strains, and sphericity remained unaffected, but diastolic (1.04 ± 0.07 to 1.09 ± 0.09 on D3/D4, P < .05) and systolic (1.00 ± 0.06 to 1.08 ± 0.1 [D3] and 1.06 ± 0.07 [D4], P < .05) eccentricity slightly increased, indicating mild septal flattening. LV torsion decreased from 2.14 ± 0.85 to 1.34 ± 0.68 (P < .05) and 1.65 ± 0.54 (P = .08) degrees/cm on D3/D4, respectively. Changes in torsion showed a weak inverse relationship to changes in systolic (r = −0.369, P = .013) and diastolic (r = −0.329, P = .032) eccentricity but not to changes in TRPG, heart rate or preload. Conclusions High-altitude exposure was associated with mild septal flattening of the LV and reduced ventricular torsion at unchanged global LV function and preload, suggesting a relation between LV geometry and torsional mechanics.

    更新日期:2018-01-04
  • Clinical Utility of Left Atrial Strain in Children in the Acute Phase of Kawasaki Disease
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-01-03
    Soo Jung Kang, Yoo Won Kwon, Seo Jung Hwang, Hyo Jin Kim, Bo Kyeong Jin, Dong Keon Yon

    Background We aimed to evaluate the diagnostic utility of peak left atrial longitudinal strain (PALS) during left ventricular (LV) systole to differentiate children in the acute phase of Kawasaki disease (aKD) from controls. We also aimed to compare the diagnostic utility of PALS with those of conventional echocardiographic indices of diastolic function. Methods Retrospectively measured PALS, LV longitudinal peak systolic strain, and strain rate obtained via velocity vector imaging were compared in a derivation cohort comprising 95 aKD and 67 controls. The utility of PALS in differentiating aKD from controls was compared with those of E/E′, E/A, and maximum left atrial volume index (LAVImax). Derived cutoffs from receiver operating characteristic curves were validated in a separate validation cohort comprising 37 aKD and 19 controls. Results In the derivation cohort, PALS was significantly decreased in aKD as compared with in controls. For differentiating aKD from controls, PALS outperformed E/E′, E/A, and LAVImax. However, cutoffs of PALS (≤40% and ≤39%, before and after adjusting for the presence of significant mitral regurgitation and LV systolic dysfunction, respectively), like those of E/E′, E/A, and LAVImax, showed low sensitivity and poor discriminative ability for differentiating aKD from controls. In the validation cohort, for differentiating aKD from controls, both cutoffs of PALS showed low sensitivity, like those of E/E′, E/A, and LAVImax. Conclusion In aKD, impaired left atrial reservoir function could be detected as decreased PALS. For differentiating aKD from controls, PALS outperforms E/E′, E/A, and LAVImax. However, like E/E′, E/A, and LAVImax, PALS as a single parameter is limited in its clinical utility to differentiate aKD from controls because of its low sensitivity and poor discriminative ability.

    更新日期:2018-01-03
  • Right Ventricular Structure and Function in the Veteran Ultramarathon Runner: Is There Evidence for Chronic Maladaptation?
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-01-03
    Oliver Rothwell, Keith George, John Somauroo, Rachel Lord, Mike Stembridge, Rob Shave, Martin D. Hoffman, Mathew Wilson, Euan Ashley, Francois Haddad, Thijs M.H. Eijsvogels, David Oxborough

    Background It has been proposed that chronic exposure to prolonged strenuous exercise may result in maladaptation of the right ventricle (RV). The of this study aim was to establish RV structure and function, including septal insertion points, using conventional echocardiography and myocardial strain (ε) imaging in a veteran population of ultramarathon runners (UR) and age- and sex-matched controls. Methods A retrospective study design provided 40 UR (>35 years old; mean ± SD training experience, 18 ± 12 years) and 24 sedentary controls who had previously undergone conventional two-dimensional, tissue Doppler and speckle-tracking echocardiography to measure RV size and function. Peak RV ε and strain rate (SR) were assessed from the base, mid, and apical lateral wall. SR were assessed during systole (SRs'), early diastole (SRe′) and late diastole (SRa′). Regional assessment of RV insertion points was made at the basal inferoseptum and apical septum using left ventricular (LV) longitudinal ε and at the anteroseptum and inferoseptum using LV circumferential and radial ε. Results All structural indices of RV size were significantly larger in UR. RV regional and global peak ε were not different between groups, whereas basal RV SR was significantly lower in UR. UR had significantly higher peak LV circumferential ε (anteroseptum, −26% ± 8% vs −21% ± 6%; inferoseptum, −25% ± 6% vs −16% ± 9%) and higher peak LV longitudinal ε (apical septum, −28% ± 7% vs −22% ± 4%) compared with controls. There was regional heterogeneity in UR that was not observed in controls with significantly lower longitudinal ε at the basal inferoseptal insertion point when compared with the global ε (−19% ± 2% vs −22% ± 4%). Conclusions Myocardial ε imaging highlights no overt maladaptation in this cohort of veteran UR, although lower insertion point ε, compared with global ε, in UR may warrant further investigation.

    更新日期:2018-01-03
  • Tricuspid Valve Adaptation during the First Interstage Period in Hypoplastic Left Heart Syndrome
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-29
    Timothy Colen, Shelby Kutty, Richard B. Thompson, Edythe Tham, Andrew S. Mackie, Ling Li, Dongngan T. Truong, Michiko Maruyama, Jeffrey F. Smallhorn, Nee Scze Khoo

    Background Tricuspid regurgitation (TR) is an important risk factor for morbidity and mortality in hypoplastic left heart syndrome (HLHS), yet the evolution of tricuspid valve (TV) dysfunction in HLHS is poorly understood. This study sought to examine changes in TV function in HLHS between the first two stages of surgical palliation and to determine the mechanism of TR at the time of stage two surgery—bidirectional cavopulmonary anastomosis (BCPA). Methods We prospectively investigated 44 infants at two time points—prior to Norwood-Sano (T1 - median age 5.4 days) and prior to BCPA (T2 - median age 4.7 months) using two-dimensional (2DE) and three-dimensional echocardiography (3DE). Right ventricular (RV) size, function and shape was assessed with 2DE. Extracted spatial coordinates from 3DE were used to calculate TV leaflet and annular area, tethering and prolapse volumes, bending angle, and coaptation index. TR was graded qualitatively, and 2D and 3D vena contracta (VC) were measured. Results The cohort from T1 to T2 had increased indexed leaflet and annular area (P < .0001) and tethering volume (P < .0001), with no change in coaptation. Significant TR was present in 14 infants (32%) at T2 and was associated with greater leaflet (P = .02) and annular areas (P = .002) and greater prolapse volume (P = .008), but not tethering volume or reduced coaptation. At latest follow-up (median 23 months), 13 patients died or required transplantation. Only 3DE VC at T2 was associated with death or transplantation. Conclusions The TV in HLHS adapts to interstage stressors (increased preload and afterload) by increasing leaflet size to maintain adequate leaflet coaptation. Significant TR at T2 was associated with greater leaflet size and prolapse. This may represent TV maladaptation from an excessive response in leaflet expansion to stressors.

    更新日期:2017-12-31
  • Pulsed-Wave Doppler Recordings in the Proximal Descending Aorta in Patients with Chronic Aortic Regurgitation: Insights from Cardiovascular Magnetic Resonance
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-29
    Odd Bech-Hanssen, Christian L. Polte, Frida Svensson, Åse A. Johnsson, Kerstin M. Lagerstrand, Ulf Cederbom, Sinsia A. Gao

    Background The pulsed-wave Doppler recording in the descending aorta (PWDDAO) is one of the parameters used in grading aortic regurgitation (AR) severity. The aim of the present study was to investigate the assessment of chronic AR by PWDDAO with insights from cardiovascular magnetic resonance (CMR). Methods This prospective study comprised 40 patients investigated with echocardiography and CMR within 4 hours either prior to valve surgery (n = 23) or as part of their follow-up (n = 17) due to moderate or severe AR. End-diastolic flow velocity (EDFV) and the diastolic velocity time integral (dVTI) were measured. The appearance of diastolic forward flow (DFF) was noted. Phase-contrast flow rate curves were obtained in the DAO. Results Twenty-five patients had severe and eight had moderate AR by echocardiography (seven were indeterminate). The EDFV was below the recommended threshold (>20 cm/sec) in 13 patients (52%) with severe AR. Lowering the EDFV threshold (>13 cm/sec) and with a dVTI threshold >13 cm showed negative likelihood ratios of 0.27 and 0.09, respectively. Detection of DFF with PWDDAO identified a nonuniform velocity profile by CMR with positive and negative likelihood ratios of 7.0 and 0.19, respectively. The relation between EDFV and DAO regurgitant volume (DAO-RVolCMR) was strong in patients without (R = 0.88) and weak in patients with DFF (R = 0.49). The DAO-RVolCMR as a percent of the total RVolCMR decreased with increasing ascending aorta (AAO) size and increased with increasing AR severity. Conclusions Our findings suggest that PWDDAO provides semiquantitative parameters useful to assess chronic AR severity. The limitations are related to nonuniform velocity contour and variable degree of lower body contribution, which depends on AR severity but also on the AAO size.

