Three-Dimensional Echocardiographic Assessment of Mitral Annular Physiology in Patients With Degenerative Mitral Valve Regurgitation Undergoing Surgical Repair: Comparison between Early- and Late-Stage Severe Mitral Regurgitation J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-16 Tien-En Chen, Kevin Ong, Rakesh M. Suri, Maurice Enriquez-Sarano, Hector I. Michelena, Harold M. Burkhart, Shane M. Gillespie, Stephen Cha, Sunil V. Mankad
BackgroundVentricular-annular decoupling is thought to exist in all degenerative myxomatous mitral valve (MV) diseases. However, the annular physiology of degenerative MV disease may differ when severe mitral regurgitation (MR) presents at different stages. The aim of this study was to assess differences in mitral annular physiology and surgical effects between early- and late-stage severe MR.MethodsThree-dimensional (3D) transesophageal echocardiography was performed before and after MV surgery in 74 patients with degenerative MV disease, including 57 with early-stage severe MR (without left ventricular remodeling) and 17 with late-stage MR (with left ventricular remodeling). A control group comprised 46 patients without MV disease. Novel 3D MV software was used to evaluate mitral annular dynamics. The degree of annular saddle shape was calculated as the ratio of annular height (AH) to lateromedial diameter (LM). Ventricular-annular decoupling was defined as insufficient systolic AH/LM compared with the control group.ResultsPrebypass 3D measurements demonstrated that systolic AH/LM in the early-stage group (0.19 ± 0.04) was similar to that in the control group (0.21 ± 0.05; P = .101), while systolic AH/LM in the late-stage group (0.17 ± 0.04) was lower than that in the control group (P = .011). Postbypass comparison showed saddle shape accentuation in the early-stage group (0.20 ± 0.04), similar to that in the control group (P = .3127); the mitral annulus remained flat in the late-stage group (0.17 ± 0.03; P = .004).ConclusionsVentricular-annular decoupling, present in the late-stage group, was absent in the early-stage group. MV repair surgery did not disrupt mitral annular saddle shape in the early-stage group; however, it failed to correct annular dysfunction in the late-stage group. Sequential 3D transesophageal echocardiographic analysis provides comprehensive mitral annular evaluation beyond conventional two-dimensional parameters for determining stages of severe MR.
Aortic Stenosis with Severe Tricuspid Regurgitation: Comparative Study between Conservative Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Combined With Tricuspid Repair J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-11 Zach Rozenbaum, Yoav Granot, Arie Steinvil, Shmuel Banai, Ariel Finkelstein, Yanai Ben-Gal, Gad Keren, Yan Topilsky
Background Severe aortic stenosis (AS) and severe tricuspid regurgitation (TR) may coexist. The aim of this study was to determine the change in right ventricular (RV) function and TR after surgical aortic valve replacement combined with tricuspid valve repair (SAVR+TVr), transcatheter aortic valve replacement (TAVR), or conservative management and compare outcomes dependent on RV functional parameters and treatment allocation. Methods A retrospective analysis was conducted in 147 consecutive patients with severe AS and TR of baseline and 6-month clinical and echocardiographic parameters, including quantitative estimation of RV size and function (end-diastolic and end-systolic areas, tricuspid annular plane systolic excursion, fractional area change, and Tei index). Results SAVR+TVr and TAVR were associated with superior reduction in TR jet area after 6 months (P = .01 for time × group interaction) compared with conservative therapy. However, RV function (tricuspid annular plane systolic excursion and stroke volume) improved after TAVR but not after SAVR+TVr (P = .007 and P = .02 for time × group interaction, respectively). Conservative therapy for combined AS and TR was associated with >80% mortality in <4 years. TAVR and SAVR+TVr were associated with improved survival compared with conservative therapy (P < .0001), without significant difference between each other. Quantitative RV functional parameters were associated with poor outcomes, including tricuspid annular plane systolic excursion (P = .002), Tei index (P = .02), and RV fractional area change (P = .03). Conclusions In this nonrandomized, retrospective, observational study, SAVR+TVr and TAVR were associated with reductions in TR in patients with severe AS combined with severe TR. Importantly, RV function improved after TAVR but not after SAVR+TVr. Patients with severe AS and TR have a very poor prognosis with conservative therapy. When contemplating invasive procedures, assessment should include quantitative functional RV parameters.
Left Ventricular Myocardial Contractile Reserve during Exercise Stress in Healthy Adults: A Two-Dimensional Speckle-Tracking Echocardiographic Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-08 Anders Hostrup Larsen, Tor Skibsted Clemmensen, Henrik Wiggers, Steen Hvitfeldt Poulsen
Background The aims of the present study were to determine left ventricular (LV) myocardial contractile reserve during exercise stress testing in healthy adults and to evaluate the effects of gender and age on exercise LV global longitudinal strain (GLS). Methods The study population consisted of 67 healthy adults (age range, 23–80 years; 49% women). Subjects were analyzed with respect to gender and predefined age groups (age < 35 years, n = 18; age 35–55 years, n = 24; age > 55 years, n = 25). All subjects underwent comprehensive echocardiographic assessment at rest and during symptom-limited semisupine exercise test. LV GLS was determined using two-dimensional speckle-tracking echocardiography. Results LV GLS magnitude during peak stress was 25.4 ± 2.0%. The average absolute numeric LV GLS increase was 5.3%, equivalent to a relative 26.7% increase of LV GLS. LV GLS magnitude at peak exercise was without clinically significant differences between age groups (P = .07). No significant difference was found in peak exercise LV GLS between genders (P = .48). Linear regression analysis revealed a significant but weak correlation between peak LV GLS and age (r = −0.30, P = .02), whereas peak LV GLS was independent of maximal heart rate (r = 0.23, P = .07), peak mean arterial blood pressure (r = −0.11, P = .38), body mass index (r = 0.15, P = .22), and peak pulsed Doppler–derived cardiac index (r = −0.06, P = .67). Conclusions LV GLS increases significantly during exercise stress in a healthy population. A dose-response relationship was found between LV GLS and exercise level independent of gender, and the influence of age appeared marginal. The technique is feasible, with low intra- and interobserver variability.
Three-Dimensional Mitral Valve Morphology in Children and Young Adults With Marfan Syndrome J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-08 Matthew A. Jolley, Peter E. Hammer, Sunil J. Ghelani, Adi Adar, Lynn A. Sleeper, Ronald V. Lacro, Gerald R. Marx, Meena Nathan, David M. Harrild
Background Mitral valve (MV) prolapse is common in children with Marfan syndrome (MFS) and is associated with varying degrees of mitral regurgitation (MR). However, the three-dimensional (3D) morphology of the MV in children with MFS and its relation to the degree of MR are not known. The goals of this study were to describe the 3D morphology of the MV in children with MFS and to compare it to that in normal children. Methods Three-dimensional transthoracic echocardiography was performed in 27 patients (3–21 years of age) meeting the revised Ghent criteria for MFS and 27 normal children matched by age (±1 year). The 3D geometry of the MV apparatus in midsystole was measured, and its association with clinical and two-dimensional echocardiographic parameters was examined. Results Compared with age-matched control subjects, children with MFS had larger 3D annular areas (P < .02), smaller annular height/commissural width ratios (P < .001), greater billow volumes (P < .001), and smaller tenting heights, areas, and volumes (P < .001 for all). In multivariate modeling, larger leaflet billow volume in MFS was strongly associated with moderate or greater MR (P < .01). Intra- and interuser variability of 3D metrics was acceptable. Conclusions Children with MFS have flatter and more dilated MV annuli, greater billow volumes, and smaller tenting heights compared with normal control subjects. Larger billow volume is associated with MR. Three-dimensional MV quantification may contribute to the identification of patients with MFS and other connective tissue disorders. Further study of 3D MV geometry and its relation to the clinical progression of MV disease is warranted in this vulnerable population.
Focused Cardiac Ultrasound by Nurses in Rural Vietnam J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-07 James N. Kirkpatrick, Hoai T.T. Nguyen, Loi Do Doan, Thanh T. Le, Son Pham Thai, David Adams, Liza Y. Sanchez, Nova Sprague, Jill Inafuku, Rachel Quang, Rebecca Hahn, Andrea M. Van Hoever, Tu Nguyen, Thanh G. Kirkpatrick, Jose Banchs
Background Multiple studies investigating the use of focused cardiac ultrasound (FCU) in lower and middle-income countries and in medically underserved areas of the United States have demonstrated utility in echocardiographic screening algorithms performed by a variety of operators at different levels of training. No study to date has employed previously untrained nurses in a medically underserved setting to identify older adults with cardiac disorders. The aim of this study was to assess the accuracy of nurse-performed FCU to screen adult subjects at a village health center in Vietnam. Methods Vietnamese nurses (N = 8) underwent structured training conducted by sonographers and physicians during an outreach event sponsored by the American Society of Echocardiography Education and Research Foundation. The nurses were trained to detect abnormalities from a single echocardiographic view (parasternal long-axis) with a laptop-sized device and underwent pre- and posttraining testing. Following training, cardiac ultrasound examinations were performed on subjects >50 years of age at a village health center. First, the nurses performed focused cardiac ultrasound using two-dimensional and color Doppler imaging in the parasternal long-axis view using the M7 device and recorded their assessments. Two-dimensional color and spectral Doppler echocardiography was thereafter performed using the same machine by a sonographer (n = 5) or a Vietnamese echocardiography-trained cardiologist (n = 1). Interviews and electrocardiography were performed at the time of FCU. Results Each nurse improved from pre- to posttraining (average improvement in correct answers, 21%; range, 2%–31%). During the scanning phase, nurses' sensitivity, specificity, and accuracy for identifying subjects with any abnormality were 51.5% (85 of 165), 78.1% (82 of 105) and 61.9%, respectively. There were 60 subjects with significant findings (22.2%); all of these subjects had significant abnormalities visible on parasternal long-axis images. Overall sensitivity, specificity, and accuracy for identifying subjects with major abnormalities were 83.3% (50 of 60), 78.1% (164 of 210), and 78.6%, respectively. Nurse-performed FCU demonstrated much higher sensitivity with lower specificity than electrocardiography alone. The combination of nurse-performed FCU plus ECG identified all of the significant findings on echocardiography and increased accuracy to 91.5%. Conclusions Nurses with no prior echocardiographic experience and with limited training can identify patients with significant cardiac abnormalities using FCU with acceptable accuracy. Screening strategies involving FCU may play a role in improving access to health care and triage in underserved areas.
Diagnosis of Isolated Cleft Mitral Valve Using Three-Dimensional Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-07 Akhil Narang, Karima Addetia, Lynn Weinert, Megan Yamat, Atman P. Shah, John E. Blair, Victor Mor-Avi, Roberto M. Lang
Background The prevalence of isolated cleft mitral valve (MV; no concomitant congenital heart disease or degenerative MV disease) with significant mitral regurgitation (MR) diagnosed using two-dimensional echocardiography (2DE) has been reported to be very low. Three-dimensional echocardiography (3DE) has enabled a more comprehensive visualization of the MV and detailed understanding of the mechanisms of MR and can potentially reveal isolated cleft MV that is not recognized with 2DE. The aim of this study was to determine, using 3DE, the prevalence, location, and associated MV annular and left ventricular characteristics of isolated cleft MV, in the absence of associated congenital heart disease, in patients with significant MR. Methods A total of 1,092 patients with unexplained moderate or greater MR on two-dimensional transthoracic echocardiography who were referred for three-dimensional transesophageal echocardiography between 2005 and 2017 (n = 626) were retrospectively studied. Left ventricular dimensions and function were determined, and quantitative MR assessment and three-dimensional analysis of the MV annulus was performed. Results Twenty-one patients (prevalence 3.3%) were diagnosed with isolated cleft MV using three-dimensional transesophageal echocardiography but not 2DE. The majority of these patients (n = 16) were noted to have anterior cleft MVs, with most located in the mid-A1 (n = 10) or mid-A3 (n = 5) scallops. Posterior clefts were less common (n = 5) and occurred at the site of the natural scallop indentations (three between P1 and P2 and two between P2 and P3). Among patients with either anterior or posterior MV cleft, there were no differences in left ventricular ejection fraction or three-dimensional MV geometry (annular distance, height, circumference, and area). There was a trend toward worse MR severity in patients with anterior cleft MV. Conclusions In patients with otherwise unexplained significant MR referred for transesophageal echocardiography, 3DE uncovered a considerably higher prevalence of isolated cleft MV than previously reported by 2DE, with the majority located in the anterior MV. Although the annular geometry was similar between patients with anterior and posterior cleft MVs, a trend toward more severe MR in anterior clefts may reflect underlying abnormalities in the embryologic development of the anterior MV leaflet. Evaluation of MV pathology is improved by 3DE, which should be used routinely in the setting significant MR.
