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  • Echocardiographic Indices of the Left and Right Heart in a Normal Black African Population
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2020-01-17
    Samantha Nel; Petros Nihoyannopoulos; Elena Libhaber; Mohammed R. Essop; Claudia Ferreira dos Santos; Hiral Matioda; Claire Waterworth; Sacha Grinter; Ruchika Meel; Ferande Peters

    Background It is unknown whether ethnic differences occur with regard to right heart echocardiographic parameters. The aim of this study therefore was to establish normative values of left and right heart parameters in a black African population and to evaluate the effect of age and body mass index (BMI) on specific right ventricle (RV) parameters. Methods Two hundred fifty-three normal subjects were prospectively studied. A standardized echocardiographic examination was conducted with the RV focused view used to derive RV measurements. All left and right heart measurements were made in accordance with the American Society of Echocardiography 2015 chamber guideline recommendations. Right ventricle free wall strain was assessed using an RV focused apical four-chamber view. Results The average age was 36.3 ± 12.2 years, and 59% of patients were female. The mean left ventricular ejection fraction was 62.3% ± 5.7%. The RV linear measurements (RV base, 31.0 ± 4.5 mm; midcavity, 26.3 ± 5.8 mm) were not associated with sex, age, or BMI except for the RV length (64.6 ± 8.9 mm), which was greater in male patients. Tricuspid annular plane systolic excursion (TAPSE) was 21.7 ± 2.8 mm, fractional area change was 42.1% ± 5.5%, tricuspid annular peak systolic velocity RV S' was 12.1 ± 1.9 m/sec, and RV free wall strain was –31.5% ± 8.6%. Age and BMI were not associated with right atrial (RA) volumetric measurements, RV linear measurements, or any RV functional parameters except TAPSE and RV A', which increased with BMI. Conclusions This study establishes normal left and right heart parameters in a black African population. Aging was not associated with RA or RV parameters except for RV E' and A'. BMI does not affect RA/RV measurements but may cause variability in TAPSE and RV A'.

    更新日期:2020-01-21
  • Association of Machine Learning–Derived Phenogroupings of Echocardiographic Variables with Heart Failure in Stable Coronary Artery Disease: The Heart and Soul Study
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2020-01-14
    Rakesh K. Mishra; Geoffrey H. Tison; Qizhi Fang; Rebecca Scherzer; Mary A. Whooley; Nelson B. Schiller

    Background Many individual echocardiographic variables have been associated with heart failure (HF) in patients with stable coronary artery disease (CAD), but their combined utility for prediction has not been well studied. Methods Unsupervised model-based cluster analysis was performed by researchers blinded to the study outcome in 1,000 patients with stable CAD on 15 transthoracic echocardiographic variables. We evaluated associations of cluster membership with HF hospitalization using Cox proportional hazards regression analysis. Results The echo-derived clusters partitioned subjects into four phenogroupings: phenogroup 1 (n = 85) had the highest levels, phenogroups 2 (n = 314) and 3 (n = 205) displayed intermediate levels, and phenogroup 4 (n = 396) had the lowest levels of cardiopulmonary structural and functional abnormalities. Over 7.1 ± 3.2 years of follow-up, there were 198 HF hospitalizations. After multivariable adjustment for traditional cardiovascular risk factors, phenogroup 1 was associated with a nearly fivefold increased risk (hazard ratio [HR] = 4.8; 95% CI, 2.4-9.5), phenogroup 2 was associated with a nearly threefold increased risk (HR = 2.7; 95% CI, 1.4-5.0), and phenogroup 3 was associated with a nearly twofold increased risk (HR = 1.9; 95% CI, 1.0-3.8) of HF hospitalization, relative to phenogroup 4. Conclusions Transthoracic echocardiographic variables can be used to classify stable CAD patients into separate phenogroupings that differentiate cardiopulmonary structural and functional abnormalities and can predict HF hospitalization, independent of traditional cardiovascular risk factors.

    更新日期:2020-01-14
  • Clinical Utility of Echocardiography in Former Preterm Infants with Bronchopulmonary Dysplasia
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2020-01-14
    Hythem Nawaytou; Martina A. Steurer; Yili Zhao; Elyssa Guslits; David Teitel; Jeffrey R. Fineman; Roberta L. Keller

    Background The clinical utility of echocardiography for the diagnosis of pulmonary vascular disease (PVD) in former preterm infants with bronchopulmonary dysplasia (BPD) is not established. Elevated pulmonary vascular resistance (PVR) rather than pulmonary artery pressure (PAP) is the hallmark of PVD. We evaluated the utility of echocardiography in infants with BPD in diagnosing pulmonary hypertension and PVD (PVR >3 Wood units × m2) assessed by cardiac catheterization. Methods A retrospective single center study of 29 infants born ≤29 weeks of gestational age with BPD who underwent cardiac catheterization and echocardiography was performed. PVD was considered present by echocardiography if the tricuspid valve regurgitation jet peak velocity was >2.9 m/sec, post-tricuspid valve shunt systolic flow velocity estimated a right ventricular systolic pressure >35 mm Hg, or systolic septal flattening was present. The utility (accuracy, sensitivity, and positive predictive value [PPV]) of echocardiography in the diagnosis of PVD was tested. Subgroup analysis in patients without post-tricuspid valve shunts was performed. Echocardiographic estimations of right ventricular pressure, dimensions, function, and pulmonary flow measurements were evaluated for correlation with PVR. Results The duration between echocardiography and cardiac catheterization was a median of 1 day (interquartile range, 1-4 days). Accuracy, sensitivity, and PPV of echocardiography in diagnosing PVD were 72%, 90.5%, and 76%, respectively. Accuracy, sensitivity, and PPV increased to 93%, 91.7%, and 100%, respectively, when infants with post-tricuspid valve shunts were excluded. Echocardiography had poor accuracy in estimating the degree of PAP elevation by cardiac catheterization. In infants without post-tricuspid valve shunts, there was moderate to good correlation between indexed PVR and right ventricular myocardial performance index (rho = 0.89, P = .005), systolic to diastolic time index (0.84, P < .001), right to left ventricular diameter ratio at end systole (0.66, P = .003), and pulmonary artery acceleration time (0.48, P = .05). Conclusions Echocardiography performs well in screening for PVD in infants with BPD and may be diagnostic in the absence of a post-tricuspid valve shunt. However, cardiac catheterization is needed to assess the degree of PAP elevation and PVR. The diagnostic utility of echocardiographic measurements that correlate with PVR should be evaluated prospectively in this patient population.

    更新日期:2020-01-14
  • Echocardiographic Evaluation of Left Ventricular Output in Patients with Heart Failure: A Per-Beat or Per-Minute Approach?
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-19
    Donato Mele; Gabriele Pestelli; Davide Dal Molin; Filippo Trevisan; Vittorio Smarrazzo; Giovanni Andrea Luisi; Alessandro Fucili; Roberto Ferrari

    Background Left ventricular (LV) output is a predictor of adverse outcome in patients with heart failure. It can be evaluated using a per-beat approach, measuring stroke volume index (SVI), or a per-minute approach, calculating cardiac index (CI). However, the prognostic value of these two approaches has never been compared. Methods A single-center retrospective observational study was conducted in 396 hospitalized patients who underwent echocardiography for suspected heart failure. In a group of 138 consecutive patients, SVI and CI cutoff values of 30 mL/m2 and 2.3 L/min/m2, respectively, were derived to separate normal from low LV forward flow conditions. Subsequently, the association of these values with all-cause mortality was compared in a group of 258 consecutive patients. Median follow-up duration was 2.6 years (interquartile range: 2-3.2 years). Results After adjustment for other outcome predictors, SVI <30 mL/m2 was independently associated with all-cause mortality with a hazard ratio of 2.67 (95% confidence interval, 1.74-4.1; P < .001), whereas CI was not. Additionally, three different subgroups of SVI (<30, 30-35, and >35 mL/m2) and CI (<1.8, 1.8-2.2, and ≥2.3 L/min/m2) were compared, and no incremental benefit of this risk stratification model was observed. Conclusions Low LV output on the basis of a per-beat definition (SVI <30 mL/m2) is strongly associated with all-cause mortality in patients hospitalized with heart failure. A per-minute approach seems to add no further information to risk stratification. These findings may have implications for selecting the LV output index when evaluating prognosis in patients with heart failure.

    更新日期:2019-12-20
  • Postoperative Recovery of Left Ventricular Function following Repair of Large Ventricular Septal Defects in Infants
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-19
    Gregory T. Adamson; Alisa Arunamata; Theresa A. Tacy; Norman H. Silverman; Michael Ma; Shiraz A. Maskatia; Rajesh Punn

    Introduction Early postoperative left ventricular (LV) dysfunction is observed following repair of large ventricular septal defects (VSDs), but the frequency and rate of recovery of LV function are unknown. This study aims to characterize the incidence and rate of recovery of postoperative LV dysfunction following repair of large VSDs and to improve understanding of LV mechanics before and after VSD repair. Methods Infants who underwent surgical repair of an isolated large VSD were included. Pre- and postoperative echocardiographic images were reviewed, and LV function was assessed by both conventional echocardiography and speckle-tracking strain analyses. Postoperative LV dysfunction was defined as an LV ejection fraction (LVEF) < 50% using the 5/6 area-length method. Echocardiograms were reviewed to assess LVEF and LV volume through 1-year follow-up. Results Of 104 infants evaluated (median age, 0.31 [0.22, 0.56] years), all had normal preoperative LVEF and 39 (38%) had postoperative LV dysfunction. Follow-up echocardiograms were available in 31 (80%) patients, all of whom had LVEF > 50% within 9 months of surgery. Lower preoperative apical four-chamber longitudinal strain (A4LS) and greater LV end-diastolic volume indexed to body surface area1.38 were independently associated with postoperative LV dysfunction. An absolute preoperative A4LS < 16.7% (area under the curve = 0.87; 95% CI, 0.78-0.95; P < .001) was most strongly associated with postoperative dysfunction. Conclusions Infants with LV dysfunction following repair of large VSDs recover function within 9 months. Preoperative A4LS can be helpful to detect subclinical LV dysfunction in the setting of a large hemodynamically significant VSD and guide postoperative expectations for providers and families.

    更新日期:2019-12-20
  • Clinical Usefulness of Pressure Recovery Adjustment in Patients with Predominantly Severe Aortic Stenosis: Asian Valve Registry Data
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-19
    Ran Heo; Xin Jin; Jin Kyung Oh; Yong-Jin Kim; Sung-Ji Park; Seung Woo Park; Lieng-Hsi Ling; Shota Fukuda; Yutaka Otsuji; Dae-Won Sohn; Jae-Kwan Song

    Background Adjustment for pressure recovery (PR) may reconcile discrepancies in pressure gradients measured by Doppler echocardiography and direct catheterization in patients with mild to moderately severe aortic stenosis (AS). The aim of this study was to evaluate whether PR adjustment is useful in a large cohort of predominantly patients with severe AS. Methods Data from 697 patients (mean age 70 ± 11 years) in the Asian Valve Registry with a mean aortic valve area (AVA) of 0.8 ± 0.3 cm2 and a mean gradient of 46 ± 21 mm Hg were analyzed. PR-adjusted AVAs were calculated using validated equations. The primary outcome included aortic valve replacement, all-cause mortality, and hospitalization for heart failure during the median follow-up period of 2.9 years. Results Before PR adjustment, 521 patients showed AVA values of ≤1.0 cm2, and after PR adjustment, 129 (24.8%) were reclassified to moderate AS with a mean AVA of 1.1 ± 0.1 cm2. PR adjustment decreased the frequency of low-gradient severe AS (AVA ≤ 1.0 cm2 and mean gradient < 40 mm Hg) from 22.4% (156 of 697) to 10.2% (71 of 697). Most reclassification (>95%) occurred in patients with aortic dimensions < 3.5 cm, mean gradients < 60 mm Hg, or AVAs between 0.8 and 1.0 cm2. Patients with reclassification to moderate AS after PR adjustment showed higher 4-year clinical event-free survival rates (46.2 ± 4.9% vs 14.6 ± 2.1% in patients with severe AS after PR adjustment, P < .001). Cox regression analysis showed that reclassification after PR adjustment had additive value to predict the primary outcome (hazard ratio, 0.678; 95% CI, 0.467-0.985; P = .041) and aortic valve replacement (hazard ratio, 0.663; 95% CI, 0.440-0.998; P = .049). Conclusions Clinically relevant PR frequently occurs in patients with moderate to severe AS. PR adjustment has prognostic implications, and accurate classification of severe AS can help prevent discordant AS grading.