    更新日期:2017-12-31
  • Echocardiographic Imaging for Transcatheter Aortic Valve Replacement
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-21
    Rebecca T. Hahn, Alina Nicoara, Samir Kapadia, Lars Svensson, Randolph Martin

    Transcatheter aortic valve replacement has become an accepted alternative to surgery for patients with severe, symptomatic aortic stenosis who are inoperable or are at high surgical risk. Recent trials support the use of transcatheter aortic valve replacement also in patients at intermediate risk, and ongoing trials are assessing appropriateness in other patient groups. The authors review the key anatomic features integral to the transcatheter aortic valve replacement procedure and the echocardiographic imaging required for preprocedural, intraprocedural, and postprocedural assessment.

    更新日期:2017-12-21
  • Normal Reference Ranges for Transthoracic Echocardiography Following Heart Transplantation
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-21
    Annika Ingvarsson, Anna Werther Evaldsson, Johan Waktare, Johan Nilsson, Gustav J. Smith, Martin Stagmo, Anders Roijer, Göran Rådegran, Carl J. Meurling

    Background Heart function following heart transplantation (HTx) is influenced by numerous factors. It is typically evaluated using transthoracic echocardiography, but reference values are currently unavailable for this context. The primary aim of the present study was to derive echocardiographic reference values for chamber size and function, including cardiac mechanics, in clinically stable HTx patients. Methods The study enrolled 124 healthy HTx patients examined prospectively. Patients underwent comprehensive two-dimensional echocardiographic examinations according to contemporary guidelines. Results were compared with recognized reference values for healthy subjects. Results Compared with guidelines, larger atrial dimensions were seen in HTx patients. Left ventricular (LV) diastolic volume was smaller, and LV wall thickness was increased. With respect to LV function, both ejection fraction (62 ± 7%, P < .01) and global longitudinal strain (−16.5 ± 3.3%, P < .0001) were lower. All measures of right ventricular (RV) size were greater than reference values (P < .0001), and all measures of RV function were reduced (tricuspid annular plane systolic excursion 15 ± 4 mm [P < .0001], RV systolic tissue Doppler velocity 10 ± 6 cm/sec [P < .0001], fractional area change 40 ± 8% [P < .0001], and RV free wall strain −16.9 ± 4.2% [P < .0001]). Ejection fraction and LV global longitudinal strain were significantly lower in patients with previous rejection. Conclusion The findings of this study indicate that the distribution of routinely used echocardiographic measures differs between stable HTx patients and healthy subjects. In particular, markedly larger RV and atrial volumes and mild reductions in both LV and RV longitudinal strain were evident. The observed differences could be clinically relevant in the assessment of HTx patients, and specific reference values should be applied in this context.

    更新日期:2017-12-21
  • Comparison of Feasibility, Accuracy, and Reproducibility of Layer-Specific Global Longitudinal Strain Measurements Among Five Different Vendors: A Report from the EACVI-ASE Strain Standardization Task Force
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13
    Serkan Ünlü, Oana Mirea, Jürgen Duchenne, Efstathios D. Pagourelias, Stéphanie Bézy, James D. Thomas, Luigi P. Badano, Jens-Uwe Voigt

    Background Despite standardization efforts, vendors still use information from different myocardial layers to calculate global longitudinal strain (GLS). Little is known about potential advantages or disadvantages of using these different layers in clinical practice. The authors therefore investigated the reproducibility and accuracy of GLS measurements from different myocardial layers. Methods Sixty-three subjects were prospectively enrolled, in whom the intervendor bias and test-retest variability of endocardial GLS (E-GLS) and midwall GLS (M-GLS) were calculated, using software packages from five vendors that allow layer-specific GLS calculation (GE, Hitachi, Siemens, Toshiba, and TomTec). The impact of tracking quality and the interdependence of strain values from different layers were assessed by comparing test-retest errors between layers. Results For both E-GLS and M-GLS, significant bias was found among vendors. Relative test-retest variability of E-GLS values differed significantly among vendors, whereas M-GLS showed no significant difference (range, 5.4%–9.5% [P = .032] and 7.0%–11.2% [P = .200], respectively). Within-vendor test-retest variability was similar between E-GLS and M-GLS for all but one vendor. Absolute test-retest errors were highly correlated between E-GLS and M-GLS for all vendors. Conclusions E-GLS and M-GLS measurements showed no relevant differences in robustness among vendors, although intervendor bias was higher for M-GLS compared with E-GLS. These data provide no technical argument in favor of a certain myocardial layer for global left ventricular functional assessment. Currently, the choice of which layer to use should therefore be based on the available clinical evidence in the literature.

    更新日期:2017-12-14
  • Complex Association of Sex Hormones on Left Ventricular Systolic Function: Insight into Sexual Dimorphism
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13

    Background Normal values of left ventricular ejection fraction (LVEF) and absolute values of global longitudinal strain (GLS) are lower in men than in women. Data concerning the association of sex hormone levels on these left ventricular systolic function surrogates are scarce. The aim of this study was to determine the association of sex hormones with systolic left ventricular function in healthy subjects and patients with congenital adrenal hyperplasia (CAH) as a model of testosterone dysregulation. Methods Eighty-four adult patients with CAH (58 women; median age, 27 years; interquartile range, 23–36 years) and 84 healthy subjects matched for sex and age were prospectively included. Circulating concentrations of sex hormones were measured within 48 hours of echocardiography with assessment of LVEF and left ventricular longitudinal, radial, and circumferential strain. Results LVEF and GLS were higher in healthy women than in healthy men (63.9 ± 4.2% vs 60.9 ± 5.1% [P < .05] and 20.0 ± 1.9% vs 17.9 ± 2.4% [P < .001], respectively), while there was no difference in LVEF or GLS between women and men with CAH (63.9 ± 4.5% vs 63.0 ± 4.6% [P = NS] and 19.4 ± 2.2% vs 18.3 ± 1.8% [P = NS], respectively). Bioavailable testosterone levels were higher in women with CAH than in female control subjects (0.08 ng/mL [interquartile range, 0.04–0.14 ng/mL] vs 0.16 ng/mL [interquartile range, 0.04–0.3 ng/mL], P < .001) and lower in men with CAH than in male control subjects (2.3 ng/mL [interquartile range, 1.3–3 ng/mL] vs 2.9 ng/mL [interquartile range, 2.5–3.4 ng/mL], P < .05). In men, LVEF and GLS were negatively correlated with bioavailable testosterone levels (r = −0.3, P ≤ .05, and r = −0.45, P < .01, respectively), while midventricular radial strain was positively correlated with bioavailable testosterone level (r = 0.38, P < .05). The absolute value of circumferential strain was positively correlated with follicle-stimulating hormone (r = 0.65, P < .0001). Conclusions These data support that the existence of sex dimorphism concerning left ventricular systolic cardiac function is significantly associated with testosterone levels.