Diastolic Dysfunction Assessed Using Contemporary Guidelines and Prognosis Following Myocardial Infarction J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-07 Sandhir B. Prasad, Andrew K. Lin, Kristyan B. Guppy-Coles, Tony Stanton, Rathika Krishnasamy, Gillian A. Whalley, Liza Thomas, John J. Atherton
Background Recent American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines for the assessment of diastolic dysfunction (DD) recommend a simplified approach with four key variables incorporated into a novel diagnostic algorithm. The aim of this study was to assess the prognostic value of significant DD assessed using the algorithm recommended in the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines (DD2016) in comparison with the prognostic value of significant DD assessed using the 2009 guidelines (DD2009) as well as the individual parameters incorporated in the 2016 algorithm. Methods Retrospective data on 419 consecutive patients with first ever myocardial infarction were included. Doppler echocardiography was performed within 24 hours of admission in all patients. Significant DD was defined as grade 2 or 3 DD. The primary outcome measure was composite major adverse cardiovascular events (MACEs), comprising death, myocardial infarction, and heart failure. Results At a median follow-up of 24 months, there were 61 MACEs. On Kaplan-Meier analysis, DD2016 showed a better association with MACEs than DD2009 (log-rank χ2 = 21.01 [P < .001] vs 13.13 [P = .001]). On Cox proportional-hazards multivariate analysis incorporating significant clinical predictors and left ventricular ejection fraction, DD2016 (hazard ratio, 2.22; 95% CI, 1.25–3.98; P = .007) was the strongest independent predictor of MACEs, whereas DD2009 (hazard ratio, 1.63; 95% CI, 0.95–2.80; P = .074) was not a significant predictor. Of the four key diastolic parameters, only left atrial volume index was independently associated with MACEs (hazard ratio, 1.79; 95% CI, 1.02–3.14; P = .041) when included in a Cox proportional-hazards multivariate model incorporating significant clinical predictors and left ventricular ejection fraction, although the association was weaker than DD2016. Intermodel comparisons with model χ2 and Harrell's C statistic were satisfactory for DD2016. Conclusions Significant DD assessed using the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines is a robust independent predictor of clinical outcomes following myocardial infarction and compares favorably with DD2009 as well as the individual parameters incorporated in the novel 2016 algorithm.
Right Atrial Function Predicts Clinical Outcome in Patients with Precapillary Pulmonary Hypertension J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-06 Sophia Anastasia Mouratoglou, Konstantinos Dimopoulos, Vasileios Kamperidis, Christos Feloukidis, Alexandros Kallifatidis, Georgia Pitsiou, Ioannis Stanopoulos, Vasileios Grosomanidis, Stavros Hadjimiltiades, Haralambos Karvounis, George Giannakoulas
BackgroundAlthough the primary role of right atrial (RA) size in the diagnosis and risk stratification of precapillary pulmonary hypertension (PH) has been studied, little is known about the clinical significance of RA function. In line with studies assessing left atrial function in heart failure, the aim of this study was to introduce the RA function index (RAFi) and to explore its prognostic power in precapillary PH.MethodsRA emptying fraction was calculated as (RA end-systolic volume − RA end-diastolic volume) × 100/(RA end-systolic volume). RAFi was calculated as (RA emptying fraction × right ventricular outflow tract velocity-time integral)/(RA end-systolic volume index). Patients were followed for the end point of clinical failure, which was defined as death, hospitalization because of PH, or disease progression.ResultsIn total, 47 patients with precapillary PH were included. Mean RAFi was 16.1 ± 22.3%. Over a median follow-up period of 25 months (interquartile range, 9.5–41.1 months), 29 patients experienced clinical failure. Univariate Cox proportional-hazard analysis showed that RAFi was a predictor of clinical failure (hazard ratio, 0.935; 95% CI, 0.890–0.981; P = .007). Addition of RAFi to established predictors of outcomes, including 6-minute walk distance, N-terminal pro–B-type natriuretic peptide, and RA area, improved their prognostic power.ConclusionsRAFi is an easily assessed echocardiographic parameter, which is strongly predictive of clinical outcomes in patients with precapillary PH. Further studies are needed to validate RAFi and define its role in clinical practice.
A New Three-Dimensional Echocardiography Method to Quantify Aortic Valve Calcification J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-01 Thomas d'Humières, Laureline Faivre, Elie Chammous, Jean-François Deux, Eric Bergoënd, Antonio Fiore, Costin Radu, Jean-Paul Couetil, Nicole Benhaiem, Geneviève Derumeaux, Jean-Luc Dubois-Randé, Julien Ternacle, Damien Fard, Pascal Lim
Background Aortic valve calcification (AVC) quantification is computed from multidetector computed tomography (MDCT). The aim of this study was to test the hypothesis that three-dimensional (3D) transthoracic echocardiography can be used to provide a bedside method to assess AVC. Methods The study included 94 patients (mean age, 78 ± 12 years; mean aortic valve [AV] area, 1.0 ± 0.6 cm2) referred for MDCT and echocardiography for AV assessment. Apical 3D full-volume data sets focused on the AV region were acquired during transthoracic echocardiography, and a region-growing algorithm was applied offline to compute 3D transthoracic echocardiographic AVC (AVC-3DEcho). AVC-3DEcho was compared with AVC by MDCT and with calcium weight in the subgroup of patients referred for surgery, with explanted AVs analyzed by a pathologist (n = 22). Results In the explanted valve group, AVC-3DEcho score exhibited fair correlations with MDCT score (r = 0.85, P < .001), calcium load (r = 0.81, P < .001), and peak AV velocity (r = 0.64, P < .001). In the overall population, AVC-3DEcho score correlated modestly with MDCT score (r = 0.61, P < .001) but had similar accuracy to identify severe aortic stenosis (area under the curve = 0.94). AVC-3DEcho > 1,054 mm3 identified severe aortic stenosis with specificity of 100% and sensitivity of 76%. In addition, AVC-3DEcho was associated with the presence of significant paravalvular regurgitation after transcatheter aortic valve implantation. Finally, intraobserver and interobserver variability for AVC-3DEcho score was 4.2% and 8.9%, respectively. Conclusions AVC-3DEcho correlated with calcium weight obtained from pathologic analysis and MDCT. These data suggest that a bedside method for quantifying AV calcification with ultrasound is feasible.
Usefulness of Echocardiography in Children with New-Onset Supraventricular Tachycardia J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-07-31 Kaitlin L'Italien, Steven Conlon, Naomi Kertesz, Louis Bezold, Anna Kamp
BackgroundSupraventricular tachycardia (SVT) is the most common sustained arrhythmia in children. Infants with SVT and ventricular preexcitation (Wolff-Parkinson-White syndrome) are known to have up to 30% prevalence of congenital heart disease (CHD). Infants without ventricular preexcitation who present with SVT at <1 year of age have a similar prevalence of CHD. However, for children without ventricular preexcitation who present with SVT at older ages, the prevalence of CHD is not known. The aim of this study was to determine the prevalence of CHD in older children and adolescents presenting with SVT without ventricular preexcitation, with the goal of providing guidance regarding the usefulness of echocardiography in this patient population.MethodsChildren aged 2 to 18 years presenting with confirmed SVT between January 2011 and December 2015 were included in this retrospective review. Patients with any history of ventricular preexcitation or preexisting heart disease were excluded. Medical records were reviewed, and electrocardiographic and echocardiographic findings were classified as normal, incidental, or abnormal.ResultsTwo hundred ninety patients met the inclusion criteria. Echocardiographic examinations were completed on 224 patients. Only one patient was found to have CHD, a moderate primum atrial septal defect. This patient was noted to have electrocardiographic abnormalities consistent with primum atrial septal defect.ConclusionsFor older children and adolescents with no known heart disease presenting with SVT without ventricular preexcitation, echocardiography may not be a necessary part of initial evaluation when the results of physical examination and electrocardiography are normal.
Direct Comparison of Severity Grading Assessed by Two-Dimensional, Three-Dimensional, and Doppler Echocardiography for Predicting Prognosis in Asymptomatic Aortic Stenosis J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-07-27 Yosuke Nabeshima, Yasufumi Nagata, Kazuaki Negishi, Yoshihiro Seo, Tomoko Ishizu, Kimi Sato, Kazutaka Aonuma, Dan Koto, Masaki Izumo, Yoshihiro J. Akashi, Eiji Yamashita, Shigeru Oshima, Yutaka Otsuji, Masaaki Takeuchi
Background Reliable assessment of aortic stenosis (AS) severity relies on stroke volume (SV) determination using Doppler echocardiography, but it can also be estimated with two-dimensional/three dimensional echocardiography (2DE/3DE). The aim of this study was to compare SV measurements and AS subgroup classifications among the three modalities and determine their prognostic strength in asymptomatic AS. Methods We prospectively enrolled 359 patients with asymptomatic AS. SV was determined using three methods, and the patients were divided into four AS subgroups according to indexed aortic valve area (iAVA) and SV index (SVI) determined by each method and mean pressure gradient. The primary end point was major adverse cardiovascular events (MACEs), which included cardiac death, ventricular fibrillation, heart failure, and aortic valve replacement. We also assessed the presence or absence of upper septal hypertrophy. Results Doppler-derived SVI was significantly larger than that derived from 2DE/3DE with modest correlations (r = 0.33 and 0.47). Thus, group classification varied substantially by modality. During the median follow-up period of 17 months, 112 patients developed a major adverse cardiovascular event. Although iAVA assessed by Doppler echocardiography had a significantly better net reclassification improvement compared with iAVA by 2DE or 3DE, prognostic values were nearly identical among the three methods. Ventricular septal geometry affected the accuracy of risk stratification. Conclusions AS severity grading varied considerably according to the methods applied for calculating SV. Thus, SV measurements are not interchangeable, even though their prognostic power is similar. Hence, examiners should select one of the three methods to assess AS severity and should use the same method in longitudinal examinations.
Prognostic Value of Transthoracic Doppler Echocardiography Coronary Flow Velocity Reserve in Patients with Nonculprit Stenosis of Intermediate Severity Early after Primary Percutaneous Coronary Intervention J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-04-03 Milorad Tesic, Ana Djordjevic-Dikic, Vojislav Giga, Jelena Stepanovic, Milan Dobric, Ivana Jovanovic, Marija Petrovic, Zlatko Mehmedbegovic, Dejan Milasinovic, Vladimir Dedovic, Milorad Zivkovic, Stefan Juricic, Dejan Orlic, Sinisa Stojkovic, Vladan Vukcevic, Goran Stankovic, Milan Nedeljkovic, Miodrag Ostojic, Branko Beleslin
BackgroundTreatment of nonculprit coronary stenosis during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction may be beneficial, but the mode and timing of the intervention are still controversial. The aim of this study was to examine the significance and prognostic value of preserved coronary flow velocity reserve (CFVR) in patients with nonculprit intermediate stenosis early after primary percutaneous coronary intervention.MethodsTwo hundred thirty patients with remaining intermediate (50%–70%) stenosis of non-infarct-related arteries, in whom CFVR was performed within 7 days after primary percutaneous coronary intervention, were prospectively enrolled. Twenty patients with reduced CFVR and positive results on stress echocardiography or impaired fractional flow reserve underwent revascularization and were not included in further analysis. The final study population of 210 patients (mean age, 58 ± 10 years; 162 men) was divided into two groups on the basis of CFVR: group 1, CFVR > 2 (n = 174), and group 2, CFVR ≤ 2 (n = 36). Cardiac death, nonfatal myocardial infarction, and revascularization of the evaluated vessel were considered adverse events.ResultsMean follow-up duration was 47 ± 16 months. Mean CFVR for the whole group was 2.36 ± 0.40. There were six adverse events (3.4%) related to the nonculprit coronary artery in group 1, including one cardiac death, one ST-segment elevation myocardial infarction, and four revascularizations. In group 2, there were 30 adverse events (83.3%, P < .001 vs group 1), including two cardiac deaths, two ST-segment elevation myocardial infarctions, and 26 revascularizations.ConclusionsIn patients with CFVR > 2 of the intermediate nonculprit coronary lesion, deferral of revascularization is safe and associated with excellent long-term clinical outcomes.