    更新日期:2019-12-20
  • Systematic Assessment of the Impact of Ultrasound-Enhancing Agents upon Measurements of Cardiac Size and Function by Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-19
    Sachiyo Igata; Megan Kraushaar; Monet Strachan; Janet I. Ma; Marin Nishimura; Ajit Raisinghani; Daniel G. Blanchard; Anthony N. DeMaria

    Background Echocardiography with an ultrasound-enhancing contrast agent (CON) is a powerful tool for identifying the endocardial border. However, the precise relationship of measurements obtained from CON to the reference values of two-dimensional unenhanced echocardiography (BASL) remains undefined, especially regarding wall thickness. The aim of this study was to systematically determine the differences between unenhanced and enhanced images for a broad range of left ventricular (LV) measurements and to define reference values for the relationship between the two methods. Methods We examined the echocardiograms of 624 consecutive patients in whom CON was performed for clinical indications. We excluded 192 patients in whom studies were technically difficult for measurement by either or both methods. Echocardiograms were from standard parasternal and apical views according to American Society of Echocardiography guidelines. Recordings were measured for wall thickness and chamber dimension in 343 patients and for LV volumes and ejection fraction in 212 patients. Results LV wall thickness measurements were systematically reduced with a bias of 0.2 cm with limits of agreement (LOA) from −0.5 to 0.16 cm in interventricular septal thickness, and from −0.46 to 0.13 cm in posterior wall thickness in CON. LV dimensions and volumes systematically increased with a bias of 0.2 cm (LOA, −0.19 to 0.58 cm) and 14 to 16 mL (LOA, −11.9 to 42.8 mL), respectively. LV ejection fraction systematically decreased with a bias of 3.4% (LOA, −13.5% to 6.8%) in CON compared to BASL. All differences showed normal distribution in the Kolmogorov-Smirnov test. Conclusion CON yields significantly different measurements of cardiac size and function compared to unenhanced imaging. These data define the systematic differences in measurements between CON and BASL images; the range of differences is narrow. These differences may influence management when the measurement value is a borderline.

    更新日期:2019-12-19
  • Importance of Abdominal Compression Valsalva Maneuver and Microbubble Grading in Contrast Transthoracic Echocardiography for Detecting Patent Foramen Ovale
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-16
    Yoichi Takaya; Nobuhisa Watanabe; Madoka Ikeda; Teiji Akagi; Rie Nakayama; Koji Nakagawa; Norihisa Toh; Hiroshi Ito

    Background Although transthoracic echocardiography (TTE) may be useful for patent foramen ovale (PFO) screening, the optimal methodologies remain unclear. The aims of this study were to evaluate the efficacy of the abdominal compression Valsalva maneuver and identify the optimal cutoff value of microbubbles in contrast TTE for detecting PFO, compared with transesophageal echocardiography and catheterization as the reference. Methods One hundred thirty-four patients with cryptogenic stroke or migraine who had suspected PFO and underwent TTE and transesophageal echocardiography plus catheterization were enrolled. The sensitivity, specificity, and accuracy of TTE for PFO detection were analyzed according to different provocations (spontaneous Valsalva maneuver, abdominal compression Valsalva maneuver) and different cutoff values of microbubbles for a positive result (at least one microbubble, at least five microbubbles). Results Eighty patients had PFO confirmed by transesophageal echocardiography and catheterization. When the cutoff was at least one microbubble, the sensitivity of TTE in detecting PFO was 93% with the spontaneous Valsalva maneuver and 99% with the abdominal compression Valsalva maneuver. When the cutoff was at least five microbubbles, sensitivity was 85% with the spontaneous Valsalva maneuver and 99% with the abdominal compression Valsalva maneuver. With the abdominal compression Valsalva maneuver, specificity was increased using the cutoff of at least five microbubbles compared with at least one microbubble (89% vs 57%). The abdominal compression Valsalva maneuver with the cutoff of at least 5 microbubbles provided the greatest accuracy of 95%. Conclusions TTE with the abdominal compression Valsalva maneuver had excellent sensitivity. The cutoff of at least five microbubbles increased specificity. Our findings suggest that TTE with these criteria is valuable for PFO diagnosis.

    更新日期:2019-12-17
  • Clinical Impact of Size, Shape, and Orientation of the Tricuspid Annulus in Tricuspid Regurgitation as Assessed by Three-Dimensional Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-16
    Hiroto Utsunomiya; Yuji Itabashi; Sayuki Kobayashi; Florian Rader; Robert J. Siegel; Takahiro Shiota

    Background Tricuspid annuloplasty for tricuspid regurgitation (TR) depends on the measurements of tricuspid annular diameter (TAD) obtained in an apical four-chamber view on two-dimensional (2D) transthoracic echocardiography (TTE). We performed a combined 2D and three-dimensional (3D) echocardiographic study to understand the impact of the size, shape, and orientation of a dilated annulus on the inconsistencies between measured 2D TTE-TAD and the actual annular diameter. Methods A total of 185 patients with grade ≥3+ TR and 50 controls underwent 2D TTE and 3D transesophageal echocardiography (TEE) assessment of the tricuspid valve. The 3D TEE-TAD, defined as the longest dimension, and tricuspid annulus (TA) eccentricity index, defined as the shortest/longest dimension ratio, were obtained. The angle between the major tricuspid annulus axis and interatrial septum parallel to the vertical axis (α°) was measured as an index of TA orientation. Results Compared with controls, TR subgroups had a larger α° irrespective of TR etiology and cardiac rhythm (P < .05), with the posteriorly displaced TA most frequently noted in patients with atrial fibrillation. An excellent correlation was found between 3D TEE-TAD and 2D TTE-TAD, but 2D TTE-TAD was significantly smaller than 3D TEE-TAD (35.9 ± 5.4 vs 39.8 ± 5.7 mm; P < .001; bias, 3.9 ± 2.6 mm; limits of agreement, −1.1-8.9 mm). After multivariate adjustment, a larger 3D TEE-TAD and larger absolute value of 90° − α° were independent determinants of the bias between 3D TEE-TAD and 2D TTE-TAD (both P < .001). Conclusions The inconsistencies between measured 2D TTE-TAD and the actual annular diameter can be explained through morphologic factors such as TA size and orientation.

    更新日期:2019-12-17
  • The Association between Left Ventricular Diastolic Dysfunction and Myocardial Scar and Their Collective Impact on All-Cause Mortality
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-10
    Lin Wang, Harsimar Singh, Rajasekhar R. Mulyala, Jonathan Weber, Eddy Barasch, J. Jane Cao

    Background Left ventricular diastolic dysfunction (DD) and myocardial scar are important contributors to cardiovascular morbidity and mortality. The aim of this study was to test the hypothesis that myocardial scar is a substrate of DD and that collectively they contribute to increased risk for all-cause mortality. Methods The study included 607 consecutive patients who underwent echocardiography and cardiac magnetic resonance imaging within 1 week. DD was assessed by echocardiography according to the contemporary guidelines and myocardial scar by late gadolinium enhancement (LGE). All-cause mortality was the main outcome. Results Scar prevalence was significantly higher comparing no DD with mild and advanced DD (25%, 61%, and 80%, respectively; P < .001), and scar burden was greater by semiquantitative LGE scores (1.4 ± 3.4, 4.8 ± 6.3, and 6.8 ± 8.8, respectively; P < .001). After 10 years of follow-up, 50 patients (8.2%) had died. The mortality incidence was significantly higher comparing no DD with mild and advanced DD (2.5, 17.3, and 55.7 deaths per 1,000 person-years, respectively; P < .001). It was also higher in patients with higher LGE scores (4.3, 22.7, and 35.2 deaths per 1,000 person-years in groups with LGE scores of 0, 1–6, and ≥7, respectively; P < .001). The risk for death was higher among patients with both DD and scar. The additive interaction of DD and scar for mortality was significant (P < .001). In the multivariate Cox proportional-hazards analysis, DD and scar were associated with mortality (P < .001). Conclusions There is a strong link between the echocardiographic findings of DD and the morphologic changes of myocardial tissue. DD assessed according to contemporary guidelines effectively differentiates mortality risk. The additive interaction of DD and scar on mortality risk highlights the pivotal role of myocardial tissue characterization in patients with DD.

    更新日期:2019-12-11
  • Parameters of Right Ventricular Function Reveal Ventricular-Vascular Mismatch as Determined by Right Ventricular Stroke Work versus Pulmonary Vascular Resistance in Children with Pulmonary Hypertension
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-10
    Michael V. Di Maria, Kristen R. Campbell, Dale A. Burkett, Adel K. Younoszai, Bruce F. Landeck, Luc Mertens, D. Dunbar Ivy, Kendall S. Hunter, Mark K. Friedberg

    Background Right ventricular (RV) failure, a determinant of outcomes in pulmonary hypertension (PH), occurs when the right ventricle cannot compensate for increased afterload. The authors showed that RV stroke work (RVSW) can be estimated in children with PH as the product of stroke volume and RV pressure and is related to adverse outcomes. The aim of this study was to test the hypothesis that ventricular-vascular (VV) mismatch (high afterload and low RVSW) is associated with echocardiographic measures of RV performance and adverse outcomes. Methods Invasive hemodynamic data and concurrent echocardiograms were reviewed. Fifty subjects with PH were included. Four groups were created by dividing the patients using median RVSW and median pulmonary vascular resistance. For each group, tricuspid annular plane systolic excursion, fractional area change, myocardial performance index, and anterior RV wall thickness were determined. Both major (i.e., death) and minor (i.e., worsening World Health Organization class) clinical outcomes were tabulated. Groups were compared using the Kruskal-Wallis or Fisher exact test. Results Patients in the high pulmonary vascular resistance/low RVSW cohort (VV mismatch) had the worst RV dysfunction: median tricuspid annular plane systolic excursion, 0.8 cm (interquartile range, 0.7–0.8 cm; P = .0002); median fractional area change, 0.29% (interquartile range, 0.27%–0.30%; P = .004); median myocardial performance index, 0.622 (interquartile range, 0.548–0.789; P = .0004). This group had the highest incidence of adverse outcomes: major events in 40%, minor events in 80%, and syncope in 60%. Conclusion VV mismatch in pediatric PH can be assessed using RVSW and pulmonary vascular resistance and is associated with RV performance and adverse events. RVSW increases in compensated high-afterload states and falls as the right ventricle fails to meet increased load; thus, VV matching status may be a sensitive predictor of outcomes in pediatric PH.

    更新日期:2019-12-11
  • Blood Stasis Imaging Predicts Cerebral Microembolism during Acute Myocardial Infarction
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-05
    Antonia Delgado-Montero, Pablo Martinez-Legazpi, M. Mar Desco, Daniel Rodríguez-Pérez, Fernando Díaz-Otero, Lorenzo Rossini, Candelas Pérez del Villar, Elena Rodríguez-González, Christian Chazo, Yolanda Benito, Oscar Flores, José Carlos Antoranz, Francisco Fernández-Avilés, Juan C. del Álamo, Javier Bermejo

    Background Cardioembolic stroke is a major source of mortality and disability worldwide. The authors hypothesized that quantitative characterization of intracardiac blood stasis may be useful to determine cardioembolic risk in order to personalize anticoagulation therapy. The aim of this study was to assess the relationship between image-based metrics of blood stasis in the left ventricle and brain microembolism, a surrogate marker of cardiac embolism, in a controlled animal experimental model of acute myocardial infarction (AMI). Methods Intraventricular blood stasis maps were derived from conventional color Doppler echocardiography in 10 pigs during anterior AMI induced by sequential ligation of the mid and proximal left anterior descending coronary artery (AMI-1 and AMI-2 phases). From these maps, indices of global and local blood stasis were calculated, such as the average residence time and the size and ratio of contact with the endocardium of blood regions with long residence times. The incidence of brain microemboli (high-intensity transient signals [HITS]) was monitored using carotid Doppler ultrasound. Results HITS were detected in 0%, 50%, and 90% of the animals at baseline and during AMI-1 and AMI-2 phases, respectively. The average residence time of blood in the left ventricle increased in parallel. The residence time performed well to predict microemboli (C-index = 0.89, 95% CI, 0.75–1.00) and closely correlated with the number of HITS (R = 0.87, P < .001). Multivariate and mediation analyses demonstrated that the number of HITS during AMI phases was best explained by stasis. Among conventional echocardiographic variables, only apical wall motion score weakly correlated with the number of HITS (R = 0.3, P = .04). Mural thrombosis in the left ventricle was ruled out in all animals. Conclusions The degree of stasis of blood in the left ventricle caused by AMI is closely related to the incidence of brain microembolism. Therefore, stasis imaging is a promising tool for a patient-specific assessment of cardioembolic risk.

