Echocardiographic Evaluation of Patients Undergoing Transcatheter Tricuspid Valve-In-Valve Replacement J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-02-15 Rose Tompkins, Angela M. Kelle, Allison K. Cabalka, George K. Lui, Jamil Aboulhosn, Danny Dvir, Doff B. McElhinney,
BackgroundTranscatheter tricuspid valve-in-valve replacement (TVIV) is an emerging therapy for dysfunctional surgical valves in patients with congenital and acquired TV disease. The present study was performed to establish baseline quantitative data for echocardiographic and invasive parameters obtained pre- and immediately post-TVIV.MethodsPatients were drawn from the VIVID Registry. This study included two cohorts. The registry cohort included all patients entered in the VIVID registry through February 2017 who had both echocardiographic and invasively measured gradients across the TV. The focused cohort comprised a subset of patients from a single institution who had both pre- and post-TVIV echocardiogram images reviewed offline by a single investigator. The echocardiographic variables measured were based on published guidelines from the American Society of Echocardiography.ResultsAssessment of paired pre- and/or postimplant echocardiographic and invasive pressure measurements (n = 199) showed reasonable correlation between mean TV gradient measured invasively with cardiac catheterization and noninvasively both pre- and post-TVIV (R = 0.72, P < .001), although there was a bias toward the echocardiographic gradient being higher than the invasively measured gradient and sizable discrepancies were reported in several patients. In the focused cohort (n = 42), the mean TV inflow gradient was 9.3 ± 5.0 mm Hg pre- and 5.6 ± 2.3 mm Hg post-TVIV (P < .001). The TV pressure halftime and TV:left ventricular outflow tract Doppler velocity index were 215 ± 94 msec and 3.4 ± 1.2, respectively, at baseline, and 170 ± 44 msec and 2.4 ± 0.6 post-TVIV. Both the Doppler velocity index and the TV E velocity correlated with the mean TV inflow gradient.ConclusionsThis study provides benchmark data for the echocardiographic assessment of valve function after TVIV. In this population, the significance of an inflow gradient after TVIV should be interpreted in the clinical context. The appropriate threshold for defining dysfunction may differ from the levels proposed for assessment of native or newly placed surgical valves.
ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-02-07 , John U. Doherty, Smadar Kort, Roxana Mehran, Paul Schoenhagen, Prem Soman, , Gregory J. Dehmer, John U. Doherty, Paul Schoenhagen, Thomas M. Bashore, Nicole M. Bhave, Dennis A. Calnon, Blase Carabello, John Conte, Timm Dickfeld, Daniel Edmundowicz, Victor A. Ferrari, Michael J. Wolk
This document is the second 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. The first document1 addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular 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 Clinical Practice Guidelines. A separate, independent rating panel scored the 102 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 in which 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.
Subcostal View-Based Longitudinal Strain in Patients With Breast Cancer Is an Alternative to Conventional Apical View-Based Longitudinal Strain J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-02-06 Sarah Chuzi, Vibhav Rangarajan, Lua Jafari, Inga Vaitenas, Nausheen Akhter
Contribution of Cardiovascular Reserve to Prognostic Categories of Heart Failure With Preserved Ejection Fraction: A Classification Based on Machine Learning J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-02-01 Monika Przewlocka-Kosmala, Thomas H. Marwick, Andrzej Dabrowski, Wojciech Kosmala
Background The authors used cluster analysis of data from cardiovascular domains associated with exercise intolerance to help define prognostic phenotypes of patients with heart failure with preserved ejection fraction (HFpEF). Methods Resting and postexercise echocardiography was performed in 177 patients with HFpEF and 51 asymptomatic control subjects sharing a common clinical profile. Patterns of features that determine exercise capacity were sought from automated hierarchical clustering of left ventricular (LV) diastolic and systolic function, left atrial function, right ventricular function, ventricular-arterial coupling, chronotropic reserve and myocardial fibrosis. Results Automated clustering separated a distinct subgroup characterized by a relatively isolated impairment of LV systolic reserve. The clinical factors identified by this process were used to define two phenotypes of patients with symptomatic HFpEF: those with reduced chronotropic and/or diastolic reserve (abnormal CR/DR; n = 137) and those with preserved heart rate reserve and exertional E/e′ ratio < 14 (normal CR/DR; n = 40). Change in global LV strain rate from rest to exercise was similar in patients with abnormal CR/DR (0.16 ± 0.18 sec−1) and those with normal CR/DR (0.21 ± 0.17 sec−1) and significantly lower than in asymptomatic subjects (0.54 ± 0.20 sec−1; P < .001 for all). However, although the former group also showed abnormal longitudinal deformation, ventricular-arterial coupling, and cardiac output responses to exercise, the latter group showed only reduced LV systolic reserve. The normal CR/DR group had a lower incidence of cardiovascular hospitalization or death (P = .003) and heart failure hospitalization (P = .002) than the abnormal CR/DR group during 2-year follow-up. Conclusions Diminished LV systolic reserve may represent the major identifiable cardiac functional abnormality associated with exercise intolerance in some patients with HFpEF. Despite significant functional limitation, these patients are characterized by a better prognosis than subjects with HFpEF with more physiologic abnormalities.
Optimal Number of Heartbeats Required for Representing Left Chamber Volumes and Function in Patients with Rate-Controlled Atrial Fibrillation J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-02-01 Victor Chien-Cha Wu, Kyoko Otani, Chia-Hung Yang, Pao-Hsien Chu, Masaaki Takeuchi
Background The optimal number of heartbeats required for representing left heart chamber function in patients with atrial fibrillation (AFib) has not been extensively studied. Methods To determine the optimal number, we performed an automated quantification analysis of three-dimensional echocardiography (3DE) data sets in 93 patients with AFib for whom 10–20 consecutive one-beat full-volume 3DE data sets were acquired twice. We measured left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), and maximal left atrial volume (LAVmax) in each heartbeat; each parameter was averaged using a serial number of heartbeats randomly selected, and these values were compared with the averaged value obtained from the entire set of heartbeats. Coverage probability was determined using predefined cutoff values, the relative percentage differences in LVEDV and LAVmax of 5%, and the absolute percentage differences in LVEF of 5%. The optimal number of heartbeats was defined as the minimum number of heartbeats showing coverage probability ≥95%. Results Out of 93 patients, 73 patients had acceptable left ventricular contour casts (feasibility, 78%), and 79 patients had acceptable left atrial contour casts (feasibility, 85%). Using the aforementioned criteria, the minimum optimal number of heartbeats was nine for LVEDV and six for LAVmax. The corresponding minimum optimal number of heartbeats for LVEF was eight. However, the results varied as a function of the size of the chamber, the left ventricular function, and whether the AFib ventricular rate was controlled. Conclusions In patients with AFib, the optimal number of heartbeats required to obtain representative chamber volumes and function was six to nine heartbeats randomly selected using 3DE automated quantification software.
Accuracy of the Single Cycle Length Method for Calculation of Aortic Effective Orifice Area in Irregular Heart Rhythms J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-28 Kerry A. Esquitin, Omar K. Khalique, Qi Liu, Susheel K. Kodali, Leo Marcoff, Tamim M. Nazif, Isaac George, Torsten P. Vahl, Martin B. Leon, Rebecca T. Hahn
Introduction In irregular heart rhythms, echocardiographic calculation of aortic effective orifice area (EOA) requires averaging measurements from multiple cardiac cycles. Whether a single cycle length method can be used to calculate aortic EOA in aortic stenosis with nonsinus rhythms is not known. Methods Transthoracic echocardiograms of 100 patients with aortic stenosis and either atrial fibrillation (AF) or frequent ectopy (FE) were retrospectively reviewed. The aortic valve velocity time integral (VTIAV) and the left ventricular outflow tract VTI (VTILVOT) were measured by two methods: the standard method (averaging multiple beats) and the single cycle length method. The latter matches the R-R intervals for VTIAV and VTILVOT. Stroke volume, EOA, and Doppler velocity index were calculated by both methods in all patients. The single cycle length method was used for short and long R-R cycles in AF and for postectopic beats (long R-R cycles) in FE. Results In AF, long R-R cycles resulted in larger stroke volumes (73 ± 21 vs 63 ± 18 mL; P ≤ .0001) but no difference in EOA (0.84 ± 0.27 vs 0.82 ± 0.27 cm2; P = .11), whereas short R-R cycles resulted in smaller stroke volumes (55 ± 18 vs 63 ± 18 mL, P ≤ .0001) but a larger EOA (0.86 ± 0.28 vs 0.82 ± 0.27 cm2; P = .01). In FE, the postectopic beat led to larger stroke volumes (96.1 ± 28 vs 78 ± 23 mL; P < .0001) and a larger EOA (0.99 ± 0.32 vs 0.94 ± 0.32 cm2; P = .0006) and Doppler velocity index (0.24 ± 0.07 vs 0.23 ± 0.07; P < .001). Conclusions In AF patients, the single, long cycle length method of calculating EOA can be used instead of averaging multiple cardiac cycles. The single cycle length method used on a postextrasystolic beat results in a larger EOA than a normal sinus beat and may have utility in clinical decision-making.
Comparison Between Four-Chamber and Right Ventricular–Focused Views for the Quantitative Evaluation of Right Ventricular Size and Function J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-25 Davide Genovese, Victor Mor-Avi, Chiara Palermo, Denisa Muraru, Valentina Volpato, Eric Kruse, Megan Yamat, Patrizia Aruta, Karima Addetia, Luigi P. Badano, Roberto M. Lang
Background Right ventricular (RV) function plays a pivotal prognostic role in multiple cardiac diseases. Echocardiography guidelines recommend that RV quantification be performed in the RV-focused view, which is theoretically more reproducible than the four-chamber (4Ch) view. However, differences between views in RV size and function measurements have never been systematically studied. Accordingly, the aim of this study was to compare (1) RV size and function parameters obtained from the RV-focused and 4Ch views and (2) test-retest variability between these two views. Methods Fifty patients (26 men; mean age, 63 ± 18 years) undergoing clinically indicated transthoracic echocardiography were prospectively enrolled. Each patient underwent three repeated acquisitions of the 4Ch and RV-focused views by two sonographers. The first operator performed two acquisitions at the beginning and the end of the clinical transthoracic echocardiographic study, and the second operator performed the third acquisition afterward. RV size and function measurements were obtained from the two views and compared using paired t-test analysis and Bland-Altman analysis. Intra- and interoperator test-retest and intra- and interreader variability for both views were assessed using intraclass correlations and coefficients of variation. Results All RV size parameters were significantly larger when measured in the RV-focused view compared with the 4Ch view. Also, all RV function parameters, including RV free wall and global longitudinal strain, were larger in magnitude when measured in the RV-focused view. Measurements variability was consistently better for the RV-focused view. Conclusions RV size and function measurements obtained from the RV-focused and 4Ch views are not interchangeable. RV size and function parameters measured from the RV-focused view are more reproducible than from 4Ch acquisitions. Therefore, only the RV-focused view should be used for quantitative assessment of the right ventricle.
Global Left Ventricular Relaxation: A Useful Echocardiographic Marker of Heart Transplant Rejection and Recovery in Children J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-22 Lazaro E. Hernandez, Maryanne K. Chrisant, Lilliam M. Valdes-Cruz
Background Tissue Doppler velocities are impaired after heart transplantation and further diminished in acute rejection. Methods Left ventricular relaxation index (LVRI) was calculated as the sum of E′ of the left ventricular lateral, septal and posterior walls divided by left ventricular posterior wall (LVPW) thinning (LVRI = E′ lateral + E′ septal + E′ posterior/[systolic LVPW − diastolic LVPW/systolic LVPW]). On the basis of a prior study, LVRI > 0.8 was considered normal after transplantation. Serial LVRI measurements (n = 941) were analyzed in a total of 35 patients who underwent transplantation. The sensitivity and specificity of LVRI < 0.8 for detecting rejection were calculated. LVRI was compared at baseline, at diagnosis of rejection, and at recovery after rejection treatment for each patient. The potential role of ischemic graft time, pretransplantation waiting period, and pretransplantation diagnosis on LVRI recovery was also assessed. Results LVRI was low early after transplantation (mean, 0.69) normalizing (mean, 0.91) at a median of 39.6 days (range, 5–115 days) after transplantation. Fifteen episodes of rejection were seen in 11 patients. LVRI was lower at diagnosis of rejection compared with baseline (P = .0013). LVRI < 0.8 had 93.3% sensitivity (95% CI, 68%–99.8%) and 89.5% specificity (95% CI, 67%–99%) for detecting all rejection. LVRI recovered at a mean of 28.3 days after onset of treatment. No correlation was found to ischemic graft time, to pretransplantation waiting period, or to pretransplantation diagnosis. Conclusion After the early posttransplantation period, serial measurements of LVRI appear to be a useful echocardiographic marker of heart transplantation rejection in children and of the effectiveness of rejection treatment. As such, this method may be of value in the ongoing clinical management of these difficult patients.
Mitral Annular and Left Ventricular Dynamics in Atrial Functional Mitral Regurgitation: A Three-Dimensional and Speckle-Tracking Echocardiographic Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-21 Zhe Tang, Yi-Ting Fan, Yu Wang, Chun-Na Jin, Ka-Wai Kwok, Alex Pui-Wai Lee
Background Patients with atrial fibrillation (AF) and left atrial (LA) enlargement may develop functional, normal leaflet motion mitral regurgitation (MR) without left ventricular (LV) remodeling. Mitral annular dynamics and LV mechanics are important for preserving normal mitral valve function. The aim of this study was to assess the annular and LV dynamics in patients with AF and functional MR. Methods Twenty-one patients with AF with moderate or more MR (AFMR+ group), 46 matched patients with AF with no or mild MR (AFMR− group), and 19 normal patients were retrospectively studied. Mitral annular dynamics were quantitatively assessed using three-dimensional echocardiography. Systolic LV global longitudinal strain (GLS), global circumferential strain, and LA strain were measured using two-dimensional speckle-tracking echocardiography. Results The normal annulus displayed presystolic followed by systolic contraction and increase in saddle shape (P < .01 for all). Presystolic annular dynamics were abolished in both groups of patients with AF (P > .05 vs normal). In contrast, systolic and total annular dynamics during the cardiac cycle were preserved in AFMR− patients (P > .10 vs normal) but impaired in AFMR+ patients (P < .05 vs normal and AFMR−). LV GLS (P < .0001) and LA strain (P = .02), but not LV global circumferential strain (P = .97), were impaired in AFMR+ compared with AFMR− patients despite comparable LA and LV volumes. MR severity correlated with systolic annular contraction (r = 0.64, P < .0001), saddle deepening (r = 0.53, P = .003), and LV GLS (r = 0.46, P < .0001). Multivariate analysis identified that impaired systolic contraction (odds ratio, 2.18; P = .001) and saddle deepening (odds ratio, 2.68; P = .04) were independently associated with MR. Excluding annular dynamics from the model, less negative LV GLS, but not LA strain, became associated with MR (odds ratio, 1.93; P < .0001). Conclusions In patients with AF and absent LA contraction, the normal predominantly “atriogenic” annular dynamics become “ventriculogenic.” Isolated LA enlargement is insufficient to cause important MR without coexisting abnormal LV mechanics and annular dynamics during systole. “Atrial” functional MR may not be purely an atrial disorder.