A Preliminary Study of Left Ventricular Rotational Mechanics in Children with Noncompaction Cardiomyopathy: Do They Influence Ventricular Function? J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-04-13 Hythem M. Nawaytou, Andrea E. Montero, Putri Yubbu, Renzo J.C. Calderón-Anyosa, Tomoyuki Sato, Matthew J. O'Connor, Kelley D. Miller, Philip C. Ursell, Julien I.E. Hoffman, Anirban Banerjee
BackgroundCurrent diagnostic criteria for noncompaction cardiomyopathy (NCC) lack specificity, and the disease lacks prognostic indicators. Reverse apical rotation (RAR) with abnormal rotation of the cardiac apex in the same clockwise direction as the base has been described in adults with NCC. The aim of this study was to test the hypothesis that RAR might differentiate between symptomatic NCC and benign hypertrabeculations and might be associated with ventricular dysfunction.MethodsEchocardiograms from 28 children with NCC without cardiac malformations were prospectively compared with those from 29 age-matched normal control subjects. A chart review was performed to identify the patients’ histories and clinical characteristics. Speckle-tracking was used to measure longitudinal strain, circumferential strain, and rotation.ResultsRAR occurred in 39% of patients with NCC. History of left ventricular (LV) dysfunction or arrhythmia was universal in, but not exclusive to, patients with RAR. Patients with RAR had lower LV longitudinal strain but similar ejection fractions compared with patients without RAR (median, -15.6% [interquartile range, -12.9% to -19.3%] vs -19% [interquartile range, -14.5% to -21.9%], P < .01; 53% [interquartile range, 43% to 68%] vs 61% [interquartile range, 58% to 67%], P = .08). Only a pattern of contraction with RAR, early arrest of twisting by mid-systole, and premature untwisting was associated with lower ejection fraction (46%; interquartile range, 43% to 52%; P = .006).ConclusionsRAR is not a sensitive but is a specific indicator of complications in children with NCC. Therefore, RAR may have prognostic rather than diagnostic value. Premature untwisting of the left ventricle during ejection may be an even more worrisome indicator of LV dysfunction.
The Impact of the Left Ventricle on Right Ventricular Function and Clinical Outcomes in Infants with Single–Right Ventricle Anomalies up to 14 Months of Age J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-07-03 Meryl S. Cohen, Nicholas Dagincourt, Victor Zak, Jeanne Marie Baffa, Peter Bartz, Andreea Dragulescu, Gul Dudlani, Heather Henderson, Catherine D. Krawczeski, Wyman W. Lai, Jami C. Levine, Alan B. Lewis, Rachel T. McCandless, Richard G. Ohye, Sonal T. Owens, Steven M. Schwartz, Timothy C. Slesnick, Carolyn L. Taylor, Peter C. Frommelt
Background Children with single–right ventricle anomalies such as hypoplastic left heart syndrome (HLHS) have left ventricles of variable size and function. The impact of the left ventricle on the performance of the right ventricle and on survival remains unclear. The aim of this study was to identify whether left ventricular (LV) size and function influence right ventricular (RV) function and clinical outcome after staged palliation for single–right ventricle anomalies. Methods In the Single Ventricle Reconstruction trial, echocardiography-derived measures of LV size and function were compared with measures of RV systolic and diastolic function, tricuspid regurgitation, and outcomes (death and/or heart transplantation) at baseline (preoperatively), early after Norwood palliation, before stage 2 palliation, and at 14 months of age. Results Of the 522 subjects who met the study inclusion criteria, 381 (73%) had measurable left ventricles. The HLHS subtype of aortic atresia/mitral atresia was significantly less likely to have a measurable left ventricle (41%) compared with the other HLHS subtypes: aortic stenosis/mitral stenosis (100%), aortic atresia/mitral stenosis (96%), and those without HLHS (83%). RV end-diastolic and end-systolic volumes were significantly larger, while diastolic indices suggested better diastolic properties in those subjects with no left ventricles compared with those with measurable left ventricles. However, RV ejection fraction was not different on the basis of LV size and function after staged palliation. Moreover, there was no difference in transplantation-free survival to Norwood discharge, through the interstage period, or at 14 months of age between those subjects who had measurable left ventricles compared with those who did not. Conclusions LV size varies by anatomic subtype in infants with single–right ventricle anomalies. Although indices of RV size and diastolic function were influenced by the presence of a left ventricle, there was no difference in RV systolic function or transplantation-free survival on the basis of LV measures.
Which Cardiac Structure Lies Nearby? Revisiting Two-Dimensional Cross-Sectional Anatomy J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-06-27 Francesco F. Faletra, Siew Yen Ho, Laura Anna Leo, Vera Lucia Paiocchi, Sunil Mankad, Mani Vannan, Tiziano Moccetti
Two-dimensional (2D) transthoracic echocardiography is one of the most used diagnostic tools in clinical cardiology. Similarly, 2D transesophageal echocardiography is considered an indispensable tool for cardiologists and cardiac anesthesiologists worldwide. However, because of their tomographic nature, both techniques display only thin cut planes of a given area of the heart, which are far from representing the “anatomic reality.” It is widely accepted that experienced echocardiographers are able to reconstruct mentally a three-dimensional image of any cardiac structure on the basis of their interpretation of multiple tomographic slices. However, this may not be the case with less experienced echocardiographers. In particular, the authors noticed that less experienced echocardiographers are almost totally unaware of which structures lie “nearby” a given 2D tomographic plane, that is, what is adjacent in the elevation plane. In this article, the authors report the use of three-dimensional transesophageal echocardiographic images to discover which structures are located nearby (i.e., “behind” and “in front”) the corresponding 2D cross-sections. The authors believe that this novel use of three-dimensional echocardiography is a unique aid to disclose what cannot be seen in a given 2D cross-section, thereby expanding our understanding of 2D echocardiographic anatomy. This may be an effective method to encourage all to “think” in three dimensions, even when they use 2D echocardiography.
Three-Dimensional Echocardiographic Guidance of Right Heart Catheterization Decreases Radiation Exposure in Atrial Septal Defect Closures J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-06-27 Pei-Ni Jone, Jenny E. Zablah, Dale A. Burkett, Michal Schäfer, Neil Wilson, Gareth J. Morgan, Michael Ross
BackgroundRadiation reduction is desirable in children undergoing cardiac catheterization. Three-dimensional (3D) transesophageal echocardiographic (3D TEE) imaging obviates the need for mental reconstruction of 3D structures from two-dimensional images. Three-dimensional TEE imaging is used in atrial septal defect (ASD) closures. Three-dimensional TEE guidance of right heart catheterization (RHC) without fluoroscopy for ASD closures has not been demonstrated. The aim of this study was to evaluate the feasibility of 3D TEE guidance of RHC in ASD closures and radiation reduction compared with historical control subjects.MethodsTwenty-two patients underwent 3D TEE guidance of RHC and ASD closures and were compared with 44 control subjects. RHC time, total fluoroscopy time, radiation dose, and procedural time were compared. Fluoroscopy time during RHC was recorded in patients undergoing 3D TEE guidance.ResultsThere was a 54% reduction in total fluoroscopy time and a 78% radiation reduction demonstrated with 3D TEE guidance of patients with ASDs compared with control subjects. Although there were no statistically significant differences in the RHC time compared with control subjects, the fluoroscopy time (mean, 0.06 ± 0.23 min) for RHC guidance using 3D TEE imaging was almost zero. There was decreased RHC time as we progressed through the learning curve of performing 3D TEE guidance of RHC (r = −0.63, P < .01). There were no statistically significant differences in total procedural time.ConclusionsThree-dimensional TEE guidance in RHC is feasible without the use of fluoroscopy and reduces radiation exposure in percutaneous ASD closures. Three-dimensional TEE guidance may be used in other interventional procedures in the future to further reduce radiation exposure and facilitate catheter interventions.
Three-Dimensional Echocardiography for the Assessment of Right Ventriculo-Arterial Coupling J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-06-27 Raphaël Aubert, Clément Venner, Olivier Huttin, Djalila Haine, Laura Filippetti, Anne Guillaumot, Damien Mandry, Pierre-Yves Marie, Yves Juilliere, François Chabot, Ari Chaouat, Christine Selton-Suty
BackgroundThe analysis of right ventriculo-arterial coupling (RVAC) from pressure-volume loops is not routinely performed. RVAC may be approached by the combination of right heart catheterization (RHC) pressure data and cardiac magnetic resonance (CMR)–derived right ventricular (RV) volumetric data. RV pressure and volume measurements by Doppler and three-dimensional echocardiography (3DE) allows another way to approach RVAC.MethodsNinety patients suspected of having pulmonary hypertension underwent RHC, 3DE, and CMR (RHC mean pulmonary artery pressure [mPAP] 37.9 ± 11.3 mm Hg; range, 15–66 mm Hg). Three-dimensional (3D) echocardiography was performed in 30 normal patients (echocardiographic mPAP 18.4 ± 3.1 mm Hg). Pulmonary artery (PA) effective elastance (Ea), RV maximal end-systolic elastance (Emax), and RVAC (PA Ea/RV Emax) were calculated from RHC combined with CMR and from 3DE using simplified formulas including mPAP, stroke volume, and end-systolic volume.ResultsThree-dimensional echocardiographic and RHC-CMR measures for PA Ea (3DE, 1.27 ± 0.94; RHC-CMR, 0.71 ± 0.52; r = 0.806, P < .001), RV Emax (3DE, 0.72 ± 0.37; RHC-CMR, 0.38 ± 0.19; r = 0.798, P < .001), and RVAC (3DE, 2.01 ± 1.28; RHC-CMR, 2.32 ± 1.77; r = 0.826, P < .001) were well correlated despite a systematic overestimation of 3DE elastance parameters. Among the whole population, 3D echocardiographic PA Ea and 3D echocardiographic RVAC but not 3D echocardiographic RV Emax were significantly lower in patients with mPAP < 25 mm Hg (n = 41) than in others (n = 79). Among the 90 patients who underwent RHC, 3D echocardiographic PA Ea and 3D echocardiographic RVAC but not 3D echocardiographic RV Emax increased significantly with increasing levels of pulmonary vascular resistance.ConclusionsThree-dimensional echocardiography–derived PA Ea, RV Emax, and RVAC correlated well with the reference RHC-CMR measurements. Ea and RVAC but not Emax were significantly different between patients with different levels of afterload, suggesting failure of the right ventricle to maintain coupling in severe pulmonary hypertension.
Improvements of Myocardial Deformation Assessment by Three-Dimensional Speckle-Tracking versus Two-Dimensional Speckle-Tracking Revealed by Cardiac Magnetic Resonance Tagging J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-06-21 Mihaela S. Amzulescu, Hélène Langet, Eric Saloux, Alain Manrique, Allison Slimani, Pascal Allain, Clotilde Roy, Christophe de Meester, Agnès Pasquet, Oudom Somphone, Mathieu De Craene, David Vancraeynest, Anne-Catherine Pouleur, Jean-Louis Vanoverschelde, Bernhard L. Gerber
Background In prior work, the authors demonstrated that two-dimensional speckle-tracking (2DST) correlated well but systematically overestimated global longitudinal strain (LS) and circumferential strain (CS) compared with two-dimensional cardiac magnetic resonance tagging (2DTagg) and had poor agreement on a segmental basis. Because three-dimensional speckle-tracking (3DST) has recently emerged as a new, more comprehensive evaluation of myocardial deformation, this study was undertaken to evaluate whether it would compare more favorably with 2DTagg than 2DST. Methods In a prospective two-center trial, 119 subjects (29 healthy volunteers, 63 patients with left ventricular dysfunction, and 27 patients with left ventricular hypertrophy) underwent 2DST, 3DST, and 2DTagg. Global, regional (basal, mid, and apical), and segmental (18 and 16 segments per patient) LS and CS by 2DST and 3DST were compared with 2DTagg using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Test-retest reproducibility of 3DST and 2DST was compared in 48 other patients. Results Both global LS and CS by 3DST agreed better with 2DTagg (ICC = 0.89 and ICC = 0.83, P < .001 for both; bias = 0.5 ± 2.3% and 0.2 ± 3%) than 2DST (ICC = 0.65 and ICC = 0.55, P < .001 for both; bias = −5.5 ± 2.5% and −7 ± 5.3%). Unlike 2DST, 3DST did not overestimate deformation at the regional and particularly the apical levels and at the segmental level had lower bias (LS, 0.8 ± 2.8% vs −5.3 ± 2.4%; CS, −0.01 ± 2.8% vs −7 ± 2.8%, respectively) but similar agreement with 2DST (LS: ICC = 0.58 ± 0.16 vs 0.56 ± 0.12; CS: ICC = 0.58 ± 0.12 vs 0.51 ± 0.1) with 2DTagg. Finally, 3DST had similar global LS, but better global CS test-retest variability than 2DST. Conclusions Using 2DTagg as reference, 3DST had better agreement and less bias for global and regional LS and CS. At the segmental level, 3DST demonstrated comparable agreement but lower bias versus 2DTagg compared with 2DST. Also, test-retest variability for global CS by 3DST was better than by 2DST. This suggests that 3DST is superior to 2DST for analysis of global and regional myocardial deformation, but further refinement is needed for both 3DST and 2DST at the segmental level.