    更新日期:2019-12-05
  • The Impact of Distinct Exercise Training Modalities on Echocardiographic Measurements in Patients with Heart Failure with Reduced Ejection Fraction
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-04
    Nick S.R. Lan, Kaitlyn Lam, Louise H. Naylor, Daniel J. Green, Novia S. Minaee, Peter Dias, Andrew J. Maiorana

    Background Exercise training is an important component of multidisciplinary heart failure management. However, the effects of aerobic training (AT) versus resistance training (RT) on cardiac function in patients with heart failure with reduced ejection fraction are not well defined. The aim of this study was to evaluate the impact of these exercise modalities on echocardiographic parameters. Methods Participants with stable heart failure with reduced ejection fraction (ejection fraction < 50%) were randomized to 12 weeks of AT, RT, or untrained control. Exercise was performed at matched relative intensities of each training modality (50%–70% of maximum). Echocardiography and cardiopulmonary exercise testing were performed at baseline and after 12 weeks of training. Results Thirty-eight participants were randomized, and 12 in each group completed the intervention (mean age, 61.5 ± 1.7 years; 89% men). Peak oxygen consumption increased from 14.5 ± 1.3 to 17.2 ± 1.6 ml · min−1 · kg−1 after AT and from 13.7 ± 1.2 to 16.4 ± 1.1 ml · min−1 · kg−1 after RT (P < .001 for both). In the AT group, there was a decrease in septal e′ (from 0.052 ± 0.004 to 0.041 ± 0.004 m/sec) and increases in E/e′ ratio (from 18.2 ± 3.1 to 23.8 ± 3.5), left atrial volume (from 86 ± 9 to 99 ± 10 mL), and right ventricular end-diastolic area (from 18 ± 1 to 20 ± 1 cm2; P < .05 for all), but these were unchanged in the control and RT groups. There were no significant changes in left ventricular diameters or volumes or right ventricular fractional area change after exercise. Conclusions There is a differential effect of AT versus RT on some echocardiographic parameters in patients with heart failure with reduced ejection fraction. AT was associated with evidence of worsening myocardial diastolic function, whereas this was not apparent after RT. Further studies are indicated to investigate the long-term clinical significance of these adaptations.

    更新日期:2019-12-05
  • Therapeutic Ultrasound Improves Myocardial Blood Flow and Reduces Infarct Size in a Canine Model of Coronary Microthromboembolism
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-12-04
    Mrinal Yadava, D. Elizabeth Le, Igor V. Dykan, Marjorie R. Grafe, Matthew Nugent, Azzdine Y. Ammi, David Giraud, Yan Zhao, Jessica Minnier, Sanjiv Kaul

    Background Therapeutic ultrasound (TUS) has been used to lyse infarct-related coronary artery thrombus. There has been no study examining the effect of TUS specifically on myocardial microthromboemboli seen in acute myocardial infarction and acute coronary syndromes. The aim of this study was to test the hypothesis that TUS improves myocardial blood flow (MBF) and reduces infarct size (IS) in this situation by dissolving myocardial microthrombi. Methods An open-chest canine model of myocardial microthromboembolism was created by disrupting a thrombus in the left anterior descending coronary artery, and 1.05- and 0.25-MHz TUS (n = 7 each) delivered epicardially for 30 min was compared with control (n = 6). MBF and IS (as a percentage of left anterior descending coronary artery perfusion bed size) were measured 60 min after treatment. In addition, immunohistochemistry was performed to assess microthrombi, and histopathology was performed to define inflammation. Results Transmural, epicardial, and endocardial myocardial blood volume and MBF (measured using myocardial contrast echocardiography) and percentage wall thickening were significantly higher 60 min after receiving TUS compared with control. The ratio of IS to left anterior descending coronary artery perfusion bed size was significantly smaller (P = .03) in the 1.05-MHz TUS group (0.14 ± 0.04) compared with the control (0.31 ± 0.06, P = .04) and 0.25-MHz (0.36 ± 0.08) groups. MBF versus percentage wall thickening exhibited a linear relation (r = 0.65) in the control and 1.05-MHz TUS groups but not in the 0.25-MHz TUS group (r = 0.29). The presence of myocardial microemboli in vessels >10 μm in diameter was significantly reduced in the 1.05-MHz TUS group compared with the other two groups. The distribution and intensity of inflammation was higher in the 0.25-MHz TUS group compared with the other groups. Conclusions TUS at 1.05 MHz is effective in restoring myocardial blood volume and MBF, thus reducing IS by clearing the microcirculation of microthrombi. IS reduction is not seen at 0.25 MHz, despite improvement in MBF, which may be related to the increased inflammation noted at this frequency. Because both acute myocardial infarction and acute coronary syndromes are associated with microthromboembolism, these results suggest that TUS could have a potential adjunctive role in the treatment of both conditions.

    更新日期:2019-12-05
  • Left Ventricular Longitudinal Strain as a Marker for Point of No Return in Hypertensive Heart Failure Treatment
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-11-15
    Tomoko Ishizu, Yoshihiro Seo, Mikiko Namekawa, Nobuyuki Murakoshi, Masaki Ieda, Yasushi Kawakami

    Background There are currently no therapies that can improve prognosis in cases of heart failure (HF) with preserved ejection fraction (EF). We hypothesized that there is a point of no return after which no response to treatment is noted and that for the prevention of hypertensive HF this point may be determined by left ventricle (LV) strain, in the prevention of hypertensive HF. Here an angiotensin-converting enzyme inhibitor (ACE-I) was initiated based on myocardial strain imaging and its effects were determined in an animal model. Methods Thirty-two male Dahl salt-sensitive rats, age 6 weeks, were divided into six experimental groups and compared with low-salt (n = 8) and high-salt control groups (n = 8). In the early treatment group, ACE-I was administered from the age of 6 weeks (n = 4); in the longitudinal strain (LS) group, at 10-12 weeks when LS impairment was >–21% (n = 4); in the circumferential strain (CS) group, at 16-18 weeks when CS impairment was >–18% (n = 4); and in the EF group, at 20 weeks when EF was <55% (n = 4). Subsequently, all rats were sacrificed at 23 weeks age, the LV and lung weight were measured, and pathologic analyses were performed. Results At 23 weeks of age, the lung and LV weights increased in the high-salt control, EF, and CS groups, whereas the lung and LV weights in the LS and early groups were similar to those in the low-salt control group. The percentage of area of subendocardial fibrosis was >6% in the high-salt control, EF, and CS groups and <3% in the LS, early, and low-salt groups. Serial echocardiography demonstrated LS improvement in the LS group; however, the CS and EF groups showed no differences. Conclusions Heart failure–related lung congestion was prevented when ACE-I was administered soon after LS impairment, accompanied by suppression of cardiac hypertrophy and fibrosis, thereby suggesting that the point of no return of myocardial remodeling due to hypertension was present after LS but before CS impairment.

    更新日期:2019-11-15
  • Intraoperative Provocative Testing in Patients with Obstructive Hypertrophic Cardiomyopathy Undergoing Septal Myectomy
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-11-15
    Ali Bedair Elsayes, Alaa Basura, Farhad Zahedi, Ingrid Moreno-Duarte, Ethan J. Rowin, Martin Maron, Hassan Rastegar, Frederick C. Cobey

    Background Resolution of left ventricular outflow tract (LVOT) obstruction predicts symptom relief postmyectomy. Intraoperative measurement of LVOT gradients thus is essential for surgical guidance. We hypothesized that (1) hypertrophic cardiomyopathy patients have lower LVOT gradients when measured intraoperatively with transesophageal echocardiography (TEE) compared with preoperative measurements with transthoracic echocardiography (TTE) and that (2) intraoperative provocative testing can help evaluate the adequacy of surgical resection. Methods We compared resting LVOT gradients on preoperative TTE to intraoperative TEE. We also compared intraoperative resting and provoked gradients pre- and postresection. Either isoproterenol 10 μg/kg/min or dobutamine 20 μg/kg/min was used. Patients with provoked LVOT gradients >30 mm Hg were considered for further resection based on LVOT/mitral valve morphology and clinical comorbidities. Results Of 315 patients identified, 293 patients were included in the analysis. There was a statistically significant difference between preoperative TTE and intraoperative TEE resting LVOT gradients (60.9 ± 39.4 mm Hg vs 42.0 ± 30.5 mm Hg, P < .0001). Out of 197 patients who had significant resting obstruction preoperatively, 82 (41.6%) demonstrated mild or no dynamic obstruction under general anesthesia. Provocative testing with both isoproterenol and dobutamine increased peak gradients (116.8 ± 33 mm Hg isoproterenol vs 107.5 ± 33 mm Hg dobutamine, P = .03). Post–cardiopulmonary bypass, seven patients (2.3%) had LVOT gradients > 30 mm Hg at rest, while 63 patients (21.5%) had residual gradients >30 mm Hg only with provocation. Elevated gradients, persistent systolic anterior motion of the mitral valve with near contact, and/or significant mitral regurgitation with provocative testing resulted in return to cardiopulmonary bypass in 41 patients (14%). Conclusions Resting intraoperative TEE LVOT gradients are significantly lower than preoperative TTE gradients, with systolic anterior motion of the MV and outflow obstruction often not visualized after inducing general anesthesia. Intraoperative pharmacologic provocation can identify patients who may benefit from further surgical intervention, facilitating procedural success.

    更新日期:2019-11-15
  • Effect of Pressure Recovery on Pressure Gradients in Congenital Stenotic Outflow Lesions in Pediatric Patients—Clinical Implications of Lesion Severity and Geometry: A Simultaneous Doppler Echocardiography and Cardiac Catheter Correlative Study
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-11-04
    Gautam K. Singh, Katie L. Mowers, Cynthia Marino, David Balzer, P. Syamasundar Rao

    Background Doppler pressure gradients (PGs) are routinely used as a surrogate for catheter peak-to-peak gradient (PPG) for referring pediatric patients with aortic stenosis (AS), pulmonary stenosis (PS), and coarctation of the aorta (CoA) for intervention but do not always predict the catheter PPG accurately, which results in misclassification of lesion severity. We hypothesized that recovered pressure (RP) accounts for the discrepancy between Doppler PG and catheter PPG. We aimed to study the occurrence of clinically significant RP in AS, PS, and CoA. Methods Simultaneous Doppler and catheter PGs were prospectively measured in 82 patients (median age, 12.2 months; weight, 7.5 kg) with isolated AS (n = 30), PS (n = 24), and CoA (n = 28), and agreement before and after correcting for RP were analyzed. RP was calculated from a fluid dynamic–based equation. Effects of lesion geometry on the magnitude of RP were analyzed. Results Recovered pressure–corrected Doppler peak instantaneous gradient (PIG) had significantly closer agreement and correlation with the catheter PPG (P < .001) than the uncorrected PIG and mean Doppler gradients. Recovered pressure–corrected Doppler PIG predicted PPG with high specificity and accuracy in all lesions (95% CI, 36%-97% and 85%-100%, respectively, P < .05 for both). RP magnitude was weakly related (r = 0.33 to 0.47) to valve area and inversely related (r = −0.22 to −0.34) to downstream vessel area. Conclusions Significant RP occurs in congenital AS, PS, and CoA, accounting for misclassification of lesion severity by Doppler PIG. The RP magnitude is at a maximum in mild to moderate stenotic outflow lesions, with small-size downstream vessels causing the most misclassification of lesion severity by Doppler PIG.

