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 6.852) 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 6.852) 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 6.852) 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 6.852) 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.
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 6.852) 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
Background Treatment 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. Methods Two 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. Results Mean 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. Conclusions In patients with CFVR > 2 of the intermediate nonculprit coronary lesion, deferral of revascularization is safe and associated with excellent long-term clinical outcomes.
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 6.852) 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 6.852) 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.
Dynamic Myocardial Response to Exercise in Childhood Cancer Survivors Treated with Anthracyclines J. Am. Soc. Echocardiog. (IF 6.852) 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.
Apical Transverse Motion Is Associated with Interventricular Mechanical Delay and Decreased Left Ventricular Function in Children with Dilated Cardiomyopathy J. Am. Soc. Echocardiog. (IF 6.852) 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.
Echocardiographic Assessment of Patients with Fabry Disease J. Am. Soc. Echocardiog. (IF 6.852) 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 6.852) 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.
Hemodynamic Mechanisms of Exercise-Induced Pulmonary Hypertension in Patients with Lymphangioleiomyomatosis: The Role of Exercise Stress Echocardiography J. Am. Soc. Echocardiog. (IF 6.852) 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).
Noninvasive Echocardiographic Measures of Pulmonary Vascular Resistance in Children and Young Adults with Cardiomyopathy J. Am. Soc. Echocardiog. (IF 6.852) 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.
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 6.852) 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.
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 6.852) 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.
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 6.852) 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.
Standardized Goal-Directed Valsalva Maneuver for Assessment of Inducible Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy J. Am. Soc. Echocardiog. (IF 6.852) 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.
Stressing the Cardiopulmonary Vascular System: The Role of Echocardiography J. Am. Soc. Echocardiog. (IF 6.852) 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.
Left-Sided Atrial Septal Pouch is a Risk Factor for Cryptogenic Stroke J. Am. Soc. Echocardiog. (IF 6.852) 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.
Doppler Echocardiography Assessment of Aortic Stiffness in Female Adolescents with Anorexia Nervosa J. Am. Soc. Echocardiog. (IF 6.852) 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.
Cardiac Point-of-Care Ultrasound: State of the Art in Medical School Education J. Am. Soc. Echocardiog. (IF 6.852) 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.
Left Ventricular Mechanical Dispersion and Global Longitudinal Strain and Ventricular Arrhythmias in Predialysis and Dialysis Patients J. Am. Soc. Echocardiog. (IF 6.852) 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.
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 6.852) 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 6.852) 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 6.852) 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 6.852) 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 6.852) 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 6.852) 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 6.852) Pub Date : 2018-02-21 Matthias Aurich, Patrick Fuchs, Matthias Müller-Hennessen, Lorenz Uhlmann, Matthias Niemers, Sebastian Greiner, Tobias Täger, Kristof Hirschberg, Philipp Ehlermann, Benjamin Meder, Lutz Frankenstein, Evangelos Giannitsis, Hugo A. Katus, Derliz Mereles
Background Impaired left ventricular (LV) longitudinal function (LF) is a known predictor of cardiac events in patients with heart failure, but two-dimensional strain imaging, the reference method to measure myocardial deformation, is not always feasible or available. Therefore, reliable and reproducible alternatives are needed. The aim of the present study was to evaluate unidimensional longitudinal strain (ULS) as a simple echocardiographic parameter for the assessment of LV LF. Methods Two hundred two patients with dilated cardiomyopathy who had their first presentation in the authors' cardiology department, as well as the same number of age- and gender-matched control subjects, were prospectively included in this study. ULS was compared with global longitudinal strain (GLS), the current gold standard for LV LF assessment by echocardiography. Uni- and multivariate Cox regression analyses were conducted to evaluate the prognostic value of ULS. Results LV LF was higher in the control group compared with patients: GLS −19.5 ± 1.7% versus −12.6 ± 4.8% and ULS −16.3 ± 1.5% versus −10.2 ± 3.9% (P < .001 for each). Correlation between ULS and GLS was excellent (r = 0.94), while Bland-Altman plots revealed lower values for ULS (bias −2.76%, limits of agreement ±3.31%). During a mean follow-up time of 39 months, the combined end point of cardiovascular death or hospitalization for acute cardiac decompensation was reached by 28 patients (13.9%). GLS (hazard ratio, 1.21; 95% CI, 1.10–1.34; P < .001) and ULS (hazard ratio, 1.24; 95% CI, 1.12–1.39; P < .001) had comparable prognostic impact on patient outcomes. Conclusions ULS might be an alternative echocardiographic method for the assessment of LV LF, with similar diagnostic and prognostic value compared with GLS.
Morphologic Analysis of the Normal Right Ventricle Using Three-Dimensional Echocardiography–Derived Curvature Indices J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-21 Karima Addetia, Francesco Maffessanti, Denisa Muraru, Amita Singh, Elena Surkova, Victor Mor-Avi, Luigi P. Badano, Roberto M. Lang
Background Right ventricular (RV) remodeling involves changes in size, wall thickness, function, and shape. Previous studies have suggested that regional curvature indices (rCI) may be useful for RV shape analysis. The aim of this study was to establish normal three-dimensional echocardiographic values of rCI in a large group of healthy subjects to facilitate future three-dimensional echocardiographic study of adverse RV remodeling. Methods RV endocardial surfaces were reconstructed at end-diastole and end-systole in 245 healthy subjects (mean age, 42 ± 12 years) and analyzed using custom software to calculate mean curvature in six regions: RV inflow tract (RVIT) and RV outflow tract, apex, and body (both divided into free wall and septal regions). Associations with age and gender were studied. Results The apical free wall was convex, while the septum (apex and body) was more concave than the body free wall. Septal curvature did not change significantly from end-diastole to end-systole. The RV outflow tract and RVIT became flatter from end-diastole to end-systole. In keeping with the “bellows-like” action of RV contraction, the body free wall became flatter, while the apex free wall changed to a more convex surface. There were no intergender differences in rCI. In older subjects (≥55 years of age), the RV free wall and RV outflow tract were flatter, and from end-diastole to end-systole, the RVIT became less flattened and the apex less pointed. These changes suggest that the right ventricle is stiffer in older subjects, with less dynamic contraction of the RVIT and less bellows-like movement. Conclusions This study established normal three-dimensional echocardiographic values for RV rCI, which are needed to further study RV diastolic dysfunction and remodeling with disease.
Relationship Between Proximal Aorta Morphology and Progression Rate of Aortic Stenosis J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-16 Romain Capoulade, Jonathan G. Teoh, Philipp E. Bartko, Eliza Teo, Jan-Erik Scholtz, Lionel Tastet, Mylene Shen, Christos G. Mihos, Yong H. Park, Julio Garcia, Eric Larose, Eric M. Isselbacher, Thoralf M. Sundt, Thomas E. MacGillivray, Serguei Melnitchouk, Brian B. Ghoshhajra, Philippe Pibarot, Judy Hung
Background The aim of this study was to examine the association between abnormal morphology of the proximal aorta and aortic stenosis (AS) progression rate. The main hypothesis was that morphologic changes of the proximal aorta, such as effacement of the sinotubular junction (STJ), result in increased biomechanical stresses and contribute to calcification and progression of AS. Methods Between 2010 and 2012, 426 patients with mild to moderate AS were included in this study. Proximal aortic dimensions were measured at three different levels (i.e., sinus of Valsalva, STJ, and ascending aorta), and sinuses of Valsalva/STJ and ascending aorta/STJ ratios were used to determine degree of aortic deformity. AS progression rate was assessed by annualized increase in mean gradient (median follow-up time, 3.1 years; interquartile range, 2.6–3.9 years). The degree of aortic flow turbulence was examined in 18 matched patients with and without STJ effacement using cardiac magnetic resonance phase-contrast imaging. Results Patients' mean age was 71 ± 13 years, and 64% were men. Patients with low ratios had greater AS progression (P < .05). After comprehensive adjustment, sinuses of Valsalva/STJ (P = .025) and ascending aorta/STJ (P = .027) ratios were independently associated with greater AS progression rate. Compared with patients without STJ effacement, those with effacement of the STJ had higher degrees of aortic flow turbulence (24.4% vs 17.2%, P = .038). Conclusions Effacement of the STJ is independently associated with greater AS progression, regardless of arterial hemodynamics, aortic valve phenotype, or baseline AS severity. Patients with abnormal proximal aortic geometry had disturbed aortic flow patterns. These findings suggest an interrelation between proximal aorta morphology and stenosis progression.