Transcatheter Mitral Valve Implantation in Degenerated Bioprosthetic Valves J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-06-21 Sunil V. Mankad, Gabriel S. Aldea, Natalie M. Ho, Rekha Mankad, Sorin Pislaru, L. Leonardo Rodriguez, Brian Whisenant, Karen Zimmerman
The use of bioprosthetic valves for mitral valve disease has been increasingly popular with both patients and physicians, and current practice uses these valves for increasingly younger patients. However, these valves are known to degenerate over time. Historically, reoperation was the only recourse for a failing bioprosthetic valve. Today, however, percutaneous options exist with the use of transcatheter valve implantation. Determining candidacy for this less invasive option requires careful evaluation with echocardiography. This review is focused on the echocardiographic evaluation required pre-, intra-, and postprocedurally during transcatheter mitral valve insertion.
Validation and Reference Values for Three-Dimensional Echocardiographic Right Ventricular Volumetry in Children: A Multicenter Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-06-19 Kai Thorsten Laser, Ayşe Karabiyik, Hermann Körperich, Jan-Pit Horst, Peter Barth, Deniz Kececioglu, Wolfgang Burchert, Robert DallaPozza, Ulrike Herberg
Background Functional assessment of the right ventricle using real-time three-dimensional echocardiography (RT3DE) has fundamental relevance in young patients with congenital heart disease. Reference values for the pediatric population are scarce. This multicenter study was designed to (1) validate new evaluation software for RT3DE and (2) establish pediatric reference values. Methods For validation, right ventricular (RV) end-diastolic volume (EDV) and end-systolic volume (ESV) were determined from real-time three-dimensional echocardiographic data sets of 38 subjects (n = 17 healthy individuals and n = 21 patients with congenital heart disease) using new dedicated evaluation software (RV-Function 2.0) and compared with cardiac magnetic resonance investigations of the same patient cohort. In a prospective multicenter design, 360 real-time three-dimensional echocardiographic data sets of healthy children (172 girls) were analyzed. To create reference centiles, the cohort was subdivided into group I (children <7 years of age, n = 136 [female and male]), group II (girls 7–18 years of age, n = 106), and group III (boys 7–18 years of age, n = 118). Results Using RT3DE, RV volumes were slightly higher than using cardiac magnetic resonance (EDV, 0.8 ± 5.8% [limits of agreement, −10.8% to 12.5%; r = 0.993]; ESV, 2.0 ± 13.1% [limits of agreement, −24.2% to 28.2%; r = 0.989). Reproducibility was promising (intraobserver variability, 3.9 ± 11.4% for EDV and −1.7 ± 13.4% for ESV [intraclass correlation coefficient range, 0.94–0.98]; interobserver variability, 1.9 ± 11.8% for EDV and −0.3 ± 22.8% for ESV [intraclass correlation coefficient range, 0.85–0.96]). Regarding functional parameters, no significant gender differences were found among children in group I. In contrast, children in groups II and III differed in RV volumes, dimensional parameters, and tricuspid annular plane systolic excursion (P < .005); the children did not differ in deformation parameters. Feasibility was 90%. Conclusions RT3DE yields accurate and reproducible RV volumes. The calculated percentile curves may facilitate the clinical use of RT3DE to analyze RV function in children.
Three-Dimensional Inferior Vena Cava for Assessing Central Venous Pressure in Patients with Cardiogenic Shock J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-06-13 Raphaëlle Huguet, Damien Fard, Thomas d’Humieres, Ophelie Brault-Meslin, Laureline Faivre, Louis Nahory, Jean-Luc Dubois-Randé, Julien Ternacle, Leopold Oliver, Pascal Lim
Background The inferior vena cava (IVC) has a complex three-dimensional (3D) shape, but measurements used to estimate central venous pressure (CVP) remain based on two-dimensional (2D) echocardiographic imaging. The aim of this study was to investigate the accuracy of IVC size and collapsibility index obtained by 3D echocardiography for assessing CVP in patients with cardiogenic shock. Methods Eighty consecutive echocardiographic examinations performed in 33 patients (mean age, 72 ± 15 years; mean left ventricular ejection fraction, 19 ± 10%) admitted for cardiogenic shock were prospectively included. Two-dimensional and 3D images of the IVC were acquired simultaneously with invasive measurement of CVP, both at rest and during a sniff test. IVC diameters, 3D IVC area, and IVC collapsibility index (IVCCI) were assessed. The eccentricity index was computed from 3D data as the ratio of maximum to minimum IVC diameter. A cutoff value of 10 mm Hg for CVP defined patients with euvolemic hemodynamic status. Results At rest, IVC diameter averaged 23 ± 7 mm by 2D imaging and 25 ± 8 × 19 ± 7 mm by 3D imaging. The IVC had an eccentric shape (eccentricity index = 1.3) that increased when CVP was ≤10 mm Hg and during the sniff test (P < .001). IVC measurements by 2D and 3D imaging were correlated with CVP. The best correlation was obtained with IVCCI derived from 2D diameters (R = −0.69) and 3D areas (R = −0.82). Using a cutoff value of 50% for IVCCI, 11 examinations were misclassified by 2D imaging and only one by 3D imaging. Inter- and intraobserver reproducibility for IVC area was 7 ± 6% and 5 ± 3%, respectively. Conclusions In patients with cardiogenic shock, IVCCI from area by 3D echocardiography is reproducible and accurate to evaluate CVP.
Left Ventricular Mechanical Dispersion and Global Longitudinal Strain and Ventricular Arrhythmias in Predialysis and Dialysis Patients J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-10 Liselotte C.R. Hensen, Kathleen Goossens, Tomaz Podlesnikar, Joris I. Rotmans, J. Wouter Jukema, Victoria Delgado, Jeroen J. Bax
Background Patients with advanced chronic kidney disease (CKD) have high risk for sudden cardiac death (SCD) and may benefit from implantable cardioverter-defibrillators (ICDs). However, the risk for ICD-related complications is also high in this population. Therefore, there is an unmet need for accurate risk stratification tools to identify patients with CKD at risk for ventricular arrhythmias (VAs), who may benefit from ICD implantation. The aim of this hypothesis-generating study was to investigate the association between left ventricular (LV) mechanical dispersion and LV global longitudinal strain (GLS) measured using two-dimensional speckle-tracking echocardiography and VA and SCD in patients with CKD. Methods Patients with CKD stages 3b to 5 (estimated glomerular filtration rate < 45 mL/min/1.73 m2 or on dialysis) were included and were divided into two groups according to the occurrence of VA or SCD during follow-up. LV mechanical dispersion, as a measure of the temporal heterogeneity of the LV deformation, was measured as the SD of time to peak longitudinal strain of 17 LV segments. The ability of LV mechanical dispersion, LV ejection fraction, and LV GLS to discriminate patients with VA or SCD during follow-up was evaluated using receiver operating characteristic curve analysis. Results Of 250 patients (66% men; mean age, 61 ± 14 years), 16 (6%) experienced VA or SCD during a median follow-up duration of 28 months (interquartile range, 16–53 months). Using receiver operating characteristic curve analyses, LV GLS (area under the curve = 0.79; 95% CI, 0.68–0.89) and LV mechanical dispersion (area under the curve = 0.71; 95% CI, 0.61–0.82) showed modest discrimination to identify patients at risk for VA or SCD. In contrast, LV ejection fraction showed poor discrimination (area under the curve = 0.60; 95% CI, 0.41–0.78). Conclusions LV mechanical dispersion along with LV GLS may be an additional valuable risk marker of VA and SCD in predialysis and dialysis patients.
Cardiac Point-of-Care Ultrasound: State of the Art in Medical School Education J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-15 Amer M. Johri, Joshua Durbin, Joseph Newbigging, Robert Tanzola, Ryan Chow, Sabe De, James Tam,
The development of small, user friendly, handheld ultrasound devices has stimulated the growth of cardiac point-of-care ultrasound (POCUS) for the purpose of rapid, bedside cardiac assessment. Medical schools have begun integrating cardiac POCUS into their curricula. In this review the authors summarize the variable approaches taken by several medical training programs with respect to duration of POCUS training, prerequisite knowledge, and methods of delivering these skills (including e-learning, hands-on training, and simulation). The authors also address issues related to the need for competency evaluation and the limitations of the technology itself. The studies reviewed suggest that undergraduate education is a viable point at which to introduce basic POCUS concepts.
Doppler Echocardiography Assessment of Aortic Stiffness in Female Adolescents with Anorexia Nervosa J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-17 Carolina A. Escudero, James E. Potts, Pei-Yoong Lam, Astrid M. De Souza, Gerald J. Mugford, George G.S. Sandor
Background Anorexia nervosa (AN) is associated with abnormalities in biomarkers of cardiovascular risk. Arterial stiffness, as measured by pulse-wave velocity (PWV), is also a risk factor for cardiovascular disease. The aims of this study were to determine the stiffness of the aorta in female adolescents with AN and to determine if either the severity or the type of AN was associated with PWV. Methods This was a retrospective case-control study. Adolescent patients with a clinical diagnosis of AN were included. Aortic diameter and pulse-wave transit time over a portion of the thoracic aorta were measured using Doppler echocardiography, and PWV was calculated. Results There were 94 female patients with AN and 60 adolescent female control subjects. There was no significant difference in age between patients with AN and control subjects (15.5 ± 1.7 vs 15.1 ± 2.6 years, P = .220). Body mass index (16.0 ± 2.4 vs 19.7 ± 2.7 kg/m2, P < .001) and body mass index percentile (9.4 ± 15.6 vs 45.5 ± 26.2, P < .001) were significantly lower for patients with AN than control subjects. PWV (443 ± 106 vs 383 ± 77 cm/sec, P < .001) was significantly higher in patients with AN than control subjects. Similar differences from control subjects were found in patients with AN with both lower and higher body mass index percentiles and also in patients with AN with the restrictive or the binge-purge subtype. Conclusions Female adolescents with AN have increased aortic stiffness compared with control subjects. This study suggests that patients with AN may be at increased risk for future cardiovascular disease. Future studies are required to determine the reversibility of these changes with weight restoration.
Left-Sided Atrial Septal Pouch is a Risk Factor for Cryptogenic Stroke J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-21 Mateusz K. Hołda, Agata Krawczyk-Ożóg, Mateusz Koziej, Danuta Sorysz, Jakub Hołda, Dariusz Dudek, Wiesława Klimek-Piotrowska
Background The atrial septal pouch is an anatomic variant of the interatrial septum. The morphology of the left-sided septal pouch (LSSP) may favor blood stasis and predispose to thromboembolic events. The aim of this study was to determine the association between LSSP presence and cryptogenic stroke. Methods A total of 126 consecutive patients with cryptogenic stroke and 137 age-matched control patients without stroke were analyzed retrospectively. The presence and dimensions of LSSPs were assessed using transesophageal echocardiography. Results LSSP was present in 55.6% of patients with cryptogenic stroke and in 40.9% of those without stroke (P = .02). In univariate analysis, patients with LSSP were more likely to have cryptogenic stroke (odds ratio, 1.81; 95% CI, 1.11–2.95; P = .02). After adjusting for other risk factors using multiple logistic regression, the presence of an LSSP was found to be associated with an increased risk for cryptogenic stroke (odds ratio, 2.02; 95% CI, 1.19–3.41; P = .01). There were no statistically significant differences in size of the LSSP between patients with and those without stroke (P > .05). Conclusions There is an association between the presence of an LSSP and an increased risk for cryptogenic stroke. More attention should be paid to clinical evaluations of LSSPs.
Standardized Goal-Directed Valsalva Maneuver for Assessment of Inducible Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-21 Suwen Kumar, Grace Van Ness, Aron Bender, Mrinal Yadava, Jessica Minnier, Sriram Ravi, Lidija McGrath, Howard K. Song, Stephen B. Heitner
Background The Valsalva maneuver is widely used to provoke left ventricular outflow tract obstruction in hypertrophic cardiomyopathy (HCM). Whereas early experiments used a standardized, goal-directed approach by maintaining an intraoral pressure >40 mm Hg for >10 sec, current practice depends on patients' understanding and effort. The aim of this study was to evaluate the clinical effectiveness of the goal-directed Valsalva maneuver (GDV) in HCM as a method to provoke left ventricular outflow tract obstruction. Methods In this prospective study, patients blew into a syringe barrel connected to a manometer with rubber tubing and maintained an intraoral pressure of >40 mm Hg for >10 sec (GDV). Using Doppler echocardiography, peak left ventricular outflow tract gradient (pLVOTG) was measured at rest and using the provocative maneuvers of the self-directed Valsalva maneuver (SDV), GDV, and exercise. Results A total of 52 patients were included. Mean pLVOTG with GDV was higher compared with SDV (48 vs 38 mm Hg, P = .001, n = 52) and was similar to exercise (GDV, 52 mm Hg; exercise, 58 mm Hg; P = .42; n = 43). Reclassification to obstructive HCM (pLVOTG ≥ 30 mm Hg) with GDV was significantly higher than with SDV (38% vs 16.6%, P = .016) and comparable with exercise (50%, P = .51). Reclassification to severe obstruction (pLVOTG ≥ 50 mm Hg) was higher with GDV compared with SDV (28.3% vs 13.5%, P = .045) and was similar to exercise (29.7%). Furthermore, GDV identified two patients with occult severe obstruction in isolation. Conclusions GDV is an objective, practical, and effective physiologic method of provoking left ventricular outflow tract obstruction. It can significantly alter patient management by reclassifying disease severity and should be incorporated in the routine clinical evaluation of patients with HCM.