    更新日期:2017-12-14
  • Value of Myocardial Work Estimation in the Prediction of Response to Cardiac Resynchronization Therapy
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13
    Elena Galli, Christophe Leclercq, Maxime Fournet, Arnaud Hubert, Anne Bernard, Otto A. Smiseth, Philippe Mabo, Eigil Samset, Alfredo Hernandez, Erwan Donal

    Background Cardiac resynchronization therapy (CRT) in heart failure is plagued by too many nonresponders. The aim of the present study is to evaluate whether the estimation of myocardial performance by pressure-strain loops (PSLs) is useful for the selection of CRT candidates. Methods Ninety-seven patients undergoing CRT were included in the study. Bidimensional and speckle-tracking echocardiography were performed before CRT and at the 6-month follow-up (FU). Conventional dyssynchrony parameters were evaluated. Left ventricular (LV) constructive work (CW) and wasted work (WW) were estimated by PSLs. Positive response to CRT (CRT+) was defined as ≥15% reduction in LV end-systolic volume at FU and was observed in 63 (65%) patients. Results The addition of CW > 1,057 mm Hg% (area under the curve, 0.72, P < .0001) and WW > 384 mm Hg% (area under the curve, 0.67, P = .005) to a baseline model including clinical, echocardiographic, and conventional dyssynchrony parameters significantly increased the model power (χ2, 25.11 vs 47.5, P < .0001). In this model, septal flash (odds ratio [OR] = 2.78; P = .001), CW > 1,057 mm Hg% (OR = 9.49; P = .002), and WW > 384 mm Hg% (OR = 16.24, P < .006) remained the only parameters associated with CRT+. The combination of CW > 1,057 mm Hg% and WW > 384 mm Hg% showed a good specificity (100%) and positive predictive value (100%) but a low sensitivity (22%), negative predictive value (41%), and accuracy (49%) for the identification of CRT+. Conclusions The estimation of CW and WW by PSLs is a novel tool for the assessment of CRT patients. Although these parameters cannot be used by their own to select CRT candidates, they can provide further insights into the comprehension of dyssynchrony mechanisms and contribute to improving the identification of CRT responders.

    更新日期:2017-12-14
  • Fetal Cardiac Function in Maternal Diabetes: A Conventional and Speckle-Tracking Echocardiographic Study
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13
    Joana O. Miranda, Rui J. Cerqueira, Carla Ramalho, José Carlos Areias, Tiago Henriques-Coelho

    Background Intrauterine exposure to a diabetic environment is associated with adverse fetal myocardial remodeling. The aim of this study was to assess the biventricular systolic and diastolic function of fetuses exposed to maternal diabetes (MD) compared with control subjects, using a comprehensive cardiac functional assessment and exploring the role of speckle-tracking to assess myocardial deformation. The authors hypothesized that fetuses exposed to MD present signs of biventricular dysfunction, which can be detected by deformation analysis. Methods A cross-sectional study was conducted in 129 fetuses with structurally normal hearts, including 76 fetuses of mothers with diabetes and 53 of mothers without diabetes. Maternal baseline characteristics, standard fetoplacental Doppler indices, and conventional echocardiographic and myocardial deformation parameters were prospectively collected at 30 to 33 weeks of gestation. Results Fetuses of mothers with diabetes had a significantly thicker interventricular septum compared with control subjects (median, 4.25 mm [interquartile range (IQR), 3.87–4.50 mm] vs 3.67 mm [IQR, 3.40–3.93 mm), P < .001), but no effect modification was demonstrated on myocardial deformation analysis. No significant differences were found in conventional systolic and diastolic functional parameters for the left ventricle and right ventricle, except for lower left ventricular cardiac output in the MD group (median, 320 mL/min [IQR, 269–377 mL/min] vs 365 mL/min [IQR, 311–422 mL/min], P < .05]. Deformation analysis demonstrated a significantly lower early diastolic strain rate (SRe) and late diastolic strain rate (SRa) for both ventricles in the MD group (left ventricle: SRe 1.85 ± 0.72 vs 2.26 ± 0.68 sec−1, SRa 1.50 ± 0.52 vs 1.78 ± 0.57 sec−1; right ventricle: SRe 1.57 ± 0.73 vs 1.97 ± 0.73 sec−1, SRa 2 ± 0.77 vs 1.68 ± 0.79 sec−1; P < .05), suggesting biventricular diastolic impairment. Additionally, the right ventricle presented a lower global longitudinal strain in the study group (−13.67 ± 4.18% vs −15.52 ± 3.86%, P < .05). Multivariate analysis revealed that maternal age is an independent predictor of left and right ventricular global longitudinal strain (P < .05), with a significant effect only in MD after group stratification. Conclusions Fetuses of mothers with diabetes present signs of biventricular diastolic dysfunction and right ventricular systolic dysfunction by deformation analysis in the third trimester of pregnancy. They may represent a special indication group for functional cardiac assessment, independently of septal hypertrophy. Two-dimensional speckle-tracking could offer an additional benefit over conventional echocardiography to detect subclinical unfavorable changes in myocardial function in this population.

    更新日期:2017-12-14
  • Atrial Enlargement in the Athlete's Heart: Assessment of Atrial Function May Help Distinguish Adaptive from Pathologic Remodeling
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13
    Flavio D'Ascenzi, Francesca Anselmi, Marta Focardi, Sergio Mondillo

    Intensive training is associated with hemodynamic changes that typically induce an enlargement of cardiac chambers, involving not only the ventricles but also the atria. The hearts of competitive athletes are characterized by increases in left and right atrial dimensions that have been interpreted as a physiologic adaptation to training. Conversely, some authors have hypothesized maladaptive remodeling; furthermore, the extent of left atrial dimensional remodeling may overlap atrial dilation observed in patients with cardiac disease, representing a challenge for clinicians. However, studies investigating left and right atrial function in athletes have demonstrated that atrial size is insufficient to provide mechanistic information about the atrium itself, and an increase in atrial size is not intrinsically an expression of atrial dysfunction. The authors critically analyze training-induced atrial remodeling, taking into account not only the assessment of atrial size but also the evaluation of atrial function, suggesting that the characterization of atrial function plays a fundamental role in the evaluation of athlete's heart, being useful to differentiate physiologic remodeling induced by exercise from pathologic changes occurring in cardiac disorders.

    更新日期:2017-12-14
  • Diagnostic Concordance and Clinical Outcomes in Patients Undergoing Fractional Flow Reserve and Stress Echocardiography for the Assessment of Coronary Stenosis of Intermediate Severity
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13
    Sothinathan Gurunathan, Asrar Ahmed, Anastasia Vamvakidou, Ihab S. Ramzy, Mohammed Akhtar, Aamir Ali, Nikos Karogiannis, Spiros Zidros, Gothandaraman Balaji, Grace Young, Ahmed Elghamaz, Roxy Senior

    Background The ischemic consequences of coronary artery stenosis can be assessed by invasive fractional flow reserve (FFR) or by noninvasive imaging. We sought to determine (1) the concordance between wall thickening assessment during clinically indicated stress echocardiography (SE) and FFR measurements and (2) the factors associated with hard events in these patients. Methods Two hundred twenty-three consecutive patients who underwent SE and invasive FFR measurements in close succession were analyzed retrospectively for diagnostic concordance and clinical outcomes. Results At the vessel level, the sensitivity, specificity, positive predictive value, and negative predictive value of SE for identifying significant disease as assessed by FFR was 68%, 75%, 43%, and 89%, respectively. The greatest discordance was seen in patients with wall thickening abnormalities (WTAs) and negative FFR. During a follow-up of 3.6 ± 2.2 years, there were 23 cardiovascular (CV) events (death and nonfatal myocardial infarction). The number of wall segments with inducible WTAs emerged as the strongest factor associated with CV events (hazard ratio, 1.18 [1.05-1.34]; P = .008). FFR was not associated with outcome. There was a significant increase in event rate in patients with WTA/negative FFR versus no WTA/negative FFR (P = .01), but no significant difference versus WTA/positive FFR (P = .85). Conclusions In a patient population with significant CV risk factors, a normal SE had a high negative predictive value for excluding abnormal FFR. WTAs were associated with outcomes regardless of FFR value, suggesting that this is a superior marker of ischemia to FFR.