Characterization of Medical Professional Liability Risks Associated With Transesophageal Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-21 David M. Dudzinski, Sandeep S. Mangalmurti, William J. Oetgen
Background Medical claim data offer the possibility to improve patient care and mitigate liability. Although published analyses exist in cardiology, no information is available for transesophageal echocardiography (TEE). In this study, the authors reviewed medical claims involving TEE to identify potential risk management concerns so that these lessons could be used to improve the safety and quality of transesophageal echocardiographic practice. Methods The authors reviewed anonymized clinical and claims data from all closed claims from 2008 to 2013 for a single national physician liability insurer. Results There were no claims involving transthoracic echocardiography and eight involving TEE. Three claims involved esophageal perforation, a known risk of TEE. Two claims involved quadriplegia allegedly due to neck manipulation in the setting of a cervical spinal abscess that should have been suspected. Three claims involved the cardiologist's failure to diagnose endocarditis, with allegations that the cardiologist did not perform TEE in an appropriate time frame to avoid major morbidity and mortality from endocarditis. Conclusions Liability claims associated with TEE involve failure to order and perform TEE in an appropriate clinical scenario and in a timely manner; failure to properly document medical decision making; failure to inform patients regarding risks of TEE; failure to properly monitor the patient before, during, and after TEE; and technical difficulties in performing the procedure. Cardiologists should recognize guideline-based indications when TEE is needed and be mindful of the complication rates of this procedure. When screening a patient for TEE, consider expert input that may reduce the risks of TEE (e.g., a spine specialist for a neck injury, a gastroenterologist for esophageal comorbidity). Informed consent and medical record documentation should be practiced as a vehicle to inform patients of these risks and chronicle decision-making processes.
Speckle-Tracking Echocardiography in Children With Duchenne Muscular Dystrophy: A Prospective Multicenter Controlled Cross-Sectional Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-21 Pascal Amedro, Marie Vincenti, Gregoire De La Villeon, Kathleen Lavastre, Catherine Barrea, Sophie Guillaumont, Charlene Bredy, Lucie Gamon, Albano C. Meli, Olivier Cazorla, Jeremy Fauconnier, Pierre Meyer, François Rivier, Jerome Adda, Thibault Mura, Alain Lacampagne
Background Prognosis of Duchenne muscular dystrophy (DMD) is related to cardiac dysfunction. Speckle-tracking echocardiographic (STE) imaging is emerging as a noninvasive functional biomarker to consider in the early detection of DMD-related cardiomyopathy. However, STE analysis has not been assessed in a prospectively controlled study, especially in presymptomatic children with DMD, and no study has used STE analysis in all three displacements (longitudinal, radial, and circumferential) and for both ventricles. Methods This prospective controlled study enrolled 108 boys, 36 of whom had DMD (mean age, 11 ± 3.8 years) and 72 of whom were age-matched control subjects in a 1:2 case-control design. Conventional echocardiographic variables were collected for the left and right ventricles. STE analyses were performed in the longitudinal, radial, and circumferential displacements for the left ventricle and in the free wall longitudinal displacement for the right ventricle. The effect of age on the evolution of two-dimensional strain in children with DMD was studied by adding an interaction term, DMD × age, in the models. Results Conventional echocardiographic measures were normal in both groups. Left ventricular (LV) ejection fraction ranged from 45% to 76% (mean, 63 ± 6%) in the DMD group and from 55% to 76% (mean, 64 ± 5%) in the control group. Global LV strain mean measures were significantly worse in the DMD group for the longitudinal (−16.8 ± 3.9% vs −20.6 ± 2.6%, P < .0001), radial (22.7 ± 11.3% vs 31.7 ± 14%, P = .002), and circumferential (−16.5 ± 3.8% vs −20.3 ± 3.1%, P < .0001) displacements. The decrease of global LV longitudinal strain with age in children with DMD was 0.34% per year more marked than that in control subjects. The LV inferolateral and anterolateral segments were specifically impaired, especially in the basal area. Right ventricular function evaluated using conventional echocardiography and STE analysis was normal and not different between children with DMD and control subjects. Conclusions The existence of altered LV strain despite normal LV function in children with DMD represents an important perspective for future pediatric drug trials in DMD-related cardiomyopathy prevention.
Estimation of Mean Left Atrial Pressure in Patients with Acute Coronary Syndromes: A Doppler Echocardiographic and Cardiac Catheterization Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-16 Ara Tachjian, Saket R. Sanghai, Jason Stencel, Matthew W. Parker, Nikolaos Kakouros, Gerard P. Aurigemma
Background Doppler echocardiography, including the ratio of transmitral E to tissue Doppler e′ velocities (E/e′), is widely used to estimate mean left atrial pressure (mLAP). This method, however, has not been validated in patients with acute coronary syndromes. Methods Fifty-seven patients with acute coronary syndromes who underwent left heart catheterization and transthoracic echocardiography within 8 hours of each other were retrospectively analyzed. Forty-two of the patients (74%) were men, with a mean age of 65 ± 11 years. Patients with known cardiomyopathy, atrial fibrillation, or left-sided valvular disease were excluded. Doppler mLAP was estimated using Nagueh's formula (1.24 × [E/e′] + 1.9). Invasive mLAP was estimated using the formula of Yamamoto et al. (1.20 × mean left ventricular diastolic pressure – 0.82), wherein we averaged left ventricular diastolic pressure starting from the isovolumic relaxation phase to the post-A inflection point. Subanalyses were performed in groups with reduced or normal left ventricular ejection fraction (EF). Results There was stronger agreement between the two techniques to estimate mLAP in the reduced EF group (r = 0.73, r2 = 0.53, P < .001) compared with the normal EF group (r = 0.33, r2 = 0.11, P = .08). The κ statistic for agreement was 0.34 for the overall study cohort, suggesting fair agreement according to partition values of mean mLAP: <8, 8 to 15, and >15 mm Hg. Left atrial volume index did not correlate with invasively estimated mLAP in this cohort. Conclusions In patients with acute coronary syndromes, Doppler- and catheter-derived estimates of mLAP correlate well in patients with reduced EFs. In the acute setting, echocardiographic evaluation is a reliable adjunct to clinical examination in assessment of heart failure in this subgroup of patients.
Intracardiac Flow Analysis: Techniques and Potential Clinical Applications J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-14 Donato Mele, Vittorio Smarrazzo, Gianni Pedrizzetti, Fabio Capasso, Marco Pepe, Salvatore Severino, Giovanni Andrea Luisi, Marco Maglione, Roberto Ferrari
Analysis of intracardiac flows has gained increasing interest in the last years. This analysis has become possible due to the development of technologies for noninvasive cardiovascular imaging, which allow visualization and quantitation of intracardiac flow dynamics. Several studies have shown that abnormalities in cardiac function are related to changes in intracardiac vortical flows. Thus, analysis of cardiac vortex has been used for better understanding of the pathophysiology in many heart diseases and to test initial clinical hypotheses. The aims of this review are to introduce the reader to the topic of intracardiac flow dynamics, to briefly describe current cardiac imaging techniques for analysis of the intracardiac vortex, and to indicate potential clinical applications of a vortex-based approach to the study of cardiac function.
Echocardiographic Assessment of Ventricular Function During Exercise in Adolescent Female Patients With Anorexia Nervosa J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-09 Carolina A. Escudero, James E. Potts, Pei-Yoong Lam, Astrid M. De Souza, Kathryn Duff, Gerald J. Mugford, George G.S. Sandor
Background Patients with anorexia nervosa (AN) have altered physiologic responses to exercise. The aim of this study was to investigate exercise capacity and ventricular function during exercise in adolescent patients with AN. Methods Sixty-six adolescent female patients with AN and 21 adolescent female control subjects who exercised to volitional fatigue on a semisupine ergometer, using an incremental step protocol of 20 W every 3 min, were retrospectively studied. Heart rate, blood pressure, and echocardiographic Doppler indices were measured at rest and during each stage of exercise. Fractional shortening, rate-corrected mean velocity of circumferential fiber shortening, stress at peak systole, cardiac output, and cardiac index were calculated. Minute ventilation, oxygen consumption, carbon dioxide production, and respiratory exchange ratio were measured using open-circuit spirometry. Results Patients with AN had significantly lower body mass index (16.7 vs 19.7 kg/m2, P < .001), total work (1,126 vs 1,914 J/kg, P < .001), and test duration (13.8 vs 20.8 min, P < .001) compared with control subjects. Peak minute ventilation, oxygen consumption, and carbon dioxide production were significantly decreased in patients with AN. Heart rate, systolic blood pressure, cardiac index, fractional shortening, and rate-corrected mean velocity of circumferential fiber shortening demonstrated similar patterns of increase with progressive exercise between groups but were decreased at peak exercise in patients with AN. Body mass index percentile, age, peak oxygen consumption, and peak cardiac output were independently associated with exercise duration. Conclusions Adolescent patients with AN have reduced exercise capacity and peak cardiovascular indices compared with control subjects but normal patterns of cardiovascular response during progressive exercise. Systolic ventricular function is maintained during exercise in adolescents with AN.
Prognostic Value of Energy Loss Coefficient for Predicting Asymptomatic Aortic Stenosis Outcomes: Direct Comparison With Aortic Valve Area J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2019-01-09 Hirokazu Yoshida, Yoshihiro Seo, Tomoko Ishizu, Masaki Izumo, Yoshihiro J. Akashi, Eiji Yamashita, Yutaka Otsuji, Kazuaki Negishi, Masaaki Takeuchi
Background The pressure recovery–adjusted aortic valve area (AVA), called the energy loss coefficient (ELCo), is theoretically a more accurate parameter for evaluating aortic stenosis (AS) severity. The aim of this study was to compare the prognostic value of ELCo with that of conventional AVA. Methods Indexed AVA (iAVA) was measured using Doppler echocardiography in 301 asymptomatic Japanese patients with AS and preserved left ventricular ejection fractions. Sinotubular junction diameter was also measured, and the indexed ELCo (iELCo) was calculated. Patients were followed for major cardiac events, including cardiac death, ventricular fibrillation, myocardial infarction, heart failure requiring admission, and aortic valve replacement. Results The mean sinotubular junction diameter was 2.5 ± 0.3 cm, and >90% of patients had sinotubular junction diameters < 3 cm. There was a quadratic correlation between iAVA and iELCo (r = 0.97, P < .001). During a median of 17.4 months of follow-up, 90 patients had major cardiac events. Statistical analysis failed to show any superiority of iELCo over iAVA for predicting major cardiac events. However, iELCo stratified high-risk patients for cardiac outcome in a subset of patients whose AS grades were classified as severe using iAVA and in those whose AS severity was inconsistent (iAVA < 0.6 cm2/m2 but mean pressure gradient < 40 mm Hg). Conclusions The calculation of iELCo may not be always required, even in patients with asymptomatic AS with small aortic roots. However, this index should be calculated in patients whose AS grading assessed by iAVA is severe and in those in whom AS severity criteria are inconsistent.
Left and Right Ventricular Systolic and Diastolic Functional Reserves Are Impaired in Anthracycline-Treated Long-Term Survivors of Childhood Cancers J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-12-28 Vivian W.Y. Li, Anthony P.Y. Liu, Wilfred H.S. Wong, Karin K.H. Ho, Jeffrey P.W. Yau, Daniel K.L. Cheuk, Yiu-fai Cheung
Background The aim of this study was to test the hypothesis that left ventricular (LV) and right ventricular (RV) functional reserves are altered in anthracycline-treated long-term survivors of childhood cancers. Methods One hundred three survivors (55% men) aged 25.0 ± 5.8 years at 15.2 ± 5.8 years after chemotherapy and 61 healthy control subjects (52% men) were studied. Tissue Doppler–derived mitral and tricuspid systolic (s) and early diastolic (e) velocities and LV myocardial acceleration during isovolumic contraction (IVA) were determined at rest and during bicycle exercise. The slope of the LV force-frequency relationship was derived from changes in IVA with heart rate during exercise (ΔIVA/Δ[heart rate]). LV and RV functional reserves were further assessed by the systolic functional reserve index (Δs × [1 − 1/s at baseline]) and diastolic functional reserve index (Δe × [1 − 1/e at baseline]). Results At baseline, mitral annular tissue Doppler indices were similar between survivors and control subjects (P > .05 for all), while tricuspid s and e velocities were significantly lower in survivors (P < .05 for both). The force-frequency relationship slope (P < .001), LV systolic functional reserve index (P < .001), and RV systolic functional reserve index (P = .001) were significantly lower in survivors than control subjects. For diastolic functional reserve, LV but not RV diastolic functional reserve index was significantly lower in survivors (P < .001). Multivariate analysis revealed survivor status (β = −0.39, P < .001) and baseline LV IVA (β = 0.15, P < .044) as significant determinants of the LV force-frequency relationship. Conclusions LV and RV functional reserves during exercise are impaired in anthracycline-treated long-term survivors of childhood cancer.