Mean Right Atrial Pressure for Estimation of Left Ventricular Filling Pressure in Patients with Normal Left Ventricular Ejection Fraction: Invasive and Noninvasive Validation J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-24 Sherif F. Nagueh, Otto A. Smiseth, Hisham Dokainish, Oyvind S. Andersen, Muaz M. Abudiab, Robert C. Schutt, Arnav Kumar, Einar Gude, Kimi Sato, Serge C. Harb, Allan L. Klein
Background There is a paucity of data on the utility of right atrial pressure (RAP) for estimating pulmonary capillary wedge pressure (PCWP) in patients with normal ejection fraction (EF), including patients with heart failure with preserved EF. Methods Mean RAP was compared with PCWP in 129 patients (mean age, 61 ± 11 years; 45% men) with exertional dyspnea enrolled in a multicenter study. Measurements included left ventricular volumes, EF, and mitral inflow velocities. Results Mean PCWP was 14 ± 7 mm Hg, and mean RAP was 8 ± 5 mm Hg. A significant relation was present between mean RAP and mean PCWP (r2 = 0.5, P < .001). RAP > 8 mm Hg had 76% sensitivity and 86% specificity in detecting mean PCWP > 12 mm Hg. In 101 patients with inconclusive mitral filling pattern (defined according to American Society of Echocardiography/European Association of Cardiovascular Imaging 2016 diastolic function recommendations), RAP by catheterization had sensitivity of 73% and specificity of 91%. In a subset of 59 patients with echocardiographic assessment of mean RAP, RAP by echocardiography had sensitivity of 76% and specificity of 89%. Conclusions Mean RAP provides useful information about mean PCWP in many patients with normal left ventricular EF. There is good sensitivity and excellent specificity when combining invasive or noninvasive RAP and mitral velocities to determine if PCWP is elevated.
Noninvasive Echocardiographic Measures of Pulmonary Vascular Resistance in Children and Young Adults with Cardiomyopathy J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-27 Dor Markush, Robert D. Ross, Ronald Thomas, Sanjeev Aggarwal
Background Patients with cardiomyopathy (CM) are at increased risk for pulmonary hypertension (PH). Data are lacking on the use of noninvasive PH measures by echocardiography in patients with CM. The aim of this study was to evaluate the correlation between Doppler-derived echocardiographic indices and catheterization-based measurement of pulmonary vascular resistance (PVR) in children and young adults with CM. Methods Imaging studies were retrospectively reviewed from pediatric patients with CM who underwent both echocardiography and cardiac catheterization within a 72-hour period. The ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, the S/D ratio, and right ventricular myocardial performance index were correlated with invasive PVR. Receiver operating characteristic curves were developed to determine cutoffs for detecting PVR ≥ 6 indexed Wood units, a value associated with higher heart transplantation risk. Results Twenty-three patients with CM (median age, 11.7 years; range, 0.5–21 years) met the criteria for analysis, the majority (n = 17 [74%]) of whom had dilated CM. Linear regression showed significant correlations between echocardiography-based ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, S/D ratio, and right ventricular myocardial performance index versus invasive PVR (r = 0.84, r = 0.72, and r = 0.72, respectively, P < .001). All echocardiographic measures showed high sensitivity, specificity, and predictive values to detect PVR ≥ 6 indexed Wood units, with ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral demonstrating the highest area under the curve (0.958; 95% CI, 0.866–1). Conclusions Right-sided Doppler-derived echocardiographic indices correlate with PVR measured by cardiac catheterization in children and young adults with CM. These parameters may serve as useful adjuncts in serial assessment of right ventricular hemodynamics in this population.
Hemodynamic Mechanisms of Exercise-Induced Pulmonary Hypertension in Patients with Lymphangioleiomyomatosis: The Role of Exercise Stress Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-28 Andrea Sonaglioni, Massimo Baravelli, Roberto Cassandro, Olga Torre, Davide Elia, Claudio Anzà, Sergio Harari
Background The pathogenesis of pulmonary hypertension (PH) in lymphangioleiomyomatosis (LAM) has not yet been completely clarified. The aim of this study was to conduct a noninvasive evaluation of the main hemodynamic mechanisms of exercise-induced PH in patients with LAM, assessed using exercise stress echocardiography. Methods Fifteen patients with LAM (mean age, 47 ± 13 years; all women) without resting PH were enrolled in a prospective single-center study and compared with 15 healthy female control subjects (mean age, 45.2 ± 8 years; P = .65). A complete echocardiographic study with Doppler tissue imaging was performed at baseline and during semisupine symptom-limited exercise testing to evaluate (1) left ventricular systolic and diastolic function, (2) right ventricular contractile function, (3) estimated pulmonary capillary wedge pressure, (4) estimated systolic and mean pulmonary artery pressure, and (5) estimated pulmonary vascular resistance. Results Compared with healthy control subjects, patients with LAM during exercise showed echocardiographic signs of right ventricular overload and right ventricular systolic dysfunction and significant increases in mean pulmonary artery pressure (14.4 ± 6.5 vs 4.2 ± 3.1 mm Hg, P < .0001), pulmonary vascular resistance (+68.3 ± 42.1 vs −0.1 ± 18.3 dyne-sec/cm5, P < .0001), and, unexpectedly, pulmonary capillary wedge pressure (+8.3 ± 5.3 vs −0.5 ± 1.3 mm Hg, P < .0001). Conclusions Exercise-induced PH in patients with LAM could be related not only to hypoxic pulmonary vascular vasoconstriction during exercise (precapillary PH) but also to a significant exercise-induced increase in estimated pulmonary capillary wedge pressure, probably secondary to diastolic dysfunction (postcapillary PH).
Apical Transverse Motion Is Associated with Interventricular Mechanical Delay and Decreased Left Ventricular Function in Children with Dilated Cardiomyopathy J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-29 Wei Hui, Cameron Slorach, Mark K. Friedberg
Background Apical transverse motion (ATM) is associated with electromechanical dyssynchrony in adult dilated cardiomyopathy (DCM). Bundle branch block electromechanical dyssynchrony is uncommon in pediatric DCM, but ATM and its association with ventricular function have not been characterized. Methods Fifty-six children with DCM were retrospectively studied. Using echocardiography, ATM was assessed visually and by speckle-tracking longitudinal displacement of the interventricular septal and left ventricular (LV) lateral walls in opposite directions. Doppler tissue imaging–derived displacement and velocities were used to time the onset and peak LV and right ventricle motion, from which intra- and interventricular delays were calculated to assess their association with ATM. The timing of aortic valve opening and closure in relation to onset and peak LV displacement was used as a measure of LV mechanical efficiency. Results LV ATM was observed in 35 of 56 patients (62.5%), occurring in two patterns: 45% had ATM (interventricular septum displacing toward the lateral wall and lateral wall displacing toward the mitral annulus during systole), and 18% showed reverse ATM (r-ATM; lateral wall displaced toward the apex and interventricular septum displaced toward the septal annulus during systole). Both patterns were associated with increased interventricular but not intraventricular mechanical delay (controls: 2 msec, ATM 16 msec, r-ATM 8 msec, both P < .05 vs control subjects). Patients with ATM or r-ATM had lower LV ejection fractions (19% vs 29%, P < .05) and higher mechanical inefficiency compared with those without ATM. Survival was not statistically different in those with ATM or r-ATM compared with those without ATM or r-ATM. Conclusions In pediatric DCM, ATM is associated with LV dysfunction, mechanical inefficiency, and interventricular mechanical delay.
Dynamic Myocardial Response to Exercise in Childhood Cancer Survivors Treated with Anthracyclines J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-31 Barbara Cifra, Ching Kit Chen, Chun-Po S. Fan, Cameron Slorach, Cedric Manlhiot, Brian W. McCrindle, Andreea Dragulescu, Andrew N. Redington, Mark K. Friedberg, Paul C. Nathan, Luc Mertens
Background Anthracycline cardiotoxicity can cause significant long-term morbidity in childhood cancer survivors (CCS), but many CCS do not manifest clinical symptoms until adulthood. The aims of this study were to characterize the dynamic myocardial response to exercise of CCS at long-term follow-up by combining semisupine bicycle exercise stress echocardiography with myocardial imaging techniques and to establish whether semisupine bicycle exercise stress echocardiography could identify CCS with abnormal exercise response. Methods This was a single-center prospective cross-sectional study. One hundred CCS and 51 control subjects underwent semisupine bicycle exercise stress echocardiography. Color Doppler tissue imaging peak systolic (s′) and diastolic (e′) velocities, myocardial acceleration during isovolumic contraction, and longitudinal strain were measured at rest and at incremental heart rates in the left ventricular (LV) lateral wall, basal septum, and right ventricle. The relationship with increasing heart rate was evaluated for each parameter by plotting the values against heart rate at each stage of exercise. Kernel density estimate was used to establish the normality of the individual CCS exercise responses. Results At rest, no significant differences were found for LV lateral wall, right ventricular (RV), and basal septal systolic and diastolic velocities between CCS and control subjects. Only septal e′ was lower in CCS. LV longitudinal strain was similar between groups, while RV longitudinal strain was lower in CCS. At peak exercise, LV lateral wall, RV, and septal s′ were not different between groups, while e′ were significantly lower in CCS. LV lateral wall and septal isovolumic acceleration were also reduced in CCS. LV longitudinal strain was different between groups, while RV longitudinal strain was similar. The dynamic response of Doppler tissue imaging velocities, isovolumic acceleration, and strain was similar between CCS and control subjects. Kernel density estimate analysis confirmed that most CCS responses were within the normal range. Conclusions At 10-year follow-up, anthracycline-treated CCS with normal baseline ejection fractions have LV and RV systolic and diastolic myocardial exercise response comparable with that of control subjects. Minor differences were observed between CCS and control subjects at rest and at peak exercise, but the dynamic response is within the normal range.
High Prevalence of Clinically Important Echocardiographic Abnormalities in Patients with a Normal Electrocardiogram Referred for Transthoracic Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-05-31 Jeremy R. Stone, Linda Lee, Jack P. Ward, R. Parker Ward
Background Normal electrocardiographic (ECG) results have been reported to be associated with a low prevalence of structural heart disease and thus may preclude the need for transthoracic echocardiographic (TTE) imaging. The goal of this study was to determine the prevalence of important TTE abnormalities in patients with a normal ECG referred for TTE imaging. Methods Consecutive electrocardiograms over 6 months were reviewed. Patients with a normal ECG who underwent TTE imaging within 30 days formed the study group. TTE indication and appropriateness designation were determined. TTE findings were noted, including a composite, “major TTE abnormalities” (Maj TTE ABNs). Results Of 26,254 electrocardiograms reviewed, 3,955 (15%) were normal, 522 with qualifying TTE studies. Maj TTE ABNs were common (27%). The most common TTE indication was signs or symptoms of congestive heart failure (17%), 35% of which had Maj TTE ABNs. Two echocardiographic indications were found to have significantly fewer of Maj TTE ABNs: palpitations (4%, P < .01) and preoperative evaluation before noncardiac surgery (6%, P < .01). A majority of TTE studies were appropriate (76%), with only 14% rarely appropriate. Maj TTE ABNs were less common in rarely appropriate compared with appropriate TTE studies (13% vs 30%, P < .01), with a very low prevalence of Maj TTE ABNs in outpatient rarely appropriate TTE studies (4%). Conclusions Clinically important TTE abnormalities in patients with a normal ECG are common, suggesting that normal ECG results should not routinely preclude TTE imaging to identify structural heart disease. However, recognition of common clinical indications and application of the appropriate use criteria may identify patients with a normal ECG in whom TTE imaging is of very low yield.