    更新日期:2017-12-14
  • Echocardiographic Detection of Increased Ventricular Diastolic Stiffness in Pediatric Heart Transplant Recipients: A Pilot Study
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13
    Shahryar M. Chowdhury, Ryan J. Butts, Anthony M. Hlavacek, Carolyn L. Taylor, Karen S. Chessa, Varsha M. Bandisode, Girish S. Shirali, Arni Nutting, G. Hamilton Baker

    Background Pediatric heart transplant recipients are at risk for increased left ventricular (LV) diastolic stiffness. However, the noninvasive evaluation of LV stiffness has remained elusive in this population. The objective of this study was to compare novel echocardiographic measures of LV diastolic stiffness versus gold-standard measures derived from pressure-volume loop (PVL) analysis in pediatric heart transplant recipients. Methods Patients undergoing left heart catheterization were prospectively enrolled. PVLs were obtained via conductance. The end-diastolic pressure-volume relationship was obtained via balloon occlusion. The stiffness constant, β, was calculated. Echocardiographic measures of diastolic function were derived from spectral and tissue Doppler and two-dimensional speckle-tracking. Ventricular volumes were measured using three-dimensional echocardiography. The novel echocardiographic estimates of ventricular stiffness included E:e′/end-diastolic volume (EDV) and E:early diastolic strain rate/EDV. Results Of 24 children, 18 were heart transplant recipients. Six control patients had hemodynamically insignificant patent ductus arteriosus or coronary fistula. The mean age was 9.1 ± 5.6 years. Median end-diastolic pressure was 9 mm Hg (interquartile range, 8–13 mm Hg). Lateral E:e′/EDV (r = 0.59, P < .01), septal E:e′/EDV (r = 0.57, P < .01), and (E:circumferential early diastolic strain rate)/EDV (r = 0.54, P < .01) correlated with β. Lateral E:e′/EDV displayed a C statistic of 0.93 in detecting patients with abnormal LV stiffness (β > 0.015 mL−1). A lateral E:e′/EDV of >0.15 mL−1 had 89% sensitivity and 93% specificity in detecting an abnormal β. Conclusions Echocardiographic estimates of ventricular stiffness may be accurate compared with the gold standard in pediatric heart transplant recipients. The clinical usefulness of these noninvasive measures in assessing LV stiffness merits further study in children.

    更新日期:2017-12-14
  • Intervendor Consistency and Accuracy of Left Ventricular Volume Measurements Using Three-Dimensional Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-08
    Denisa Muraru, Antonella Cecchetto, Umberto Cucchini, Xiao Zhou, Roberto M. Lang, Gabriella Romeo, Mani Vannan, Sorina Mihaila, Marcelo Haertel Miglioranza, Sabino Iliceto, Luigi P. Badano

    Background Intervendor consistency of left ventricular (LV) volume measurements using three-dimensional transthoracic echocardiography (3DTTE) has never been reported. Accordingly, we designed a prospective study to (1) compare head-to-head the accuracy of three three-dimensional echocardiography (3DE) systems in measuring LV volumes and ejection fraction (EF) against cardiac magnetic resonance (CMR); (2) assess the intervendor variability of LV volumes and EF; and (3) compare the accuracy of fully automated versus semiautomated (i.e., manually corrected) methods of LV endocardial delineation against CMR. Methods We studied 92 patients (64% males, 52 years [95% CI, 20-83]) with a wide range of end-diastolic volumes (from 87 to 446 mL) and EFs (from 16% to 77%) using three different 3DE platforms (iE33; Vivid E9; Acuson SC2000) during the same echo study. CMR was performed within 3 ± 5 hours from the 3DE study in 35 patients. Results LV volumes provided by the three 3DE systems correlated with CMR volumes: end-diastolic volume (iE33: R2 = 0.93; E9: R2 = 0.94; SC2000: R2 = 0.94), end-systolic volume (iE33: R2 = 0.93; E9: R2 = 0.95; SC2000: R2 = 0.94), and EF (iE33: R2 = 0.79; E9: R2 = 0.80; SC2000: R2 = 0.77). In the 92 patients studied, LV volumes and EFs measured with the three systems were similar. Use of fully automated endocardial border detection algorithms significantly underestimated LV volumes, and the degree of underestimation was higher with larger LV volumes. Conclusions LV volumes and EFs measured with the three 3DE systems are consistent. Fully automated algorithms underestimated LV volumes. Our findings may help in the clinical interpretation of LV parameters obtained using different 3DE systems and encourage the clinical use of 3DTTE.

    更新日期:2017-12-14
  • Classic-Pattern Dyssynchrony in Adolescents and Adults With a Fontan Circulation
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-08
    Assami Rösner, Tigran Khalapyan, Håvard Dalen, Doff B. McElhinney, Mark K. Friedberg, George K. Lui

    Background Previous studies have suggested the presence of dyssynchrony in the functionally single ventricle. The aim of this study was to investigate the presence of classic-pattern dyssynchrony (CPD), characterized by typical early and late deformation of opposite walls, and its relation to QRS duration and myocardial function in patients with single-ventricle physiology after Fontan palliation. Methods In a retrospective cross-sectional study, 101 adolescent and adult patients with single-ventricle physiology after the Fontan procedure were investigated. Strain curves were visually assessed for the presence of CPD. Systolic and diastolic function were assessed using echocardiography. Results One hundred one patients were included, with varying anatomic morphology: two sizable ventricular components (n = 21), right dominant (n = 21), left dominant (n = 49), and undefined anatomy (n = 10). Fifteen of 101 Fontan patients had CPD. Forty-three percent of patients with two sizable ventricular masses displayed CPD, mostly with prolonged QRS, while the number of patients with CPD with right-dominant (9%) and left-dominant (6%) morphology was significantly lower (P = .016). Those with CPD displayed significantly (P < .05) larger QRS widths (142 ± 22 vs 112 ± 24 msec), lower ejection fractions (31 ± 14% vs 45 ± 14%), lower global early diastolic strain rates (0.7 ± 0.5 vs 1.2 ± 0.8 sec−1), and global systolic circumferential (−10 ± 5% vs −16 ± 7%) and longitudinal (−9 ± 5% vs −14 ± 5%) strain, respectively. Conclusions CPD is present in a proportion of adolescent and adult patients after Fontan palliation. The presence of CPD is associated with reduced systolic and diastolic function compared with Fontan patients without CPD. Because the presence of CPD appears to be a promising predictor for response to cardiac resynchronization therapy in patients with biventricular circulation, these findings may have important potential for prospective evaluation of cardiac resynchronization therapy in patients with univentricular circulation.

    更新日期:2017-12-14
  • Pulmonary Hypertension and Pulmonary Artery Acceleration Time: A Systematic Review and Meta-Analysis
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-08
    Yi-Chia Wang, Chi-Hsiang Huang, Yu-Kang Tu

    Background Measuring mean pulmonary artery pressure by right-heart catheterization is the gold standard for pulmonary hypertension (PH) diagnosis. However, its invasiveness and complication leads to its limited use. The aim of this study was to determine whether echocardiography-derived pulmonary artery acceleration time (PAAT) possesses adequate diagnostic performance for PH, using right-heart catheterization as a reference standard. Methods MEDLINE, Embase, PubMed, and the Cochrane Central Register of Controlled Trials were searched through July 2016 for studies evaluating PAAT for the diagnosis of PH. Methodologic quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. For each study, the sensitivity, specificity, and diagnostic odds ratio, along with 95% CIs, were calculated to determine the diagnostic accuracy of PAAT. Meta-regression was conducted to evaluate the impact of potential confounding factors. Results Of 430 articles, 21 studies (1,280 patients) were identified, including three studies that used transesophageal echocardiography and 18 studies that used transthoracic echocardiography. The pooled sensitivity across studies was 0.84 (95% CI, 0.75–0.90), the pooled specificity was 0.84 (95% CI, 0.78–0.89), and the pooled diagnostic odds ratio was 28 (95% CI, 16–49). The arrhythmia ratio in the population did not affect the specificity of PAAT's diagnostic performance and increased the sensitivity of PH detection. Conclusions The results of this study suggest that PAAT is useful for PH detection.