Utility of Left Atrial Expansion Index and Stroke Volume in Management of Chronic Systolic Heart Failure J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-14 Shih-Hung Hsiao, Shih-Kai Lin, Yi-Ran Chiou, Chin-Chang Cheng, Hwong-Ru Hwang, Kuan-Rau Chiou
Background Titration of evidence-based medications, important for treating heart failure (HF), is often underdosed by symptom-guided treatment. The aim of this study was to investigate, using echocardiographic parameters, stroke volume and left ventricular (LV) filling pressure to guide up-titration of medications, increasing prognostic benefits. Methods A total of 765 patients with chronic HF and severely reduced LV ejection fractions (<35%), referred from 2008 to 2016, were prospectively studied. Echocardiographic guidance was performed in 149 patients. LV filling pressure was assessed by left atrial expansion index, and stroke volume was estimated from diameter and time-velocity integral in the LV outflow tract. Up-titration of evidence-based medications and adjustment for side effects or worsening clinical conditions according to those parameters were performed. Propensity score matching was used to match pairs of patients with (n = 110) or without (n = 110) echocardiographic guidance. End points were 4-year frequencies of HF hospitalization and all-cause mortality. Results During a mean follow-up time of 4.1 years, rates of adverse events were 58 (52.7%) with no echocardiographic guidance and 36 (32.7%) with echocardiographic guidance (P < .0001). Echocardiography provided effective guidance to reduce prescribing frequency and dose of diuretics and to promote evidence-based medication prescription. It reduced HF rehospitalization and all-cause mortality. By multivariate analysis, prognostic improvement was associated with up-titration of medications with echocardiographic guidance. Conclusions There was a statistically significant difference in long-term prognosis between propensity score–matched pairs of patients with chronic severe HF with and without echocardiographic guidance. These findings need further validation in large prospective clinical trials.
Rest and Stress Longitudinal Systolic Left Ventricular Mechanics in Hypertrophic Cardiomyopathy: Implications for Prognostication J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-14 Iraklis Pozios, Aurelio Pinheiro, Celia Corona-Villalobos, Lars L. Sorensen, Zeina Dardari, Hong-yun Liu, Kenneth Cresswell, Susan Phillip, David A. Bluemke, Stefan L. Zimmerman, M. Roselle Abraham, Theodore P. Abraham
Background Exercise intolerance is the most common symptom in hypertrophic cardiomyopathy (HCM). We examined whether inability to augment myocardial mechanics during exercise would influence functional performance and clinical outcomes in HCM. Methods Ninety-five HCM patients (32 nonobstructive, 32 labile-obstructive, 31 obstructive) and 26 controls of similar age and gender distribution were recruited prospectively. They underwent rest and treadmill stress strain echocardiography, and 61 of them underwent magnetic resonance imaging. Mechanical reserve (MRES) was defined as percent change in systolic strain rate (SR) immediately postexercise. Results Global strain and SR were significantly lower in HCM patients at rest (strain: nonobstructive, −15.6 ± 3.0; labile-obstructive, −15.9 ± 3.0; obstructive, −13.8 ± 2.9; control, −17.7% ± 2.1%, P < .001; SR: nonobstructive, −0.92 ± 0.20; labile−obstructive, −0.94 ± 0.17; obstructive, −0.85 ± 0.18; control, −1.04 ± 0.14 s−1, P = .002); and immediately postexercise (strain: nonobstructive, −15.6 ± 3.0; labile-obstructive, −17.6 ± 3.6; obstructive, −15.6 ± 3.6; control, −19.2 ± 3.1%; P = .001; SR: nonobstructive, −1.41 ± 0.37; labile-obstructive, −1.64 ± 0.38; obstructive, −1.32 ± 0.29; control, −1.82 ± 0.29 s−1, P < .001). MRES was lower in nonobstructive and obstructive compared with labile-obstructive and controls (51% ± 29%, 54% ± 31%, 78% ± 38%, 77% ± 30%, P = .001, respectively). Postexercise SR and MRES were associated with exercise capacity (r = 0.47 and 0.42, P < .001 both, respectively). When adjusted for age, gender, body mass index, E/e’, and resting peak instantaneous systolic gradient, postexercise SR best predicted exercise capacity (r = 0.74, P = .003). Postexercise SR was correlated with extent of late gadolinium enhancement (r = 0.34, P = .03). By Cox regression, exercise SR and MRES predicted ventricular tachycardia/ventricular fibrillation (VT/VF) even after adjustment for age, gender, family history of sudden cardiac death, septum ≥ 3 cm and abnormal blood pressure response (P = .04 and P = .046, respectively). Conclusions Nonobstructive and obstructive patients have reduced MRES compared with labile-obstructive and controls. Postexercise SR correlates with LGE and exercise capacity. Exercise SR and MRES predict VT/VF.
Contrast-Enhanced Echocardiography Has the Greatest Impact in Patients with Reduced Ejection Fractions J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-10-27 Hang Zhao, Rupal O'Quinn, Marietta Ambrose, Dinesh Jagasia, Bonnie Ky, Joyce Wald, Victor A. Ferrari, James N. Kirkpatrick, Yuchi Han
Background Contrast-enhanced echocardiography (CE) helps to improve image quality in patients with suboptimal acoustic windows. Despite current recommendations, contrast use remains low. The aim of this study was to identify populations that would benefit more from contrast use. Methods A total of 176 subjects (137 men; mean age, 60.8 ± 13.7 years) with technically difficult transthoracic echocardiographic studies who received clinically indicated intravenous contrast were prospectively studied. The impact on clinical decision making (including alterations in medical therapy, referral, imaging, or clinical procedures) was evaluated. Results The use of CE enabled biplane left ventricular (LV) ejection fraction measurement in 97.2% of studies and the interpretation of regional wall motion in 95% of studies. CE allowed definitive assessment of the presence or absence of LV thrombus in 99% of the cases. In the 174 patients whose ordering physicians could be reached at the time of image interpretation, changes in management occurred in 51% of subjects. There was no difference in the proportion of management changes between inpatients and outpatients (60.0% vs 48.1%, P = .225). Subjects with heart failure, cardiomyopathy, and arrhythmia had a higher proportion of changes (61.4% vs 44.2% [P = .031], 62.5% vs 45.0% [P = .028], and 72.0% vs 47.7% [P = .030], respectively). The proportion of management change after CE increased as pre-CE estimated ejection fraction decreased. Logistic regression showed that pre-CE estimated LV ejection fraction < 50% was the only significant predictor of change of management after contrast (P = .004). Conclusions The use of CE has a significant impact on clinical decision making in patients with suboptimal acoustic windows, especially in those with depressed pre-CE LV ejection fractions.
ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-10-20 , John U. Doherty, Smadar Kort, Roxana Mehran, Paul Schoenhagen, Prem Soman, , Greg J. Dehmer, John U. Doherty, Paul Schoenhagen, Zahid Amin, Thomas M. Bashore, Andrew Boyle, Dennis A. Calnon, Blase Carabello, Manuel D. Cerqueira, John Conte, Milind Desai, Joseph M. Allen
Abstract This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.