Determinants of Physician, Sonographer, and Laboratory Productivity: Analysis of the Third Survey from the American Society of Echocardiography Committee on Pediatric Echocardiography Laboratory Productivity J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-05-31 Brian D. Soriano, Craig E. Fleishman, Andrea M. Van Hoever, Bonnie Wright, Beth Printz, Theresa A. Tacy, Vivekanand Allada, Wyman W. Lai, Sujatha Buddhe, Shubhika Srivastava
Background The American Society of Echocardiography Committee on Pediatric Echocardiography Laboratory Productivity was formed in 2011 to study institutional factors that could influence the clinical productivity of physicians and sonographers in academic pediatric echocardiography laboratories. In the previous two surveys, staff clinical productivity remained stable while total echocardiography volumes increased. This third survey was designed to assess how clinical productivity is associated with laboratory infrastructure elements such as training, administrative tasks, quality improvement, research, and use of focused cardiac ultrasound (FCU). Methods Survey questions were sent by e-mail to North American laboratories. The aims were to assess (1) educational and training obligations, (2) academic productivity and research, (3) laboratory medical director satisfaction, (4) quality improvement, (5) laboratory leadership roles, and (6) impact and use of FCU. Survey responses were compared with clinical productivity metrics defined in the first two surveys. Results There were 38 responses. Academic productivity was higher at institutions with more dedicated imaging personnel, personnel with dedicated protected academic time, and advanced imaging fellows. Academic productivity did not correlate with clinical productivity and was not significantly affected by the presence of dedicated research sonographers. The satisfaction level of laboratory medical directors was related to dedicated administrative time and an administrative stipend. The majority of administrative roles were tasked to the laboratory medical director with support of the technical director. FCU was listed as a hospital privilege at four institutions (13%). Twenty-two (58%) were training FCU providers in one or more subspecialties. FCU was not associated with clinical or academic productivity. Conclusion This third survey gathered supplemental data to complement the clinical productivity data collected from the first two surveys. Together, the results of these surveys further describe the range of factors that can affect North American academic pediatric echocardiography laboratories.
Evaluation of the Integrative Algorithm for Grading Chronic Aortic and Mitral Regurgitation Severity Using the Current American Society of Echocardiography Recommendations: To Discriminate Severe from Moderate Regurgitation J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-05-31 Sinsia A. Gao, Christian L. Polte, Kerstin M. Lagerstrand, Åse A. Johnsson, Odd Bech-Hanssen
Background The recently published integrative algorithms for echocardiographic grading of native aortic regurgitation (AR) and mitral regurgitation (MR) by the American Society of Echocardiography are consensus based and have not been evaluated. Thus, the aims of the present study were to investigate the feasibility of individual parameters and to evaluate the ability of the algorithms to discriminate severe from moderate regurgitation. Methods This prospective study comprised 93 patients with chronic AR (n = 45) and MR (n = 48). All patients underwent echocardiography and cardiovascular magnetic resonance within 4 hours. The algorithms were evaluated using two different definitions for severe regurgitation: (1) a cardiovascular magnetic resonance standard indicating future need for valve surgery and (2) a clinical standard using patients who underwent valve surgery with proven postoperative left ventricular reverse remodeling and improved functional class (AR/MR, n = 26/26). Results The feasibility of the criteria in the first step of the algorithm was higher (AR/MR, 95%/91%) compared with the second step using quantitative Doppler parameters (74%/57%). For the AR algorithm, sensitivity was 95% and specificity 44%, whereas for the MR algorithm, sensitivity was 73% and specificity 92%. Among patients with benefit of surgery, the algorithms correctly identified 77%, misclassified 8%, and were inconclusive in 15% of the patients with AR; the corresponding figures were 73%, 15%, and 12% in the patients with MR. Conclusions Using cardiovascular magnetic resonance as reference, the recommended algorithms for grading of regurgitation have the ability to rule out severe AR and rule in severe MR. The quantitative Doppler methods are hampered by feasibility issues, and our findings suggest that the decision regarding surgical intervention in symptomatic patients with discordant or inconclusive echocardiographic grading should be based on a consolidated assessment of clinical and multimodality findings.
Left Atrial Function Is Associated with Earlier Need for Cardiac Surgery in Moderate to Severe Mitral Regurgitation: Usefulness in Targeting for Early Surgery J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-05-24 Liam Ring, Yasir Abu-Omar, Nikki Kaye, Bushra S. Rana, William Watson, David P. Dutka, Vassilios S. Vassiliou
Background The aim of this study was to determine whether assessment of left atrial (LA) function helps identify patients at risk for early deterioration during follow-up with mitral valve prolapse and mitral regurgitation. Methods Patients with moderate to severe mitral regurgitation but no guideline-based indications for surgery were retrospectively identified from a dedicated clinical database. Maximal and minimal LA volumes were used to derive total LA emptying fraction ([maximal LA volume − minimal LA volume]/maximal L volume × 100%). Average values of peak contractile, conduit, and reservoir strain were obtained using two-dimensional speckle-tracking imaging. The study outcome was time to mitral surgery. Results One hundred seventeen patients were included; median follow-up was 18 months. Sixty-eight patients underwent surgery. Receiver operating characteristic curves were used to derive optimal cutoffs for TLAEF (>50.7%) and strain (reservoir, >28.5%; contractile, >12.5%). Using Cox analysis, TLAEF and contractile, reservoir, and conduit strain were univariate predictors of time to event. After multivariate analysis, TLAEF (hazard ratio, 2.59; P = .001), reservoir strain (hazard ratio, 3.06; P < .001), and contractile strain (hazard ratio, 2.01; P = .022) remained independently associated with events, but conduit strain did not. Using Kaplan-Meier curves, event-free survival was considerably improved in patients with values above the derived thresholds (TLAEF: 1-year survival, 78 ± 5% vs 28 ± 8%; 3-year survival, 68 ± 6% vs 13 ± 5%; P < .001 for both; reservoir strain: 1-year survival, 79 ± 5% vs 29 ± 7%; 3-year survival, 67 ± 6% vs 15 ± 6%; P < .001 for both; contractile strain: 1-year survival, 80 ± 5% vs 41 ± 7%; 3-year survival, 69 ± 6% vs 24 ± 6%; P < .001 for both). Conclusion LA function is independently associated with surgery-free survival in patients with mitral valve prolapse and moderate to severe mitral regurgitation. Quantitative assessment of LA function may have clinical utility in guiding early surgical intervention in these patients.
A Preliminary Study of Left Ventricular Rotational Mechanics in Children with Noncompaction Cardiomyopathy: Do They Influence Ventricular Function? J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-04-13 Hythem M. Nawaytou, Andrea E. Montero, Putri Yubbu, Renzo J.C. Calderón-Anyosa, Tomoyuki Sato, Matthew J. O'Connor, Kelley D. Miller, Philip C. Ursell, Julien I.E. Hoffman, Anirban Banerjee
Background Current diagnostic criteria for noncompaction cardiomyopathy (NCC) lack specificity, and the disease lacks prognostic indicators. Reverse apical rotation (RAR) with abnormal rotation of the cardiac apex in the same clockwise direction as the base has been described in adults with NCC. The aim of this study was to test the hypothesis that RAR might differentiate between symptomatic NCC and benign hypertrabeculations and might be associated with ventricular dysfunction. Methods Echocardiograms from 28 children with NCC without cardiac malformations were prospectively compared with those from 29 age-matched normal control subjects. A chart review was performed to identify the patients’ histories and clinical characteristics. Speckle-tracking was used to measure longitudinal strain, circumferential strain, and rotation. Results RAR occurred in 39% of patients with NCC. History of left ventricular (LV) dysfunction or arrhythmia was universal in, but not exclusive to, patients with RAR. Patients with RAR had lower LV longitudinal strain but similar ejection fractions compared with patients without RAR (median, -15.6% [interquartile range, -12.9% to -19.3%] vs -19% [interquartile range, -14.5% to -21.9%], P < .01; 53% [interquartile range, 43% to 68%] vs 61% [interquartile range, 58% to 67%], P = .08). Only a pattern of contraction with RAR, early arrest of twisting by mid-systole, and premature untwisting was associated with lower ejection fraction (46%; interquartile range, 43% to 52%; P = .006). Conclusions RAR is not a sensitive but is a specific indicator of complications in children with NCC. Therefore, RAR may have prognostic rather than diagnostic value. Premature untwisting of the left ventricle during ejection may be an even more worrisome indicator of LV dysfunction.
Reduced Right Ventricular Fractional Area Change, Strain, and Strain Rate before Bidirectional Cavopulmonary Anastomosis is Associated with Medium-Term Mortality for Children with Hypoplastic Left Heart Syndrome J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-04-12 Lily Q. Lin, Jennifer Conway, Silvia Alvarez, Benjamin Goot, Jesus Serrano-Lomelin, Timothy Colen, Edythe B. Tham, Shelby Kutty, Ling Li, Nee Scze Khoo
Background Ventricular dysfunction is associated with increased morbidity and mortality in children with hypoplastic left heart syndrome. The aim of this study was to assess the diagnostic performance of conventional and speckle-tracking echocardiographic measures of right ventricular (RV) function before bidirectional cavopulmonary anastomosis palliation in predicting death or need for heart transplantation (HTx). Methods RV fractional area change (RVFAC) and longitudinal and circumferential strain and strain rate (SR) were measured in 64 prospectively recruited patients with hypoplastic left heart syndrome from echocardiograms obtained before bidirectional cavopulmonary anastomosis surgery. The composite end point of death or HTx was examined. Receiver operating characteristic analysis was performed, and cutoff values optimizing sensitivity and specificity were derived. Results At a median follow-up of 5.0 years (interquartile range, 2.8–6.4 years), 13 patients meeting the composite end point had lower longitudinal strain and SR, circumferential SR, and RVFAC compared with survivors (n = 51). The conventional cutoff of RVFAC < 35% was specific for death or HTx (86%) but had poor sensitivity (46%), with an area under the curve of 0.73. Speckle-tracking echocardiographic variables showed similar areas under the curve (range, 0.69–0.79), with negative predictive values >90%. Addition of speckle-tracking echocardiographic variables to RVFAC < 35% showed no added benefit. However, in a subpopulation of patients with RVFAC ≥ 35% (n = 44), those meeting the composite end point (n = 7) had lower longitudinal SR (median, −1.0 1/sec [interquartile range, −0.8 to −1.1 1/sec] vs −1.21/sec [interquartile range, −1.0 to −1.3 1/sec], P = .03). Interobserver reproducibility was superior for longitudinal strain and SR (intraclass correlation coefficient > 0.92) compared with RVFAC (intraclass correlation coefficient = 0.75). Conclusions Children with hypoplastic left heart syndrome with normal RVFAC and ventricular deformation before bidirectional cavopulmonary anastomosis have a low likelihood of death or HTx in the medium term. In the presence of reduced RVFAC, speckle-tracking echocardiography does not provide additional prognostic value. However, in patients with “normal” RVFAC, it may have a role in improving outcome prediction and warrants further investigation.
Longitudinal Changes in Right Ventricular Function in Tetralogy of Fallot in the Initial Years after Surgical Repair J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-04-04 Michael P. DiLorenzo, Okan U. Elci, Yan Wang, Anirban Banerjee, Tomoyuki Sato, Bonnie Ky, Elizabeth Goldmuntz, Laura Mercer-Rosa
Background Right ventricular (RV) dysfunction is associated with adverse long-term outcomes in patients with tetralogy of Fallot. Little is known about RV function in the first years after surgical repair. The aim of this study was to investigate perioperative changes in myocardial deformation using global longitudinal strain. Methods A retrospective analysis of patients with surgically repaired tetralogy of Fallot was performed. Global longitudinal peak systolic RV strain was measured on early postoperative echocardiograms, two subsequent postoperative echocardiograms through 2 years postoperatively, and preoperative echocardiograms, when available. Preoperative and late follow-up strain was compared with strain in 0- to 8-month-old and 1- to 4-year-old control subjects, respectively. Results Forty-seven patients were included. Compared with postoperative strain (7 ± 7 days postoperatively), strain at follow-up 1 (8.3 ± 4 months postoperatively) was significantly improved (−12.3 ± 3.3% vs −18.8 ± 2.5%, P < .001), with no additional improvement 23.2 ± 6 months postoperatively (−18.8 ± 2.5% vs −19.8 ± 3.1%, P = .12). Postoperative strain was worse than preoperative strain (n = 25, −12.5 ± 3.6% vs −18.4 ± 2.9%, P < .001). Compared with control subjects, preoperative strain was similar (−19.3 ± 3.8% vs −18.4 ± 2.9%, P = .30), though late follow-up strain was significantly worse (−27.7 ± 2.8% vs −19.8 ± 3.1%, P < .001). Conclusions RV global longitudinal strain worsens in the early postoperative period following surgical repair of tetralogy of Fallot but recovers through 2 postoperative years. Despite recovery to preoperative values, the presence of RV dysfunction compared with control subjects suggests that long-term dysfunction may begin early. The trajectory of RV dysfunction through the later years needs further study.