    更新日期:2019-11-04
  • Functional Regurgitation of Atrioventricular Valves and Atrial Fibrillation: An Elusive Pathophysiological Link Deserving Further Attention
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-11-01
    Denisa Muraru, Andrada-Camelia Guta, Roberto Carlos Ochoa-Jimenez, Daniela Bartos, Patrizia Aruta, Sorina Mihaila, Bogdan A. Popescu, Sabino Iliceto, Cristina Basso, Luigi Paolo Badano
    更新日期:2019-11-01
  • 20th Annual Feigenbaum Lecture: Echocardiography for Precision Medicine—Digital Biopsy to Deconstruct Biology
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-31
    Sanjiv J. Shah

    Heart failure with preserved ejection fraction (HFpEF) is a complex, heterogeneous syndrome in need of improved classification given its high morbidity and mortality and few effective treatment options. HFpEF represents an ideal setting to examine the utility and feasibility of a precision medicine approach. This article (based on the 20th annual Feigenbaum Lecture, presented at the 2019 American Society of Echocardiography Scientific Sessions) describes the utility of echocardiography as a “digital biopsy” and how deep quantitative echocardiographic phenotyping, coupled with machine learning, can be used to identify novel HFpEF phenotypes. The cellular and ultrastructural basis of abnormal speckle-tracking echocardiography– (STE-) based measurements of cardiac mechanics can provide a window into cardiomyocyte calcium homeostasis. STE-based measurements of longitudinal strain can thus inform the extent of myocardial involvement in patients with HFpEF, which may help to determine responsiveness to cardiac-specific HF medications. However, classifying the complex, systemic, multiorgan nature of HFpEF appropriately likely requires more advanced methods. Using unsupervised machine learning, HFpEF can be classified into three distinct phenogroups with differing clinical and echocardiographic characteristics and outcomes: (1) natriuretic peptide deficiency syndrome; (2) extreme cardiometabolic syndrome; and (3) right ventricle-cardio-abdomino-renal syndrome. Each can be probed to determine their biological basis. The goal of improved classification of HFpEF is to match the right patient with the right treatment, with the hope of improving the track record of HFpEF clinical trials. This article emphasizes the central role of echocardiography in advancing precision medicine and illustrates the integration of basic, translational, clinical, and population research in echocardiography with the goal of better understanding the pathobiology of a complex cardiovascular syndrome.

    更新日期:2019-11-01
  • Similarities and Differences in Left Ventricular Size and Function among Races and Nationalities: Results of the World Alliance Societies of Echocardiography Normal Values Study
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-31
    Federico M. Asch, Tatsuya Miyoshi, Karima Addetia, Rodolfo Citro, Masao Daimon, Sameer Desale, Pedro Gutierrez Fajardo, Ravi R. Kasliwal, James N. Kirkpatrick, Mark J. Monaghan, Denisa Muraru, Kofo O. Ogunyankin, Seung Woo Park, Ricardo E. Ronderos, Anita Sadeghpour, Gregory M. Scalia, Masaaki Takeuchi, Wendy Tsang, James Kirkpatrick

    Background The World Alliance Societies of Echocardiography (WASE) Normal Values Study evaluates individuals from multiple countries and races with the aim of describing normative values that could be applied to the global community worldwide and to determine differences and similarities among people from different countries and races. The present report focuses specifically on two-dimensional (2D) left ventricular (LV) dimensions, volumes, and systolic function. Methods The WASE Normal Values Study is a multicenter international, observational, prospective, cross-sectional study of healthy adult individuals. Participants recruited in each country were evenly distributed among six predetermined subgroups according to age and gender. Comprehensive 2D transthoracic echocardiograms were acquired and analyzed following strict protocols based on recent American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines. Analysis was performed at the WASE 2D core laboratory and included 2D LV dimensions, LV volumes, and LV ejection fraction (LVEF) by the biplane Simpson method and global longitudinal strain (GLS). Results Two thousand eight subjects were enrolled in 15 countries. The median age was 45 years (interquartile range, 32–65 years), 42.8% were white, 41.8% were Asian, and 9.7% were black. LV dimensions and volumes were larger in male subjects, while LVEF and GLS were higher in female subjects. Global WASE normal ranges for LV dimensions were smaller than those in the guidelines, but the upper limits of normal for LV volumes and the lower limits of normal for LVEF were higher in the WASE study. Significant intercountry variation was identified for all LV parameters reflecting LV size (dimensions, mass, and volumes) even after indexing to body surface area, with LV end-diastolic and end-systolic volumes having the highest variation. The largest volumes were noted in Australia, while the smallest were measured in India for both genders. This finding suggests that in addition to gender and body surface area, specific country should be considered when evaluating LV volumes. Intercountry variation for LVEF and GLS was smaller but still statistically significant (P < .05 for all). Conclusions LV dimensions and volumes are larger in men, while LVEF and GLS are higher in women. Current guideline-recommended normal ranges for LV volumes and LVEF should be adjusted. Intercountry variability is significant for LV volumes, and therefore nationality should be considered for defining ranges of normality.

    更新日期:2019-11-01
  • Use of the Valve Visualization on Echocardiography Grade Tool Improves Sensitivity and Negative Predictive Value of Transthoracic Echocardiogram for Exclusion of Native Valvular Vegetation
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-31
    Katherine Connolly, Geraldine Ong, Michael Kuhlmann, Edwin Ho, Kevin Levitt, Husam Abdel-Qadir, Jeremy Edwards, Chi-Ming Chow, Mohammed-Salah Annabi, Ezequiel Guzzetti, Erwan Salaun, Philippe Pibarot, Idan Roifman, Howard Leong-Poi, Kim A. Connelly

    Background Transesophageal echocardiography (TEE) remains the preferred test to rule out infective endocarditis (IE) but is resource intensive and carries risk. Multiple studies report low sensitivity of transthoracic echocardiography (TTE) for detection of IE; however, these studies did not account for TTE quality. We test the validity of a simple valve visualization grading tool to stratify TTEs by quality and determine whether a high-quality TTE may be used to exclude valvular vegetation and forgo the need for TEE. Methods The Valve Visualization on Echocardiography Grade (VEG) tool scores the TTE from 0 to 10 based on leaflet visualization and valve leaflet clarity. The tool was retrospectively applied to 309 sequential patients who underwent both TTE and TEE at an academic teaching hospital between 2011 and 2015. The TEE report was the gold standard for presence or absence of vegetation. Patients with prosthetic valves and pacemaker wires were excluded. Sensitivity of TTE for detecting vegetation was calculated at each VEG score, and the optimal cutoff was identified. Results A total of 309 patients were included in the analysis. Among the 216 negative TTEs, 19 (9%) had a positive TEE. The median VEG score was 4. A VEG score cutoff >6 provided optimal sensitivity and was used as the cutoff. Overall, 75 (25%) patients had a VEG score >6, and 234 (75%) had a score ≤6. Sensitivity and negative predictive value for IE were higher in the VEG >6 versus VEG ≤6 group (sensitivity 96% vs 66%, negative predictive value 97.5% vs 90%; P < .05). The false-negative rate was lower (2.5% vs 10%; P = .04) in VEG > 6 versus VEG ≤ 6 groups, respectively. Conclusions Leaflet visualization and valve leaflet clarity are important components in the TTE evaluation of patients with suspected IE. This study demonstrates that the better the valve leaflets are visualized on TTE (as represented in this population by a score >6), the higher the confidence one can have that the TTE will not be falsely negative for vegetation(s) when vegetation(s) are not noted on these TTEs. If validated in future prospective studies, this may reduce the need to perform an invasive TEE in selected patients undergoing evaluation for native valve IE.

    更新日期:2019-11-01
  • Clinical Situations Associated with Inappropriately Large Regurgitant Volumes in the Assessment of Mitral Regurgitation Severity Using the Proximal Flow Convergence Method in Patients with Chordae Rupture
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-23
    Kyusup Lee, Sang Yong Om, Sun Hack Lee, Jin Kyung Oh, Hong-Kyung Park, Yoon-Sil Choi, Seung-Ah Lee, Sahmin Lee, Dae-Hee Kim, Jong-Min Song, Duk-Hyun Kang, Jae-Kwan Song

    Background Regurgitant volume (RVol) calculated using the proximal flow convergence method (proximal isovelocity surface area [PISA]) has been accepted as a key quantitative parameter for the diagnosis of and clinical decision-making with regard to severe mitral regurgitation (MR). However, a recent prospective study showed a significant overestimation of RVol by the echocardiographic PISA method compared with the MR volume measured using magnetic resonance imaging. We aimed to evaluate the frequency of overestimation of RVol by the PISA method and the clinical conditions that require a different quantitative method to correct the overestimation. Methods We retrospectively enrolled 166 consecutive patients with degenerative MR and chordae rupture, in whom RVol was measured using both the PISA and two-dimensional Doppler volumetric methods. The volumetric method was used to measure total stroke volume using the two-dimensional Simpson biplane method, and forward stroke volume was measured using pulsed Doppler tracing at the left ventricular (LV) outflow tract. RVol by the volumetric method was calculated using total stroke volume – forward stroke volume. Severe MR was defined as an RVol >60 mL. Results All patients had severe MR based on RVol by the PISA method, but 68 (41.1%) showed RVol by the volumetric method values of <60 mL, resulting in discordant results. The patients with discordant results were characterized by a higher prevalence of female sex, lower body surface area, smaller LV diastolic and systolic dimensions and volumes, smaller left atrial volume, smaller PISA angle, and lower frequency of flail leaflets (39.7% vs 62.2%, P = .004). Multivariate analysis revealed that LV end-diastolic volume (LVEDV) and PISA angle were independent factors, with the best cutoff LVEDV and PISA angle being 173 mL and 103°, respectively. During follow-up (median, 3.4 years; interquartile range, 2.0-4.8 years), mitral valve repair and replacement were performed in 103 and six patients, respectively. The 2-year mitral valve surgery-free survival rate was higher in the discordant group (51.8% ± 0.06% vs 31.2% ± 0.05%, P < .001). Conclusions Even in the patients with documented chordae rupture, the PISA method alone resulted in inappropriate overestimation of MR severity in a significant proportion of patients. Thus, an additive quantitative method is absolutely necessary in patients with a small LVEDV or narrow PISA angle.

    更新日期:2019-10-24
  • Reproducibility and Intervendor Agreement of Left Ventricular Global Systolic Strain in Children Using a Layer-Specific Analysis
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-23
    Sandhya Ramlogan, Doaa Aly, Rita France, Stephanie Schmidt, Julie Hinzman, Ashley Sherman, Suma P. Goudar, Daniel Forsha

    Background Speckle-tracking strain analysis provides additive data to the assessment of pediatric and congenital heart disease; however, the variety of strain analysis software platforms by different vendors and the lack of data on intervendor strain agreement in children have limited its utility. The purpose of this study is to evaluate the intervendor agreement of strain on two commonly used analysis platforms in pediatrics by layer of myocardium and data compression. Methods This prospective study analyzed two-dimensional speckle-tracking strain on two software platforms in 53 children with normal cardiac segmental anatomy and varying function. Three standard apical views and one parasternal short-axis view were exported at their acquired frame rates to workstations with GE EchoPAC and TomTec software and then also to TomTec at compressed frame rates. Both software platforms had been updated with European Association of Cardiovascular Imaging/American Society of Echocardiography Task Force recommendations for left ventricular (LV) global strain. Intravendor and intervendor agreement between layer-specific comparisons were assessed using Bland-Altman analysis (limits of agreement and bias) and intraclass correlation coefficients. Results This study included subjects with normal LV function (n = 38) and cardiomyopathy (n = 15) with an age range of 1 month to 18 years. Intertechnique agreement by default vendor myocardial layer (GE mid-TomTec endocardial layer) was robust for both global longitudinal (GLS) and circumferential strain (GCS; higher for GLS than GCS). Intravendor (inter- and interreader) agreement was slightly higher than intervendor. Only small differences in intraclass correlation coefficients were present between various myocardial layers and acquired versus compressed TomTec data with narrow limits of agreement and small bias except in certain subgroup comparisons. Conclusions Comparison of LV GLS and GCS between two commonly used software platforms after European Association of Cardiovascular Imaging/American Society of Echocardiography Industry Task Force recommendations demonstrated good to excellent agreement in pediatrics, regardless of the layer of analysis or the image format, although some degree of variability remains between vendor platforms. Overall, GLS agreement was more robust than GCS, and this difference is exaggerated in specific subanalyses. These data suggest that comparisons of strain values obtained on these two vendors will be reasonable, but caution should be used when the indication is the detection of small differences between serial echocardiograms.