Accuracy of Jet Direction on Doppler Echocardiography in Identifying the Etiology of Mitral Regurgitation in Obstructive Hypertrophic Cardiomyopathy J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-12-28 Dustin Hang, Hartzell V. Schaff, Rick A. Nishimura, Brian D. Lahr, Martin D. Abel, Joseph A. Dearani, Steve R. Ommen
Background Mitral valve regurgitation (MR) mediated by systolic anterior motion (SAM) in obstructive hypertrophic cardiomyopathy (HCM) is traditionally characterized by a posteriorly directed jet on Doppler echocardiography. Many believe that MR in the absence of a posteriorly directed jet signals the presence of intrinsic mitral valve (MV) disease. Methods A total of 709 adult patients with obstructive HCM who underwent septal myectomy were evaluated; 330 of these patients had >2 + MR preoperatively and constituted the study group. SAM-mediated MR was defined as MR that was eliminated or substantially reduced by myectomy for relief of left ventricular outflow tract obstruction with no need for MV intervention. Results On preoperative transthoracic echocardiography, 168 of 258 patients with SAM-mediated MR and nine of 28 patients with intrinsic MV disease had isolated posterior jets, corresponding to sensitivity and specificity of 65.1% and 67.9% for identifying SAM-mediated MR; the positive predictive value was 94.9% and the negative predictive value was 17.4%. On prebypass transesophageal echocardiography, 169 of 284 patients with SAM-mediated MR and five of 28 patients with intrinsic MV disease had isolated posterior jets, corresponding to sensitivity and specificity of 59.5% and 82.1%; the positive predictive value and negative predictive value were 97.1% and 16.7%. Conclusion A posteriorly directed jet of MR in obstructive HCM correlates highly with SAM as the underlying pathophysiologic mechanism, but because of the low negative predictive value, clinicians should be cautious in using the jet direction of MR on preoperative transthoracic echocardiography to guide the decision for concomitant MV surgery during septal myectomy for HCM.
Parental Acquisition of Echocardiographic Images in Pediatric Heart Transplant Patients Using a Handheld Device: A Pilot Telehealth Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-12-28 John C. Dykes, Alaina K. Kipps, Angela Chen, Susan Nourse, David N. Rosenthal, Elif Seda Selamet Tierney
Background Pediatric heart transplant patients (PedHtx) require frequent monitoring by echocardiography (echo); however, they often live far from hospitals with pediatric echo services, resulting in urgent/emergent transfers to specialized institutions. Our primary objective was to evaluate the feasibility of parental acquisition of echo images to assess left ventricular (LV) systolic function in PedHtx using a handheld echo device. Secondary objectives included retesting for skill maintenance and in patients with decreased LV systolic function. Methods During a routine clinic visit, parents received 1-hour training with a handheld echo device to acquire images in parasternal short-axis and apical views. Parents recorded images on their children at training completion and 24 hours later at home. An independent echocardiographer assessed clinic, training, and home echos for LV systolic function. Results Fifteen PedHtx (mean age of 12.6 years of age; range, 4.1-16.7) were enrolled. All parents could acquire home images adequate for qualitative assessment of LV systolic function with no discrepancy compared with clinical echos. LV ejection fraction (LVEF) could be calculated (5/6 area-length method) in 86% of training and 43% of home echos with <10% difference in LVEF measurements between home and clinic echos. Five parents repeated home echos >12 months later. All home echos were adequate for qualitative assessment of LV systolic function (LVEF measurable in two). Additionally, five heart failure patients with decreased LV systolic function (mean age of 8.6 years; range 1.9-15.1) were enrolled. All home echos were adequate for qualitative assessment of LV systolic function (LVEF measurable in one). Conclusions Our results suggest that parental home echo acquisition using a handheld echo device is feasible and adequate for qualitative assessment of LV systolic function in PedHtx. However, quantitative assessment of LV systolic function, especially in patients with dysfunction, and retention of the skill set without additional training are suboptimal.
Quantile Score: A New Reference System for Quantitative Fetal Echocardiography Based on a Large Multicenter Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-12-24 Xiaoyan Gu, Haogang Zhu, Ye Zhang, Jiancheng Han, Hongjia Zhang, Ying Liu, Airong Wang, Baomin Liu, Jun Xue, Baojuan Sun, Zongjie Weng, Shuping Ge, Yihua He
Background Normative ranges of fetal echocardiographic measurements are important for quantitative diagnosis of fetal cardiovascular disease. The current normative ranges were derived from small samples and were based on the hypothesis of a normal distribution of these measurements during fetal cardiovascular growth. The aims of this study were to test the hypothesis of a normal distribution of fetal echocardiographic measurements in a large multicenter cohort and to propose a reference system without the normal distribution hypothesis to improve accuracy of fetal echocardiographic measurements. Methods Fifty-two variables from 6,343 normal fetal echocardiographic examinations were acquired from seven Chinese centers. The hypothesis of a normal distribution used in ordinary least squares regression was tested with the Jarque-Bera test. The quantile score (q score) derived from quantile regression without normal distribution hypothesis was compared with the Z score derived from ordinary least squares regression. A total of 288 fetuses with outflow tract and great artery abnormalities and 300 normal fetuses were used to compare the diagnostic accuracy of q and Z scores. Results All fetal echocardiographic measurements showed non-normal distributions (P < .001). The normal range was underestimated by ordinary least squares regression compared with quantile regression by 30 ± 11%. The partial normalized areas under the receiver operating characteristic curve within the 20% false-positive rate were 0.62 and 0.50 for the q and Z scores, respectively. Conclusions The q score provides a more robust system for determining normative ranges of fetal echocardiographic measurements. The improved sensitivity of matched false-positive rates makes the q score a more accurate reference for prenatal diagnosis, assessment, and prognosis of fetal cardiovascular disease.
Characterization of Right Ventricular Deformation in Pulmonary Arterial Hypertension Using Three-Dimensional Principal Strain Analysis J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-12-11 Alessandro Satriano, Payam Pournazari, Naushad Hirani, Doug Helmersen, Mitesh Thakrar, Jason Weatherald, James A. White, Nowell M. Fine
Background Pulmonary arterial hypertension (PAH) can cause maladaptive right ventricular (RV) functional changes associated with adverse prognosis that are challenging to accurately quantify noninvasively. The aim of this study was to explore principal strain (PS) with contraction angle analysis using three-dimensional echocardiography to characterize RV deformation changes in patients with PAH. Methods Three-dimensional echocardiography was performed in 37 patients with PAH and 20 healthy control subjects with two-component (primary and secondary) PS and principal contraction angle analysis. Patients were stratified according to World Health Organization (WHO) functional class. Results Primary PS differed significantly between patients with PAH and healthy control subjects (−20.2 ± 3.3% vs −26.8 ± 3.3%, P = .01), while secondary PS was not significantly different (3.6 ± 5.1% vs −2.5 ± 4.7%, P = .12). Principal contraction angle was significantly lower in patients with PAH (63 ± 22° vs 71 ± 7°, P = .01), with the greatest reduction for the RV free wall. Primary PS and principal contraction angle differed significantly between WHO class I and II and class III and IV patients (−23.9 ± 4.7% vs −18.1 ± 4.8% [P = .03] and 69 ± 9° vs 58 ± 14° [P = .03], respectively), while secondary PS was not significantly different between groups (P = .13). Compared with healthy control subjects, septal principal contraction angle was not different in patients with WHO class I and II PAH (P = .62), but it was significantly reduced in those with WHO class III and IV PAH (P < .01). The area under the curve for primary PS to differentiate patients with PAH by WHO functional class was 0.81 (95% CI, 0.77–0.89; P = .01). Primary PS intraclass correlation coefficients for intraobserver and interobserver variability were 0.91 (95% CI, 0.88–0.93) and 0.86 (95% CI, 0.81–0.88), respectively. Conclusions PS analysis using three-dimensional echocardiography provides comprehensive quantification of RV deformation and characterizes alterations occurring in PAH that are associated with WHO functional class.
Diagnosis of Heart Failure With Preserved Ejection Fraction: Machine Learning of Spatiotemporal Variations in Left Ventricular Deformation J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-23 Mahdi Tabassian, Imran Sunderji, Tamas Erdei, Sergio Sanchez-Martinez, Anna Degiovanni, Paolo Marino, Alan G. Fraser, Jan D'hooge
Background Stress testing helps diagnose heart failure with preserved ejection fraction (HFpEF), but there are no established criteria for quantifying left ventricular (LV) functional reserve. The aim of this study was to investigate whether comprehensive analysis of the timing and amplitude of LV long-axis myocardial motion and deformation throughout the cardiac cycle during rest and stress can provide more informative criteria than standard measurements. Methods Velocity, strain, and strain rate traces were measured from all 18 LV segments by echocardiographic myocardial velocity imaging at rest and during semisupine bicycle exercise in 100 subjects aged 69 ± 7 years, including patients with HFpEF and healthy, hypertensive, and breathless control subjects. A machine-learning algorithm, composed of an unsupervised statistical method and a supervised classifier, was used to model spatiotemporal patterns of the traces and compare the predicted labels with the clinical diagnoses. Results The learned strain rate parameters gave the highest accuracy for allocating subjects into the four groups (overall, 57%; for patients with HFpEF, 81%), and into two classes (asymptomatic vs symptomatic; area under the curve, 0.89; accuracy, 85%; sensitivity, 86%; specificity, 82%). Machine learning of strain rate, compared with standard measurements, gave the greatest improvement in accuracy for the two-class task (+23%, P < .0001), compared with +11% (P < .0001) using velocity and +4% (P < .05) using strain. Strain rate was also best at predicting 6-min walk distance as an independent reference criterion. Conclusions Machine learning of spatiotemporal variations of LV strain rate during rest and exercise could be used to identify patients with HFpEF and to provide an objective basis for diagnostic classification.
Feeding Induces Left Atrial Compression and Impedes Cardiac Filling in Patients With Large Hiatal Hernia J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-11-22 Sonali R. Gnanenthiran, Christopher Naoum, Dianna Hanzek, Zoya Pogrebizhsky, David Martin, Leonard Kritharides, John Yiannikas
Background Patients with large hiatal hernias (HH) frequently experience postprandial dyspnea. The aim of this study was to evaluate whether feeding induced cardiac compression in these patients using echocardiography. Methods Transthoracic echocardiography was performed during fasting and 30 min after feeding (300 g rice pudding) in patients with HHs (n = 32; mean age, 72 ± 9 years). A subset of patients (n = 15; mean age, 76 ± 6 years) were evaluated postoperatively. Results Preoperatively, feeding decreased left atrial (LA) volumes (maximal 27.4 ± 11.3 vs 19.2 ± 9.7 mL/m2, P < .001; minimal 13.1 ± 7.0 vs 6.9 ± 5.1 mL/m2, P < .001), and increased LA inflow velocities (systolic wave 0.62 ± 0.14 vs 0.77 ± 0.17 m/sec, P < .01; diastolic wave 0.46 ± 0.13 vs 0.59 ± 0.13 m/sec, P < .01), mitral inflow velocities (E wave 0.79 ± 0.17 vs 0.94 ± 0.19 m/sec, P < .01; A wave 0.93 ± 0.20 vs 1.05 ± 0.22 m/sec, P < .01), and E/E′ ratio (12.1 ± 2.7 vs 13.7 ± 3.9, P < .01). Cardiac output (6.3 ± 1.6 vs 7.24 ± 2.0 L, P < .01) increased postprandially by marked heart rate augmentation (68.8 ± 7.0 vs 84.2 ± 8.4 beats/min, P < .01), with modest stroke volume increase (88.5 ± 16.7 vs 94.3 ± 19.5 mL, P = .03). After HH surgery, feeding did not change LA volumes (maximal 52.9 ± 13.6 vs 53.4 ± 12.5 mL, P = .89; minimal 28.6 ± 12.2 vs 27.4 ± 8.7 mL, P = .59) or E/E′ ratio (10.9 ± 2.1 vs 11.3 ± 2.3) and induced more modest alterations in LA inflow (systolic wave 0.58 ± 0.17 vs 0.68 ± 0.16 m/sec, P = .01; diastolic wave 0.41 ± 0.12 vs 0.47 ± 0.13 m/sec, P = .01) and mitral inflow (E wave 0.69 ± 0.15 vs 0.80 ± 0.13 m/sec, P < .01; A wave 0.92 ± 0.13 vs 1.01 ± 0.18 m/sec, P = .02). Postoperatively, feeding increased cardiac output by substantial stroke volume augmentation (81.9 ± 16.5 vs 90.8 ± 16.0 mL, P = .01), with only modest increase in heart rate (69.8 ± 9.1 vs 75.9 ± 10.5 beats/min, P < .01). Conclusions Feeding produces marked LA compression in patients with HHs, inducing compensatory exaggerated responses in cardiac inflow and hemodynamic status. These compensatory mechanisms improve postoperatively following resolution of LA compression, likely explaining the debility noted preoperatively.
Echocardiographic Assessment of the Tricuspid Annulus: The Effects of the Third Dimension and Measurement Methodology J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-11-17 Valentina Volpato, Roberto M. Lang, Megan Yamat, Federico Veronesi, Lynn Weinert, Gloria Tamborini, Manuela Muratori, Laura Fusini, Mauro Pepi, Davide Genovese, Victor Mor-Avi, Karima Addetia
Background Evaluation of the tricuspid annulus is crucial for the decision making at the time of left heart surgery. Current recommendations for tricuspid valve repair are based on two-dimensional (2D) transthoracic echocardiography (TTE), despite the known underestimation compared with three-dimensional (3D) echocardiography. However, little is known about the differences in 3D tricuspid annular (TA) sizing using TTE versus transesophageal echocardiography (TEE). The aims of this study were to (1) compare 2D and 3D TA measurements performed with both TTE and TEE and (2) compare two 3D methods for TA measurements: multiplanar reconstruction (MPR) and dedicated software (DS) designed to take into account TA nonplanarity. Methods Seventy patients underwent 2D and 3D TTE and TEE. Two-dimensional images were used to measure TA diameter from apical four-chamber, right ventricular–focused (TTE), and midesophageal four-chamber (TEE) views. Three-dimensional full-volume data sets were analyzed using both MPR and DS, to obtain major and minor axes, perimeter, and area. Intertechnique agreement was assessed using Bland-Altman analysis. Results Measurements on 2D TTE and TEE, which were view dependent, underestimated TA major dimensions in all views compared with 3D values, irrespective of the 3D method. MPR and DS measurements were significantly different, with DS resulting in larger values for all parameters, irrespective of approach. No differences were found between 3D TTE and 3D TEE for both MPR and DS. Conclusions Our findings highlight the need for methodology that respects the 3D geometry of the tricuspid annulus, including its nonplanarity, which cannot be accurately assessed from 2D images and is not equally taken into account by different 3D measurement methodologies. Accordingly, a 3D cutoff value for TA enlargement needs to be established and is likely to be larger than the guideline-recommended 2D-based 40-mm cutoff. Importantly, noninvasive 3D TTE can be used instead of 3D TEE because TA measurements are not different.