    更新日期:2017-12-14
  • Left Atrial Volumes and Strain in Healthy Children Measured by Three-Dimensional Echocardiography: Normal Values and Maturational Changes
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-06
    Sunil J. Ghelani, David W. Brown, Joseph D. Kuebler, Douglas Perrin, Divya Shakti, David N. Williams, Gerald R. Marx, Steven D. Colan, Tal Geva, David M. Harrild

    Background Assessment of left atrial (LA) size and function is important in a number of pediatric cardiac conditions including those affecting the diastolic performance of the left ventricle. Measurements of LA volume and strain by two-dimensional echocardiography rely upon inaccurate geometric assumptions and are hampered by out-of-plane motion. The objective of this study was to characterize LA volumes and strain by three-dimensional echocardiography in healthy children. Methods LA volumes and strain were retrospectively measured by three-dimensional echocardiography in healthy children with no known structural or functional heart disease using a commercial speckle-tracking package applied to the LA to compute maximum volume (Vmax), minimum volume (Vmin), ejection volume (LAEV), ejection fraction (LAEF), and the following components of global strain: 3D principal (3DS), longitudinal (GLS), and circumferential (GCS). Results The study population included 196 normal subjects (median age, 12 years; range, 4 days to 20.9 years). Vmax, Vmin, and LAEV increased with age and body surface area. Significant age-related declines were present in all measured functional indices including LAEF, 3DS, GLS, and GCS. Analysis of a subset of 50 subjects showed excellent agreement between Vmax derived by three-dimensional and two-dimensional biplane area-length method. Regression equations with standard deviations were generated to enable calculation of Z scores. Conclusions LA volume and functional indices can be reliably calculated using a commercial three-dimensional analysis software. All components of LA strain decline modestly with age. Normative data generated in this study have the potential to greatly enhance the utility of three-dimensional echocardiography-derived measurements in a wide range of cardiac pathologies.

    更新日期:2017-12-14
  • Clinical Outcome of Isolated Tricuspid Regurgitation in Patients with Preserved Left Ventricular Ejection Fraction and Pulmonary Hypertension
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-28
    Nir Bar, Lorin Arie Schwartz, Simon Biner, Galit Aviram, Meirav Ingbir, Ido Nachmany, Gilad Margolis, Ben Sadeh, Rami Barashi, Gad Keren, Yan Topilsky

    Background The outcome of tricuspid regurgitation (TR) remains unclear because of heterogeneity of etiology and the contradictory results of outcome studies. The aim of this study was to evaluate the clinical outcomes of TR in patients with pulmonary hypertension (PH) and normal left systolic function, stratified to patients with post- or precapillary PH. Methods In patients with no left valvar disease (isolated) functional TR, preserved left systolic function (ejection fraction ≥ 50%), and PH (systolic pulmonary pressure > 50 mm Hg), TR was assessed both qualitatively (grade) and semiquantitatively using the vena contracta method, and retrospective analysis of long-term outcomes was conducted. Patients with severe comorbid diseases were excluded. Results The study included 245 patients (age 80.5 years, 37% men, ejection fraction 57%, all with pulmonary systolic pressure > 50 mm Hg). At least moderate to severe TR was diagnosed in 178 patients, and their outcomes were compared with those of 67 patients with the same characteristics and less than mild TR. At least moderate to severe TR was associated with lower survival, independent of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (P = .03 for grade and P = .02 for vena contracta). Cox proportional-hazard analysis with interaction terms for TR severity and etiology of PH (post- vs precapillary) showed that the etiology of PH did not affect the association of TR with outcome (P = .90 for the interaction term). Conclusions At least moderate to severe isolated TR is independently associated with excess mortality in patients with preserved systolic function and PH, warranting heightened attention to diagnosis and grading. This is irrespective of etiology (pre- or postcapillary) of PH. Semiquantitative assessment of TR by vena contracta is an independent associate of outcome, superior to standard qualitative assessment.

    更新日期:2017-12-14
  • Quantification of Aortic Valve Regurgitation by Pulsed Doppler Examination of the Left Subclavian Artery Velocity Contour: A Validation Study with Cardiovascular Magnetic Resonance Imaging
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-28
    Ricardo A. Spampinato, Cosima Jahnke, Ingo Paetsch, Sebastian Hilbert, Franziska Busch, Valerie Schloma, Yaroslava Dmitrieva, Fernanda Bonamigo Thome, Susanne Löbe, Elfriede Strotdrees, Gerhard Hindricks, Friedrich-Wilhelm Mohr, Michael A. Borger

    Background Reflux of the aortic regurgitation (AR) causes an increased diastolic reverse flow in the aorta and its branching vessels. We aimed to evaluate the feasibility and accuracy of Doppler measurements in the left subclavian artery (LSA) for quantification of AR in a cardiovascular magnetic resonance imaging (CMR) validation study. Methods Systolic and diastolic flow profiles of the LSA (subclavicular approach) were evaluated prospectively by use of pulsed wave Doppler in 59 patients (55.5 ± 15 years; 44 men), 47 with a wide spectrum of AR and 12 as control group. Using CMR phase-contrast sequences (performed 1 cm above the aortic valve), the AR was divided into three groups: mild, regurgitant fraction (RF) < 20% (n = 17); moderate, RF 20%-40% (n = 10); and severe, RF > 40% (n = 20). The LSA Doppler-derived RF was calculated as the ratio between diastolic and systolic velocity-time integrals (VTI). Results Quality LSA Doppler signal could be obtained in all cases. Patients with CMR severe AR had higher values of LSA Doppler-derived RF (51% ± 9% vs 36% ± 11% vs 16% ± 8%; P < .0001). LSA Doppler showed a good correlation with CMR, with a sensitivity of 95%, specificity of 89%, and diagnostic accuracy for severe AR of 91.5%. Finally, Bland-Altman plots showed agreement in the group with moderate to severe AR (mean bias = −2.2% ± 8%, 95% CI, −17.7 to 13.3; P = .145) but differed in mild AR. Conclusions Measurements of the RF for quantification of AR using LSA Doppler are comparable to those of CMR, highlighting the potential role of LSA Doppler as an adjunctive technique to assess the severity of AR.

    更新日期:2017-12-14
  • Characteristic Morphologies of the Bicuspid Aortic Valve in Patients with Genetic Syndromes
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-28
    Talha Niaz, Joseph T. Poterucha, Timothy M. Olson, Jonathan N. Johnson, Cecilia Craviari, Thomas Nienaber, Jared Palfreeman, Frank Cetta, Donald J. Hagler

    Background In patients with bicuspid aortic valve (BAV), complications including progressive aortic stenosis and aortic dilatation develop over time. The morphology of cusp fusion is one of the determinants of the type and severity of these complications. We present the association of morphology of cusp fusion in BAV patients with distinctive genetic syndromes. Methods The Mayo Clinic echocardiography database was retrospectively reviewed to identify patients (age ≤ 22 years) diagnosed with BAV from 1990 to 2016. Cusp fusion morphology was determined from the echocardiographic studies, while coexisting cardiac defects and genetic syndromes were determined from chart review. Results A total of 1,037 patients with BAV were identified: 550 (53%) had an isolated BAV, 299 (29%) had BAV and a coexisting congenital heart defect, and 188 (18%) had BAV and a coexisting genetic syndrome or disorder. There were no differences in distribution of morphology across the three groups. However, right-noncoronary (RN) cusp fusion was the predominant morphology associated with Down syndrome (P = .002) and right-left (RL) cusp fusion was the predominant morphology associated with Turner syndrome (P = .02), DiGeorge syndrome (P = .02), and Shone syndrome (P = .0007), when compared with valve morphology in patients with isolated BAV. Isolated BAV patients with RN cusp fusion had larger ascending aorta diameter (P = .001) and higher number of patients with ≥ moderate aortic regurgitation (P = .02), while those with RL cusp fusion had larger sinus of Valsalva diameter (P = .0006). Conclusions Morphological subtypes of BAV are associated with different genetic syndromes, suggesting distinct perturbations of developmental pathways in aortic valve malformation.