Integration of Wall Motion, Coronary Flow Velocity, and Left Ventricular Contractile Reserve in a Single Test: Prognostic Value of Vasodilator Stress Echocardiography in Patients with Diabetes J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-04-03 Lauro Cortigiani, Alda Huqi, Quirino Ciampi, Tonino Bombardini, Francesco Bovenzi, Eugenio Picano
Background Coronary flow velocity reserve (CFVR) and left ventricular contractile reserve (LVCR) have demonstrated prognostic importance in patients with diabetes. The aim of this study was to investigate the prognostic contribution of combined evaluation of CFVR and LVCR in patients with diabetes with nonischemic stress echocardiography. Methods Three hundred seventy-five patients with diabetes (mean age, 68 ± 9 years) with nonischemic dipyridamole stress echocardiography underwent assessment of CFVR of the left anterior descending coronary artery (prospectively) and LVCR with left ventricular force (retrospectively) in a multicenter study. Results On receiver operating characteristic analysis, LVCR ≤ 1.1 was the best prognostic predictor and was considered an abnormal value. CFVR was abnormal (≤2) in 139 patients (37%), LVCR in 156 (42%), neither in 157 (42%), and both in 77 (21%). During a median follow-up period of 16 months, 86 major adverse cardiac events occurred: 16 deaths, 13 myocardial infarctions, and 57 revascularizations. Multivariate prognostic indicators were CFVR ≤ 2 (P < .0001), age (P = .03), and LVCR ≤ 1.1 (P = .04). The 3-year rate of major adverse cardiac events was 63% in patients with both abnormal CFVR and LVCR, 42% in those with abnormal CFVR only, 19% in those with abnormal LVCR only, and 10% in patients with both normal CFVR and LVCR. The 3-year hard event rate was 3% in patients with both normal CFVR and LVCR, fivefold higher in patients with abnormal CFVR or LVCR only, and ninefold higher in patients with both abnormal CFVR and LVCR. Conclusions Patients with diabetes with nonischemic dipyridamole stress echocardiography may still have significant risk in presence of abnormal CFVR and/or LVCR, which assess the underlying, largely unrelated, microvascular and myocardial components of coronary circulation.
Evaluation of Staff Radiation Exposure during Transthoracic Echocardiography Close to Myocardial Perfusion Imaging J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-04-03 Samia Massalha, Rachel Lugassi, Elyahu Raysberg, Amjad Koskosi, Gerson Lechtenberg, Ora Israel, John A. Kennedy
Background Transthoracic echocardiography (TTE) and myocardial perfusion imaging (MPI) are used in cardiac patients. In this study the radiation exposure of sonographers performing TTE following MPI was evaluated. Methods Of 40 study patients, 30 underwent same-day 99mTc sestamibi MPI and TTE, while another 10 underwent only TTE. Patients who underwent both studies were divided into three groups: right-handed TTE performed by an echocardiographer and right- and left-handed TTE performed by a cardiac sonographer. Seven thermoluminescent radiation dosimeter badges monitored the forehead, wrists, anterolateral right and left chest, sternal notch, and umbilical region of each examiner. Group characteristics were compared. Radiation exposures were deemed positive if >0.1 mSv. Results There were no statistical differences in patient weight and body mass index. The left-handed approach group had higher residual radioactivity (979 ± 73 vs 884 ± 73 MBq [P < .01] and 906 ± 81 MBq [P < .04]), but no statistical difference in duration of TTE, compared with the other two MPI groups. Radiation exposure was positive in the right anterolateral chest and hand (0.45 and 1 mSv, respectively) for the echocardiographer, the right anterolateral chest and wrist and umbilical region (0.59, 1.06, and 0.15 mSv, respectively) for the right-handed sonographer, and the left chest and hand (0.12 and 0.34 mSv, respectively) for the left-handed sonographer. Dosimeters indicated no radiation exposure in the TTE-only group. Conclusions Staff members performing TTE after MPI are exposed to radiation that might warrant monitoring. Altering study sequence, adopting a left-handed approach, and using other radiation-reducing techniques can minimize the degree of exposure.
Echocardiographic Assessment of Patients with Fabry Disease J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-29 Darwin F. Yeung, Sandra Sirrs, Michael Y.C. Tsang, Kenneth Gin, Christina Luong, John Jue, Parvathy Nair, Pui K. Lee, Teresa S.M. Tsang
Fabry disease is an X-linked lysosomal storage disorder that results from a deficiency of α-galactosidase A. Increased left ventricular wall thickness has been the most commonly described cardiovascular manifestation of the disease. However, a variety of other structural and functional abnormalities have also been reported. Echocardiography is an effective noninvasive method of assessing the cardiac involvement of Fabry disease. A more precise and comprehensive characterization of Fabry cardiomyopathy using conventional and novel echocardiographic techniques may lead to earlier diagnosis, more accurate prognostication, and timely treatment. The aim of this review is to provide a comprehensive overview of the structural and functional abnormalities on echocardiography that have thus far been described in patients with Fabry disease and to highlight potential areas that would benefit from further research.
Real-Time Three-Dimensional Echocardiography of the Left Ventricle—Pediatric Percentiles and Head-to-Head Comparison of Different Contour-Finding Algorithms: A Multicenter Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-28 Kristina Krell, Kai Thorsten Laser, Robert Dalla-Pozza, Christian Winkler, Ursula Hildebrandt, Deniz Kececioglu, Johannes Breuer, Ulrike Herberg
Background Real-time three-dimensional echocardiography (RT3DE) is a promising method for accurate assessment of left ventricular (LV) volumes and function, however, pediatric reference values are scarce. The aim of the study was to establish pediatric percentiles in a large population and to compare the inherent influence of different evaluation software on the resulting measurements. Methods In a multicenter prospective-design study, 497 healthy children (ages 1 day to 219 months) underwent RT3DE imaging of the LV (ie33, Philips, Andover, MA). Volume analysis was performed using QLab 9.0 (Philips) and TomTec 4DLV2.7 (vendor-independent; testing high (TomTec75) and low (TomTec30) contour-finding activity). Reference percentiles were computed using Cole's LMS method. In 22 subjects, cardiovascular magnetic resonance imaging (CMR) was used as the reference. Results A total of 370/497 (74.4%) of the subjects provided adequate data sets. LV volumes had a significant association with age, body size, and gender; therefore, sex-specific percentiles were indexed to body surface area. Intra- and interobserver variability for both workstations was good (relative bias ± SD for end-diastolic volume [EDV] in %: intraobserver: QLab = −0.8 ± 2.4; TomTec30 = −0.7 ± 7.2; TomTec75 = −1.9 ± 6.7; interobserver: QLab = 2.4 ± 7.5; TomTec30 = 1.2 ± 5.1; TomTec75 = 1.3 ± 4.5). Intervendor agreement between QLab and TomTec30 showed larger bias and wider limits of agreement (bias: QLab vs TomTec30: end-systolic volume [ESV] = 0.8% ± 23.6%; EDV = −2.2% ± 17.0%) with notable individual differences in small children. QLab and TomTec underestimated CMR values, with the highest agreement between CMR and QLab. Conclusions RT3DE allows reproducible noninvasive assessment of LV volumes and function. However, intertechnique variability is relevant. Therefore, our software-specific percentiles, based on a large pediatric population, serve as a reference for both commonly used quantification programs.
Vasodilator Stress Single-Photon Emission Computed Tomography or Contrast Stress Echocardiography Association with Hard Cardiac Events in Suspected Coronary Artery Disease J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-24 Nicola Gaibazzi, Carmine Siniscalchi, Thomas R. Porter, Antonio Crocamo, Manuela Basaglia, Francesca Boffetti, Valentina Lorenzoni
Background We compared the long-term outcome of subjects without prior cardiac disease who underwent either vasodilator single-photon emission computed tomography (SPECT) or contrast stress-echocardiography (cSE) for suspected coronary artery disease (CAD). Methods Subjects who underwent vasodilator SPECT or cSE between 2008 and 2012 for suspected CAD but no history of cardiac disease were included. We retrospectively compared the association of each method with combined all-cause death and nonfatal myocardial infarction and their positive predictive value (PPV) for angiographically obstructive CAD. Results A total of 1,387 subjects were selected: 497 who underwent SPECT and 890 who underwent cSE. During 4 years of mean follow-up there were 78 hard events in the cSE group and 51 in the SPECT group. Event-free survival in subjects testing positive for ischemia, either with SPECT or cSE, was significantly worse both in the overall population and after propensity matching patients. In multivariable analyses, vasodilator SPECT or cSE demonstrated significant stratification capability with an ischemic test doubling (SPECT) or more than doubling (cSE) the risk of future hard events independently from other variables. PPV of vasodilator SPECT for the diagnosis of obstructive CAD was inferior to vasodilator cSE (PPV = 63% vs 89%, respectively; P < .001). Conclusions Our study suggests that the associations of vasodilator SPECT or cSE with outcome are comparable, with cSE demonstrating better diagnostic PPV for CAD. The absence of ionizing radiation and anticipated lower costs from higher PPV suggest that vasodilator cSE is a valid alternative to vasodilator SPECT as a gatekeeper in subjects without a prior history of CAD.
Fusion of Three-Dimensional Echocardiographic Regional Myocardial Strain with Cardiac Computed Tomography for Noninvasive Evaluation of the Hemodynamic Impact of Coronary Stenosis in Patients with Chest Pain J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-22 Victor Mor-Avi, Mita B. Patel, Francesco Maffessanti, Amita Singh, Diego Medvedofsky, S. Javed Zaidi, Anuj Mediratta, Akhil Narang, Noreen Nazir, Nadjia Kachenoura, Roberto M. Lang, Amit R. Patel
Background Combined evaluation of coronary stenosis and the extent of ischemia is essential in patients with chest pain. Intermediate-grade stenosis on computed tomographic coronary angiography (CTCA) frequently triggers downstream nuclear stress testing. Alternative approaches without stress and/or radiation may have important implications. Myocardial strain measured from echocardiographic images can be used to detect subclinical dysfunction. The authors recently tested the feasibility of fusion of three-dimensional (3D) echocardiography–derived regional resting longitudinal strain with coronary arteries from CTCA to determine the hemodynamic significance of stenosis. The aim of the present study was to validate this approach against accepted reference techniques. Methods Seventy-eight patients with chest pain referred for CTCA who also underwent 3D echocardiography and regadenoson stress computed tomography were prospectively studied. Left ventricular longitudinal strain data (TomTec) were used to generate fused 3D displays and detect resting strain abnormalities (RSAs) in each coronary territory. Computed tomographic coronary angiographic images were interpreted for the presence and severity of stenosis. Fused 3D displays of subendocardial x-ray attenuation were created to detect stress perfusion defects (SPDs). In patients with stenosis >25% in at least one artery, fractional flow reserve was quantified (HeartFlow). RSA as a marker of significant stenosis was validated against two different combined references: stenosis >50% on CTCA and SPDs seen in the same territory (reference standard A) and fractional flow reserve < 0.80 and SPDs in the same territory (reference standard B). Results Of the 99 arteries with no stenosis >50% and no SPDs, considered as normal, 19 (19%) had RSAs. Conversely, with stenosis >50% and SPDs, RSAs were considerably more frequent (17 of 24 [71%]). The sensitivity, specificity, and accuracy of RSA were 0.71, 0.81, and 0.79, respectively, against reference standard A and 0.83, 0.81, and 0.82 against reference standard B. Conclusions Fusion of CTCA and 3D echocardiography–derived resting myocardial strain provides combined displays, which may be useful in determination of the hemodynamic or functional impact of coronary abnormalities, without additional ionizing radiation or stress testing.
Stressing the Cardiopulmonary Vascular System: The Role of Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-21 Lawrence G. Rudski, Luna Gargani, William F. Armstrong, Patrizio Lancellotti, Steven J. Lester, Ekkehard Grünig, Michele D'Alto, Meriam Åström Aneq, Francesco Ferrara, Rajeev Saggar, Rajan Saggar, Robert Naeije, Eugenio Picano, Nelson B. Schiller, Eduardo Bossone
The cardiopulmonary vascular system represents a key determinant of prognosis in several cardiorespiratory diseases. Although right heart catheterization is considered the gold standard for assessing pulmonary hemodynamics, a comprehensive noninvasive evaluation including left and right ventricular reserve and function and cardiopulmonary interactions remains highly attractive. Stress echocardiography is crucial in the evaluation of many cardiac conditions, typically coronary artery disease but also heart failure and valvular heart disease. In stress echocardiographic applications beyond coronary artery disease, the assessment of the cardiopulmonary vascular system is a cornerstone. The possibility of coupling the left and right ventricles with the pulmonary circuit during stress can provide significant insight into cardiopulmonary physiology in healthy and diseased subjects, can support the diagnosis of the etiology of pulmonary hypertension and other conditions, and can offer valuable prognostic information. In this state-of-the-art document, the topic of stress echocardiography applied to the cardiopulmonary vascular system is thoroughly addressed, from pathophysiology to different stress modalities and echocardiographic parameters, from clinical applications to limitations and future directions.