    更新日期:2019-10-24
  • A Practical Guide to Assess the Reproducibility of Echocardiographic Measurements
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-22
    Karina V. Bunting, Richard P. Steeds, Luke T. Slater, Jennifer K. Rogers, Georgios V. Gkoutos, Dipak Kotecha

    Echocardiography plays an essential role in the diagnosis and assessment of cardiovascular disease. Measurements derived from echocardiography are also used to determine the severity of disease, its progression over time, and to aid in the choice of optimal therapy. It is therefore clinically important that echocardiographic measurements be reproducible, repeatable, and reliable. There are a variety of statistical tests available to assess these parameters, and in this article the authors summarize those available for use by echocardiographers to improve their clinical practice. Correlation coefficients, linear regression, Bland-Altman plots, and the coefficient of variation are explored, along with their limitations. The authors also provide an online tool for the easy calculation of these statistics in the clinical environment (www.birmingham.ac.uk/echo). Quantifying and enhancing the reproducibility of echocardiography has important potential to improve the value of echocardiography as the basis for good clinical decision-making.

    更新日期:2019-10-23
  • Pulmonary Artery Acceleration Time in Young Adulthood and Cardiovascular Outcomes Later in Life: The Coronary Artery Risk Development in Young Adults Study
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-21
    Henrique T. Moreira, Henrique D. Vasconcellos, Bharath Ambale-Venkatesh, Evan L. Brittain, Chike C. Nwabuo, André Schmidt, Donald M. Lloyd-Jones, John J. Carr, Cora E. Lewis, David R. Jacobs, Samuel S. Gidding, João A.C. Lima

    Background Lower pulmonary artery acceleration time (PAcT) is correlated with higher pulmonary artery pressure. The aim of this study was to test the hypothesis that PAcT measured in young adulthood would be associated with future cardiovascular outcomes. Methods In the Coronary Artery Risk Development in Young Adults year 5 examination (1990–1991), PAcT was measured as the time interval from onset to peak flow velocity at the pulmonary valve annulus on Doppler echocardiography. The primary outcome was a composite of fatal or nonfatal cardiovascular disease events: myocardial infarction, non–myocardial infarction acute coronary syndrome, coronary revascularization, congestive heart failure, stroke, transient ischemic attack, carotid artery disease, and peripheral arterial disease. Results PAcT was obtained in 4,171 participants (mean age, 30 ± 4 years, 55% women, 51% white). PAcT groups obtained using linear spline methodology were as follows: group I, PAcT ≥ 196 msec (n = 122); group II, PAcT < 196 and ≥115 msec (n = 3,195); and group III, PAcT < 115 msec (n = 854). During follow-up (median, 24.9 years), the primary outcome occurred in 216 participants (5.2%); 66 of 854 (7.7%) of those with PAcT < 115 msec, 149 of 3,195 (4.7%) of those with intermediate PAcT level, and one of 122 (0.8%) of those with PAcT ≥ 196 msec. In a fully adjusted model, the lowest and intermediate PAcT groups had hazard ratios of 8.3 (95% CI, 1.1–62.1; P = .04) and 6.8 (95% CI, 0.9–50.5; P = .06), respectively, in comparison with the highest PAcT group. Conclusions PAcT is useful for better identifying young adults at higher risk for cardiovascular events, who may benefit from a strict control of modifiable cardiovascular risk factors.

    更新日期:2019-10-21
  • Lack of Increased Cardiovascular Risk due to Functional Tricuspid Regurgitation in Patients with Left-Sided Heart Disease
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-14
    Diab Mutlak, Emad Khoury, Jonathan Lessick, Izhak Kehat, Yoram Agmon, Doron Aronson

    Background Significant tricuspid regurgitation (TR) is associated with higher risk for adverse cardiovascular outcomes. Left-sided heart disease (LHD) is a potentially important confounder of this association because it is strongly linked to both TR and clinical outcome. Methods We studied 5,886 patients who were followed for a period of 10 years after the index echocardiographic examination. The relationship between TR severity and the end point of admission for heart failure or cardiovascular mortality was analyzed using competing risk analysis, Cox model, and propensity score matching. Results Higher TR grade was associated with markers of LHD including left ventricular systolic dysfunction, valvular heart disease ≥ moderate, left atrial enlargement, and pulmonary hypertension (all P < .001). There was a significant interaction between TR and the presence of LHD with regard to the end point of heart failure in the competing risks model (P = .01) and the combined end point of heart failure and cardiovascular mortality (P = .02). In both models, moderate/severe TR was associated with higher risk for heart failure (hazard ratio [HR] = 3.10; 95% CI, 1.41-6.84; P = .005) and the combined end point of heart failure or cardiovascular mortality (HR = 2.75; 95% CI, 1.33-5.63, P = .006) only in patients without LHD. Propensity score matching yielded 350 patient pairs, of which 88% had LHD. The HR for heart failure or cardiovascular mortality at 10 years was 0.78 (95% CI, 0.56-1.08; P = .14) in the moderate/severe TR group as compared with the trivial/mild TR. Conclusions Moderate or severe functional TR portends an increased risk for heart failure and cardiovascular mortality only when isolated, without concomitant LHD.

    更新日期:2019-10-14
  • Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-14
    Beatrice von Jeinsen, Meghan I. Short, Martin G. Larson, Vanessa Xanthakis, David D. McManus, Emelia J. Benjamin, Gary F. Mitchell, Jayashri Aragam, Susan Cheng, Ramachandran S. Vasan

    Background In recent decades, novel echocardiographic measures have constantly emerged. It is still unclear which echocardiographic measures have the most significant prognostic value in the general population. Accordingly, the aim of this study was to compare the prognostic value of a large panel of echocardiographic measures to identify the most promising measures. Methods A total of 1,497 Framingham study participants (mean age, 65 years; 55.4% women) who underwent echocardiographic measurements of left ventricular ejection fraction, left ventricular mass index, global longitudinal strain, global circumferential strain, mitral annular plane systolic excursion, mitral E/e′ ratio, maximum and minimum left atrial (LA) volume index, LA emptying fraction, and left ventricular longitudinal synchrony were evaluated. These measures were related to the incidence of two composite outcomes: cardiovascular disease (CVD) or death and atrial fibrillation (AF) or congestive heart failure (CHF). Results On follow-up (mean, 8.3 years), there were 241 CVD events or deaths and 139 AF or CHF events. In multivariate-adjusted Cox models, higher LA emptying fraction was associated with a lower risk (hazard ratios per SD, 0.80 and 0.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) while higher minimum LA volume index (hazard ratios per SD, 1.32 and 1.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) and maximum LA volume index (hazard ratios per SD, 1.26 and 1.54 for CVD or death and AF or CHF, respectively; P ≤ .002 for both) were associated with a higher risk for both composite outcomes. Conclusions In this community-based sample, LA volumes and function were the best echocardiographic predictors of clinical outcomes. Therefore, these values should be considered for inclusion in standard echocardiographic assessments for the purpose of risk stratification.

    更新日期:2019-10-14
  • The Average Pixel Intensity Method and Outcome of Mitral Regurgitation in Mitral Valve Prolapse
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-13
    Victor Kamoen, Milad El Haddad, Tine De Backer, Marc De Buyzere, Frank Timmermans

    Background Mitral regurgitation (MR) is a frequent consequence of mitral valve prolapse (MVP). However, the echocardiographic grading of MR is challenging, and the recommended grading parameters have several limitations. The authors developed a novel echocardiographic parameter to grade MR, the average pixel intensity (API) method, on the basis of pixel intensity analysis of the continuous-wave Doppler signal. Methods Transthoracic echocardiography was performed prospectively in consecutive patients with MVP (N = 149). MR was quantitatively assessed using the API method, vena contracta width, effective regurgitant orifice area, and regurgitant volume. The primary clinical events were cardiovascular mortality, mitral valve surgery, percutaneous mitral intervention, and heart failure hospitalization. Results The API method was feasible in 90% of all patients with MVP, which was significantly higher than vena contracta width, effective regurgitant orifice area, and regurgitant volume. During a median follow-up period of 17 months, 44 patients (32%) had major adverse cardiac events, and the majority of events occurred in the holosystolic MVP subgroup. The degree of MR severity by the API method was highly significant for the prediction of events. An API cutoff of 111 arbitrary units was defined as “severe” MR due to MVP, with overall superior sensitivity and specificity compared with cutoffs for established MR grading parameters. In patients who did not have major adverse cardiac events during the follow-up period (n = 92), no significant changes in measures of MR severity were found on follow-up echocardiography. Conclusions The API method is predictive of clinical events and outcomes in MR due to MVP. Therefore, the API method may be considered for grading the severity of MR due to MVP in clinical practice.

    更新日期:2019-10-14
  • Practical Impact of New Diastolic Recommendations on Noninvasive Estimation of Left Ventricular Diastolic Function and Filling Pressures
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-13
    Regina Sorrentino, Roberta Esposito, Ciro Santoro, Andrea Vaccaro, Sara Cocozza, Maria Scalamogna, Maria Lembo, Federica Luciano, Alessandro Santoro, Bruno Trimarco, Maurizio Galderisi
    更新日期:2019-10-14
  • Alteration in Left Ventricular Contractile Function Develops in Puppies With Duchenne Muscular Dystrophy
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-11
    Bijan Ghaleh, Inès Barthélemy, Lucien Sambin, Alain Bizé, Luc Hittinger, Stéphane Blot, Jin Bo Su

    Background Dystrophin-deficient cardiomyopathy is becoming the dominant cause of death in patients with Duchenne muscular dystrophy (DMD), but its developmental process remains elusive. This study aimed to assess the development of left ventricular (LV) dysfunction that mimics DMD pathologies in golden retriever muscular dystrophy (GRMD) dogs. Methods Transthoracic echocardiography was sequentially performed in GRMD dogs (n = 23) and age-matched healthy littermates (n = 7) from 2 to 24 months old. Conventional, tissue Doppler imaging, and speckle-tracking echocardiography parameters were analyzed. Results At 2 months of age, GRMD dogs showed a pathologic decrease in the subendocardial-subepicardial gradient of radial systolic myocardial velocity along with altered LV twist and longitudinal strain, all being aggravated with age (analysis of variance, P < .001). Receiver operator characteristic curve analysis showed good ability to discriminate normal from GRMD dogs. LV ejection fraction was significantly decreased in GRMD dogs starting from 9 months and reached a pathologic level (<50%) at 24 months. Conclusions The development of cardiomyopathy in GRMD dogs was characterized by subendocardial dysfunction, altered LV twist, and reduced longitudinal strain at a very young age to overall LV dysfunction in adults with transmural dysfunction, reduced LV ejection fraction and diastolic abnormalities, and even heart failure. This indicates the necessity to evaluate LV transmural myocardial velocity gradient, twist, and longitudinal strain in the early childhood of DMD patients.