Prognostic Value of Preserved Coronary Flow Velocity Reserve by Noninvasive Transthoracic Doppler Echocardiography in Patients With Angiographically Intermediate Left Main Stenosis J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-11-17 Ana Djordjevic Dikic, Milorad Tesic, Nikola Boskovic, Vojislav Giga, Jelena Stepanovic, Marija Petrovic, Milan Dobric, Srdjan Aleksandric, Stefan Juricic, Miodrag Dikic, Ivana Nedeljkovic, Milan Nedeljkovic, Miodrag Ostojic, Branko Beleslin
Background The potential of angiography to evaluate the hemodynamic severity of a left main coronary artery (LM) stenosis is limited. Noninvasive transthoracic Doppler echocardiographic coronary flow velocity reserve (CFVR) evaluation of intermediate coronary stenosis has demonstrated remarkably high negative prognostic value. The aim of this study was to assess clinical outcomes in patients with angiographically intermediate LM stenosis and preserved CFVR (>2.0) as evaluated by transthoracic Doppler echocardiographic CFVR. Methods The initial study population included 102 patients with intermediate coronary stenosis of the LM referred for transthoracic Doppler echocardiographic CFVR assessment. Peak diastolic CFVR measurements were performed in the distal segment of the left anterior descending coronary artery after intravenous adenosine (140 μg/kg/min), and CFVR was calculated as the ratio between maximal hyperemic and baseline coronary flow velocity. Nineteen patients had impaired CFVR (≤2.0) and were excluded from further analysis, as well as two patients with poor acoustic windows. The final group consisted of 81 patients (mean age, 60 ± 9 years; 76 men) evaluated for adverse cardiac events including death, myocardial infarction, and revascularization. Results Mean follow-up duration was 62 ± 26 months. Mean CFVR was 2.4 ± 0.4. Total event-free survival was 75 of 81 (92.6%), as six patients were referred for revascularization (five patients with coronary artery bypass grafting, one patient with percutaneous coronary intervention). There were no documented myocardial infarctions or cardiovascular deaths in the follow-up period. Conclusions In patients with angiographically intermediate and equivocal LM stenosis and preserved CFVR values of >2.0, revascularization can be safely deferred.
Echocardiographic Assessment for the Detection of Cardiotoxicity Due to Vascular Endothelial Growth Factor Inhibitor Therapy in Metastatic Renal Cell and Colorectal Cancers J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-11-17 Lara F. Nhola, Sahar S. Abdelmoneim, Hector R. Villarraga, Manish Kohli, Axel Grothey, Kimberly-Ann Bordun, Matthew Cheung, Ryan Best, David Cheung, Runqing Huang, Sergio Barros-Gomes, Marshall Pitz, Pawan K. Singal, Davinder S. Jassal, Sharon L. Mulvagh
Background Cardio-oncology is a recently established discipline that focuses on the management of patients with cancer who are at risk for developing cardiovascular complications as a result of their underlying oncologic treatment. In metastatic colorectal cancer (mCRC) and metastatic renal cell carcinoma (mRCC), vascular endothelial growth factor inhibitor (VEGF-i) therapy is commonly used to improve overall survival. Although these novel anticancer drugs may lead to the development of cardiotoxicity, whether early detection of cardiac dysfunction using serial echocardiography could potentially prevent the development of heart failure in this patient population requires further study. The aim of this study was to investigate the role of two-dimensional speckle-tracking echocardiography in the detection of cardiotoxicity due to VEGF-i therapy in patients with mCRC or mRCC. Methods Patients with mRCC or mCRC were evaluated using serial echocardiography at baseline and 1, 3, and 6 months following VEGF-i treatment. Results A total of 40 patients (34 men; mean age, 63 ± 9 years) receiving VEGF-i therapy were prospectively recruited at two academic centers: 26 (65%) were receiving sunitinib, eight (20%) pazopanib, and six (15%) bevacizumab. The following observations were made: (1) 8% of patients developed clinically asymptomatic cancer therapeutics–related cardiac dysfunction; (2) 30% of patients developed clinically significant decreases in global longitudinal strain, a marker for early subclinical cardiac dysfunction; (3) baseline abnormalities in global longitudinal strain may identify a subset of patients at higher risk for developing cancer therapeutics–related cardiac dysfunction; and (4) new or worsening hypertension was the most common adverse cardiovascular event, afflicting nearly one third of the study population. Conclusions Cardiac dysfunction defined by serial changes in myocardial strain assessed using two-dimensional speckle-tracking echocardiography occurs in patients undergoing treatment with VEGF-i for mCRC or mRCC, which may provide an opportunity for preventive interventions.
Ethical Challenges in the Practice of Echocardiography: What Is Right and How Do We Do It? J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-11-17 James N. Kirkpatrick, Alan S. Pearlman
At the 2018 Scientific Sessions, the American Society of Echocardiography inaugurated the Richard E. Kerber Ethics/Humanitarian Lecture, continuing its tradition of providing ethics education and exploring the use of echocardiography to improve cardiovascular care in medically underserved settings. Echocardiography is one of the most widely applicable, safe, and cost-effective diagnostic tools available in cardiovascular medicine. The American Society of Echocardiography Foundation is well known for harnessing the power of echocardiography in its many successful humanitarian outreaches all over the world. Some practitioners might conclude that because of its important advantages, echocardiography involves few ethical complexities; however, several historical and recent scandals involving conflicts of interest and lapses in quality suggest otherwise. Every day, sonographers and echocardiographers grapple with ethical issues: integrity, truth telling, doing good and avoiding harm, altruism, and humanism. In the near future, population aging and technological advances, among other issues, will ensure that a steady stream of ethical issues will confront the practitioners of echocardiography. Medical science and engineering have given us many things that can be done, but central to the art of medical practice and research are decisions about what should be done. In this article, based in part on the first Richard E. Kerber Ethics/Humanitarian Lecture, the authors discuss ethical challenges in the practice of echocardiography, illustrated by accompanying online videos, and offer a general principle for meeting these challenges.
Effects of Trypanocidal Treatment on Echocardiographic Parameters in Chagas Cardiomyopathy and Prognostic Value of Wall Motion Score Index: A BENEFIT Trial Echocardiographic Substudy J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-11-09 André Schmidt, Minna Moreira Dias Romano, José Antônio Marin-Neto, Purnima Rao-Melacini, Anis Rassi, Antônio Mattos, Álvaro Avezum, Erick Villena, Sergio Sosa-Estani, Rina Bonilla, Salim Yusuf, Carlos A. Morillo, Benedito Carlos Maciel,
Background Serial echocardiographic studies in chronic Chagas cardiomyopathy are scarce. The aims of this study were to evaluate whether therapy with benznidazole modifies the progression of cardiac impairment and to identify baseline echocardiographic parameters related to prognosis. Methods A prospective substudy was conducted in 1,508 patients with chronic Chagas cardiomyopathy randomized to benznidazole or placebo, who underwent two-dimensional echocardiography at enrollment, 2 years, and final follow-up (5.4 years). Left ventricular (LV) ejection fraction, LV wall motion score index (WMSI), indexed left atrial volume, and chamber dimensions were collected and correlated to all-cause death and a composite hard outcome using univariate and multivariate analyses. Results At enrollment, most patients had normal chamber dimensions, and 70.5% had preserved LV ejection fractions. During follow-up, all chamber dimensions increased similarly in both treatment arms. LV ejection fraction was comparably reduced (55.7 ± 12.7% to 52.1 ± 14.6% vs 56.3 ± 12.7% to 52.8 ± 14.1%) and LV WMSI similarly increased (1.31 ± 0.41 to 1.49 ± 0.03 and 1.27 ± 0.38 to 1.51 ± 0.03) for the benznidazole and placebo groups, respectively (P > .05). A higher baseline LV WMSI was identified in subjects who died compared with those alive at final echocardiography (1.76 ± 0.517 vs 1.271 ± 0.393, P < .0001). There was a significant (P < .0001) graded increase in the risk for the composite outcome with worsening LV WMSI (hazard ratios, 2.27 [95% CI, 1.69–3.06] and 6.42 [95% CI, 4.94–8.33]) and also of death (hazard ratios, 2.45 [95% CI, 1.62–3.71] and 8.99 [95% CI, 6.3–12.82]) for 1 < LV WMSI < 1.5 and LV WMSI > 1.5, respectively. Both LV WMSI and indexed left atrial volume remained independent predictors in multivariate analysis. Conclusions Trypanocidal treatment had no effect on echocardiographic progression of chronic Chagas cardiomyopathy over 5.4 years. Despite normal global LV systolic function, regional wall motion abnormalities and indexed left atrial volume identified patients at higher risk for hard adverse clinical outcomes.
The Prognostic Value of Coronary Flow Velocity Reserve in Two Coronary Arteries During Vasodilator Stress Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-25 Lauro Cortigiani, Fausto Rigo, Francesco Bovenzi, Rosa Sicari, Eugenio Picano
Background Vasodilator stress echocardiography (SE) allows combined evaluation of regional wall motion and Doppler coronary flow velocity reserve (CFVR) of both the left anterior descending coronary artery (LAD) and the right coronary artery (RCA). The aim of this study was to prospectively assess the prognostic correlates of LAD and RCA CFVR on SE. Methods A total of 1,365 patients with known or suspected coronary artery disease underwent dipyridamole SE with combined evaluation of CFVR in both the LAD and the RCA. Results Ischemia was present on SE in 263 patients (19%). CFVR was abnormal (≤2.0) in 545 patients (40%): 172 in the LAD only, 149 in the RCA only, and 224 in both the LAD and the RCA. During a median follow-up period of 20 months, 44 deaths and 98 myocardial infarctions occurred. In the overall population, LAD CFVR ≤ 2.0 (hazard ratio [HR], 3.93) and inducible ischemia (HR, 2.74) were multivariate prognostic predictors. In the subset with ischemia on SE, CFVR did not add to peak wall motion score index (HR, 2.23). In patients without ischemia on SE, age (HR, 1.04), anti-ischemic therapy at the time of testing (HR, 1.6) and LAD CFVR ≤ 2.0 (HR, 10.8) were independent prognostic indicators. In patients without ischemia on SE and LAD CFVR >2.0, the 4-year event rate was 4% in those with RCA CFVR > 2.0 and 18% in those with RCA CFVR ≤ 2.0 (P < .0001). Conclusions Ischemia on SE with high peak wall motion score index identifies a high-risk subset regardless of the underlying CFVR response. Absence of ischemia on SE is associated with intermediate risk, and LAD CFVR is essential to identify a truly low-risk subset. RCA CFVR is less useful than LAD CFVR but may have a role for further risk stratification in patients without ischemia and normal LAD CFVR.
Clinical Implementation of Continuous-Wave Doppler: It Made All the Difference J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-23 Randolph P. Martin
Today, Doppler echocardiography is central to our ability to determine cardiovascular hemodynamics, especially in valvular heart diseases, noninvasively. Continuous-wave Doppler (CWD) plays a central diagnostic role in the diagnosis and management of patients with aortic stenosis. The development and use of CWD in aortic stenosis was due to the pioneering work of Dr. Liv Hatle and her outstanding medical and engineering colleagues in Norway. The author was fortunate to be the first to use the early CWD instruments in North America. Therefore, this article highlights key lessons learned: the importance and value of key contributions made by our engineering and young cardiology and sonographer colleagues, the key importance of the independent PEDOF CWD probe as well as use of the audio signal for accurate detection of high-velocity flows, and the value of CWD for the diagnosis and management of other cardiovascular conditions.
Strain and Rotational Mechanics in Children With Single Left Ventricles After Fontan J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-18 Carmen Lopez, Luc Mertens, Andreea Dragulescu, Bruce Landeck, Adel Younoszai, Mark K. Friedberg, Kendall Hunter, Michael V. Di Maria
Background Left ventricular (LV) mechanics in patients with different single morphologic LV subtypes, including tricuspid atresia, double-inlet left ventricle, and pulmonary atresia with intact ventricular septum, remain poorly studied. Given that histologic studies indicate differences in LV myocardial fiber orientation, we hypothesized that this may result in altered LV mechanics. The aim of this study was to evaluate the influence of LV morphology on LV mechanics. Methods Fifty-two children with single left ventricles after Fontan operation and age-matched control subjects were prospectively enrolled. Using two-dimensional speckle-tracking echocardiography, longitudinal strain was measured in the four-, three-, and two-chamber long-axis planes, and circumferential strain was measured at the basal, mid, and apical short-axis planes. Apical and basal rotation were measured, and twist and torsion were calculated. We compared strain and rotational mechanics in cases versus control subjects and among LV subtypes. Results Compared with control subjects, subjects with single left ventricles had similar LV end-diastolic dimensions but significantly decreased ejection fractions. The single left ventricle cohort had normal global longitudinal strain (P = .20) but lower basal mean circumferential strain (P < .0001). Single left ventricle subjects had higher apical rotation (P = .0001) but decreased basal rotation (P = .0007); there was no difference in twist but increased torsion (P = .001). LV subtypes had different four-chamber (P = .01), two-chamber (P = .006), and global longitudinal strain (P = .01), lowest in the pulmonary atresia with intact ventricular septum subtype. Conclusions Longitudinal LV strain was preserved in children with single left ventricles after Fontan. A pattern of reduced basal circumferential strain and rotation with an increase in apical rotation and torsion in the single left ventricle cohort may be related to differences in myofiber orientation, increased fibrosis, and the impact of altered loading conditions throughout palliation. Decreased longitudinal strain in the pulmonary atresia with intact ventricular septum group may also reflect detrimental interventricular interactions.