Transcatheter Tricuspid Valve-in-Valve Intervention for Degenerative Bioprosthetic Tricuspid Valve Disease J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-08-23 Fabien Praz, Isaac George, Susheel Kodali, Konstantinos P. Koulogiannis, Linda D. Gillam, Mary Z. Bechis, David Rubenson, Wei Li, Alison Duncan
Isolated reoperative tricuspid valve replacement is one of the highest risk operations classified in the Society of Thoracic Surgeons registry, particularly in the setting of preexisting right ventricular dysfunction. Transcatheter tricuspid valve-in-valve implantation represents an attractive alternative to redo surgery in patients with tricuspid bioprosthetic valve degeneration who are considered high-risk or unsuitable surgical candidates. In this review article, the authors discuss the emergence of transcatheter tricuspid valve-in-valve therapy, preprocedural echocardiographic assessment of tricuspid bioprosthetic valve dysfunction, periprocedural imaging required for tricuspid valve-in-valve implantation, and postprocedural assessment of tricuspid transcatheter device function.
Mitral Effective Regurgitant Orifice Area Predicts Pulmonary Artery Pressure Level in Patients with Aortic Valve Stenosis J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-01 Giovanni Benfari, Stefano Nistri, Pompilio Faggiano, Marie-Annick Clavel, Caterina Maffeis, Maurice Enriquez-Sarano, Corrado Vassanelli, Andrea Rossi
Background Mitral regurgitation (MR) and elevated pulmonary artery pressure are common findings in patients with aortic valve stenosis (AS). The pathophysiologic role of quantitatively defined MR as a determinant of pulmonary hypertension (PH) is incompletely characterized across the whole spectrum of AS degrees. The purpose of the study was to investigate whether the quantification of MR reveals a link to PH in patients with AS. Methods Consecutive patients undergoing comprehensive echocardiography and presenting peak aortic velocity ≥ 2.5 m/sec were prospectively enrolled. Effective regurgitant orifice area (ERO) and regurgitant volume were obtained using the proximal isovelocity surface area method. Systolic pulmonary artery pressure was calculated by adding right atrial pressure to the tricuspid regurgitation pressure gradient. Results A total of 642 patients were enrolled between 2008 and 2013 (mean age, 79 ± 11 years; mean ejection fraction, 62 ± 10%; mean aortic valve area, 1.09 ± 0.39 cm2); MR was present in 187 (29%). Of note, 154 of 187 patients (82%) showed ERO < 0.20 cm2. ERO and regurgitant volume had the most significant associations with systolic pulmonary artery pressure (R2 = 0.30 and R2 = 0.35, respectively, P < .0001). This relationship persisted after multivariate adjustment and in the subgroups of patients with severe AS or reduced ejection fraction (P < .0001). For each 0.10-cm2 increase, the odds ratio for PH was 3.56 (95% CI, 2.65–4.86; P < .0001). Conclusions In patients with MR and a wide range of AS severity, ERO is independently associated with PH. Also, the role of MR quantification appears stronger than other continuous variables commonly associated with left ventricular diastolic dysfunction, such as E/e′ ratio and left atrial volume.
Echocardiography Core Laboratory Reproducibility of Cardiac Safety Assessments in Cardio-Oncology J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-02-02 Michel G. Khouri, Bonnie Ky, Gary Dunn, Ted Plappert, Virginia Englefield, Dawn Rabineau, Eric Yow, Huiman X. Barnhart, Martin St. John Sutton, Pamela S. Douglas
Background As the potential for cancer therapy–related cardiac dysfunction is increasingly recognized, there is a need for the standardization of echocardiographic measurements and cut points to guide treatment. The aim of this study was to determine the reproducibility of cardiac safety assessments across two academic echocardiography core laboratories (ECLs) at the University of Pennsylvania and the Duke Clinical Research Institute. Methods To harmonize the application of guideline-recommended measurement conventions, the ECLs conducted multiple training sessions to align measurement practices for traditional and emerging assessments of left ventricular (LV) function. Subsequently, 25 echocardiograms taken from patients with breast cancer treated with doxorubicin with or without trastuzumab were independently analyzed by each laboratory. Agreement was determined by the proportion (coverage probability [CP]) of all pairwise comparisons between readers that were within a prespecified minimum acceptable difference. Persistent differences in measurement techniques between laboratories triggered retraining and reassessment of reproducibility. Results There was robust reproducibility within each ECL but differences between ECLs on calculated LV ejection fraction and mitral inflow velocities (all CPs < 0.80); four-chamber global longitudinal strain bordered acceptable reproducibility (CP = 0.805). Calculated LV ejection fraction and four-chamber global longitudinal strain were sensitive to small but systematic interlaboratory differences in endocardial border definition that influenced measured LV volumes and the speckle-tracking region of interest, respectively. On repeat analyses, reproducibility for mitral velocities (CP = 0.940–0.990) was improved after incorporating multiple-beat measurements and homogeneous image selection. Reproducibility for four-chamber global longitudinal strain was unchanged after efforts to develop consensus between ECLs on endocardial border determinations were limited primarily by a lack of established reference standards. Conclusions High-quality quantitative echocardiographic research is feasible but requires a commitment to reproducibility, adherence to guideline recommendations, and the time, care, and attention to detail to establish agreement on measurement conventions. These findings have important implications for research design and clinical care.
Clinical Significance of Ejection Dynamics Parameters in Patients with Aortic Stenosis: An Outcome Study J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-01-04 Anne Ringle Griguer, Christophe Tribouilloy, Ariane Truffier, Anne-Laure Castel, François Delelis, Franck Levy, André Vincentelli, Yohann Bohbot, Sylvestre Maréchaux
Background Ejection dynamics parameters are useful in assessing prosthetic valve obstruction, but very limited data are available in the setting of native aortic stenosis (AS). The aim of this study was to evaluate and compare the prognostic value of acceleration time (AT) and the ratio of AT to ejection time (ET) in patients with AS. Methods AT and AT/ET were prospectively measured in 456 patients with AS (aortic valve area < 1.3 cm2; mean aortic valve area, 0.85 ± 0.24 cm2). The relationships between AT/ET, AT, and mortality during follow-up were studied. Results During a median follow-up period of 35 months (interquartile range, 33–37 months), 124 patients died. After adjustment for variables of prognostic importance, including mean pressure gradient, stroke volume index, and aortic valve replacement as a time-dependent covariate, patients in the highest tertiles of both AT/ET (>0.36) and AT (>112 msec) were at high risk for overall mortality (adjusted hazard ratios, 2.44 [95% CI, 1.46–4.08; P = .001] and 1.78 [95% CI, 1.06–2.98; P = .029], respectively) compared with those in the lowest tertiles of AT/ET and AT, while survival was similar for the other tertiles (P = NS for all). Compared with patients with AT/ET ≤ 0.36, an increased risk for overall mortality was observed in patients with AT/ET > 0.36 (adjusted hazard ratio, 2.51; 95% CI, 1.66–3.78; P < .0001), while the risk for mortality was not significantly increased in patients with AT > 112 msec compared with those with AT ≤ 112 msec. Adding AT/ET > 0.36 to a multivariate model including classical variables of prognostic importance, including mean pressure gradient and stroke volume index, improved predictive performance in terms of overall mortality, with improved global model fit, reclassification, and better discrimination. Conclusions Among ejection dynamics parameters in patients with AS, AT/ET is strongly associated with excess risk for death during follow-up. AT/ET should be considered in the multiparametric echocardiographic prognostic assessment of patients with AS in clinical practice.