    更新日期:2019-10-12
  • Normal Ranges of Left Ventricular Strain by Three-Dimensional Speckle-Tracking Echocardiography in Adults: A Systematic Review and Meta-Analysis
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-11
    Vien T. Truong, Hoang T. Phan, Khanh N.P. Pham, Hoang N.H. Duong, Tam N.M. Ngo, Cassady Palmer, Tuy T.H. Nguyen, Bao H. Truong, Minh A. Vo, Justin T. Tretter, Sherif F. Nagueh, Eugene S. Chung, Wojciech Mazur

    Background Establishing normal values and associated variations of three-dimensional speckle-tracking echocardiography– (3DSTE-) derived left ventricular (LV) strain is necessary for accurate interpretation and comparison of measurements. We aimed to perform a meta-analysis of normal ranges of LV global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) measurements derived by 3DSTE and to identify confounding factors that may contribute to variance in reported measures. Methods The authors searched four databases, PubMed, Scopus, Embase, and Cochrane Library, through January 2019 using the key terms “left ventricular/left ventricle/left ventricles”, “strain/deformation/speckle tracking”, and “three dimensional/three-dimensional/three-dimension/three dimension/3D”. Studies were included if the articles reported LV strain using 3DSTE in healthy normal subjects, either in the control group or comprising the entire study cohort. The weighted mean was estimated by using the random effects model with a 95% CI. Heterogeneity across studies was assessed using the I2 test. Effects of demographic (age), clinical, and vendor variables were assessed in a metaregression. The National Institutes of Health tools were used to assess the quality of included articles. Publication bias was examined by Begg's funnel plot and Egger's regression test. Results The search yielded 895 articles. After abstract and full-text screening we included 33 data sets with 2,346 patients for meta-analysis. The reported normal mean values of GLS among the studies varied from −15.80% to −23.40% (mean, −19.05%; 95% CI, −18.18% to −19.93%; I2 = 99.0%), GCS varied from −15.50% to −39.50% (mean, −22.42%; 95% CI, −20.96% to −23.89%, I2 = 99.7%), GRS varied from 19.81% to 86.61% (mean, 47.48%; 95% CI, 41.50%-53.46%; I2 = 99.8%), and GAS varied from –27.40% to –50.80% (mean, –35.03%; 95% CI, –33.19% to –36.87%; I2 = 99.3%). Software for strain analysis was consistently associated with variations in normal strain values (GLS: P = .016; GCS: P < .001; GRS: P < .001; GAS: P < .001). Conclusions Variations in the normal ranges across studies were significantly associated with the software used for strain analysis, emphasizing that this factor must be considered in the interpretation of strain data.

    更新日期:2019-10-12
  • Combined Femoral and Carotid Plaque Burden Identifies Obstructive Coronary Artery Disease in Women
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-10
    Kayla N. Colledanchise, Laura E. Mantella, Milena Bullen, Marie-France Hétu, Joseph G. Abunassar, Amer M. Johri

    Background It remains difficult to assess cardiovascular risk in symptomatic women. The development of femoral plaque precedes adverse cardiovascular events. However, associations of femoral plaque burden with coronary artery disease (CAD) severity and extent are unknown. The aim of this study was to determine sex-specific plaque quantification markers by vascular ultrasound for identifying significant, obstructive CAD. Methods In this cross-sectional study, 500 participants (34% women) underwent carotid and femoral ultrasound following coronary angiography. Maximal plaque height and total plaque area were quantified. Logistic regression was used to determine associations of plaque burden with significant, obstructive CAD (≥50% stenosis), when adjusted for age and cardiac risk factors. CAD prediction was evaluated using receiver operating characteristic areas under the curve (AUCs). Results Two hundred thirty-one men (70%) and 78 women (46%) had significant CAD. A combined assessment of femoral bifurcation and carotid maximal plaque height was the most accurate identifier of CAD in men (AUC = 0.773, cutoff ≥ 2.7 mm, 87% sensitivity, 53% specificity) but a poorer indicator of CAD in women (AUC = 0.659, P < .01). In contrast, the strongest identification of CAD in women was achieved by a combined analysis of common femoral and carotid total plaque area (AUC = 0.764, cutoff ≥ 42.0 mm2, 86% sensitivity, 53% specificity). At this value, more than half of women with false-positive stress test results were correctly identified as having no significant CAD. Conclusion Combined femoral and carotid plaque burden assessments effectively ruled out significant disease in both sexes. Vascular ultrasound may have particular value for cardiovascular risk stratification in women, in whom traditional screening tools are less effective.

    更新日期:2019-10-10
  • Congenital and Structural Heart Disease Interventions Using Echocardiography-Fluoroscopy Fusion Imaging
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-06
    Pei-Ni Jone, Alexander Haak, Michael Ross, Dominik M. Wiktor, Edward Gill, Robert A. Quaife, John C. Messenger, Ernesto E. Salcedo, John D. Carroll

    With the increasing frequency of catheter-based interventions in congenital heart disease and structural heart disease, the use of fusion imaging has become a major enhancement for understanding complex anatomy and facilitating key steps in interventional procedures. Because transesophageal echocardiography and fluoroscopy are displayed in different visual perspectives, the interventional cardiologist must mentally reregister the images from the two modalities during the procedure. Echocardiography-fluoroscopy fusion (EFF) imaging displays the x-ray and ultrasound overlay images in the same visual perspective. This new technology allows for enhanced team communication, improved visual guidance, and more efficient navigation. The purpose of this review is to describe the EFF imaging technology, current uses of EFF imaging in congenital and structural heart disease, and future directions that will enhance this unique imaging technology to guide interventional procedures.

    更新日期:2019-10-07
  • Incremental Utility of Right Ventricular Dysfunction in Patients With Myeloproliferative Neoplasm–Associated Pulmonary Hypertension
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-03
    Jiwon Kim, Spencer Krichevsky, Lola Xie, Maria Chiara Palumbo, Sara Rodriguez-Diego, Brian Yum, Lillian Brouwer, Richard T. Silver, Andrew I. Schafer, Ellen K. Ritchie, Maria Mia Yabut, Claudia Sosner, Evelyn M. Horn, Richard B. Devereux, Joseph M. Scandura, Jonathan W. Weinsaft

    Background Myeloproliferative neoplasm (MPN) has been associated with pulmonary hypertension (PH) on the basis of small observational studies, but the mechanism and clinical significance of PH in MPN are not well established. The aims of this study were to expand understanding of PH in a well-characterized MPN cohort via study of PH-related symptoms, mortality risk, and cardiac remodeling sequalae of PH using quantitative echocardiographic methods. Methods The population comprised a retrospective cohort of patients with MPN who underwent transthoracic echocardiography: Doppler-derived pulmonary arterial systolic pressure applied established cutoffs for PH (≥35 mm Hg) and advanced PH (≥50 mm Hg); right ventricular (RV) performance was assessed via conventional indices (tricuspid annular plane systolic excursion [TAPSE], S′) and global longitudinal strain. Symptoms and mortality were discerned via standardized review. Results Three hundred one patients were studied; 56% had echocardiography-demonstrated PH (20% advanced) paralleling a high prevalence (67%) among patients with invasively quantified PASP. PH was associated with adverse left ventricular (LV) remodeling indices, including increased myocardial mass and diastolic dysfunction (P ≤ .001 for all): LV mass and filling pressure (P < .01) were associated with PH independent of LV ejection fraction. RV dysfunction by strain and TAPSE and S′ increased in relation to PH (P ≤ .001) and was about threefold greater among patients with advanced PH compared with those without PH. Patients with RV dysfunction were more likely to report dyspnea, as were those with advanced PH (P < .05). During median follow-up of 2.2 years, all-cause mortality was 27%. PH grade (hazard ratio, 1.9; 95% CI, 1.1–3.0; P = .012) and TAPSE- and S′-demonstrated RV dysfunction (hazard ratio, 3.3; 95% CI, 1.3–8.2; P = .01) were independently associated with mortality; substitution of global longitudinal strain for TAPSE and S′ yielded similar associations of RV dysfunction with death (hazard ratio, 3.2; 95% CI, 1.5–6.7; P = .003) independent of PH. Conclusions PH is highly prevalent in patients with MPN and is linked to LV diastolic dysfunction; echocardiography-quantified RV dysfunction augments risk for mortality independent of PH.

    更新日期:2019-10-04
  • Diagnostic Potential of Intracardiac Echocardiography in Patients with Suspected Prosthetic Valve Endocarditis
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-03
    Lauge Østergaard, Niels Vejlstrup, Lars Køber, Emil Loldrup Fosbøl, Lars Søndergaard, Nikolaj Ihlemann

    Background The use of transthoracic and transesophageal echocardiography may be challenging in patients suspected of having prosthetic valve endocarditis (PVE). Intracardiac echocardiography (ICE) provides a new diagnostic tool in the examination of patients with PVE, yet few data on its use have been published. Methods From January 2012 to December 2016, patients with suspected PVE and inconclusive findings on transthoracic and transesophageal echocardiography were further examined with ICE. Medical records were reviewed to assess clinical status, microbiologic etiology, echocardiography, antibiotic treatment, and surgical procedures. The modified Duke criteria were used to assess the diagnostic classification after ICE. Results A total of 38 patients suspected of having PVE were included, of whom 17 patients had undergone transcatheter aortic heart valve implantation, 19 had surgically prosthetic valves, and two had tetralogy of Fallot with transcatheter pulmonary valves. After ICE, 19 patients were classified with definite PVE, and four patients were treated as having PVE because of overall clinical presentation. Of the 15 patients not treated for endocarditis after ICE, one patient had a relapse. Regarding procedural safety, no vascular complications occurred, whereas six of the patients (16%) had groin hematomas, which did not require intervention and had no sequelae. Conclusions Among patients with suspected PVE, ICE changed the diagnosis to definite PVE in half of the patients, with a low frequency of relapse among patients in whom PVE could not be confirmed by ICE. ICE may help guide clinicians in the duration of antibiotic treatment and surgical intervention in the treatment of patients with PVE.

    更新日期:2019-10-04
  • Echocardiographic Risk Assessment to Guide Screening for Atrial Fibrillation
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-03
    Satish Ramkumar, Ayame Ochi, Hiroshi Kawakami, Hong Yang, Elizabeth L. Potter, Nicholas D'Elia, Tomoko Negishi, Kazuaki Negishi, Thomas H. Marwick

    Background Although atrial fibrillation (AF) is a significant population health burden, and an avoidable cause of stroke, AF screening remains controversial. The aim of this study was to investigate whether coincidental echocardiography could provide information about patients at risk for AF. Methods Asymptomatic participants ≥65 years of age with more than one AF risk factor (N = 445) undergoing echocardiography for risk evaluation were followed over a median of 15 months for incident AF. Left atrial volume index (LAVi), left ventricular (LV) global longitudinal strain (GLS; absolute value), left atrial (LA) strain, and LV mass were measured. During the follow-up period, AF was diagnosed clinically by primary care physicians or by using a single-lead portable electrocardiographic monitoring device (five 60-sec recordings performed by participants over 1 week). Results AF was diagnosed in 45 patients (10%; mean age, 70.5 ± 4.2 years; 55% women). AF detection was higher in those with LV hypertrophy, GLS < 16%, LAVi > 34 mL/m2, and LA reservoir strain < 34%. GLS, LAVi, and LA reservoir strain were independently associated with AF (P < .05). Those with AF had reduced GLS, higher LAVi, and higher LV mass (P < .05), but LA strain was similar in both groups (P > .05). GLS and LAVi were the strongest predictors, and cut points of 14.3% for GLS and 39 mL/m2 were associated with increased risk for developing AF. Those with all four risk parameters (LV hypertrophy, GLS < 16%, LA reservoir strain < 34%, and LAVi > 34 mL/m2) had a 60% AF detection rate, compared with 7% without these features (P = .004). Conclusion Echocardiography is widely used in patients at risk for AF, and simple LV and LA measurements may be used to enrich the process of AF screening.