Adding Speckle-Tracking Echocardiography to Visual Assessment of Systolic Wall Motion Abnormalities Improves the Detection of Myocardial Infarction J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-17 Manouk J.W. van Mourik, Daniëlle V.J. Zaar, Martijn W. Smulders, Jordi Heijman, Joost Lumens, Jeffrey E. Dokter, Valeria Lima Passos, Simon Schalla, Christian Knackstedt, Georg Schummers, Ola Gjesdal, Thor Edvardsen, Sebastiaan C.A.M. Bekkers
Background The aim of this study was to investigate whether speckle-tracking echocardiography (STE) improves the detection of myocardial infarction (MI) over visual assessment of systolic wall motion abnormalities (SWMAs) using delayed enhancement cardiac magnetic resonance imaging as a reference. Methods Transthoracic echocardiography was performed in 95 patients with first ST segment elevation MI 110 days (interquartile range, 97–171 days) after MI and in 48 healthy control subjects. Two experienced observers independently assessed SWMAs. Separately, longitudinal peak negative, peak systolic, end-systolic, global strain, and strain rate were measured and averaged for the American Heart Association–recommended coronary artery perfusion territories. Receiver operating characteristic analysis was used to determine a single optimal cutoff value for each strain parameter. The diagnostic accuracy of an algorithm combining visual assessment and STE was evaluated. Results Median infarct size and transmurality were 15% (interquartile range, 7%–24%) and 64% (interquartile range, 46%–78%), respectively. Sensitivity, specificity, and accuracy of visual assessment to detect MI were 74% (95% CI, 63%–82%), 85% (95% CI, 72%–93%), and 78% (95% CI, 70%–84%), respectively. Among the strain parameters, SR had the highest diagnostic accuracy (area under the curve, 0.88; 95% CI, 0.83–0.94; cutoff value, −0.97 sec−1). The combination with STE improved sensitivity compared with visual assessment alone (94%; 95% CI, 86%–97%; P < .001), minimally affecting specificity (79%; 95% CI, 65%–89%; P = .607). Overall accuracy improved to 89% (95% CI, 82%–93%; P = .011). Multivariate analysis accounting for age and sex demonstrated that SR was independently associated with MI (odds ratio, 2.0; 95% CI, 1.6–2.7). Conclusions The sensitivity and diagnostic accuracy of visually detecting chronic MI by assessing SWMAs are moderate but substantially improve when adding STE.
Ventricular Torsion in Young Patients With Single-Ventricle Anatomy J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-17 Michael Grattan, Luc Mertens, Lars Grosse-Wortmann, Mark K. Friedberg, Barbara Cifra, Andreea Dragulescu
Background In normal left ventricles, clockwise basal rotation and counterclockwise apical rotation result in systolic torsion. Torsion is important for contractile efficiency and may be especially important in single-ventricle (SV) physiology. However, little is known about torsion in patients with SVs. The aim of this study was to measure torsion in SVs and to determine its relationship with other measures of ventricular function. The hypothesis was that torsion would be decreased in all SVs, most significantly in single right ventricles, and that it would correlate with other measures of ventricular function. Methods A prospective cross-sectional study was performed in 61 patients with SVs undergoing pre- or post-Fontan cardiac catheterization and 30 matched control subjects. Echocardiography, catheterization, and cardiac magnetic resonance imaging were performed under the same anesthetic. Torsion and strain were measured using speckle-tracking echocardiography. Intracardiac pressures, pulmonary vascular resistance, and cardiac magnetic resonance imaging–derived ventricular volume and ejection fraction were measured. Results Thirty-five patients were left ventricular dominant, 15 were right ventricular dominant, 10 were codominant, and one had indeterminate morphology. Thirty-seven patients were pre-Fontan and 24 were post-Fontan. Patients with SVs had similar overall torsion as control subjects (median, 1.7°/cm vs 1.65°/cm; P = NS); however, they had decreased or reversed basal rotation (−0.32°/cm vs −0.93°/cm, P < .0001) and increased apical rotation (1.45°/cm vs 1.06°/cm, P = .0065). There were no differences on the basis of ventricular dominance or palliative stage. Torsion did not significantly correlate with other echocardiographic, catheter-based, or cardiac magnetic resonance imaging measures of cardiac function. Conclusions Single left and right ventricles exhibit preserved torsion, mainly because of preserved or increased apical rotation. Possible mechanisms of torsion in single right ventricles include myofiber remodeling and altered ventricular-ventricular interactions. Understanding myocardial deformation in SVs will improve the ability to interpret ventricular function in this precarious population.
The Integration of Doppler Ultrasound With Two-Dimensional Echocardiography and the Noninvasive Cardiac Hemodynamic Revolution of the 1980s J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-16 Fletcher A. Miller
In the 1970s, as cardiac imaging matured from M-mode to two-dimensional echocardiography, investigators in Norway showed that continuous-wave Doppler ultrasonography could be used to accurately measure the mean gradient and pressure half-time for stenotic mitral valves. In the 1980s, continuous-wave Doppler was validated for measurement of the pressure gradient across stenotic aortic valves, and pulsed-wave Doppler combined with two-dimensional echocardiographic imaging was validated for noninvasive measurement of stroke volume and cardiac output. The combination of stroke volume measurement and measurement of the time-velocity integral of flow through the aortic valve was then validated as a means to accurately calculate valve area for patients with stenotic aortic valves or aortic prostheses. This integration of cardiac Doppler ultrasonography with two-dimensional echocardiographic cardiac imaging led to a revolution in noninvasive hemodynamic evaluations, which have replaced invasive hemodynamic evaluations in surgical decision making for most patients with native or prosthetic valvular stenosis.
Impact of Cardiovascular Risk Factors and Pharmacologic Treatments on Carotid Intraplaque Neovascularization Detected by Contrast-Enhanced Ultrasound J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-16 Marco Magnoni, Enrico Ammirati, Francesco Moroni, Giuseppe D. Norata, Paolo G. Camici
Background Neovascularization is a marker of plaque vulnerability that can be assessed noninvasively using contrast-enhanced ultrasound (CEUS). The presence and extent of plaque neovascularization and their relation to cardiovascular risk factors and treatments were assessed in asymptomatic patients with carotid stenosis of intermediate severity and no indication for revascularization. Methods Sixty-six patients aged 69 ± 8 years (59% men) were prospectively enrolled. Plaque neovascularization was assessed using CEUS with sulfur hexafluoride contrast in each of the four carotid segments bilaterally (a total of 528 segments). In each plaque, the presence or absence of contrast enhancement was assessed semiquantitatively as CEUS grade 1 (no signal or signal confined to the adventitia and/or shoulder of the plaque) or CEUS grade 2 (signal within the plaque). Results Plaques were detectable in 289 of 528 carotid segments (54.7%). CEUS grade 2 was present in at least one plaque in 48 of 66 patients (72.7%) and was not influenced by stenosis severity or morphology. The highest CEUS grade 2 prevalence was observed in patients with diabetes and the lowest in those treated with angiotensin-converting enzyme inhibitors and statins, especially when low-density lipoprotein cholesterol was <100 mg/dL. Patients with multiple CEUS grade 2 plaques (20 of 66 [30%]) had both higher low-density lipoprotein and higher C-reactive protein. Conclusion Intraplaque neovascularization is frequent in asymptomatic patients with intermediate carotid stenosis and is more prevalent in those with diabetes. Low-density lipoprotein cholesterol < 100 mg/dL and treatment with angiotensin-converting enzyme inhibitors seem to confer protection from neovascularization, although larger interventional studies are necessary to confirm these data.
The Incremental Benefit of Color Tissue Doppler in Fetal Arrhythmia Assessment J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-16 Silvia G.V. Alvarez, Nee S. Khoo, Timothy Colen, Angela McBrien, Luke Eckersley, Paul Brooks, Winnie Savard, Lisa K. Hornberger
Background Accurate fetal arrhythmia (FA) diagnosis is key for effective management. Currently, FA assessment relies on standard echocardiography-based techniques (M mode and spectral Doppler), which require adequate fetal position and cursor alignment to define temporal relationships of mechanical events. Few data exist on the application of color Doppler tissue imaging (c-DTI) in FA assessment. The aim of this study was to examine the feasibility and clinical applicability of c-DTI in FA assessment in comparison with standard techniques. Methods Pregnancies with diagnosed FA were prospectively recruited to undergo c-DTI following fetal echocardiography. Multiple-cycle four-chamber clips in any orientation were recorded (mean frame rate, 180 ± 16 frames/sec). With offline analysis, sample volumes were placed on atrial (A) and ventricular (V) free walls for simultaneous recordings. Atrial and ventricular rates, intervals (for atrial-ventricular conduction and tachyarrhythmia mechanism), and relationships were assessed to decipher FA mechanism. FA diagnosis by c-DTI, conventional echocardiographic techniques, and postnatal electrocardiography and/or Holter monitoring were compared. Results FA was assessed by c-DTI in 45 pregnancies at 15 to 39 weeks, including 16 with atrial and/or ventricular ectopic beats; 18 with supraventricular tachyarrhythmias, including ectopic atrial tachycardia in 11, atrioventricular reentrant tachycardia in four, atrial flutter in two, and intermittent atrial flutter and junctional ectopic rhythm in one; three with ventricular tachycardias; and eight with bradycardias or atrioventricular conduction pathology, including five with complete atrioventricular block (AVB), one with first-degree AVB evolving into complete AVB, one with second-degree AVB, and one with sinus bradycardia. After training, FA diagnosis by c-DTI could be made irrespective of fetal orientation within 10 to 15 min. FA diagnosis by c-DTI concurred with standard techniques in 41 cases (91%), with additional findings identified by c-DTI in 10. c-DTI led to new FA diagnoses in four cases (9%) not definable by standard techniques. FA diagnosis by c-DTI was confirmed in all 20 with persistent arrhythmias after birth, including three with new diagnoses defined by c-DTI. c-DTI was particularly helpful in deciphering SVT mechanism (long vs short ventricular-atrial interval) in all 18 cases, whereas standard techniques permitted definition in only half. Conclusions c-DTI with offline analysis permits rapid and accurate definition of FA mechanism, providing new information in nearly one-third of affected pregnancies.
Left Atrial Function Predicts Cardiovascular Events in Patients With Chronic Heart Failure With Reduced Ejection Fraction J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-10 Alessandro Malagoli, Luca Rossi, Francesca Bursi, Alessia Zanni, Concetta Sticozzi, Massimo Francesco Piepoli, Giovanni Quinto Villani
Background Heart failure (HF) is known to be the most widespread epidemic of cardiovascular disease. Among several factors with prognostic value for the clinical course of HF, left atrial (LA) function has not yet been fully examined. The aim of this prospective study was to evaluate LA function for the prediction of major cardiovascular outcomes in stable patients with chronic HF with reduced ejection fraction. Additionally, as secondary end points, cardiovascular mortality and atrial fibrillation were analyzed separately. Methods The predictive value of LA function evaluated by speckle-tracking echocardiography was assessed in a population of 286 outpatients referred to the authors’ institution for routine evaluation of chronic HF. Global peak atrial longitudinal strain was measured at the end of the reservoir phase and calculated by averaging in all LA segments. Results During a median follow-up period of 48 ± 11 months, major adverse cardiac events occurred in 98 patients (34%). In a multivariate model, global peak atrial longitudinal strain (hazard ratio, 0.95; 95% CI, 0.94–0.96; P = .02), left ventricular ejection fraction (hazard ratio, 0.95; 95% CI, 0.93–0.97; P = .01), and renal failure (hazard ratio, 0.98; 95% CI, 0.97–0.99; P = .01) were independent predictors of an adverse outcome. Sixty-six patients (23%) died of cardiac causes. Fifty-four patients (19%) developed atrial fibrillation. Patients with lower global peak atrial longitudinal strain showed worse event-free survival and developed atrial fibrillation more frequently than those with higher levels. Conclusions LA function assessed by speckle-tracking echocardiography is an independent prognostic marker in patients with HF with reduced ejection fraction.
Validation of a Holographic Display for Quantification of Mitral Annular Dynamics by Three-Dimensional Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-10-05 Karl-Andreas Dumont, John-Peder Escobar Kvitting, Jørn S. Karlsen, Espen W. Remme, John Hausken, Runar Lundblad, Arnt E. Fiane, Stig Urheim
Implications of Asymmetry and Valvular Morphotype on Echocardiographic Measurements of the Aortic Root in Bicuspid Aortic Valve J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-27 Jeroen C. Vis, Jose F. Rodríguez-Palomares, Gisela Teixidó-Tura, Laura Galian-Gay, Chiara Granato, Andrea Guala, Augusto Sao-Aviles, Laura Gutiérrez, Teresa González-Alujas, David García-Dorado, Arturo Evangelista
Background Transthoracic echocardiography (TTE) and magnetic resonance imaging (MRI) have yielded excellent results in aortic root diameter measurement in patients with tricuspid aortic valve. However, accuracy in bicuspid aortic valve (BAV), often associated with aortic root asymmetry, is not fully defined. The aim of this study was to determine the agreement between TTE and MRI in proximal ascending aortic diameters in patients with BAVs. Methods Seventy-six consecutive patients with BAVs (mean age, 53 ± 15 years; 65% men) who underwent both TTE and MRI for ascending aortic assessment in a follow-up protocol were included in the study. Maximum aortic root and ascending aortic diameters were compared. Results For the whole population, TTE slightly underestimated aortic root diameter (difference, −0.8 ± 2.9 mm; P = .02). However, agreement was significantly better in BAV with fusion of the left and right coronary cusps than with fusion of the right coronary and noncoronary cusps, both with (type 1) and without (type 0) raphe (mean difference, 0.1 ± 2.5 vs −2.8 ± 2.8 mm, P < .001, respectively). In raphe BAV, mean absolute differences of maximum diameters between both techniques were significantly greater in asymmetric versus symmetric aortic roots (3.3 ± 2.2 vs 1.6 ± 1.9 mm, P = .002). BAV type and root asymmetry were independent related to measurement disagreement between both modalities. Conclusions Although TTE is the technique of choice in the follow-up of patients with BAVs, aortic root diameter measurements may be inaccurate in the presence of root asymmetry and in BAV with fusion of the right coronary and noncoronary cusps. In these cases, cross-sectional imaging, with MRI or computed tomography, to confirm aortic diameters may be advisable.
Right Ventricular Contractile Reserve Is Impaired in Children and Adolescents With Repaired Tetralogy of Fallot: An Exercise Strain Imaging Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-27 Shivani M. Bhatt, Yan Wang, Okan U. Elci, Elizabeth Goldmuntz, Michael McBride, Stephen Paridon, Laura Mercer-Rosa
Background Pulmonary insufficiency (PI) and right ventricular (RV) dysfunction are long-term complications in patients with repaired tetralogy of Fallot (rTOF). The aim of this study was to investigate RV contractile reserve and changes in PI that occur during exercise in patients with rTOF and the associations of these changes with exercise performance using stress echocardiography. Methods Subjects with rTOF (n = 32) and healthy control subjects (n = 10) were prospectively enrolled and underwent rest and peak exercise echocardiography during standard cardiopulmonary exercise test protocol on a cycle ergometer or treadmill. RV contractile reserve was defined as the change in RV global longitudinal strain from rest to peak exercise. PI was assessed with the diastolic-to-systolic time-velocity integral ratio and diastolic/systolic velocity ratio from pulmonary artery Doppler interrogation. Exercise measures included heart rate reserve, percentage predicted maximum oxygen consumption, percentage predicted maximum work, and oxygen pulse. Results RV contractile reserve was impaired in patients with rTOF compared with control subjects, with a significant drop in the absolute value of RV global longitudinal strain from 17% (range, 8%–27%) at rest to 13% (range, 5%–28%) at peak exercise. Similarly, PI decreased at peak exercise, with decreases in diastolic-to-systolic time-velocity integral and diastolic/systolic velocity ratios. Reduction in PI was directly associated with percentage predicted maximum oxygen consumption, percentage predicted maximum work, and greater oxygen pulse. Heart rate reserve was directly associated with percentage predicted maximum oxygen consumption and percentage predicted maximum work. RV contractile reserve was not associated with any exercise parameters. Conclusions Patients with rTOF have an abnormal myocardial response to exercise with impaired RV contractile reserve compared with control subjects. Heart rate reserve and reduction in PI at peak exercise are associated with better exercise performance and appear to be significant contributors to exercise performance in rTOF. Measures to improve chronotropic health in rTOF should be explored.