Altered Left Ventricular Geometry and Torsional Mechanics in High Altitude-Induced Pulmonary Hypertension: A Three-Dimensional Echocardiographic Study J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-01-04 Bart W. De Boeck, Aurel Toma, Stephanie Kiencke, Christoph Dehnert, Stefanie Zügel, Christoph Siebenmann, Katja Auinger, Peter T. Buser, Marco Maggiorini, Beat A. Kaufmann
Background Changes in left ventricular (LV) torsion have been related to LV geometry in patients with concomitant long-standing myocardial disease or pulmonary hypertension (PH). We evaluated the effect of acute high altitude-induced isolated PH on LV geometry, volumes, systolic function, and torsional mechanics. Methods Twenty-three volunteers were prospectively studied at low altitude and after the second (D3) and third night (D4) at high altitude (4,559 m). LV ejection fraction, multidirectional strains and torsion, LV volumes, sphericity, and eccentricity were derived by speckle-tracking on three-dimensional echocardiographic data sets. Pulmonary pressure was estimated from the transtricuspid pressure gradient (TRPG), LV preload from end-diastolic LV volume, and transmitral over mitral annular E velocity (E/e′). Results At high altitude, oxygen saturation decreased by 15%–20%, heart rate and cardiac index increased by 15%–20%, and TRPG increased from 21 ± 2 to 37 ± 9 mm Hg (P < .01). LV volumes, preload, ejection fraction, multidirectional strains, and sphericity remained unaffected, but diastolic (1.04 ± 0.07 to 1.09 ± 0.09 on D3/D4, P < .05) and systolic (1.00 ± 0.06 to 1.08 ± 0.1 [D3] and 1.06 ± 0.07 [D4], P < .05) eccentricity slightly increased, indicating mild septal flattening. LV torsion decreased from 2.14 ± 0.85 to 1.34 ± 0.68 (P < .05) and 1.65 ± 0.54 (P = .08) degrees/cm on D3/D4, respectively. Changes in torsion showed a weak inverse relationship to changes in systolic (r = −0.369, P = .013) and diastolic (r = −0.329, P = .032) eccentricity but not to changes in TRPG, heart rate or preload. Conclusions High-altitude exposure was associated with mild septal flattening of the LV and reduced ventricular torsion at unchanged global LV function and preload, suggesting a relation between LV geometry and torsional mechanics.
Clinical Utility of Left Atrial Strain in Children in the Acute Phase of Kawasaki Disease J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-01-03 Soo Jung Kang, Yoo Won Kwon, Seo Jung Hwang, Hyo Jin Kim, Bo Kyeong Jin, Dong Keon Yon
Background We aimed to evaluate the diagnostic utility of peak left atrial longitudinal strain (PALS) during left ventricular (LV) systole to differentiate children in the acute phase of Kawasaki disease (aKD) from controls. We also aimed to compare the diagnostic utility of PALS with those of conventional echocardiographic indices of diastolic function. Methods Retrospectively measured PALS, LV longitudinal peak systolic strain, and strain rate obtained via velocity vector imaging were compared in a derivation cohort comprising 95 aKD and 67 controls. The utility of PALS in differentiating aKD from controls was compared with those of E/E′, E/A, and maximum left atrial volume index (LAVImax). Derived cutoffs from receiver operating characteristic curves were validated in a separate validation cohort comprising 37 aKD and 19 controls. Results In the derivation cohort, PALS was significantly decreased in aKD as compared with in controls. For differentiating aKD from controls, PALS outperformed E/E′, E/A, and LAVImax. However, cutoffs of PALS (≤40% and ≤39%, before and after adjusting for the presence of significant mitral regurgitation and LV systolic dysfunction, respectively), like those of E/E′, E/A, and LAVImax, showed low sensitivity and poor discriminative ability for differentiating aKD from controls. In the validation cohort, for differentiating aKD from controls, both cutoffs of PALS showed low sensitivity, like those of E/E′, E/A, and LAVImax. Conclusion In aKD, impaired left atrial reservoir function could be detected as decreased PALS. For differentiating aKD from controls, PALS outperforms E/E′, E/A, and LAVImax. However, like E/E′, E/A, and LAVImax, PALS as a single parameter is limited in its clinical utility to differentiate aKD from controls because of its low sensitivity and poor discriminative ability.
Right Ventricular Structure and Function in the Veteran Ultramarathon Runner: Is There Evidence for Chronic Maladaptation? J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2018-01-03 Oliver Rothwell, Keith George, John Somauroo, Rachel Lord, Mike Stembridge, Rob Shave, Martin D. Hoffman, Mathew Wilson, Euan Ashley, Francois Haddad, Thijs M.H. Eijsvogels, David Oxborough
Background It has been proposed that chronic exposure to prolonged strenuous exercise may result in maladaptation of the right ventricle (RV). The of this study aim was to establish RV structure and function, including septal insertion points, using conventional echocardiography and myocardial strain (ε) imaging in a veteran population of ultramarathon runners (UR) and age- and sex-matched controls. Methods A retrospective study design provided 40 UR (>35 years old; mean ± SD training experience, 18 ± 12 years) and 24 sedentary controls who had previously undergone conventional two-dimensional, tissue Doppler and speckle-tracking echocardiography to measure RV size and function. Peak RV ε and strain rate (SR) were assessed from the base, mid, and apical lateral wall. SR were assessed during systole (SRs'), early diastole (SRe′) and late diastole (SRa′). Regional assessment of RV insertion points was made at the basal inferoseptum and apical septum using left ventricular (LV) longitudinal ε and at the anteroseptum and inferoseptum using LV circumferential and radial ε. Results All structural indices of RV size were significantly larger in UR. RV regional and global peak ε were not different between groups, whereas basal RV SR was significantly lower in UR. UR had significantly higher peak LV circumferential ε (anteroseptum, −26% ± 8% vs −21% ± 6%; inferoseptum, −25% ± 6% vs −16% ± 9%) and higher peak LV longitudinal ε (apical septum, −28% ± 7% vs −22% ± 4%) compared with controls. There was regional heterogeneity in UR that was not observed in controls with significantly lower longitudinal ε at the basal inferoseptal insertion point when compared with the global ε (−19% ± 2% vs −22% ± 4%). Conclusions Myocardial ε imaging highlights no overt maladaptation in this cohort of veteran UR, although lower insertion point ε, compared with global ε, in UR may warrant further investigation.
Tricuspid Valve Adaptation during the First Interstage Period in Hypoplastic Left Heart Syndrome J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-29 Timothy Colen, Shelby Kutty, Richard B. Thompson, Edythe Tham, Andrew S. Mackie, Ling Li, Dongngan T. Truong, Michiko Maruyama, Jeffrey F. Smallhorn, Nee Scze Khoo
Background Tricuspid regurgitation (TR) is an important risk factor for morbidity and mortality in hypoplastic left heart syndrome (HLHS), yet the evolution of tricuspid valve (TV) dysfunction in HLHS is poorly understood. This study sought to examine changes in TV function in HLHS between the first two stages of surgical palliation and to determine the mechanism of TR at the time of stage two surgery—bidirectional cavopulmonary anastomosis (BCPA). Methods We prospectively investigated 44 infants at two time points—prior to Norwood-Sano (T1 - median age 5.4 days) and prior to BCPA (T2 - median age 4.7 months) using two-dimensional (2DE) and three-dimensional echocardiography (3DE). Right ventricular (RV) size, function and shape was assessed with 2DE. Extracted spatial coordinates from 3DE were used to calculate TV leaflet and annular area, tethering and prolapse volumes, bending angle, and coaptation index. TR was graded qualitatively, and 2D and 3D vena contracta (VC) were measured. Results The cohort from T1 to T2 had increased indexed leaflet and annular area (P < .0001) and tethering volume (P < .0001), with no change in coaptation. Significant TR was present in 14 infants (32%) at T2 and was associated with greater leaflet (P = .02) and annular areas (P = .002) and greater prolapse volume (P = .008), but not tethering volume or reduced coaptation. At latest follow-up (median 23 months), 13 patients died or required transplantation. Only 3DE VC at T2 was associated with death or transplantation. Conclusions The TV in HLHS adapts to interstage stressors (increased preload and afterload) by increasing leaflet size to maintain adequate leaflet coaptation. Significant TR at T2 was associated with greater leaflet size and prolapse. This may represent TV maladaptation from an excessive response in leaflet expansion to stressors.