    更新日期:2019-10-03
  • Relationship between Cardiac Remodeling and Exercise Capacity in Elite Athletes: Incremental Value of Left Atrial Morphology and Function Assessed by Three-Dimensional Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-10-01
    Bálint Károly Lakatos, Andrea Ágnes Molnár, Orsolya Kiss, Nóra Sydó, Márton Tokodi, Balázs Solymossi, Alexandra Fábián, Zsófia Dohy, Hajnalka Vágó, Máté Babity, Csaba Bognár, Attila Kovács, Béla Merkely

    Background Data are scarce regarding left atrial (LA) adaptation to regular physical exercise. The aim of this study was to examine left ventricular (LV) and also LA morphologic and functional remodeling in elite athletes using three-dimensional (3D) echocardiography. Methods In this retrospective analysis, the study group consisted of 138 elite athletes (mean age, 20 ± 4 years; 62% men) and 50 sedentary control subjects. Electrocardiographically gated full-volume 3D data sets were obtained for offline analysis using dedicated software for 3D LA and LV measurements. Body surface area–indexed LA maximal volume (LAVmax) and LV end-diastolic volume were determined. LA total emptying fraction, LA passive and LA active emptying fraction, and LV global longitudinal strain were also calculated. Athletes also underwent cardiopulmonary exercise testing to determine peak oxygen uptake. Results Athletes demonstrated higher 3D LAVmax (32 ± 6 vs 26 ± 8 mL/m2) and indexed LV end-diastolic volume (85 ± 12 vs 62 ± 10 mL/m2) compared with control subjects (P < .001 for both). Functional measures of the left ventricle and left atrium, such as the absolute value of 3D LV global longitudinal strain (19 ± 2% vs 22 ± 2%), LA total emptying fraction (58 ± 6% vs 64 ± 6%), and active emptying fraction (24 ± 10% vs 32 ± 10%) were lower in athletes (P < .001 for all). Male athletes had higher indexed LV end-diastolic volume compared with female athletes (89 ± 13 vs 80 ± 8 mL/m2, P < .001), but LAVmax did not differ between genders (32 ± 6 vs 33 ± 5 mL/m2, P = .18). Besides heart rate, gender, and body surface area, 3D LAVmax, LV global longitudinal strain, and LA passive emptying fraction were independent predictors of peak oxygen uptake. Conclusions Regular physical exercise results in marked LA and LV remodeling with considerable gender differences as explored by 3D echocardiography. In contrast with various cardiovascular diseases, more pronounced LA dilation and lower resting functional measures are associated with better exercise performance.

    更新日期:2019-10-02
  • Reproducibility of Combined Acquisition and Measurement of Left Ventricular Longitudinal Peak Segmental Strain in Relation to the Severity of Left Ventricular Dysfunction
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-09-23
    Andrei D. Mărgulescu, Maria-Claudia-Berenice Şuran, Dragoş Vinereanu

    Background Whether left ventricular (LV) longitudinal peak systolic segmental strain (LPSS) has sufficient reproducibility to be used in clinical practice (e.g., in patient follow-up) remains unclear. The aim of this study was to assess the reproducibility of combined acquisition and measurements of LPSS across the spectrum of LV ejection fraction (LVEF). Methods In this prospective study, 72 subjects (mean age, 63 ± 14 years; 65% men) were included in four equal groups: group 1, LVEF ≥ 50%, healthy; group 2, LVEF ≥ 50%, presence of cardiovascular disease and/or risk factors; group 3, LVEF 30%–49%; and group 4, LVEF ≤ 29%. Two observers performed four sets of image acquisitions and measurements (three during the same session, one after a median of 1 day) to account for intraobserver, interobserver, and test-retest reproducibility of combined acquisition and measurements. LPSS was measured in each of the 17 LV segments. Results On average, the intraobserver and test-retest intraclass correlation coefficients and mean absolute differences of repeated acquisition and measurement of LPSS were similar across groups. However, interobserver intraclass correlation coefficients and mean absolute differences decreased in group 4 compared with groups 1 to 3. The intraobserver, test-retest, and interobserver coefficients of variation of all LV segments became worse as LVEF decreased, especially in group 4, in which LPSS was not reproducible in most segments. Reproducibility of LPSS in basal LV segments was worse compared with apical segments. The average measurement uncertainty (defined as the 95% limits of agreement of repeated acquisition and measurements) of LPSS in a test-retest scenario was ±8.9%, ±11.8%, ±10.7%, and ±9.0% in groups 1, 2, 3, and 4, respectively. Conclusions The clinical applicability of LPSS is hindered by suboptimal reproducibility, even if a single observer repeats both acquisition and measurements. Changes in LPSS during patient follow-up should be interpreted with caution.

    更新日期:2019-09-23
  • Quantitative Assessment of Left Ventricular Dysfunction in Fetal Ebstein's Anomaly and Tricuspid Valve Dysplasia
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-09-21
    Luke G. Eckersley, Lisa W. Howley, Mary E. van der Velde, Nee S. Khoo, Kandice Mah, Paul Brooks, Timothy Colen, Lisa K. Hornberger

    Background Fetal Ebstein's anomaly and tricuspid valve dysplasia (EA/TVD) are associated with high perinatal mortality relative to pulmonary atresia with intact ventricular septum (PAIVS), despite both requiring redistribution of the cardiac output (CO) to the left ventricle (LV). LV dysfunction is suspected to contribute to adverse outcomes in EA/TVD. Objective We sought to examine global and segmental LV function in fetal EA/TVD with comparison to normal controls and PAIVS. We hypothesized that LV dysfunction in EA/TVD is associated with abnormal LV remodeling and interventricular mechanics. Methods We retrospectively identified 63 cases of fetal EA/TVD (40 with retrograde ductal flow) and 22 cases of PAIVS encountered from 2004 to 2015 and compared findings to 77 controls of comparable gestational age. We measured the combined CO and global LV function using two-dimensional, Doppler-derived, deformational (six-segmental vector velocity imaging) and dyssynchrony indices (DIs; SD of time to peak), and a novel global DI. Results EA/TVD fetuses demonstrated abnormal LV global systolic function with reduced ejection fraction, fractional area change, and CO, while in PAIVS we observed a normal ejection fraction, fractional area change, and CO. PAIVS, but not EA/TVD, demonstrated increased LV sphericity, suggestive of remodeling, and associated enhanced radial function in the third trimester. In contrast, while EA/TVD fetuses had normal LV segmental longitudinal strain, there was abnormal radial segmental deformation and LV dyssynchrony with increased SD of time to peak and DI. Conclusions Fetal EA/TVD is associated with a lack of spherical remodeling and presence of mechanical dyssynchrony, which likely contribute to reduced CO and ejection fraction. Clinical monitoring of LV function is warranted in fetal EA/TVD. Further studies incorporating quantification of LV function into prediction models for adverse outcomes are required.

    更新日期:2019-09-22
  • Prognostic Value of Global Longitudinal Strain-Based Left Ventricular Contractile Reserve in Candidates for Percutaneous Correction of Functional Mitral Regurgitation: Implications for Patient Selection
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-09-21
    Antonio De Luca, Davide Stolfo, Thomas Caiffa, Renata Korcova, Giulia Barbati, Giancarlo Vitrella, Serena Rakar, Andrea Perkan, Gabriele Secoli, Bruno Pinamonti, Marco Merlo, Gianfranco Sinagra

    Purpose Patients with symptomatic heart failure (HF), reduced left ventricular ejection fraction (LVEF), and high-grade functional mitral regurgitation (MR) may benefit from percutaneous edge-to-edge mitral valve repair (PMVR). However, patient selection still remains a central issue. We sought to investigate the potential role of the global longitudinal strain- (GLS-) based left ventricular contractile reserve (LVCR) at dobutamine stress echocardiography (DSE) in this setting. Methods Thirty-three stable HF patients (MR grade ≥ 3+; median LVEF, 29%; median GLS, –8.3%) who were candidates for PMVR were prospectively enrolled. All patients underwent DSE to assess LVCR (LVEF increase ≥ 5%; GLS increase ≥ 2%; stroke volume [SV] increase ≥ 20% of the measured SV value). Results After DSE, a positive LVCRLVEF was detected in 21 patients (64%), positive LVCRGLS in 12 patients (36%), and positive LVCRSV in 14 patients (42%). LVCRGLS was associated with better symptom relief, MR improvement, and LV reverse remodeling in a short-term follow-up. A significant improvement of GLS during DSE (hazard ratio [HR], 0.549; 95% CI, 0.395-0.765; P < .001), along with history of HF hospitalization (HR, 1.48; 95% CI, 1.119-1.967; P = .006) and beta-blocker therapy (HR, 0.146; 95% CI, 0.046-0.462; P = .001), were independently associated with risk of death/heart transplantation/HF-related hospitalizations. Conclusions LVCR, assessed by speckle-tracking DSE, is associated with better results after PMVR in the setting of advanced HF. Improvement of longitudinal function emerged, beyond the ejection fraction, as an independent predictor of outcomes and could improve the selection of best candidates for the percutaneous correction of functional MR.

    更新日期:2019-09-22
  • Myocardial Strain for Identification of β-Blocker Responders in Heart Failure with Preserved Ejection Fraction
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-09-17
    Jin Joo Park, Hong-Mi Choi, In-Chang Hwang, Jun-Bean Park, Jae-Hyeong Park, Goo-Yeong Cho
    更新日期:2019-09-18
  • Quantitative Three-Dimensional Echocardiographic Correlates of Optimal Mitral Regurgitation Reduction during Transcatheter Mitral Valve Repair
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-08-26
    Didem Oguz, Mackram F. Eleid, Sumandeep Dhesi, Sorin V. Pislaru, Sunil V. Mankad, Joseph F. Malouf, Vuyisile T. Nkomo, Jae K. Oh, David R. Holmes, Guy S. Reeder, Charanjit S. Rihal, Jeremy J. Thaden

    Background Patient selection for transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging because of heterogenous mitral valve pathology and highly variable anatomy. The aim of this study was to investigate whether quantitative three-dimensional (3D) transesophageal echocardiographic modeling parameters are associated with optimal mitral regurgitation (MR) reduction in patients undergoing TMVR. Methods Fifty-nine patients underwent 3D transesophageal echocardiography during TMVR. Volumetric data sets were retrospectively analyzed using mitral valve quantitative 3D modeling software (Mitral Valve Navigator). Optimal MR reduction was defined as less than moderate residual MR. Logistic regression was used to correlate 3D transesophageal echocardiographic quantitative data to procedural success. Results Thirty-five patients had primary MR, 24 had mixed or secondary MR, and all patients had grade ≥ 3/4 MR before the procedure. Optimal MR reduction was achieved in 40 of 59 patients (68%). Univariate correlates of optimal MR reduction in patients with primary MR were lower mitral leaflet tenting volume (P = .049) and lower tenting height (P = .025); tenting height < 3 mm and tenting volume < 0.7 mL were associated with increased likelihood of optimal MR reduction (92% vs 48% [P = .01] and 81% vs 47% [P = .03], respectively). In mixed or secondary MR, annular height ≥ 5.5 mm was associated with increased likelihood of optimal MR reduction (94% vs 38%; P = .03). During follow-up, redo TMVR or surgical mitral valve replacement occurred exclusively in patients with suboptimal anatomy defined by 3D transesophageal echocardiography (10% vs 0%, P = .045). Conclusions Quantitative 3D echocardiographic data are associated with favorable response to TMVR and could help optimize patient selection.

    更新日期:2019-08-26
  • The Impact of Basal Septal Hypertrophy on Outcomes after Transcatheter Aortic Valve Replacement
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-08-26
    Nicholas J. Kiefer, Gregory C. Salber, Gordon M. Burke, James D. Chang, Kimberly A. Guibone, Jeffrey J. Popma, Rebecca T. Hahn, Duane S. Pinto, Jordan B. Strom

    Background The role of basal septal hypertrophy (BSH) on preprocedural transthoracic echocardiography in transcatheter aortic valve replacement (TAVR) is unknown. Methods Medical charts and preprocedural transthoracic echocardiograms of 378 patients who underwent TAVR were examined. The association between BSH and the primary composite outcome of valve pop-out, recapture, embolization, aborted procedure, conversion to open procedure, new conduction disturbance, or need for permanent pacemaker ≤30 days after TAVR was evaluated. Patients with preexisting pacemakers were excluded. Sensitivity analyses were performed varying the definition of BSH. Results Of 296 TAVR patients (78.3%) with interpretable images, 55 (18.6%) had BSH at a median of 40 days (interquartile range, 19–62 days) before TAVR. Age and sex were similar among those with and without BSH. BSH patients received postdilation more frequently (BSH+ vs BSH−: 41.8% vs 29.9%, P = .04). A total of 50 individuals (16.9%) received pacemakers within 30 days, and 128 (43.2%) developed conduction disturbances (with left bundle branch block most common), without differences between groups. BSH was unrelated to the primary outcome on multivariate analysis (adjusted odds ratio BSH+ vs BSH−, 0.94; 95% CI, 0.42−2.11; P = .88). Conclusions In this convenience sample of TAVR recipients at a large academic medical center, patients with BSH were more likely to receive postdilation. BSH was not associated with procedural or conduction outcomes after TAVR in patients without preexisting pacemakers.