Comparison between Three-Dimensional Echocardiography and Computed Tomography for Comprehensive Tricuspid Annulus and Valve Assessment in Severe Tricuspid Regurgitation: Implications for Tricuspid Regurgitation Grading and Transcatheter Therapies J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-27 Fabien Praz, Omar K. Khalique, Leon G. Dos Reis Macedo, Todd C. Pulerwitz, Jennifer Jantz, Isaac Y. Wu, Alex Kantor, Amisha Patel, Torsten Vahl, Vinayak Bapat, Isaac George, Tamim Nazif, Susheel K. Kodali, Martin B. Leon, Rebecca T. Hahn
Background Tricuspid valve imaging is frequently challenging and requires the use of multiple modalities. Knowledge of limitations and methodologic discrepancies among different imaging techniques is crucial for planning transcatheter valve interventions. Methods Thirty-eight patients with severe symptomatic tricuspid regurgitation were included in this retrospective analysis. Tricuspid annulus (TA) measurements were made during mid-diastole using three-dimensional (3D) transthoracic echocardiographic direct planimetry (TTE_direct) and transesophageal echocardiographic direct planimetry (TEE_direct). Moreover, a semiautomated software was used to generate two-dimensional (2D) and 3D perimeter and area on transesophageal echocardiography (TEE) images. Both methods were compared with direct computed tomographic planimetry (CT_direct) and cubic spline interpolation (CT_indirect). The different TA values were used to calculate the effective regurgitant orifice area and compared with 3D Doppler vena contracta area. For tricuspid valve area TEE_direct and CT_direct as well as CT_indirect were measured. Results Agreement between TEE and computed tomography (CT) for TA sizing was obtained using semiautomated methods (3D TEE_indirect and CT_indirect). TTE_direct was overall less reliable compared with CT. TA area quantified by TEE_direct was 25% (difference 305 ± 238 mm2, P < .001, R = 0.9) and 19% (166 ± 247 mm2, P < .001, R = 0.89) smaller compared with CT_direct and CT_indirect, respectively. TA perimeter measurements by TEE_direct differed by 11% compared with CT_direct (12 ± 11 mm, P < .001, R = 0.87) and 3D CT_indirect (12 ± 11 mm, P < .001, R = 0.88), and 9% compared with 2D CT_indirect (7 ± 11 mm, P = .002, R = 0.87). TEE_direct of the TA allows the most accurate calculation of effective regurgitant orifice area compared with 3D vena contracta area (−8 ± 62 mm2, P = .50, R = 0.85). Tricuspid valve area by CT_indirect best correlated with conventional TEE_direct (80 ± 250 mm2, P = .11, R = 0.80). Conclusions In patients with severe tricuspid regurgitation, semiautomated indirect planimetry results in high agreement between TEE and CT for TA sizing and measurement of the tricuspid valve area. TEE_direct of the TA allows the most accurate measurement of diastolic stroke volume for the calculation of regurgitation severity compared with 3D vena contracta area.
Feasibility of New Transthoracic Three-Dimensional Echocardiographic Automated Software for Left Heart Chamber Quantification in Children J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-18 Romain Amadieu, Khaled Hadeed, Marion Jaffro, Clément Karsenty, Miarisoa Ratsimandresy, Yves Dulac, Philippe Acar
Background New three-dimensional echocardiographic automated software (HeartModel) is now available to quantify the left heart chambers. The aims of this study were to assess the feasibility, reproducibility, and analysis time of this technique and its correlation with manual three-dimensional echocardiography (3DE) and cardiac magnetic resonance (CMR) in children. Methods Ninety-two children (5–17 years of age) were prospectively included in two separate protocols. In protocol 1, 73 healthy children underwent two-dimensional and three-dimensional transthoracic echocardiography. Left ventricular (LV) end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF), and left atrial volume at ventricular end-systole (LAV) by automated 3DE were compared with the same measurements obtained using manual 3DE. In protocol 2, automated three-dimensional echocardiographic measurements from 19 children with cardiomyopathy were compared with CMR values. Results Automated 3DE was feasible in 77% of data sets and significantly reduced the analysis time compared with manual 3DE. In protocol 1, there were excellent correlations for LVEDV, LVESV, and LAV between automated 3DE and manual 3DE (r = 0.89 to 0.99, P < .0001 for all) and a weak correlation for LVEF, despite contour adjustment (r = 0.57, P < .0001). Automated 3DE overestimated LVEDV, LVEF, and LAV with small biases and underestimated LVESV with wider bias. With contour adjustment, the biases and limits of agreement were reduced (bias: LVEDV, 0.9 mL; LVESV, −1.2 mL; LVEF, 2.2%). In protocol 2, correlations between automated 3DE with contour edit and CMR were good for LV volumes and LAV (r = 0.76 to 0.94, P < .0003 for all) but remained weak for LVEF (r = 0.46, P = .05). Automated 3DE slightly underestimated LV volumes (relative bias, −7.2% to −7.8%) and significantly underestimated LAV (relative bias, −31.6%). The limits of agreement were clinically acceptable only for LVEDV. Finally, test-retest, intraobserver, and interobserver variability values were low (<12%). Conclusions HeartModel is feasible, reproducible, faster than manual 3DE, and comparable with manual 3DE for measurements of LV and left atrial volumes in children >5 years of age. However, compared with CMR, only LVEDV measured by automated 3DE with contour edit seems applicable for clinical practice.
The Development of Color Doppler Echocardiography: Innovation and Collaboration J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-18 J. Geoffrey Stevenson
Conception, development, innovation, introduction, and validation are some of the steps in the introduction of new technologies and their clinical applications. More than 50 years ago, Doppler techniques and applications were introduced into echocardiography. An important further addition was the introduction of color as a medium for the display of Doppler information. The amplitude of the returning ultrasound signal has been used to generate a black and white image of structure. The phase shift between the transmitted and returning Doppler signal has been used to display Doppler shift information in color. This review focuses on some of the resources critical to this new development, the challenges imposed by the introduction of a new color display, and some of the early clinical validation and applications of color Doppler echocardiography.
Differential Clinical Implications of Current Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-18 Laura Sanchis, Rut Andrea, Carlos Falces, Silvia Poyatos, Bàrbara Vidal, Marta Sitges
Background Classification of left ventricular diastolic function (LVDF) by echocardiography is controversial. The aim of this study was to evaluate the impact of the last 2016 recommendations for LVDF evaluation on brain natriuretic peptide (BNP) levels, proportion of final heart failure (HF) diagnosis, and cardiovascular outcomes. Methods Outpatients with first consultation at a one-stop HF clinic (2009–2014) were screened. The initial visit included echocardiography with LVDF evaluation and determination of BNP level. HF diagnosis was confirmed or ruled out at the end of the visit. Cardiovascular events during follow-up were recorded. LVDF classification was originally performed with the 2009 recommendations and reevaluated using the 2016 recommendations. Results A total of 157 patients (mean age 73.24 ± 10.3 years; 70.1% women) were included. Originally (2009 recommendations), most of the patients were classified with grade I diastolic dysfunction (DD; 67.5%). After the reanalysis using the 2016 recommendations, 49% were reclassified with normal LVDF. These subjects showed lower BNP levels (40.8 pg/mL) and a lower proportion of HF diagnosis (9.6%). Another part of the initial grade I DD group (31.1%) was reclassified with indeterminate LVDF; they had intermediate BNP levels, proportion of HF, and rate of cardiovascular events. Lower reclassification rates were observed in the other groups of DD. Kaplan-Meier survival curves showed significantly better prognostic stratification after the reclassification (P = .539 vs P = .003). Conclusions Current recommendations for the evaluation of LVDF by echocardiography resulted in more accurate classification of patients, according to their BNP levels, HF diagnosis, and cardiovascular outcomes, especially for those patients previously classified with grade I DD.
Alterations in Layer-Specific Left Ventricular Global Longitudinal and Circumferential Strain in Patients With Aortic Stenosis: A Comparison of Aortic Valve Replacement versus Conservative Management Over a 12-Month Period J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-17 Matle J. Fung, Liza Thomas, Dominic Y. Leung
Background Impairment in left ventricular (LV) systolic strain in aortic stenosis (AS) is well documented. However, alterations in layer-specific LV global longitudinal strain (GLS) and global circumferential strain (GCS) and their recovery following surgical aortic valve replacement (AVR) have not been established. The aim of this study was to examine layer-specific changes in GLS and GCS in patients with AS undergoing AVR and compare these patients with those managed conservatively over 12 months. Methods Eighty-six patients (mean age, 68.8 ± 12 years; 60 men) with AS (19 mild, 15 moderate, and 52 severe) were prospectively recruited. Patients with coronary disease or other significant valvular disease were excluded. Forty patients (46.5%) with severe AS underwent AVR. All patients underwent baseline echocardiography. Patients managed conservatively underwent follow-up echocardiography at 12 months. Patients undergoing AVR underwent follow-up echocardiography at 1 week and 3, 6, and 12 months after AVR. Results There was worsening in subendocardial but not subepicardial or transmural GLS even in mild AS (−20.9 ± 1.0% vs −20.6 ± 0.8%, P = .012). In moderate AS, worsening in subendocardial (−19.6 ± 0.9% vs −18.2 ± 1.5%, P = .003), subepicardial (−14.9 ± 1.0% vs −13.8 ± 1.2%, P = .004), and transmural (−17.1 ± 0.9% vs −15.8 ± 1.3%, P = .03) GLS and a trend toward significant worsening in subendocardial GCS (−29.8 ± 5.16% vs −27.5 ± 5%, P = .054) were seen. Conservatively managed patients with severe AS had significant worsening in subendocardial (−16.1 ± 1.6% vs −13.9 ± 2.6%, P = .021), subepicardial (−11.6 ± 1.1% vs −10.1 ± 2.1%, P = .027), and transmural (−13.6 ± 1.3% vs −11.8 ± 2.3%, P = .02) GLS and subendocardial (−24.9 ± 3.6% vs −20.8 ± 4.5%, P = .002) and transmural (−16.9 ± 1.7% vs −14.3 ± 3.5%, P = .04) GCS on follow-up. Patients after AVR demonstrated significant improvement in GLS (from 3 months) and GCS (from 6 months) in both myocardial layers. Conclusions Patients with AS managed conservatively had worsening of GLS over 12 months despite preserved LV ejection fraction, detected earliest in the subendocardial layer. GCS became progressively impaired in moderate and severe AS. Improvement in LV strain after AVR was seen earlier with GLS (from 3 months) than with GCS (from 6 months) in both myocardial layers.
Feasibility, Safety and Accuracy of Echocardiography-Fluoroscopy Imaging Fusion During Percutaneous Atrial Septal Defect Closure in Children J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-13 Sebastien Hascoët, Khaled Hadeed, Clement Karsenty, Yves Dulac, Francois Heitz, Nicolas Combes, Gerald Chausseray, Xavier Alacoque, Francoise Auriol, Pascal Amedro, Alain Fraisse, Philippe Acar
Background Imaging fusion between echocardiography and fluoroscopy was recently developed. The aim of this study was to assess its feasibility and accuracy during pediatric cardiac catheterization. Methods Thirty-one patients (median weight, 26 kg; interquartile range [IQR], 21–37 kg) who underwent percutaneous atrial septal defect closure were prospectively included. The feasibility and accuracy of various imaging fusion modalities (live two-dimensional, live color two-dimensional, live three-dimensional and markers) with EchoNavigator software were assessed. To assess the accuracy of spatial registration of the echocardiogram on the fluoroscopic image, the occluder screw, an object that appeared on each image, was used as a reference tool, and the distance between the two when fused was measured. A distance was measured on the fusion screen between a marker positioned on the screw from the echocardiography screen and from the fluoroscopy screen (distance 1). Another distance was measured on the fusion screen between the screw visualized by three-dimensional echocardiography and by fluoroscopy (distance 2). The two distances were measured on four C-arm orientations in end-systolic and end-diastolic frames. Results Fusion and marker positioning were feasible in real time in all cases. On the fusion screen, median systolic and diastolic distance 1 were 0.5 mm (IQR, 0.3–1 mm) and 2 mm (IQR, 1.5–2.5 mm; P < .0001), respectively. The marker positioned from the echocardiography screen was fixed on the fusion screen and did not follow the movement of the screw. Median systolic and diastolic distance 2 were 0.5 mm (IQR, 0–0.5 mm) and 2 mm (IQR, 1.5–2.5 mm; P < .0001), respectively. Conclusions Echocardiographic fluoroscopic imaging fusion is feasible, safe, and accurate in children weighting >20 kg. This technique offers a new method of imaging guidance in the catheterization laboratory for complex procedures and training.