Pulsed-Wave Doppler Recordings in the Proximal Descending Aorta in Patients with Chronic Aortic Regurgitation: Insights from Cardiovascular Magnetic Resonance J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-29 Odd Bech-Hanssen, Christian L. Polte, Frida Svensson, Åse A. Johnsson, Kerstin M. Lagerstrand, Ulf Cederbom, Sinsia A. Gao
Background The pulsed-wave Doppler recording in the descending aorta (PWDDAO) is one of the parameters used in grading aortic regurgitation (AR) severity. The aim of the present study was to investigate the assessment of chronic AR by PWDDAO with insights from cardiovascular magnetic resonance (CMR). Methods This prospective study comprised 40 patients investigated with echocardiography and CMR within 4 hours either prior to valve surgery (n = 23) or as part of their follow-up (n = 17) due to moderate or severe AR. End-diastolic flow velocity (EDFV) and the diastolic velocity time integral (dVTI) were measured. The appearance of diastolic forward flow (DFF) was noted. Phase-contrast flow rate curves were obtained in the DAO. Results Twenty-five patients had severe and eight had moderate AR by echocardiography (seven were indeterminate). The EDFV was below the recommended threshold (>20 cm/sec) in 13 patients (52%) with severe AR. Lowering the EDFV threshold (>13 cm/sec) and with a dVTI threshold >13 cm showed negative likelihood ratios of 0.27 and 0.09, respectively. Detection of DFF with PWDDAO identified a nonuniform velocity profile by CMR with positive and negative likelihood ratios of 7.0 and 0.19, respectively. The relation between EDFV and DAO regurgitant volume (DAO-RVolCMR) was strong in patients without (R = 0.88) and weak in patients with DFF (R = 0.49). The DAO-RVolCMR as a percent of the total RVolCMR decreased with increasing ascending aorta (AAO) size and increased with increasing AR severity. Conclusions Our findings suggest that PWDDAO provides semiquantitative parameters useful to assess chronic AR severity. The limitations are related to nonuniform velocity contour and variable degree of lower body contribution, which depends on AR severity but also on the AAO size.
Echocardiographic Imaging for Transcatheter Aortic Valve Replacement J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-21 Rebecca T. Hahn, Alina Nicoara, Samir Kapadia, Lars Svensson, Randolph Martin
Transcatheter aortic valve replacement has become an accepted alternative to surgery for patients with severe, symptomatic aortic stenosis who are inoperable or are at high surgical risk. Recent trials support the use of transcatheter aortic valve replacement also in patients at intermediate risk, and ongoing trials are assessing appropriateness in other patient groups. The authors review the key anatomic features integral to the transcatheter aortic valve replacement procedure and the echocardiographic imaging required for preprocedural, intraprocedural, and postprocedural assessment.
Normal Reference Ranges for Transthoracic Echocardiography Following Heart Transplantation J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-21 Annika Ingvarsson, Anna Werther Evaldsson, Johan Waktare, Johan Nilsson, Gustav J. Smith, Martin Stagmo, Anders Roijer, Göran Rådegran, Carl J. Meurling
Background Heart function following heart transplantation (HTx) is influenced by numerous factors. It is typically evaluated using transthoracic echocardiography, but reference values are currently unavailable for this context. The primary aim of the present study was to derive echocardiographic reference values for chamber size and function, including cardiac mechanics, in clinically stable HTx patients. Methods The study enrolled 124 healthy HTx patients examined prospectively. Patients underwent comprehensive two-dimensional echocardiographic examinations according to contemporary guidelines. Results were compared with recognized reference values for healthy subjects. Results Compared with guidelines, larger atrial dimensions were seen in HTx patients. Left ventricular (LV) diastolic volume was smaller, and LV wall thickness was increased. With respect to LV function, both ejection fraction (62 ± 7%, P < .01) and global longitudinal strain (−16.5 ± 3.3%, P < .0001) were lower. All measures of right ventricular (RV) size were greater than reference values (P < .0001), and all measures of RV function were reduced (tricuspid annular plane systolic excursion 15 ± 4 mm [P < .0001], RV systolic tissue Doppler velocity 10 ± 6 cm/sec [P < .0001], fractional area change 40 ± 8% [P < .0001], and RV free wall strain −16.9 ± 4.2% [P < .0001]). Ejection fraction and LV global longitudinal strain were significantly lower in patients with previous rejection. Conclusion The findings of this study indicate that the distribution of routinely used echocardiographic measures differs between stable HTx patients and healthy subjects. In particular, markedly larger RV and atrial volumes and mild reductions in both LV and RV longitudinal strain were evident. The observed differences could be clinically relevant in the assessment of HTx patients, and specific reference values should be applied in this context.
Comparison of Feasibility, Accuracy, and Reproducibility of Layer-Specific Global Longitudinal Strain Measurements Among Five Different Vendors: A Report from the EACVI-ASE Strain Standardization Task Force J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13 Serkan Ünlü, Oana Mirea, Jürgen Duchenne, Efstathios D. Pagourelias, Stéphanie Bézy, James D. Thomas, Luigi P. Badano, Jens-Uwe Voigt
Background Despite standardization efforts, vendors still use information from different myocardial layers to calculate global longitudinal strain (GLS). Little is known about potential advantages or disadvantages of using these different layers in clinical practice. The authors therefore investigated the reproducibility and accuracy of GLS measurements from different myocardial layers. Methods Sixty-three subjects were prospectively enrolled, in whom the intervendor bias and test-retest variability of endocardial GLS (E-GLS) and midwall GLS (M-GLS) were calculated, using software packages from five vendors that allow layer-specific GLS calculation (GE, Hitachi, Siemens, Toshiba, and TomTec). The impact of tracking quality and the interdependence of strain values from different layers were assessed by comparing test-retest errors between layers. Results For both E-GLS and M-GLS, significant bias was found among vendors. Relative test-retest variability of E-GLS values differed significantly among vendors, whereas M-GLS showed no significant difference (range, 5.4%–9.5% [P = .032] and 7.0%–11.2% [P = .200], respectively). Within-vendor test-retest variability was similar between E-GLS and M-GLS for all but one vendor. Absolute test-retest errors were highly correlated between E-GLS and M-GLS for all vendors. Conclusions E-GLS and M-GLS measurements showed no relevant differences in robustness among vendors, although intervendor bias was higher for M-GLS compared with E-GLS. These data provide no technical argument in favor of a certain myocardial layer for global left ventricular functional assessment. Currently, the choice of which layer to use should therefore be based on the available clinical evidence in the literature.
Complex Association of Sex Hormones on Left Ventricular Systolic Function: Insight into Sexual Dimorphism J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13
Background Normal values of left ventricular ejection fraction (LVEF) and absolute values of global longitudinal strain (GLS) are lower in men than in women. Data concerning the association of sex hormone levels on these left ventricular systolic function surrogates are scarce. The aim of this study was to determine the association of sex hormones with systolic left ventricular function in healthy subjects and patients with congenital adrenal hyperplasia (CAH) as a model of testosterone dysregulation. Methods Eighty-four adult patients with CAH (58 women; median age, 27 years; interquartile range, 23–36 years) and 84 healthy subjects matched for sex and age were prospectively included. Circulating concentrations of sex hormones were measured within 48 hours of echocardiography with assessment of LVEF and left ventricular longitudinal, radial, and circumferential strain. Results LVEF and GLS were higher in healthy women than in healthy men (63.9 ± 4.2% vs 60.9 ± 5.1% [P < .05] and 20.0 ± 1.9% vs 17.9 ± 2.4% [P < .001], respectively), while there was no difference in LVEF or GLS between women and men with CAH (63.9 ± 4.5% vs 63.0 ± 4.6% [P = NS] and 19.4 ± 2.2% vs 18.3 ± 1.8% [P = NS], respectively). Bioavailable testosterone levels were higher in women with CAH than in female control subjects (0.08 ng/mL [interquartile range, 0.04–0.14 ng/mL] vs 0.16 ng/mL [interquartile range, 0.04–0.3 ng/mL], P < .001) and lower in men with CAH than in male control subjects (2.3 ng/mL [interquartile range, 1.3–3 ng/mL] vs 2.9 ng/mL [interquartile range, 2.5–3.4 ng/mL], P < .05). In men, LVEF and GLS were negatively correlated with bioavailable testosterone levels (r = −0.3, P ≤ .05, and r = −0.45, P < .01, respectively), while midventricular radial strain was positively correlated with bioavailable testosterone level (r = 0.38, P < .05). The absolute value of circumferential strain was positively correlated with follicle-stimulating hormone (r = 0.65, P < .0001). Conclusions These data support that the existence of sex dimorphism concerning left ventricular systolic cardiac function is significantly associated with testosterone levels.