    更新日期:2017-12-14
  • Echocardiographic Estimation of Mean Pulmonary Artery Pressure: A Comparison of Different Approaches to Assign the Likelihood of Pulmonary Hypertension
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-23
    Kristian Hellenkamp, Bernhard Unsöld, Sitali Mushemi-Blake, Ajay M. Shah, Tim Friede, Gerd Hasenfuß, Tim Seidler

    Background Current guidelines advise using echocardiography for noninvasive estimation of the likelihood that a patient has pulmonary hypertension (PH). To estimate the echocardiographic probability of PH, the maximal tricuspid regurgitation velocity (TR Vmax) is recommended as the main parameter to use over more complex algorithms that provide an estimation of pulmonary artery pressure. This preference is based on concerns about inaccuracies and amplification of measurement errors that can occur from using derived variables. However, this has not been examined systematically. Methods A retrospective database analysis was performed of invasively determined measurements of right heart pressure in 90 patients, corresponding echocardiographic estimations of pulmonary artery pressure, and additional parameters obtained within 24 hours. Several algorithms were compared for their correlations and accuracy parameters. Results Although a Bland-Altman analysis demonstrated that all examined algorithms exhibited inaccuracies that could be clinically relevant in individuals, algorithms estimating mean pulmonary artery pressure (PAPm) on the basis of tricuspid regurgitation generally exhibited stronger correlations with invasively determined PAPm and more accurate identification of PH than did TR Vmax. Echocardiographic estimation of right atrial pressure >15 mm Hg exhibited the highest odds ratio for invasively confirmed PH, suggesting that this parameter is of additional diagnostic value. Indeed, algorithms that also considered right atrial pressure performed best, whereas empirical algorithms, TR Vmax, and methods relying on pulmonary acceleration time exhibited weaker performance. Conclusions Although all methods are associated with inaccuracies, echocardiographically determined PAPm was superior to the current guideline recommendation of using TR Vmax with regard to its correlation with invasively determined PAPm and the presence of PH. PAPm may be considered as an alternative to TR Vmax for evaluating the echocardiographic probability of PH.

    更新日期:2017-12-14
  • Arterial Thickness and Stiffness Are Independently Associated with Left Ventricular Strain
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-23
    Smita Mehta, Philip R. Khoury, Nicolas L. Madsen, Lawrence M. Dolan, Thomas R. Kimball, Elaine M. Urbina

    Background The aim of this study was to examine the association between myocardial strain and arterial thickness and stiffness in young adults. Increased common carotid artery intima media thickness and peripheral arterial stiffness are known to precede coronary artery disease and cardiovascular (CV) events such as myocardial infarction and congestive heart failure. However, subclinical cardiac dysfunction can be detected in high-risk adults by myocardial strain echocardiography. The authors hypothesized that increased carotid artery intima media thickness would be associated with abnormal myocardial strain in young subjects who had obesity and type 2 diabetes mellitus. Methods CV risk factors were collected in 338 young adults participating in a prospective, cross-sectional study. The CV parameters collected included intima-media thickness, peripheral arterial stiffness by brachial distensibility, and myocardial strain and strain rate. General linear models were constructed to determine if vascular structure and function measures were independently associated with myocardial strain and strain rate. Results A linear relationship was found between global longitudinal strain obtained from the four-chamber view and global strain rate in systole and carotid intima-media thickness (four-chamber global longitudinal strain: β = 3.0, CV risk factor–adjusted R2 = 0.34; global strain rate in systole: β = 0.0053, R2 = 0.21; P ≤ .0001) and between four-chamber global longitudinal strain and lower brachial distensibility (β = −0.42, R2 = 0.22; P < .001). Conclusions Adverse changes in vascular structure and function are simultaneously present with reduced myocardial systolic function.

    更新日期:2017-12-14
  • Feasibility of Left Ventricular Global Longitudinal Strain Measurements from Contrast-Enhanced Echocardiographic Images
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-23
    Diego Medvedofsky, Roberto M. Lang, Eric Kruse, Brittney Guile, Lynn Weinert, Boguslawa Ciszek, Zachary Jacobson, Jacqueline Negron, Valentina Volpato, Aldo Prado, Amit R. Patel, Victor Mor-Avi

    Background Although left ventricular global longitudinal strain (GLS) is an index of systolic function recommended by the guidelines, poor image quality may hamper strain measurements. While contrast agents are commonly used to improve endocardial visualization, no commercial speckle-tracking software is able to measure strain in contrast-enhanced images. This study aimed to test the accuracy of speckle-tracking software when applied to contrast-enhanced images in patients with suboptimal image quality. Methods We studied patients with a wide range of GLS values who underwent transthoracic echocardiography. Protocol 1 included 44 patients whose images justified use of contrast but still allowed noncontrast speckle-tracking echocardiography (STE), which was judged as accurate and used as a reference. Protocol 2 included 20 patients with poor image quality that precluded noncontrast STE; cardiac magnetic resonance- (CMR-) derived strain was used as the reference instead. Half the manufacturer recommended dose of a commercial contrast agent (Definity/Optison/Lumason) was used to provide partial contrast enhancement. Higher than normal mechanical indices (0.6-0.7) and lowest frequency range for maximal penetration settings were used for imaging. GLS was measured (Epsilon) with and without contrast-enhanced images and by CMR-derived feature tracking (TomTec). Comparisons included linear regression and Bland-Altman analyses. Results The contrast STE analysis failed in 4/64 patients (6%). Manual corrections were needed to optimize tracking with contrast in all patients. GLS measurements were in good agreement between contrast and noncontrast images (r = 0.85; mean GLS in the contrast images, −12.9% ± 4.7%; bias, 0.34% ± 2.4%). Good agreement was also noted between contrast STE- and CMR-derived strain (r = 0.83; mean, GLS −13.5% ± 4.0%; bias, 0.72% ± 2.5%). Conclusions We found that GLS measurements from contrast-enhanced images are feasible and accurate in most patients, even in those with poor image quality that precludes strain measurements without contrast enhancement.

    更新日期:2017-12-14
  • Feasibility, Accuracy, and Reproducibility of Aortic Annular and Root Sizing for Transcatheter Aortic Valve Replacement Using Novel Automated Three-Dimensional Echocardiographic Software: Comparison with Multi–Detector Row Computed Tomography
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-23
    Edgard A. Prihadi, Philippe J. van Rosendael, E. Mara Vollema, Jeroen J. Bax, Victoria Delgado, Nina Ajmone Marsan

    Background In transcatheter aortic valve replacement (TAVR), multi–detector row computed tomography (MDCT) is currently the standard imaging modality for correct prosthesis sizing, despite risks of radiation and contrast-induced renal injury. Three-dimensional (3D) transesophageal echocardiography (TEE) has been proposed as a potential alternative imaging technique, and recently, automated 3D transesophageal echocardiographic software (Aortic Valve Navigator [AVN], an unreleased prototype from Philips) has been developed for assessment of the aortic annulus and root. The aim of this study was to assess the feasibility, accuracy, and reproducibility of AVN measurements in TAVR candidates by performing a comparison with MDCT. Methods In 150 patients with severe, symptomatic aortic stenosis referred for TAVR, data on aortic annular and root dimensions prospectively acquired using 3D TEE and MDCT were retrospectively analyzed. Image quality on 3D TEE and the duration of analysis with AVN were recorded, as well as the aortic valve Agatston score on MDCT. Results Data were obtained using 3D TEE and MDCT in 100% of patients for aortic annular dimensions and in 89% for aortic root dimensions. The mean duration of analysis using AVN was 4.2 ± 1.0 min, but it was significantly shorter with better 3D echocardiographic image quality and lower Agatston score on MDCT. Correlation of measurements between 3D TEE and MDCT was good to excellent for all anatomic locations (sinotubular junction mean diameter, R = 0.71; sinus of Valsalva mean diameter, R = 0.87; aortic annular mean diameter, R = 0.75; aortic annular perimeter, R = 0.83; aortic annular area, R = 0.91), with low inter- and intraobserver variability (intraclass correlation coefficient ≥ 0.93 and r ≥ 0.90 for all locations). Comparison based on conventional prosthesis sizing charts yielded excellent agreement in prosthesis size choice (κ = 0.90). Conclusions New automated 3D transesophageal echocardiographic software allows accurate modeling and reproducible quantification of aortic annular and root dimensions with high feasibility. An excellent correlation between measurements with AVN and MDCT and agreement in prosthesis sizing suggests the use of AVN in clinical practice as potential alternative to MDCT before TAVR.