Assessment of Novel Antioxidant Therapy in Atherosclerosis by Contrast Ultrasound Molecular Imaging J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-11 Tamara Atkinson, William Packwood, Aris Xie, Sherry Liang, Yue Qi, Zaverio Ruggeri, Jose Lopez, Brian P. Davidson, Jonathan R. Lindner
Background Ultrasound molecular imaging was used to evaluate the therapeutic effects of antioxidant therapy with EUK-207, which has superoxide dismutase and catalase activities, on suppressing high-risk atherosclerotic features. Methods Mice with age-dependent atherosclerosis produced by deletion of the low-density lipoprotein receptor and Apobec-1 were studied at 20 and 40 weeks of age. EUK-207 or vehicle was administered for the preceding 8 weeks. Therapy for 28 weeks was also studied for 40-week-old mice. Ultrasound molecular imaging of the thoracic aorta was performed with contrast agents targeted to endothelial P-selectin, von Willebrand factor A1-domain, and platelet glycoprotein Ibα or control agent. Aortic plaque area and macrophage content were assessed by histology. Results In 20-week-old double-knockout mice, EUK-207 compared with sham therapy produced only nonsignificant trends for reduction in molecular imaging signal for endothelial P-selectin, von Willebrand factor A1-domain, and platelet adhesion. At 40 weeks, EUK-207 given for 8 or 28 weeks significantly (P < .05) reduced signal for all three endothelial-associated events essentially to background levels, with the exception of glycoprotein Ibα signal after 8 weeks (P = .06). On aortic histology, EUK-207 therapy for 8 weeks did not affect plaque area or macrophage content at either age. However, EUK-207 for 28 weeks almost completely suppressed plaque development (350 ± 258 vs 4 ± 6 × 103 μm2, P = .014) and macrophage content (136 ± 103 vs 3 ± 2 × 103 μm2, P = .002) compared with control mice at 40 weeks. Conclusions Molecular imaging can be used to assess vascular responses to antioxidants and has demonstrated that certain antioxidants reduce vascular endothelial activation and platelet adhesion, but reductions in plaque size and macrophage content occurs only with long-duration therapy that is started early.
Load Dependency of Left Atrial Strain in Normal Subjects J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-08 Davide Genovese, Amita Singh, Valentina Volpato, Eric Kruse, Lynn Weinert, Megan Yamat, Victor Mor-Avi, Karima Addetia, Roberto M. Lang
Background Left atrial (LA) longitudinal strain is a novel parameter used for the evaluation of LA function, with demonstrated prognostic value in several cardiac diseases. However, the extent of load dependency of LA strain is not well known. The aim of this study was to evaluate the impact of acute changes in preload on LA strain, side by side with LA volume, in normal subjects. Methods Twenty-five healthy volunteers (13 men; mean age, 31 ± 2 years) were prospectively enrolled, who underwent two-dimensional and three-dimensional echocardiographic imaging during acute stepwise reductions in preload using a tilt maneuver: baseline at 0°, followed by 40° and 80°. Left ventricular and LA size and function parameters were measured using standard methodology, and LA strain-time curves were obtained using speckle-tracking software (TomTec), resulting in reservoir, conduit, and contractile strain components. All parameters were compared among the three loading conditions using one-way analysis of variance for repeated measurements. Results Although there were no significant changes in blood pressure, heart rate increased significantly with tilt. As expected, LA volumes, left ventricular volumes, and left ventricular ejection fraction, as well as E wave, A wave, and e′ significantly decreased with progressive inclination. In parallel, LA reservoir, conduit, and contractile strain values decreased with reduction in preload (reservoir: 42.9 ± 3.9% to 27.5 ± 3.8%, P < .001; conduit: 29.3 ± 2.7% to 20.2 ± 5.0%, P < .001; contractile: 13.6 ± 2.9% to 7.3 ± 3.5%, P < .001). Paired post hoc analysis showed that all LA strain values were significantly different among all three tilt phases. Of note, percentage change in LA reservoir strain was significantly smaller than that in LA maximum volume. Conclusions In normal subjects, LA strain is preload dependent but to a lesser degree than LA volume. This difference underscores the relative advantage of LA strain over maximum volume, when LA assessment is used as part of the diagnostic paradigm.
Ventricular-Vascular Coupling at Rest and after Exercise Is Associated with Heart Failure Hospitalizations in Patients With Coronary Artery Disease J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-08 Jesse K. Fitzpatrick, Craig S. Meyer, Nelson B. Schiller, Mary A. Whooley, Rakesh K. Mishra
Background The ventricular-vascular coupling ratio, defined as the ratio of arterial elastance (Ea) to left ventricular end-systolic elastance (Ees), has not been examined in populations with coronary artery disease (CAD), and its association with heart failure (HF) in this population is unknown. Methods Ventricular-vascular coupling was measured at rest and after exercise using echocardiography and cuff blood pressure in 815 patients with stable CAD enrolled in the Heart and Soul Study. Adjusted Cox proportional-hazard models were used to evaluate the association between ventricular-vascular coupling and future HF hospitalizations. Results After a median of 8.9 years, 144 patients (18%) were hospitalized for HF. After multivariate adjustment, patients in the highest tertile of Ees (rest: hazard ratio [HR], 0.31 [95% CI, 0.17–0.57; P < .001]; exercise: HR, 0.26 [95% CI, 0.13–0.50; P < .001]) were at decreased risk for HF hospitalization, while patients in the highest tertile of the Ea/Ees ratio (rest: HR, 3.36 [95% CI, 1.91–5.93; P < .001]; exercise: HR, 4.09; [95% CI, 2.22–7.51; P < .001]) were at increased risk, compared with the lowest tertiles. Ea and the relative change observed in Ees and the Ea/Ees ratio with exercise were not associated with HF hospitalizations. Conclusions The Ea/Ees ratio and Ees, at rest and after exercise, are strongly associated with future HF hospitalizations in patients with stable CAD and low rates of baseline HF. Ventricular-vascular coupling obtained from echocardiography shows promise as a risk assessment tool for HF in patients with CAD.
Association of Patterns of Change in Adiposity With Diastolic Function and Systolic Myocardial Mechanics From Early Adulthood to Middle Age: The Coronary Artery Risk Development in Young Adults Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-09-01 Sadiya S. Khan, Sanjiv J. Shah, Laura A. Colangelo, Anita Panjwani, Kiang Liu, Cora E. Lewis, Christina M. Shay, David C. Goff, Jared Reis, Henrique D. Vasconcellos, Joao A.C. Lima, Donald Lloyd-Jones, Norrina B. Allen
Background The aim of this study was to determine whether long-term patterns of change in adiposity throughout young adulthood are associated with systolic and diastolic function in midlife. Methods Participants in the Coronary Artery Risk Development in Young Adults study, a multicenter, population-based cohort, underwent repeated anthropometric assessment (body mass index [BMI], waist circumference, and waist-to-hip ratio) from examination years 0 to 25. At year 25, longitudinal, circumferential, and radial strain and tissue Doppler velocities were assessed by echocardiography. Group-based trajectory modeling was used to identify 25-year trajectories of change in anthropometric measures and to examine associations between trajectories of adiposity change and indices of cardiac mechanics. Results Among 3,310 participants, four distinct trajectories of BMI change were identified: stable BMI (36% of the cohort; mean ΔBMI, 1.6 kg/m2), mild increase (40%; mean ΔBMI, 6.0 kg/m2), moderate increase (18%; mean ΔBMI, 10.8 kg/m2), and major increase (6%; mean ΔBMI, 15.5 kg/m2). Trajectories of greater BMI increase were associated with lower adjusted e′ velocity and higher E/e′ ratio compared with the stable BMI group, independent of year 0 or year 25 BMI. Participants in increasing BMI trajectory groups compared with the stable BMI group had lower absolute longitudinal strain and greater odds of diastolic dysfunction, independent of year 0 BMI but not year 25 BMI. Similar patterns were observed for change in waist circumference and waist-to-hip ratio trajectory groups. Conclusions Steeper trajectories of BMI increase from young adulthood to middle age, a vulnerable period for weight gain, are independently associated with lower e′ velocity and higher E/e′ ratio, but not systolic dysfunction, in midlife.
Strategies for Accurate Diagnosis of Fetal Aortic Arch Anomalies: Benefits of Three-Dimensional Sonography With Spatiotemporal Image Correlation and a Novel Algorithm for Volume Analysis J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-23 Yu Wang, Miao Fan, Faiza Amber Siddiqui, Meilian Wang, Wei Sun, Xue Sun, Wenjia Lei, Ying Zhang
Exercise Hemodynamics After Aortic Valve Replacement for Severe Aortic Stenosis J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-22 Rasmus Carter-Storch, Jordi S. Dahl, Nicolaj L. Christensen, Eva V. Søndergaard, Akhmadjon Irmukhamedov, Redi Pecini, Christian Hassager, Niels Marcussen, Jacob E. Møller
Background Severe aortic stenosis (AS) is often accompanied by diastolic dysfunction. After aortic valve replacement (AVR), the left ventricle often undergoes considerable reverse remodeling. Despite this, diastolic dysfunction may persist after AVR. The aims of this study were to determine the incidence of elevated left ventricular (LV) filling pressure at rest and during exercise among patients with severe AS after AVR and to describe factors related to elevated LV filling pressure, especially its association with LV and left atrial remodeling and myocardial fibrosis. Methods Thirty-seven patients undergoing AVR were included. Echocardiography, cardiac computed tomography, and magnetic resonance imaging were performed before AVR. An LV biopsy sample was obtained during AVR and analyzed for collagen fraction. One year after AVR, right heart catheterization with exercise was performed. A mean pulmonary capillary wedge pressure (PCWP) ≥ 28 mm Hg during exercise was considered elevated. Results Twelve patients (32%) had elevated exercise PCWP 1 year after AVR. Exercise PCWP was highest among patients undergoing concomitant coronary artery bypass graft surgery (30 ± 7 vs 25 ± 6 mm Hg, P = .04) and among patients with preoperative stroke volume index < 35 mL/m2 (28 ± 8 vs 23 ± 4 mm Hg, P < .05). Baseline LV ejection fraction was lower among patients with elevated PCWP (56 ± 8% vs 64 ± 8%, P = .01), and coronary calcium score was significantly higher (median 870 AU [interquartile range, 454–2,491 AU] vs 179 AU [interquartile range, 63–513 AU], P = .02). Conversely, exercise PCWP was not related to the presence of high LV wall mass or to the severity of AS. Among patients undergoing isolated AVR, there was a correlation between LV interstitial volume fraction and PCWP (r = 0.57, P = .01) and mean pulmonary artery pressure (r = 0.51, P = .03) during exercise. Conclusions Elevated filling pressure during exercise was seen in one third of patients after AVR in this population and was seen primarily among patients with coexisting ischemic heart disease or diffuse myocardial fibrosis but was unrelated to preoperative severity of AS and LV remodeling.
Three-Dimensional Echocardiographic Assessment of Mitral Annular Physiology in Patients With Degenerative Mitral Valve Regurgitation Undergoing Surgical Repair: Comparison between Early- and Late-Stage Severe Mitral Regurgitation J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-16 Tien-En Chen, Kevin Ong, Rakesh M. Suri, Maurice Enriquez-Sarano, Hector I. Michelena, Harold M. Burkhart, Shane M. Gillespie, Stephen Cha, Sunil V. Mankad
Background Ventricular-annular decoupling is thought to exist in all degenerative myxomatous mitral valve (MV) diseases. However, the annular physiology of degenerative MV disease may differ when severe mitral regurgitation (MR) presents at different stages. The aim of this study was to assess differences in mitral annular physiology and surgical effects between early- and late-stage severe MR. Methods Three-dimensional (3D) transesophageal echocardiography was performed before and after MV surgery in 74 patients with degenerative MV disease, including 57 with early-stage severe MR (without left ventricular remodeling) and 17 with late-stage MR (with left ventricular remodeling). A control group comprised 46 patients without MV disease. Novel 3D MV software was used to evaluate mitral annular dynamics. The degree of annular saddle shape was calculated as the ratio of annular height (AH) to lateromedial diameter (LM). Ventricular-annular decoupling was defined as insufficient systolic AH/LM compared with the control group. Results Prebypass 3D measurements demonstrated that systolic AH/LM in the early-stage group (0.19 ± 0.04) was similar to that in the control group (0.21 ± 0.05; P = .101), while systolic AH/LM in the late-stage group (0.17 ± 0.04) was lower than that in the control group (P = .011). Postbypass comparison showed saddle shape accentuation in the early-stage group (0.20 ± 0.04), similar to that in the control group (P = .3127); the mitral annulus remained flat in the late-stage group (0.17 ± 0.03; P = .004). Conclusions Ventricular-annular decoupling, present in the late-stage group, was absent in the early-stage group. MV repair surgery did not disrupt mitral annular saddle shape in the early-stage group; however, it failed to correct annular dysfunction in the late-stage group. Sequential 3D transesophageal echocardiographic analysis provides comprehensive mitral annular evaluation beyond conventional two-dimensional parameters for determining stages of severe MR.
Aortic Stenosis with Severe Tricuspid Regurgitation: Comparative Study between Conservative Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Combined With Tricuspid Repair J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-11 Zach Rozenbaum, Yoav Granot, Arie Steinvil, Shmuel Banai, Ariel Finkelstein, Yanai Ben-Gal, Gad Keren, Yan Topilsky
Background Severe aortic stenosis (AS) and severe tricuspid regurgitation (TR) may coexist. The aim of this study was to determine the change in right ventricular (RV) function and TR after surgical aortic valve replacement combined with tricuspid valve repair (SAVR+TVr), transcatheter aortic valve replacement (TAVR), or conservative management and compare outcomes dependent on RV functional parameters and treatment allocation. Methods A retrospective analysis was conducted in 147 consecutive patients with severe AS and TR of baseline and 6-month clinical and echocardiographic parameters, including quantitative estimation of RV size and function (end-diastolic and end-systolic areas, tricuspid annular plane systolic excursion, fractional area change, and Tei index). Results SAVR+TVr and TAVR were associated with superior reduction in TR jet area after 6 months (P = .01 for time × group interaction) compared with conservative therapy. However, RV function (tricuspid annular plane systolic excursion and stroke volume) improved after TAVR but not after SAVR+TVr (P = .007 and P = .02 for time × group interaction, respectively). Conservative therapy for combined AS and TR was associated with >80% mortality in <4 years. TAVR and SAVR+TVr were associated with improved survival compared with conservative therapy (P < .0001), without significant difference between each other. Quantitative RV functional parameters were associated with poor outcomes, including tricuspid annular plane systolic excursion (P = .002), Tei index (P = .02), and RV fractional area change (P = .03). Conclusions In this nonrandomized, retrospective, observational study, SAVR+TVr and TAVR were associated with reductions in TR in patients with severe AS combined with severe TR. Importantly, RV function improved after TAVR but not after SAVR+TVr. Patients with severe AS and TR have a very poor prognosis with conservative therapy. When contemplating invasive procedures, assessment should include quantitative functional RV parameters.