Value of Myocardial Work Estimation in the Prediction of Response to Cardiac Resynchronization Therapy J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13 Elena Galli, Christophe Leclercq, Maxime Fournet, Arnaud Hubert, Anne Bernard, Otto A. Smiseth, Philippe Mabo, Eigil Samset, Alfredo Hernandez, Erwan Donal
Background Cardiac resynchronization therapy (CRT) in heart failure is plagued by too many nonresponders. The aim of the present study is to evaluate whether the estimation of myocardial performance by pressure-strain loops (PSLs) is useful for the selection of CRT candidates. Methods Ninety-seven patients undergoing CRT were included in the study. Bidimensional and speckle-tracking echocardiography were performed before CRT and at the 6-month follow-up (FU). Conventional dyssynchrony parameters were evaluated. Left ventricular (LV) constructive work (CW) and wasted work (WW) were estimated by PSLs. Positive response to CRT (CRT+) was defined as ≥15% reduction in LV end-systolic volume at FU and was observed in 63 (65%) patients. Results The addition of CW > 1,057 mm Hg% (area under the curve, 0.72, P < .0001) and WW > 384 mm Hg% (area under the curve, 0.67, P = .005) to a baseline model including clinical, echocardiographic, and conventional dyssynchrony parameters significantly increased the model power (χ2, 25.11 vs 47.5, P < .0001). In this model, septal flash (odds ratio [OR] = 2.78; P = .001), CW > 1,057 mm Hg% (OR = 9.49; P = .002), and WW > 384 mm Hg% (OR = 16.24, P < .006) remained the only parameters associated with CRT+. The combination of CW > 1,057 mm Hg% and WW > 384 mm Hg% showed a good specificity (100%) and positive predictive value (100%) but a low sensitivity (22%), negative predictive value (41%), and accuracy (49%) for the identification of CRT+. Conclusions The estimation of CW and WW by PSLs is a novel tool for the assessment of CRT patients. Although these parameters cannot be used by their own to select CRT candidates, they can provide further insights into the comprehension of dyssynchrony mechanisms and contribute to improving the identification of CRT responders.
Fetal Cardiac Function in Maternal Diabetes: A Conventional and Speckle-Tracking Echocardiographic Study J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13 Joana O. Miranda, Rui J. Cerqueira, Carla Ramalho, José Carlos Areias, Tiago Henriques-Coelho
Background Intrauterine exposure to a diabetic environment is associated with adverse fetal myocardial remodeling. The aim of this study was to assess the biventricular systolic and diastolic function of fetuses exposed to maternal diabetes (MD) compared with control subjects, using a comprehensive cardiac functional assessment and exploring the role of speckle-tracking to assess myocardial deformation. The authors hypothesized that fetuses exposed to MD present signs of biventricular dysfunction, which can be detected by deformation analysis. Methods A cross-sectional study was conducted in 129 fetuses with structurally normal hearts, including 76 fetuses of mothers with diabetes and 53 of mothers without diabetes. Maternal baseline characteristics, standard fetoplacental Doppler indices, and conventional echocardiographic and myocardial deformation parameters were prospectively collected at 30 to 33 weeks of gestation. Results Fetuses of mothers with diabetes had a significantly thicker interventricular septum compared with control subjects (median, 4.25 mm [interquartile range (IQR), 3.87–4.50 mm] vs 3.67 mm [IQR, 3.40–3.93 mm), P < .001), but no effect modification was demonstrated on myocardial deformation analysis. No significant differences were found in conventional systolic and diastolic functional parameters for the left ventricle and right ventricle, except for lower left ventricular cardiac output in the MD group (median, 320 mL/min [IQR, 269–377 mL/min] vs 365 mL/min [IQR, 311–422 mL/min], P < .05]. Deformation analysis demonstrated a significantly lower early diastolic strain rate (SRe) and late diastolic strain rate (SRa) for both ventricles in the MD group (left ventricle: SRe 1.85 ± 0.72 vs 2.26 ± 0.68 sec−1, SRa 1.50 ± 0.52 vs 1.78 ± 0.57 sec−1; right ventricle: SRe 1.57 ± 0.73 vs 1.97 ± 0.73 sec−1, SRa 2 ± 0.77 vs 1.68 ± 0.79 sec−1; P < .05), suggesting biventricular diastolic impairment. Additionally, the right ventricle presented a lower global longitudinal strain in the study group (−13.67 ± 4.18% vs −15.52 ± 3.86%, P < .05). Multivariate analysis revealed that maternal age is an independent predictor of left and right ventricular global longitudinal strain (P < .05), with a significant effect only in MD after group stratification. Conclusions Fetuses of mothers with diabetes present signs of biventricular diastolic dysfunction and right ventricular systolic dysfunction by deformation analysis in the third trimester of pregnancy. They may represent a special indication group for functional cardiac assessment, independently of septal hypertrophy. Two-dimensional speckle-tracking could offer an additional benefit over conventional echocardiography to detect subclinical unfavorable changes in myocardial function in this population.
Atrial Enlargement in the Athlete's Heart: Assessment of Atrial Function May Help Distinguish Adaptive from Pathologic Remodeling J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13 Flavio D'Ascenzi, Francesca Anselmi, Marta Focardi, Sergio Mondillo
Intensive training is associated with hemodynamic changes that typically induce an enlargement of cardiac chambers, involving not only the ventricles but also the atria. The hearts of competitive athletes are characterized by increases in left and right atrial dimensions that have been interpreted as a physiologic adaptation to training. Conversely, some authors have hypothesized maladaptive remodeling; furthermore, the extent of left atrial dimensional remodeling may overlap atrial dilation observed in patients with cardiac disease, representing a challenge for clinicians. However, studies investigating left and right atrial function in athletes have demonstrated that atrial size is insufficient to provide mechanistic information about the atrium itself, and an increase in atrial size is not intrinsically an expression of atrial dysfunction. The authors critically analyze training-induced atrial remodeling, taking into account not only the assessment of atrial size but also the evaluation of atrial function, suggesting that the characterization of atrial function plays a fundamental role in the evaluation of athlete's heart, being useful to differentiate physiologic remodeling induced by exercise from pathologic changes occurring in cardiac disorders.
Diagnostic Concordance and Clinical Outcomes in Patients Undergoing Fractional Flow Reserve and Stress Echocardiography for the Assessment of Coronary Stenosis of Intermediate Severity J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13 Sothinathan Gurunathan, Asrar Ahmed, Anastasia Vamvakidou, Ihab S. Ramzy, Mohammed Akhtar, Aamir Ali, Nikos Karogiannis, Spiros Zidros, Gothandaraman Balaji, Grace Young, Ahmed Elghamaz, Roxy Senior
Background The ischemic consequences of coronary artery stenosis can be assessed by invasive fractional flow reserve (FFR) or by noninvasive imaging. We sought to determine (1) the concordance between wall thickening assessment during clinically indicated stress echocardiography (SE) and FFR measurements and (2) the factors associated with hard events in these patients. Methods Two hundred twenty-three consecutive patients who underwent SE and invasive FFR measurements in close succession were analyzed retrospectively for diagnostic concordance and clinical outcomes. Results At the vessel level, the sensitivity, specificity, positive predictive value, and negative predictive value of SE for identifying significant disease as assessed by FFR was 68%, 75%, 43%, and 89%, respectively. The greatest discordance was seen in patients with wall thickening abnormalities (WTAs) and negative FFR. During a follow-up of 3.6 ± 2.2 years, there were 23 cardiovascular (CV) events (death and nonfatal myocardial infarction). The number of wall segments with inducible WTAs emerged as the strongest factor associated with CV events (hazard ratio, 1.18 [1.05-1.34]; P = .008). FFR was not associated with outcome. There was a significant increase in event rate in patients with WTA/negative FFR versus no WTA/negative FFR (P = .01), but no significant difference versus WTA/positive FFR (P = .85). Conclusions In a patient population with significant CV risk factors, a normal SE had a high negative predictive value for excluding abnormal FFR. WTAs were associated with outcomes regardless of FFR value, suggesting that this is a superior marker of ischemia to FFR.