    更新日期:2017-12-14
  • Left Atrial Appendage Occlusion/Exclusion: Procedural Image Guidance with Transesophageal Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-20
    Alan F. Vainrib, Serge C. Harb, Wael Jaber, Ricardo J. Benenstein, Anthony Aizer, Larry A. Chinitz, Muhamed Saric

    Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. In this article, the authors describe the crucial role of two- and three-dimensional transesophageal echocardiography in the pre- and postprocedural assessment and intraprocedural guidance of percutaneous left atrial appendage (LAA) occlusion procedures. Although recent advances have been made in the field of systemic anticoagulation with the novel oral anticoagulants, these medications come with a significant risk for bleeding and are contraindicated in many patients. Because thromboembolism in atrial fibrillation typically arises from thrombi originating in the LAA, surgical and percutaneous LAA exclusion/occlusion techniques have been devised as alternatives to systemic anticoagulation. Currently, surgical LAA exclusion is typically performed as an adjunct to other cardiac surgical procedures, which limits the number of eligible patients. Recently, several percutaneously delivered devices for LAA exclusion from the systemic circulation have been developed, some of which have been shown in clinical trials to reduce the risk for thromboembolism. These devices use an either purely endocardial LAA occlusion approach, such as the Watchman and Amulet procedures, or both an endocardial and a pericardial (epicardial) approach, such as the Lariat procedure. In the Watchman and Amulet procedures, a transseptally delivered structure composed of nitinol is placed in the LAA orifice, thereby excluding the LAA from the systemic circulation. In the Lariat procedure, a magnet link is created between a transseptally delivered endocardial wire and epicardially delivered pericardial wire, followed by epicardial suture ligation of the LAA.

    更新日期:2017-12-14
  • Impact of Significant Mitral Regurgitation on Assessing the Severity of Aortic Stenosis
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-20
    Pil Hyung Lee, Jung Ae Hong, Byung Joo Sun, Seungbong Han, Sangwoo Park, Jeong Yoon Jang, Dae-Hee Kim, Duk-Hyun Kang, Jae-Kwan Song, Jong-Min Song

    Background Significant mitral regurgitation (MR) may reduce a pressure gradient of aortic stenosis (AS) by decreasing forward stroke volume. The study objective was to evaluate whether significant MR can cause inconsistency when assessing the severity of AS. Methods Among 5,355 patients diagnosed with AS from 2000 to 2015, 68 were retrospectively found to have concomitant significant (moderate or greater) MR and normal left ventricular ejection fractions in normal sinus rhythm (AS with MR). As a control group, 136 patients with trivial or no MR were selected who were matched by age, gender, and left ventricular end-systolic volume (AS without MR). Nonlinear regression was performed for data pairs (aortic valve area [AVA] vs mean pressure gradient [MPG]) using the formula AVA = a + b/√MPG. Composite clinical events were defined as aortic valve surgery warranted by the development of symptoms or left ventricular dysfunction, admission because of heart failure, and death. Results The forward stroke volume index was significantly lower in the AS with MR group than in the AS without MR group (43.8 ± 8.3 vs 49.2 ± 10.2 mL/m2, P < .004). A significant group difference was found with respect to the relationship between (indexed) AVA and MPG (AVA, 0.02 + 4.43/√MPG vs −0.06 + 5.60/√MPG [P for interaction = .04]; indexed AVA, 0.03 + 2.66/√MPG vs −0.03 + 3.47/√MPG [P for interaction = .01]). An AVA of 1.0 cm2 corresponded to MPGs of 20.3 and 28.2 mm Hg for the groups with and without MR, respectively. Conversely, an MPG of 40 mm Hg corresponded to AVAs of 0.72 and 0.83 cm2 for the groups with and without MR, respectively. Among patients with MPGs < 40 mm Hg, clinical event rates were significantly higher in those with MR compared with those without MR (P = .009). Conclusions This quantitative analysis demonstrated that AS severity assessed by MPG measurement may be underestimated, and thus AVA measurement is essential in patients with combined significant MR.

    更新日期:2017-12-12
  • Centile Curves for Velocity-Time Integral Times Heart Rate as a Function of Ventricular Length: The Use of Minute Distance Is Advantageous to Enhance Clinical Reliability in Children
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-20
    Anna Solinski, Elmar Klusmeier, Jan-Pit Horst, Hermann Körperich, Nikolaus A. Haas, Deniz Kececioglu, Kai Thorsten Laser

    Background The generation of velocity-time integrals (VTIs) from Doppler signals is an essential component of standard echocardiographic investigations. The most effective algorithm to compensate for growth in children has, however, not yet been identified. This study was initiated to establish pediatric reference values for VTI and to enhance the interpretability of those values, considering technical and physiological factors. Methods The echocardiographic data sets of healthy children and adolescents (N = 349; age range, 0–20 years) were recorded in a prospective approach and subsequently analyzed. In a pilot study, aortic and pulmonary VTIs were set in relation to the physiologic parameters of heart size as possible influencing parameters in a subgroup of children with comparable physical characteristics. The ratio with the smallest SD was taken as the base to generate centile curves using the LMS method. The clinical utility of the model was tested by examining patients (n = 80) with shunt lesions such as patent ductus arteriosus and atrial septal defect. Results Feasibility was 94.6% for aortic VTI and 92.8% for pulmonary VTI. The pilot study identified ventricular length and heart rate as suitable parameters with the lowest relative SDs and high correlations with VTI. Gender differences were not relevant for children <7 years of age, and with increasing age, SD increased because of higher stroke volume variations. The detection of increased aortic VTI was possible with sensitivity of 73% for patients with patent ductus arteriosus with moderate or large hemodynamically significant ductus arteriosus. Patients with atrial septal defects with enlarged right ventricles could be identified as having increased pulmonary VTI with sensitivity of 84%. Conclusions These new reference values for VTI times heart rate as a function of ventricular length may be of specific clinical value to improve the assessment of cardiac function, therapeutic decision making, and follow-up in pediatric patients with heart disease.

    更新日期:2017-12-12
  • Association Between Global Longitudinal Strain and Cardiovascular Events in Patients With Left Bundle Branch Block Assessed Using Two-Dimensional Speckle-Tracking Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-02
    In-Chang Hwang, Goo-Yeong Cho, Yeonyee E. Yoon, Jin Joo Park

    Background The prognostic value of left ventricular (LV) global strain and twist in patients with left bundle branch block (LBBB) is not fully investigated. The aim of this study was to investigate the association between myocardial strain and twist and cardiovascular events in patients with LBBB, as assessed using two-dimensional speckle-tracking echocardiography. Methods A total of 269 patients with LBBB (mean age, 69.5 ± 10.9 years; 46.8% men) were retrospectively identified. Using speckle-tracking, LV global longitudinal strain (GLS), global circumferential strain, and twist were measured. Association between LV global function and a composite of cardiovascular mortality and hospitalization for heart failure was compared with clinical risk factors, LV ejection fraction (LVEF), and other echocardiographic parameters. Results During a median of 27.5 months (interquartile range, 12.8–43.9 months), the composite end point occurred in 55 patients (20.4%). In univariate analyses, diabetes mellitus, chronic kidney disease, ischemic etiology of LBBB, dilated left atrium, reduced LVEF, dilated left ventricle, and impaired LV global strain (GLS > −12.2%, global circumferential strain > −11.8%, and twist < 6.5°) showed associations with the composite end point. In multivariate analyses, GLS was significantly associated with the composite end point (adjusted hazard ratio, 4.697; 95% CI, 1.344–16.413; P = .015), whereas global circumferential strain, twist, and LVEF were not. GLS showed an additive association with poor prognosis over clinical risk factors and other echocardiographic parameters, including LVEF. Patients with preserved LVEFs (≥40%) but impaired GLS (>−12.2%) had a larger number of clinical events than those with impaired LVEFs but preserved GLS. Conclusions Among patients with LBBB, GLS can provide better risk stratification than LVEF or other echocardiographic parameters.