Left Ventricular Myocardial Contractile Reserve during Exercise Stress in Healthy Adults: A Two-Dimensional Speckle-Tracking Echocardiographic Study J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-08 Anders Hostrup Larsen, Tor Skibsted Clemmensen, Henrik Wiggers, Steen Hvitfeldt Poulsen
Background The aims of the present study were to determine left ventricular (LV) myocardial contractile reserve during exercise stress testing in healthy adults and to evaluate the effects of gender and age on exercise LV global longitudinal strain (GLS). Methods The study population consisted of 67 healthy adults (age range, 23–80 years; 49% women). Subjects were analyzed with respect to gender and predefined age groups (age < 35 years, n = 18; age 35–55 years, n = 24; age > 55 years, n = 25). All subjects underwent comprehensive echocardiographic assessment at rest and during symptom-limited semisupine exercise test. LV GLS was determined using two-dimensional speckle-tracking echocardiography. Results LV GLS magnitude during peak stress was 25.4 ± 2.0%. The average absolute numeric LV GLS increase was 5.3%, equivalent to a relative 26.7% increase of LV GLS. LV GLS magnitude at peak exercise was without clinically significant differences between age groups (P = .07). No significant difference was found in peak exercise LV GLS between genders (P = .48). Linear regression analysis revealed a significant but weak correlation between peak LV GLS and age (r = −0.30, P = .02), whereas peak LV GLS was independent of maximal heart rate (r = 0.23, P = .07), peak mean arterial blood pressure (r = −0.11, P = .38), body mass index (r = 0.15, P = .22), and peak pulsed Doppler–derived cardiac index (r = −0.06, P = .67). Conclusions LV GLS increases significantly during exercise stress in a healthy population. A dose-response relationship was found between LV GLS and exercise level independent of gender, and the influence of age appeared marginal. The technique is feasible, with low intra- and interobserver variability.
Three-Dimensional Mitral Valve Morphology in Children and Young Adults With Marfan Syndrome J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-08 Matthew A. Jolley, Peter E. Hammer, Sunil J. Ghelani, Adi Adar, Lynn A. Sleeper, Ronald V. Lacro, Gerald R. Marx, Meena Nathan, David M. Harrild
Background Mitral valve (MV) prolapse is common in children with Marfan syndrome (MFS) and is associated with varying degrees of mitral regurgitation (MR). However, the three-dimensional (3D) morphology of the MV in children with MFS and its relation to the degree of MR are not known. The goals of this study were to describe the 3D morphology of the MV in children with MFS and to compare it to that in normal children. Methods Three-dimensional transthoracic echocardiography was performed in 27 patients (3–21 years of age) meeting the revised Ghent criteria for MFS and 27 normal children matched by age (±1 year). The 3D geometry of the MV apparatus in midsystole was measured, and its association with clinical and two-dimensional echocardiographic parameters was examined. Results Compared with age-matched control subjects, children with MFS had larger 3D annular areas (P < .02), smaller annular height/commissural width ratios (P < .001), greater billow volumes (P < .001), and smaller tenting heights, areas, and volumes (P < .001 for all). In multivariate modeling, larger leaflet billow volume in MFS was strongly associated with moderate or greater MR (P < .01). Intra- and interuser variability of 3D metrics was acceptable. Conclusions Children with MFS have flatter and more dilated MV annuli, greater billow volumes, and smaller tenting heights compared with normal control subjects. Larger billow volume is associated with MR. Three-dimensional MV quantification may contribute to the identification of patients with MFS and other connective tissue disorders. Further study of 3D MV geometry and its relation to the clinical progression of MV disease is warranted in this vulnerable population.
Focused Cardiac Ultrasound by Nurses in Rural Vietnam J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-07 James N. Kirkpatrick, Hoai T.T. Nguyen, Loi Do Doan, Thanh T. Le, Son Pham Thai, David Adams, Liza Y. Sanchez, Nova Sprague, Jill Inafuku, Rachel Quang, Rebecca Hahn, Andrea M. Van Hoever, Tu Nguyen, Thanh G. Kirkpatrick, Jose Banchs
Background Multiple studies investigating the use of focused cardiac ultrasound (FCU) in lower and middle-income countries and in medically underserved areas of the United States have demonstrated utility in echocardiographic screening algorithms performed by a variety of operators at different levels of training. No study to date has employed previously untrained nurses in a medically underserved setting to identify older adults with cardiac disorders. The aim of this study was to assess the accuracy of nurse-performed FCU to screen adult subjects at a village health center in Vietnam. Methods Vietnamese nurses (N = 8) underwent structured training conducted by sonographers and physicians during an outreach event sponsored by the American Society of Echocardiography Education and Research Foundation. The nurses were trained to detect abnormalities from a single echocardiographic view (parasternal long-axis) with a laptop-sized device and underwent pre- and posttraining testing. Following training, cardiac ultrasound examinations were performed on subjects >50 years of age at a village health center. First, the nurses performed focused cardiac ultrasound using two-dimensional and color Doppler imaging in the parasternal long-axis view using the M7 device and recorded their assessments. Two-dimensional color and spectral Doppler echocardiography was thereafter performed using the same machine by a sonographer (n = 5) or a Vietnamese echocardiography-trained cardiologist (n = 1). Interviews and electrocardiography were performed at the time of FCU. Results Each nurse improved from pre- to posttraining (average improvement in correct answers, 21%; range, 2%–31%). During the scanning phase, nurses' sensitivity, specificity, and accuracy for identifying subjects with any abnormality were 51.5% (85 of 165), 78.1% (82 of 105) and 61.9%, respectively. There were 60 subjects with significant findings (22.2%); all of these subjects had significant abnormalities visible on parasternal long-axis images. Overall sensitivity, specificity, and accuracy for identifying subjects with major abnormalities were 83.3% (50 of 60), 78.1% (164 of 210), and 78.6%, respectively. Nurse-performed FCU demonstrated much higher sensitivity with lower specificity than electrocardiography alone. The combination of nurse-performed FCU plus ECG identified all of the significant findings on echocardiography and increased accuracy to 91.5%. Conclusions Nurses with no prior echocardiographic experience and with limited training can identify patients with significant cardiac abnormalities using FCU with acceptable accuracy. Screening strategies involving FCU may play a role in improving access to health care and triage in underserved areas.
Diagnosis of Isolated Cleft Mitral Valve Using Three-Dimensional Echocardiography J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-07 Akhil Narang, Karima Addetia, Lynn Weinert, Megan Yamat, Atman P. Shah, John E. Blair, Victor Mor-Avi, Roberto M. Lang
Background The prevalence of isolated cleft mitral valve (MV; no concomitant congenital heart disease or degenerative MV disease) with significant mitral regurgitation (MR) diagnosed using two-dimensional echocardiography (2DE) has been reported to be very low. Three-dimensional echocardiography (3DE) has enabled a more comprehensive visualization of the MV and detailed understanding of the mechanisms of MR and can potentially reveal isolated cleft MV that is not recognized with 2DE. The aim of this study was to determine, using 3DE, the prevalence, location, and associated MV annular and left ventricular characteristics of isolated cleft MV, in the absence of associated congenital heart disease, in patients with significant MR. Methods A total of 1,092 patients with unexplained moderate or greater MR on two-dimensional transthoracic echocardiography who were referred for three-dimensional transesophageal echocardiography between 2005 and 2017 (n = 626) were retrospectively studied. Left ventricular dimensions and function were determined, and quantitative MR assessment and three-dimensional analysis of the MV annulus was performed. Results Twenty-one patients (prevalence 3.3%) were diagnosed with isolated cleft MV using three-dimensional transesophageal echocardiography but not 2DE. The majority of these patients (n = 16) were noted to have anterior cleft MVs, with most located in the mid-A1 (n = 10) or mid-A3 (n = 5) scallops. Posterior clefts were less common (n = 5) and occurred at the site of the natural scallop indentations (three between P1 and P2 and two between P2 and P3). Among patients with either anterior or posterior MV cleft, there were no differences in left ventricular ejection fraction or three-dimensional MV geometry (annular distance, height, circumference, and area). There was a trend toward worse MR severity in patients with anterior cleft MV. Conclusions In patients with otherwise unexplained significant MR referred for transesophageal echocardiography, 3DE uncovered a considerably higher prevalence of isolated cleft MV than previously reported by 2DE, with the majority located in the anterior MV. Although the annular geometry was similar between patients with anterior and posterior cleft MVs, a trend toward more severe MR in anterior clefts may reflect underlying abnormalities in the embryologic development of the anterior MV leaflet. Evaluation of MV pathology is improved by 3DE, which should be used routinely in the setting significant MR.
Diastolic Dysfunction Assessed Using Contemporary Guidelines and Prognosis Following Myocardial Infarction J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-07 Sandhir B. Prasad, Andrew K. Lin, Kristyan B. Guppy-Coles, Tony Stanton, Rathika Krishnasamy, Gillian A. Whalley, Liza Thomas, John J. Atherton
Background Recent American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines for the assessment of diastolic dysfunction (DD) recommend a simplified approach with four key variables incorporated into a novel diagnostic algorithm. The aim of this study was to assess the prognostic value of significant DD assessed using the algorithm recommended in the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines (DD2016) in comparison with the prognostic value of significant DD assessed using the 2009 guidelines (DD2009) as well as the individual parameters incorporated in the 2016 algorithm. Methods Retrospective data on 419 consecutive patients with first ever myocardial infarction were included. Doppler echocardiography was performed within 24 hours of admission in all patients. Significant DD was defined as grade 2 or 3 DD. The primary outcome measure was composite major adverse cardiovascular events (MACEs), comprising death, myocardial infarction, and heart failure. Results At a median follow-up of 24 months, there were 61 MACEs. On Kaplan-Meier analysis, DD2016 showed a better association with MACEs than DD2009 (log-rank χ2 = 21.01 [P < .001] vs 13.13 [P = .001]). On Cox proportional-hazards multivariate analysis incorporating significant clinical predictors and left ventricular ejection fraction, DD2016 (hazard ratio, 2.22; 95% CI, 1.25–3.98; P = .007) was the strongest independent predictor of MACEs, whereas DD2009 (hazard ratio, 1.63; 95% CI, 0.95–2.80; P = .074) was not a significant predictor. Of the four key diastolic parameters, only left atrial volume index was independently associated with MACEs (hazard ratio, 1.79; 95% CI, 1.02–3.14; P = .041) when included in a Cox proportional-hazards multivariate model incorporating significant clinical predictors and left ventricular ejection fraction, although the association was weaker than DD2016. Intermodel comparisons with model χ2 and Harrell's C statistic were satisfactory for DD2016. Conclusions Significant DD assessed using the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines is a robust independent predictor of clinical outcomes following myocardial infarction and compares favorably with DD2009 as well as the individual parameters incorporated in the novel 2016 algorithm.
Right Atrial Function Predicts Clinical Outcome in Patients with Precapillary Pulmonary Hypertension J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-06 Sophia Anastasia Mouratoglou, Konstantinos Dimopoulos, Vasileios Kamperidis, Christos Feloukidis, Alexandros Kallifatidis, Georgia Pitsiou, Ioannis Stanopoulos, Vasileios Grosomanidis, Stavros Hadjimiltiades, Haralambos Karvounis, George Giannakoulas
Background Although the primary role of right atrial (RA) size in the diagnosis and risk stratification of precapillary pulmonary hypertension (PH) has been studied, little is known about the clinical significance of RA function. In line with studies assessing left atrial function in heart failure, the aim of this study was to introduce the RA function index (RAFi) and to explore its prognostic power in precapillary PH. Methods RA emptying fraction was calculated as (RA end-systolic volume − RA end-diastolic volume) × 100/(RA end-systolic volume). RAFi was calculated as (RA emptying fraction × right ventricular outflow tract velocity-time integral)/(RA end-systolic volume index). Patients were followed for the end point of clinical failure, which was defined as death, hospitalization because of PH, or disease progression. Results In total, 47 patients with precapillary PH were included. Mean RAFi was 16.1 ± 22.3%. Over a median follow-up period of 25 months (interquartile range, 9.5–41.1 months), 29 patients experienced clinical failure. Univariate Cox proportional-hazard analysis showed that RAFi was a predictor of clinical failure (hazard ratio, 0.935; 95% CI, 0.890–0.981; P = .007). Addition of RAFi to established predictors of outcomes, including 6-minute walk distance, N-terminal pro–B-type natriuretic peptide, and RA area, improved their prognostic power. Conclusions RAFi is an easily assessed echocardiographic parameter, which is strongly predictive of clinical outcomes in patients with precapillary PH. Further studies are needed to validate RAFi and define its role in clinical practice.
A New Three-Dimensional Echocardiography Method to Quantify Aortic Valve Calcification J. Am. Soc. Echocardiog. (IF 6.827) Pub Date : 2018-08-01 Thomas d'Humières, Laureline Faivre, Elie Chammous, Jean-François Deux, Eric Bergoënd, Antonio Fiore, Costin Radu, Jean-Paul Couetil, Nicole Benhaiem, Geneviève Derumeaux, Jean-Luc Dubois-Randé, Julien Ternacle, Damien Fard, Pascal Lim
Background Aortic valve calcification (AVC) quantification is computed from multidetector computed tomography (MDCT). The aim of this study was to test the hypothesis that three-dimensional (3D) transthoracic echocardiography can be used to provide a bedside method to assess AVC. Methods The study included 94 patients (mean age, 78 ± 12 years; mean aortic valve [AV] area, 1.0 ± 0.6 cm2) referred for MDCT and echocardiography for AV assessment. Apical 3D full-volume data sets focused on the AV region were acquired during transthoracic echocardiography, and a region-growing algorithm was applied offline to compute 3D transthoracic echocardiographic AVC (AVC-3DEcho). AVC-3DEcho was compared with AVC by MDCT and with calcium weight in the subgroup of patients referred for surgery, with explanted AVs analyzed by a pathologist (n = 22). Results In the explanted valve group, AVC-3DEcho score exhibited fair correlations with MDCT score (r = 0.85, P < .001), calcium load (r = 0.81, P < .001), and peak AV velocity (r = 0.64, P < .001). In the overall population, AVC-3DEcho score correlated modestly with MDCT score (r = 0.61, P < .001) but had similar accuracy to identify severe aortic stenosis (area under the curve = 0.94). AVC-3DEcho > 1,054 mm3 identified severe aortic stenosis with specificity of 100% and sensitivity of 76%. In addition, AVC-3DEcho was associated with the presence of significant paravalvular regurgitation after transcatheter aortic valve implantation. Finally, intraobserver and interobserver variability for AVC-3DEcho score was 4.2% and 8.9%, respectively. Conclusions AVC-3DEcho correlated with calcium weight obtained from pathologic analysis and MDCT. These data suggest that a bedside method for quantifying AV calcification with ultrasound is feasible.
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