Echocardiographic Detection of Increased Ventricular Diastolic Stiffness in Pediatric Heart Transplant Recipients: A Pilot Study J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-13 Shahryar M. Chowdhury, Ryan J. Butts, Anthony M. Hlavacek, Carolyn L. Taylor, Karen S. Chessa, Varsha M. Bandisode, Girish S. Shirali, Arni Nutting, G. Hamilton Baker
Background Pediatric heart transplant recipients are at risk for increased left ventricular (LV) diastolic stiffness. However, the noninvasive evaluation of LV stiffness has remained elusive in this population. The objective of this study was to compare novel echocardiographic measures of LV diastolic stiffness versus gold-standard measures derived from pressure-volume loop (PVL) analysis in pediatric heart transplant recipients. Methods Patients undergoing left heart catheterization were prospectively enrolled. PVLs were obtained via conductance. The end-diastolic pressure-volume relationship was obtained via balloon occlusion. The stiffness constant, β, was calculated. Echocardiographic measures of diastolic function were derived from spectral and tissue Doppler and two-dimensional speckle-tracking. Ventricular volumes were measured using three-dimensional echocardiography. The novel echocardiographic estimates of ventricular stiffness included E:e′/end-diastolic volume (EDV) and E:early diastolic strain rate/EDV. Results Of 24 children, 18 were heart transplant recipients. Six control patients had hemodynamically insignificant patent ductus arteriosus or coronary fistula. The mean age was 9.1 ± 5.6 years. Median end-diastolic pressure was 9 mm Hg (interquartile range, 8–13 mm Hg). Lateral E:e′/EDV (r = 0.59, P < .01), septal E:e′/EDV (r = 0.57, P < .01), and (E:circumferential early diastolic strain rate)/EDV (r = 0.54, P < .01) correlated with β. Lateral E:e′/EDV displayed a C statistic of 0.93 in detecting patients with abnormal LV stiffness (β > 0.015 mL−1). A lateral E:e′/EDV of >0.15 mL−1 had 89% sensitivity and 93% specificity in detecting an abnormal β. Conclusions Echocardiographic estimates of ventricular stiffness may be accurate compared with the gold standard in pediatric heart transplant recipients. The clinical usefulness of these noninvasive measures in assessing LV stiffness merits further study in children.
Intervendor Consistency and Accuracy of Left Ventricular Volume Measurements Using Three-Dimensional Echocardiography J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-08 Denisa Muraru, Antonella Cecchetto, Umberto Cucchini, Xiao Zhou, Roberto M. Lang, Gabriella Romeo, Mani Vannan, Sorina Mihaila, Marcelo Haertel Miglioranza, Sabino Iliceto, Luigi P. Badano
Background Intervendor consistency of left ventricular (LV) volume measurements using three-dimensional transthoracic echocardiography (3DTTE) has never been reported. Accordingly, we designed a prospective study to (1) compare head-to-head the accuracy of three three-dimensional echocardiography (3DE) systems in measuring LV volumes and ejection fraction (EF) against cardiac magnetic resonance (CMR); (2) assess the intervendor variability of LV volumes and EF; and (3) compare the accuracy of fully automated versus semiautomated (i.e., manually corrected) methods of LV endocardial delineation against CMR. Methods We studied 92 patients (64% males, 52 years [95% CI, 20-83]) with a wide range of end-diastolic volumes (from 87 to 446 mL) and EFs (from 16% to 77%) using three different 3DE platforms (iE33; Vivid E9; Acuson SC2000) during the same echo study. CMR was performed within 3 ± 5 hours from the 3DE study in 35 patients. Results LV volumes provided by the three 3DE systems correlated with CMR volumes: end-diastolic volume (iE33: R2 = 0.93; E9: R2 = 0.94; SC2000: R2 = 0.94), end-systolic volume (iE33: R2 = 0.93; E9: R2 = 0.95; SC2000: R2 = 0.94), and EF (iE33: R2 = 0.79; E9: R2 = 0.80; SC2000: R2 = 0.77). In the 92 patients studied, LV volumes and EFs measured with the three systems were similar. Use of fully automated endocardial border detection algorithms significantly underestimated LV volumes, and the degree of underestimation was higher with larger LV volumes. Conclusions LV volumes and EFs measured with the three 3DE systems are consistent. Fully automated algorithms underestimated LV volumes. Our findings may help in the clinical interpretation of LV parameters obtained using different 3DE systems and encourage the clinical use of 3DTTE.
Classic-Pattern Dyssynchrony in Adolescents and Adults With a Fontan Circulation J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-08 Assami Rösner, Tigran Khalapyan, Håvard Dalen, Doff B. McElhinney, Mark K. Friedberg, George K. Lui
Background Previous studies have suggested the presence of dyssynchrony in the functionally single ventricle. The aim of this study was to investigate the presence of classic-pattern dyssynchrony (CPD), characterized by typical early and late deformation of opposite walls, and its relation to QRS duration and myocardial function in patients with single-ventricle physiology after Fontan palliation. Methods In a retrospective cross-sectional study, 101 adolescent and adult patients with single-ventricle physiology after the Fontan procedure were investigated. Strain curves were visually assessed for the presence of CPD. Systolic and diastolic function were assessed using echocardiography. Results One hundred one patients were included, with varying anatomic morphology: two sizable ventricular components (n = 21), right dominant (n = 21), left dominant (n = 49), and undefined anatomy (n = 10). Fifteen of 101 Fontan patients had CPD. Forty-three percent of patients with two sizable ventricular masses displayed CPD, mostly with prolonged QRS, while the number of patients with CPD with right-dominant (9%) and left-dominant (6%) morphology was significantly lower (P = .016). Those with CPD displayed significantly (P < .05) larger QRS widths (142 ± 22 vs 112 ± 24 msec), lower ejection fractions (31 ± 14% vs 45 ± 14%), lower global early diastolic strain rates (0.7 ± 0.5 vs 1.2 ± 0.8 sec−1), and global systolic circumferential (−10 ± 5% vs −16 ± 7%) and longitudinal (−9 ± 5% vs −14 ± 5%) strain, respectively. Conclusions CPD is present in a proportion of adolescent and adult patients after Fontan palliation. The presence of CPD is associated with reduced systolic and diastolic function compared with Fontan patients without CPD. Because the presence of CPD appears to be a promising predictor for response to cardiac resynchronization therapy in patients with biventricular circulation, these findings may have important potential for prospective evaluation of cardiac resynchronization therapy in patients with univentricular circulation.
Pulmonary Hypertension and Pulmonary Artery Acceleration Time: A Systematic Review and Meta-Analysis J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-08 Yi-Chia Wang, Chi-Hsiang Huang, Yu-Kang Tu
Background Measuring mean pulmonary artery pressure by right-heart catheterization is the gold standard for pulmonary hypertension (PH) diagnosis. However, its invasiveness and complication leads to its limited use. The aim of this study was to determine whether echocardiography-derived pulmonary artery acceleration time (PAAT) possesses adequate diagnostic performance for PH, using right-heart catheterization as a reference standard. Methods MEDLINE, Embase, PubMed, and the Cochrane Central Register of Controlled Trials were searched through July 2016 for studies evaluating PAAT for the diagnosis of PH. Methodologic quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. For each study, the sensitivity, specificity, and diagnostic odds ratio, along with 95% CIs, were calculated to determine the diagnostic accuracy of PAAT. Meta-regression was conducted to evaluate the impact of potential confounding factors. Results Of 430 articles, 21 studies (1,280 patients) were identified, including three studies that used transesophageal echocardiography and 18 studies that used transthoracic echocardiography. The pooled sensitivity across studies was 0.84 (95% CI, 0.75–0.90), the pooled specificity was 0.84 (95% CI, 0.78–0.89), and the pooled diagnostic odds ratio was 28 (95% CI, 16–49). The arrhythmia ratio in the population did not affect the specificity of PAAT's diagnostic performance and increased the sensitivity of PH detection. Conclusions The results of this study suggest that PAAT is useful for PH detection.