Dobutamine Stress Echocardiography Unmasks Early Left Ventricular Dysfunction in Asymptomatic Patients with Uncomplicated Type 2 Diabetes: A Comprehensive Two-Dimensional Speckle-Tracking Imaging Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-08 Clothilde Philouze, Philippe Obert, Stéphane Nottin, Asma Benamor, Olivier Barthez, Falah Aboukhoudir
Background Discrepancies are present in the literature on resting myocardial mechanics in patients with uncomplicated type 2 diabetes mellitus (T2DM). Data are noticeably sparse regarding circumferential function and torsional mechanics. Resting deformation imaging may not be sensitive enough to detect subtle dysfunctions. The aim of this study was thus to comprehensively evaluate myocardial mechanics in patients with T2DM at rest and to investigate whether dobutamine stress echocardiography could unmask functional alterations that would remain otherwise subtle at rest. Methods Forty-four patients with T2DM and 35 healthy control subjects of similar age and sex were prospectively recruited. After conventional echocardiography, myocardial mechanics was evaluated at rest and during low-dose dobutamine stress echocardiography (target heart rate, 110 beats/min). Results Patients with T2DM presented with altered global diastolic function but preserved systolic function. Deformation imaging indexes were similar between groups at rest, but significant differences were noticed under dobutamine infusion for longitudinal strain (−21.2 ± 2.4% vs −24.2 ± 2.5%, P < .001), circumferential strain (apex, −32.3 ± 5.3% vs −36.3 ± 5.3%, P = .002; papillary muscle, −25.6 ± 3.2% vs −28.0 ± 3.6%, P = .001; base, −23.2 ± 3.6% vs −25.3 ± 3.8%, P = .03), apical (11.2 ± 4.4° vs 14.1 ± 6.3°, P = .020) and basal (−12.2 ± 3.3° vs −14.3 ± 3.9°, P = .021) rotation, and twist (21.9 ± 5.9° vs 26.8 ± 8.3°, P = .007). Multivariate analysis identified epicardial fat, dyslipidemia, and fasting glycaemia as significant contributors to the changes from rest to dobutamine. Conclusions These findings demonstrate the usefulness of dobutamine stress echocardiography in establishing impairments in myocardial mechanics in patients with uncomplicated T2DM. Systemic metabolic disturbances and epicardial fat act as the main contributors to the blunted response to dobutamine stress in these patients.
Normative Data for Left and Right Ventricular Systolic Strain in Healthy Caucasian Italian Children by Two-Dimensional Speckle-Tracking Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-08 Massimiliano Cantinotti, Marco Scalese, Raffaele Giordano, Eliana Franchi, Nadia Assanta, Marco Marotta, Cecilia Viacava, Sabrina Molinaro, Giorgio Iervasi, Giuseppe Santoro, Martin Koestenberger
Background There is an increasing interest in echocardiographic strain (ε) measurements for the assessment of ventricular myocardial function in children; however, pediatric nomograms remain limited. Our aim was to establish pediatric nomograms for the left ventricular (LV) and the right ventricular (RV) ε measured by two-dimensional speckle-tracking echocardiography (2D-STE) in a large cohort of healthy children prospectively enrolled. Methods Echocardiographic measurements included STE LV longitudinal and circumferential and RV longitudinal global end-systolic ε. Age, weight, height, heart rate (HR), and body surface area (BSA) were used as independent variables in different analyses to predict the mean values of each measurement. Echocardiograms were performed by Philips-iE33 systems (Philips, Bothell, WA) and offline measurements on Philips-Q-Lab-9. Results In all, 721 subjects (age 31 days to 17 years; 48% female) were studied. Low coefficients of determination (R2) were noted among all of the ε parameters evaluated and adjusted for age, weight, height, BSA, and HR (i.e., R2 all ≤ 0.10; range, 0.01-0.088). This hampered the possibility of performing z-scores with a sufficient reliability. Thus, we are limited to presenting data as mean values (±SD) stratified for age groups and divided by gender. LV longitudinal ε values decreased with age (P < .001), while no significant age-related variations were noted for RV longitudinal ε. A significant base-to-apex (lowest to highest) gradient in circumferential LV ε values was noted at all ages (P < .001). Conclusions We report pediatric echocardiographic normative data for 2D-STE for the LV and RV ε by using vendor-specific software. Our results confirm previous observations, showing only little variations of strain parameters with age and gender.
Prevalence and Predictive Value of Microvascular Flow Abnormalities after Successful Contemporary Percutaneous Coronary Intervention in Acute ST-Segment Elevation Myocardial Infarction J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-07 Sourabh Aggarwal, Feng Xie, Robin High, Gregory Pavlides, Thomas R. Porter
Background Although microvascular flow abnormalities have been observed following epicardial recanalization in acute ST-segment elevation myocardial infarction (STEMI), the prevalence and severity of these abnormalities in the current era of rapid percutaneous coronary intervention (PCI) has not been evaluated. The objective of this study was to assess microvascular perfusion (MVP) following successful primary PCI in patients with STEMI and how it affects clinical outcome. Methods In this single-center, retrospective study, 170 patients who successfully underwent emergent PCI for STEMI were assessed using real-time myocardial contrast echocardiography using a continuous infusion of intravenous commercial microbubbles (3% Definity). Three patterns of myocardial contrast replenishment were observed following intermittent high–mechanical index impulses: infarct zone replenishment within 4 sec (normal MVP), delays in contrast replenishment but normal plateau intensity (delayed MVP [dMVP]), and both delays in replenishment and reduced plateau intensity (microvascular obstruction [MVO]). Changes in left ventricular ejection fraction at 6 months and clinical event rate at 12 months (death, recurrent infarction, need for defibrillator placement, or heart failure admission) were compared. Results Normal MVP was seen in 62 patients (36%), dMVP in 49 (29%), and MVO in 59 (35%). Left anterior descending coronary artery infarct location was the only parameter independently associated with dMVP or MVO, independent of age, cardiac risk factors, door-to-dilation time, pre-PCI Thrombolysis In Myocardial Infarction flow grade, and thrombus burden. A dMVP pattern had a similar reduction in left ventricular ejection fraction as MVO at hospital discharge but had recovery of left ventricular ejection fraction at 6 months and a greater than fourfold lower event rate than the MVO group (P < .001). Conclusions MVO and dMVP are frequently seen following contemporary successful PCI for STEMI, especially following left anterior descending coronary artery infarction. Despite a similar area at risk, a dMVP pattern has better functional recovery and clinical outcome than MVO.
Right Ventricular Longitudinal Strain Reproducibility Using Vendor-Dependent and Vendor-Independent Software J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-07 Zachary J. Il’Giovine, Hillary Mulder, Karen Chiswell, Kristine Arges, Jennifer Tomfohr, Abraham Hashmi, Eric J. Velazquez, Joseph A. Kisslo, Zainab Samad, Sudarshan Rajagopal
Background Right ventricular peak systolic longitudinal strain (RVLS) has emerged as an approach for quantifying right ventricular function in diseases such as pulmonary hypertension and congenital heart disease. A major limitation in applying RVLS is that strain imaging and analysis are proprietary, which may result in systematic differences from vendor to vendor. The goal of this study was to test the reproducibility of right ventricular strain analysis among selected vendor-specific software (VSS) and vendor-independent software (VIS) on images obtained from different ultrasound scanners, as would be common in clinical practice or in a multicenter clinical trial. Methods In this prospective, single-center study, 35 patients (5 healthy subjects and 30 with pulmonary hypertension) each underwent two echocardiographic scans, one using GE (Vivid E9) and the other using Philips (iE33) ultrasound systems. Images were analyzed using both VSS and VIS (TomTec) software for determination of RVLS. A repeated-measures analysis of variance was used to assess for any systematic differences among methods, as well as effects of scanner and software and a possible interaction between scanner and software for each strain measurement. Results Differences for global strains were not statistically significant among VSS packages (P ≥ .05), but some differences were noted between VSS and VIS. Wide variability between regional peak strain measurements was noted, but no systematic differences were found. Conclusions Global RVLS values between VSS systems are not significantly different but may differ slightly from VIS. When comparing regional strain between VSS and VIS analyses, there is widespread variability without clear systematic differences.
Transcatheter Mitral Valve Repair Using the Edge-to-Edge Clip J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-01 Charles B. Nyman, G. Burkhard Mackensen, Srdjan Jelacic, Stephen H. Little, Thomas W. Smith, Feroze Mahmood
Percutaneous intervention for mitral valve (MV) disease has been established as an alternative to open surgical MV repair in patients with prohibitive surgical risk. Multiple percutaneous approaches have been described and are in various stages of development. Edge-to-edge leaflet plication with the MitraClip (Abbott, Menlo Park, CA) is currently the only Food and Drug Administration-approved device specifically for primary or degenerative lesions. Use of the edge-to-edge clip for secondary mitral regurgitation is currently under investigation and may result in expanded indications. Echocardiography has significantly increased our understanding of the anatomy of the MV and provided us with the ability to classify and quantify the associated mitral regurgitation. For percutaneous interventions of the MV, transesophageal echocardiography imaging is used for patient screening, intraprocedural guidance, and confirmation of the result. Optimal outcomes require the echocardiographer and the proceduralist to have a thorough understanding of intra-atrial septal and MV anatomy, as well as an appreciation for the key points and potential pitfalls of each of the procedural steps. With increasing experience, more complex valvular pathology can be successfully percutaneously treated. In addition to two-dimensional echocardiography, advances in three-dimensional echocardiography and fusion imaging will continue to support the refinement of current technologies, the expansion of clinical applications, and the development of novel devices.
Role of Doppler Diastolic Parameters in Differentiating Physiological Left Ventricular Hypertrophy from Hypertrophic Cardiomyopathy J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-03-01 Gherardo Finocchiaro, Harshil Dhutia, Andrew D'Silva, Aneil Malhotra, Nabeel Sheikh, Rajay Narain, Bode Ensam, Stathis Papatheodorou, Maite Tome, Rajan Sharma, Michael Papadakis, Sanjay Sharma
Background The association between athletic participation and alteration in diastolic function is not well established. The aims of this study were to determine the spectrum of Doppler parameters of left ventricular (LV) diastolic function in a large cohort of healthy athletes and to quantify the overlap between physiologic LV hypertrophy and hypertrophic cardiomyopathy (HCM). Methods A retrospective analysis of indices of LV diastolic function was performed in 1,510 healthy athletes (mean age, 22 ± 5 years; range, 13-33 years; 72% men). The results were compared with those from 58 young patients with HCM. Results Septal E′ < 7 cm/sec and lateral E′ < 10 cm/sec were found in five (0.3%) and eight (0.5%) athletes, respectively. Septal E′ was >14.6 cm/sec in 170 (11%) and lateral E′ was >19.9 cm/sec in 430 (28%) athletes. Athletes aged >25 years showed lower E′ velocities compared with younger athletes (mean septal E′, 11.8 ± 6.1 vs 12.9 ± 5.9 cm/sec [P < .001]; mean lateral E′, 17.1 ± 3.6 vs 19.3 ± 4.1 cm/sec [P < .001]). Athletes with high indexed LV end-diastolic diameters (>32 mm/m2) exhibited lower septal E′ compared with athletes with normal indexed LV end-diastolic diameters (mean septal E′, 11.9 ± 6 vs 12.7 ± 6 cm/sec; P = .002). Septal E′ < 10 cm/sec and lateral E′ < 12 cm/sec showed the best accuracy in differentiating between HCM and athlete's heart. Conclusions Reduced septal and lateral E′ are rarely observed in young elite athletes. Tissue Doppler velocities tend to decrease with increasing age and LV size, and values representative of supernormal diastolic function are found in less than one-third of young athletes. Cutoff thresholds for Doppler parameters of diastolic function should be corrected for multiple demographic and clinical variables to differentiate cardiac adaptation to exercise from HCM in young individuals.
Unidimensional Longitudinal Strain: A Simple Approach for the Assessment of Longitudinal Myocardial Deformation by Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) 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.
Morphologic Analysis of the Normal Right Ventricle Using Three-Dimensional Echocardiography–Derived Curvature Indices J. Am. Soc. Echocardiog. (IF 6.827) 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.
Relationship Between Proximal Aorta Morphology and Progression Rate of Aortic Stenosis J. Am. Soc. Echocardiog. (IF 6.827) 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.
Utility of Left Atrial Expansion Index and Stroke Volume in Management of Chronic Systolic Heart Failure J. Am. Soc. Echocardiog. (IF 6.827) 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.
Rest and Stress Longitudinal Systolic Left Ventricular Mechanics in Hypertrophic Cardiomyopathy: Implications for Prognostication J. Am. Soc. Echocardiog. (IF 6.827) 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.
Contrast-Enhanced Echocardiography Has the Greatest Impact in Patients with Reduced Ejection Fractions J. Am. Soc. Echocardiog. (IF 6.827) 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.
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 6.827) 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.
Transcatheter Tricuspid Valve-in-Valve Intervention for Degenerative Bioprosthetic Tricuspid Valve Disease J. Am. Soc. Echocardiog. (IF 6.827) 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.
Mitral Effective Regurgitant Orifice Area Predicts Pulmonary Artery Pressure Level in Patients with Aortic Valve Stenosis J. Am. Soc. Echocardiog. (IF 6.827) 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.
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