    更新日期:2017-12-12
  • Three-Dimensional Echocardiography–Derived Right Ventricular Ejection Fraction Correlates with Success of Decannulation and Prognosis in Patients Stabilized by Venoarterial Extracorporeal Life Support
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-01
    Kuan-Chih Huang, Lian-Yu Lin, Yih-Sharng Chen, Chien-Heng Lai, Juey-Jen Hwang, Lung-Chun Lin

    Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been proved to effectively rescue patients from refractory cardiogenic shock. The role of the right ventricle in VA-ECMO has been emphasized, but quantitative right ventricular (RV) analysis in this population has been lacking. Three-dimensional echocardiography (3DE) is currently suggested for RV volumetric analysis. The aims of this study were to assess 3DE-derived RV ejection fraction (RVEF) in patients with refractory cardiogenic shock stabilized by VA-ECMO and to explore the association between 3DE-derived RVEF and weaning success as well as the prognosis after the first intent of decannulation. Methods Three-dimensional echocardiographic data sets before the first intent of decannulation were retrospectively selected and analyzed in 46 patients who underwent VA-ECMO for refractory acute circulatory collapse. Results Twenty-eight of the 46 patients had protocol-defined success in weaning from VA-ECMO. In the success group, both ventricles were smaller and had better pumping function. By stepwise multivariate linear regression, RV free wall strain, left ventricular ejection fraction, RV fractional area change, and central venous pressure were found to be independently associated with RVEF. Receiver operating characteristic curve analysis showed that RVEF had the highest area under the curve (0.90, P < .001) for weaning success with a cutoff value of 24.6%. Worse RVEF (≤24.6%) was also associated with poor prognosis in terms of all-cause mortality within 30 days (hazard ratio, 15.86; 95% CI, 3.56–70.73; P < .001). Conclusions Three-dimensional echocardiography–derived RVEF might represent the composite results of RV contractility, left ventricular performance, and fluid status. Under mechanical circulatory support of VA-ECMO, RVEF > 24.6% was associated with higher weaning success and lower 30-day mortality after the first intent of decannulation.

    更新日期:2017-12-12
  • Invasive Validation of the Echocardiographic Assessment of Left Ventricular Filling Pressures Using the 2016 Diastolic Guidelines: Head-to-Head Comparison with the 2009 Guidelines
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-10-27
    Bhavna Balaney, Diego Medvedofsky, Anuj Mediratta, Amita Singh, Boguslawa Ciszek, Eric Kruse, Atman P. Shah, Karima Addetia, Roberto M. Lang, Victor Mor-Avi

    Background Recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines for echocardiographic evaluation of left ventricular (LV) diastolic function provide a practical, simplified diagnostic algorithm for estimating LV filling pressure. The aim of this study was to test the accuracy of this algorithm against invasively measured pressures and compare it with the accuracy of the previous 2009 guidelines in the same patient cohort. Methods Ninety patients underwent transthoracic echocardiography immediately before left heart catheterization. Mitral inflow E/A ratio, E/e′, tricuspid regurgitation velocity, and left atrial volume index were used to estimate LV filling pressure as normal or elevated using the ASE/EACVI algorithm. Invasive LV pre-A pressure was used as a reference, with >12 mm Hg defined as elevated. Results Invasive LV pre-A pressure was elevated in 40 (44%) and normal in 50 (56%) patients. The 2016 algorithm resulted in classification of 9 of 90 patients (10%) as indeterminate but estimated LV filling pressures in agreement with the invasive reference in 61 of 81 patients (75%), with sensitivity of 0.69 and specificity of 0.81. The 2009 algorithm could not definitively classify 4 of 90 patients (4.4%), but estimated LV filling pressures in agreement with the invasive reference in 64 of 86 patients (74%), with sensitivity of 0.79 and specificity of 0.70. Conclusions The 2016 ASE/EACVI guidelines for estimation of filling pressures are more user friendly and efficient than the 2009 guidelines and provide accurate estimates of LV filling pressure in the majority of patients when compared with invasive measurements. The simplicity of the new algorithm did not compromise its accuracy and is likely to encourage its incorporation into clinical decision making.

    更新日期:2017-12-12
  • Prognostic and Added Value of Two-Dimensional Global Longitudinal Strain for Prediction of Survival in Patients with Light Chain Amyloidosis Undergoing Autologous Hematopoietic Cell Transplantation
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-10-27
    Shawn C. Pun, Heather J. Landau, Elyn R. Riedel, Jonathan Jordan, Anthony F. Yu, Hani Hassoun, Carol L. Chen, Richard M. Steingart, Jennifer E. Liu

    Background Autologous hematopoietic cell transplantation (HCT) is a first-line therapy for prolonging survival in patients with light-chain (AL) amyloidosis. Cardiac involvement is the most important determinant of survival. However, patients with advanced cardiac involvement have often been excluded from HCT because of high risk for transplantation-related mortality and poor overall survival. Whether baseline left ventricular global longitudinal strain (GLS) can provide additional risk stratification and predict survival after HCT in this high-risk population remains unclear. The aim of this study was to evaluate the prognostic implication of baseline GLS and the added value of GLS beyond circulating cardiac biomarkers for risk stratification in patients with AL amyloidosis undergoing HCT. Methods Eighty-two patients with newly diagnosed AL amyloidosis who underwent upfront HCT between January 2007 and April 2014 were included in the study. Clinical, echocardiographic, and serum cardiac biomarker data were collected at baseline and 12 months following HCT. GLS measurements were performed using a vendor-independent offline system. The median follow-up time for survivors was 58 months. Results Sixty-four percent of patients were in biomarker-based Mayo stage II or III. GLS, brain natriuretic peptide, troponin, and mitral E/A ratio were identified as the strongest predictors of survival (P < .0001). Other predictors included sex, creatinine, free AL, wall thickness, and ejection fraction. Mayo stage was significantly associated with outcome, with 5-year survival of 93%, 72% and 31% in stage I, II, and III patients, respectively. GLS of 17% was identified as the value that best discriminated survivors from nonsurvivors, and the application of this cutoff value provided further mortality risk stratification within each Mayo stage. Conclusions GLS is a strong predictor of survival in patients with AL amyloidosis undergoing HCT, potentially providing incremental value over serum cardiac biomarkers for risk stratification. GLS should be considered as a standard parameter along with serum cardiac biomarkers when evaluating eligibility for HCT or other investigational therapies.

    更新日期:2017-12-12
  • Abnormal Coronary Flow Velocity Reserve and Decreased Myocardial Contractile Reserve Are Main Factors in Relation to Physical Exercise Capacity in Cardiac Amyloidosis
    J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-10-27
    Tor Skibsted Clemmensen, Hans Eiskjær, Henning Mølgaard, Anders Hostrup Larsen, Jens Soerensen, Niels Frost Andersen, Lars Poulsen Tolbod, Hendrik J. Harms, Steen Hvitfeldt Poulsen

    Background The aim of the present study was to evaluate the clinical importance of echocardiographic coronary flow velocity reserve (CFVR), resting and exercise left ventricular global longitudinal strain (LVGLS), and myocardial work efficiency (MWE) in patients with cardiac amyloidosis (CA). Methods The study population comprised 69 subjects: group A, 27 patients with CA confirmed by endomyocardial biopsy (CA positive); group B, 42 healthy control subjects. The amyloid phenotype in group A was as follows: patients with wild-type transthyretin-related amyloidosis (n = 10), carriers of the Danish familial transthyretin amyloidosis mutation with cardiac involvement (n = 5), and patients with amyloid light chain amyloidosis with cardiac involvement (n = 12). All subjects underwent comprehensive echocardiographic evaluation during rest and during symptom-limited, semisupine exercise testing. Furthermore, CFVR was assessed using Doppler echocardiography. Results Patients with CA had significantly lower CFVR (1.7 ± 0.6 vs 3.9 ± 0.8, P < .0001), MWE (1.9 ± 1.0 vs 3.0 ± 0.7, P < .0001), and LVGLS magnitude (11% [10%–14%] vs 20% [18%–21%], P < .0001) than control subjects. Patients with CA showed severely reduced deformation and efficiency reserve compared with control subjects (ΔLVGLS 0.9 ± 2.8% vs 5.6 ± 2.3%, P < .0001; ΔMWE 2.5 ± 2.8 vs 8.8 ± 2.6, P < .0001). In patients with CA, a strong relation was seen between physical capacity by the metabolic equivalent of tasks test and CFVR (r = 0.55, P < .01), peak exercise LVGLS (r = 0.64, P < .0001), and peak exercise MWE (r = 0.60, P < .01). Conclusions Patients with CA had a profound lack of CFVR and longitudinal myocardial deformation reserve compared with healthy control subjects. Both parameters were significantly associated with exercise capacity and may prove useful for evaluating cardiac performance in patients with CA.

    更新日期:2017-12-12
Some contents have been Reproduced with permission of the American Chemical Society.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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