Left Atrial Volumes and Strain in Healthy Children Measured by Three-Dimensional Echocardiography: Normal Values and Maturational Changes J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-12-06 Sunil J. Ghelani, David W. Brown, Joseph D. Kuebler, Douglas Perrin, Divya Shakti, David N. Williams, Gerald R. Marx, Steven D. Colan, Tal Geva, David M. Harrild
Background Assessment of left atrial (LA) size and function is important in a number of pediatric cardiac conditions including those affecting the diastolic performance of the left ventricle. Measurements of LA volume and strain by two-dimensional echocardiography rely upon inaccurate geometric assumptions and are hampered by out-of-plane motion. The objective of this study was to characterize LA volumes and strain by three-dimensional echocardiography in healthy children. Methods LA volumes and strain were retrospectively measured by three-dimensional echocardiography in healthy children with no known structural or functional heart disease using a commercial speckle-tracking package applied to the LA to compute maximum volume (Vmax), minimum volume (Vmin), ejection volume (LAEV), ejection fraction (LAEF), and the following components of global strain: 3D principal (3DS), longitudinal (GLS), and circumferential (GCS). Results The study population included 196 normal subjects (median age, 12 years; range, 4 days to 20.9 years). Vmax, Vmin, and LAEV increased with age and body surface area. Significant age-related declines were present in all measured functional indices including LAEF, 3DS, GLS, and GCS. Analysis of a subset of 50 subjects showed excellent agreement between Vmax derived by three-dimensional and two-dimensional biplane area-length method. Regression equations with standard deviations were generated to enable calculation of Z scores. Conclusions LA volume and functional indices can be reliably calculated using a commercial three-dimensional analysis software. All components of LA strain decline modestly with age. Normative data generated in this study have the potential to greatly enhance the utility of three-dimensional echocardiography-derived measurements in a wide range of cardiac pathologies.
Clinical Outcome of Isolated Tricuspid Regurgitation in Patients with Preserved Left Ventricular Ejection Fraction and Pulmonary Hypertension J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-28 Nir Bar, Lorin Arie Schwartz, Simon Biner, Galit Aviram, Meirav Ingbir, Ido Nachmany, Gilad Margolis, Ben Sadeh, Rami Barashi, Gad Keren, Yan Topilsky
Background The outcome of tricuspid regurgitation (TR) remains unclear because of heterogeneity of etiology and the contradictory results of outcome studies. The aim of this study was to evaluate the clinical outcomes of TR in patients with pulmonary hypertension (PH) and normal left systolic function, stratified to patients with post- or precapillary PH. Methods In patients with no left valvar disease (isolated) functional TR, preserved left systolic function (ejection fraction ≥ 50%), and PH (systolic pulmonary pressure > 50 mm Hg), TR was assessed both qualitatively (grade) and semiquantitatively using the vena contracta method, and retrospective analysis of long-term outcomes was conducted. Patients with severe comorbid diseases were excluded. Results The study included 245 patients (age 80.5 years, 37% men, ejection fraction 57%, all with pulmonary systolic pressure > 50 mm Hg). At least moderate to severe TR was diagnosed in 178 patients, and their outcomes were compared with those of 67 patients with the same characteristics and less than mild TR. At least moderate to severe TR was associated with lower survival, independent of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (P = .03 for grade and P = .02 for vena contracta). Cox proportional-hazard analysis with interaction terms for TR severity and etiology of PH (post- vs precapillary) showed that the etiology of PH did not affect the association of TR with outcome (P = .90 for the interaction term). Conclusions At least moderate to severe isolated TR is independently associated with excess mortality in patients with preserved systolic function and PH, warranting heightened attention to diagnosis and grading. This is irrespective of etiology (pre- or postcapillary) of PH. Semiquantitative assessment of TR by vena contracta is an independent associate of outcome, superior to standard qualitative assessment.
Quantification of Aortic Valve Regurgitation by Pulsed Doppler Examination of the Left Subclavian Artery Velocity Contour: A Validation Study with Cardiovascular Magnetic Resonance Imaging J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-28 Ricardo A. Spampinato, Cosima Jahnke, Ingo Paetsch, Sebastian Hilbert, Franziska Busch, Valerie Schloma, Yaroslava Dmitrieva, Fernanda Bonamigo Thome, Susanne Löbe, Elfriede Strotdrees, Gerhard Hindricks, Friedrich-Wilhelm Mohr, Michael A. Borger
Background Reflux of the aortic regurgitation (AR) causes an increased diastolic reverse flow in the aorta and its branching vessels. We aimed to evaluate the feasibility and accuracy of Doppler measurements in the left subclavian artery (LSA) for quantification of AR in a cardiovascular magnetic resonance imaging (CMR) validation study. Methods Systolic and diastolic flow profiles of the LSA (subclavicular approach) were evaluated prospectively by use of pulsed wave Doppler in 59 patients (55.5 ± 15 years; 44 men), 47 with a wide spectrum of AR and 12 as control group. Using CMR phase-contrast sequences (performed 1 cm above the aortic valve), the AR was divided into three groups: mild, regurgitant fraction (RF) < 20% (n = 17); moderate, RF 20%-40% (n = 10); and severe, RF > 40% (n = 20). The LSA Doppler-derived RF was calculated as the ratio between diastolic and systolic velocity-time integrals (VTI). Results Quality LSA Doppler signal could be obtained in all cases. Patients with CMR severe AR had higher values of LSA Doppler-derived RF (51% ± 9% vs 36% ± 11% vs 16% ± 8%; P < .0001). LSA Doppler showed a good correlation with CMR, with a sensitivity of 95%, specificity of 89%, and diagnostic accuracy for severe AR of 91.5%. Finally, Bland-Altman plots showed agreement in the group with moderate to severe AR (mean bias = −2.2% ± 8%, 95% CI, −17.7 to 13.3; P = .145) but differed in mild AR. Conclusions Measurements of the RF for quantification of AR using LSA Doppler are comparable to those of CMR, highlighting the potential role of LSA Doppler as an adjunctive technique to assess the severity of AR.
Characteristic Morphologies of the Bicuspid Aortic Valve in Patients with Genetic Syndromes J. Am. Soc. Echocardiog. (IF 6.852) Pub Date : 2017-11-28 Talha Niaz, Joseph T. Poterucha, Timothy M. Olson, Jonathan N. Johnson, Cecilia Craviari, Thomas Nienaber, Jared Palfreeman, Frank Cetta, Donald J. Hagler
Background In patients with bicuspid aortic valve (BAV), complications including progressive aortic stenosis and aortic dilatation develop over time. The morphology of cusp fusion is one of the determinants of the type and severity of these complications. We present the association of morphology of cusp fusion in BAV patients with distinctive genetic syndromes. Methods The Mayo Clinic echocardiography database was retrospectively reviewed to identify patients (age ≤ 22 years) diagnosed with BAV from 1990 to 2016. Cusp fusion morphology was determined from the echocardiographic studies, while coexisting cardiac defects and genetic syndromes were determined from chart review. Results A total of 1,037 patients with BAV were identified: 550 (53%) had an isolated BAV, 299 (29%) had BAV and a coexisting congenital heart defect, and 188 (18%) had BAV and a coexisting genetic syndrome or disorder. There were no differences in distribution of morphology across the three groups. However, right-noncoronary (RN) cusp fusion was the predominant morphology associated with Down syndrome (P = .002) and right-left (RL) cusp fusion was the predominant morphology associated with Turner syndrome (P = .02), DiGeorge syndrome (P = .02), and Shone syndrome (P = .0007), when compared with valve morphology in patients with isolated BAV. Isolated BAV patients with RN cusp fusion had larger ascending aorta diameter (P = .001) and higher number of patients with ≥ moderate aortic regurgitation (P = .02), while those with RL cusp fusion had larger sinus of Valsalva diameter (P = .0006). Conclusions Morphological subtypes of BAV are associated with different genetic syndromes, suggesting distinct perturbations of developmental pathways in aortic valve malformation.
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