    更新日期:2019-08-26
  • Left Atrial Mechanical Dispersion Assessed by Strain Echocardiography as an Independent Predictor of New-Onset Atrial Fibrillation: A Case-Control Study
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-08-26
    Hiroshi Kawakami, Satish Ramkumar, Mark Nolan, Leah Wright, Hong Yang, Kazuaki Negishi, Thomas H. Marwick

    Background Left atrial (LA) enlargement is associated with atrial fibrillation (AF), but new-onset AF often occurs in the absence of LA enlargement. AF may be related to myocardial fibrosis, and even though left ventricular fibrosis is associated with mechanical dispersion, this phenomenon is not well studied in AF. We hypothesized that detection of LA dysfunction and mechanical dispersion using strain echocardiography is useful for predicting new-onset AF. Methods Baseline echocardiography was performed at entry in 576 community-based participants at risk of heart failure or AF. In this case-control study, we compared 35 individuals with new-onset AF (age 70 ± 4 years; 57% men) over 2 years of follow-up with 35 age- and sex-matched individuals who did not develop AF from the same cohort. Using speckle-tracking echocardiography, we measured the LA strain in each of 12 segments in the two- and four-chamber views. LA mechanical dispersion was defined as the SD of time to peak positive strain corrected by the R-R interval (SD-TPS, %). Results There was no significant difference in LA volume index (32.5 ± 9.2 mL/m2 vs 29.5 ± 8.3 mL/m2; P = .16); patients with new-onset AF had significantly worse LA pump strain (16.6% ± 4.3% vs 20.6% ± 4.3%; P < .01) and reservoir strain (31.4% ± 7.7% vs 38.0% ± 7.3%; P < .01) than those without AF. SD-TPS was significantly higher in patients with AF than in those without it (6.3% ± 2.3% vs 3.9% ± 1.6%; P < .01). SD-TPS was independently associated with new-onset AF after adjustment for patient characteristics, LA volume, and strain (hazard ratio = 1.26; 95% CI, 1.10-1.45; P < .01). In the nested Cox models, the model based on the LA volume and strain for predicting new onset AF was significantly improved by adding SD-TPS (P < .01). Conclusions LA dispersion obtained from strain echocardiography seems to provide incremental information about LA volume and function in the prediction of new-onset AF and warrants testing in a larger study.

    更新日期:2019-08-26
  • Assessment of Myocardial Ischemic Memory Using Three-Dimensional Speckle-Tracking Echocardiography: A Novel Integrated Analysis of Early Systolic Lengthening and Postsystolic Shortening
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-08-26
    Ai Kozuma, Toshihiko Asanuma, Kasumi Masuda, Hitomi Adachi, Seina Minami, Satoshi Nakatani

    Background Persistence of subtle abnormal myocardial deformation such as postsystolic shortening (PSS) after transient ischemia can be used to diagnose a history of myocardial ischemia (myocardial ischemic memory). Furthermore, early systolic lengthening (ESL) has recently attracted attention as another marker of myocardial ischemia. However, it is unclear whether the persistence of such abnormal deformation can be detected by three-dimensional (3D) speckle-tracking echocardiography, which has relatively low spatial and temporal resolution compared with two-dimensional echocardiography. The aim of this study was to evaluate the diagnostic accuracy of myocardial ischemic memory and its spatial extent using 3D speckle-tracking echocardiography. Methods The left circumflex coronary artery was occluded for 2 min, followed by reperfusion, in 33 dogs. Their hemodynamic and 3D echocardiographic data were chronologically acquired. Peak systolic strain, early systolic strain index as a parameter of ESL, postsystolic strain index as a parameter of PSS, and myocardial dysfunction index as a combined parameter of ESL and PSS were analyzed in all left ventricular segments. Results At the center of the risk area, early systolic strain index and postsystolic strain index significantly increased until 20 min after reperfusion compared with baseline, although peak systolic strain recovered by 20 min. Myocardial dysfunction index significantly increased for >20 min after reperfusion and allowed better diagnostic accuracy of ischemic memory than the other parameters. In the 147 risk segments, abnormal values of myocardial dysfunction index remained in 49 segments (33%) at 20 min after reperfusion, whereas abnormal peak systolic strain was observed in only 13 segments (9%). Conclusions ESL and PSS persisted after transient ischemia and could be detected by 3D speckle-tracking echocardiography. Integrated analysis of ESL and PSS provided higher diagnostic accuracy of ischemic memory. This method may be useful for detecting transient ischemic insults in patients after the disappearance of anginal attack.

    更新日期:2019-08-26
  • The Diastolic and Systolic Velocity-Time Integral Ratio of the Aortic Isthmus Is a Sensitive Indicator of Aortic Coarctation in Fetuses
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-08-20
    Hongying Wang, Wenjia Lei, Jinrong Liu, Boyang Yang, Huixian Li, Danping Huang

    Background Prenatal diagnosis of coarctation of the aorta (CoA) is challenging and is affected by high false-positive and false-negative rates. The aim of this study was to identify sonographic criteria to improve the identification of fetal CoA. Methods A retrospective review was conducted of subjects with prenatal suspicion for CoA who also had postnatal follow-up. Sixty-nine fetuses were identified with possible CoA, and 47 normal fetuses were selected as control subjects. Retrospective measurements of right ventricular/left ventricular ratio, pulmonary artery/aorta ratio, aortic isthmus (AOI) Z score, diastolic velocity-time integral (VTID), and systolic velocity-time integral (VTIS) at the AOI were recorded. Receiver operating characteristic curve analysis identified the parameter most predictive of postnatal CoA. Results When comparing subjects with (n = 31) and without (n = 38) CoA, significant differences were detected for the AOI Z score, VTID, VTID/VTIS ratio, and VTID/(VTID + VTIS) ratio (P < .001). The areas under the receiver operating characteristic curve were 0.92, 0.92, 0.78, 0.74, 0.71, and 0.68 for the VTID/VTIS ratio, VTID/(VTID + VTIS) ratio, VTID, AOI Z score (sagittal view), AOI Z score (three-vessel tracheal view), and pulmonary artery/aorta ratio, respectively. There was a 25% (95% CI, 14%–35%) improvement in the area under the curve after adding the VTID/VTIS ratio to the basic model (AOI Z score [sagittal view]), and this ratio (after transformation) showed significantly better discrimination and reclassification ability for determining CoA. The pulmonary artery/aorta ratio, VTID, VTID/VTIS ratio, and VTID/(VTID + VTIS) ratio were stable throughout the normal fetal developmental period in this study. Conclusions In cases with suspected prenatal diagnosis of CoA, evaluation of spectral Doppler measurements, such as the VTID/VTIS ratio, may enhance the accuracy of diagnosis with fetal echocardiography.

    更新日期:2019-08-21
  • Relative Prognostic Importance of Left and Right Ventricular Ejection Fraction in Patients With Cardiac Diseases
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-08-07
    Elena Surkova, Denisa Muraru, Davide Genovese, Patrizia Aruta, Chiara Palermo, Luigi P. Badano

    Background The study aimed (1) to assess the prognostic value of three-dimensional echocardiography (3DE) derived right ventricular (RV) ejection fraction (EF) and (2) to evaluate relative prognostic importance of reduced and preserved left ventricular (LV) EF and RVEF to predict all-cause mortality and cardiac death in a large cohort of patients with cardiac diseases. Methods LV and RV volumes and EF were assessed by 3DE in 394 patients with various cardiovascular diseases. Patients were divided into four groups: (1) normal LVEF (≥50%) and normal RVEF (≥45%), n = 183; (2) reduced LVEF (<50%) and normal RVEF (≥45%), n = 75; (3) normal LVEF (≥50%) and reduced RVEF (<45%), n = 61; (4) reduced LVEF (<50%) and reduced RVEF (<45%), n = 75. The patients were followed up for 3.7 ± 1.1 years. Results Reduced 3DE-derived RVEF was associated with all-cause mortality (P < .0001). The four groups had significantly different survival (P < .0001). Both all-cause mortality and cardiac death in patients with reduced RVEF and normal LVEF were significantly higher than in those with reduced LVEF and normal RVEF (P = .0007 and P = .0091, respectively) and did not differ significantly from patients with reduced EF of both ventricles (P = .2198 and P = .0846, respectively). Conclusions Reduced 3DE-derived RVEF was associated with all-cause mortality and cardiac death in patients with various cardiovascular diseases. Impairment of RVEF carried a significantly higher risk of mortality independent of LVEF.

    更新日期:2019-08-07
  • Updated Left Ventricular Diastolic Function Recommendations and Cardiovascular Events in Patients with Heart Failure Hospitalization
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-08-01
    Yuta Torii, Kenya Kusunose, Hirotsugu Yamada, Susumu Nishio, Yukina Hirata, Rie Amano, Masami Yamao, Robert Zheng, Yoshihito Saijo, Nao Yamada, Takayuki Ise, Koji Yamaguchi, Shusuke Yagi, Takeshi Soeki, Tetsuzo Wakatsuki, Masataka Sata

    Background Evaluation of diastolic dysfunction is crucial in determining elevated left atrial pressure. However, a validation of the long-term prognostic value of the newly proposed algorithm updated in 2016 has not been performed. The aim of the present study was to investigate the relative value of the updated 2016 diastolic dysfunction grading system for the incidence of readmission in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Methods Two hundred thirty-two patients hospitalized with HF were retrospectively evaluated. Subjects were divided into two subgroups: those with HFrEF (n = 127) and those with HFpEF (n = 105). Readmission risk scores were calculated using the Yale Center for Outcomes Research and Evaluation HF, LACE index, and HOSPITAL scores. The primary end point was readmission following HF and cardiac death. Results Over a period of 24 months, 86 patients were either readmitted or died. Multivariate Cox analysis was performed on both the HFrEF and HFpEF groups. In the HFrEF group, both the 2009 and 2016 algorithms had superior incremental value for the association of the primary end point to several readmission risk scores. In the HFpEF group, only the 2016 algorithm led to significant improvement in association with the primary end point. The 2016 algorithm had incremental value over several readmission risk scores alone. Conclusions The recommendations of the 2016 algorithm can be useful for readmission and cardiac mortality risk assessment in patients with HFrEF and HFpEF. The use of echocardiography to estimate elevated left atrial pressure appears to identify a higher risk group and may allow a more tailored approach to therapy.

    更新日期:2019-08-02
  • The Prognostic Value of the Diastolic Stress Test in Patients Undergoing Treadmill Stress Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-31
    Benjamin T. Fitzgerald, Jeffrey J. Presneill, Isabel G. Scalia, Casey L. Hawkins, Yael Celermajer, William M. Scalia, Gregory M. Scalia

    Background Exercise stress echocardiography (SE) is well validated for the evaluation of myocardial ischemia. Diastolic stress testing (DST) is recommended in the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging Guidelines for unexplained dyspnea. This study's aim was to prognostically evaluate the DST prospectively in a large stress testing population. Methods Patients underwent SE with mitral E/e' measured before and after maximal treadmill exertion to estimate diastolic function. Patients were divided into four groups: group 1 (n = 201)—ischemic; group 2 (n = 1,563)—negative DST (E/e'pre < 12, E/e'post < 12); group 3 (n = 68)—positive DST (E/e'pre < 12, E/e'post ≥ 12); group 4 (n = 314)—high baseline E/e' (E/e'pre ≥ 12). Results Consecutive patients (n = 2,201, 770 [35%] female; 58 ± 12 years) were followed after SE for 27,964 patient-months. Time to first heart failure event (composite of heart failure admission, worsening New York Heart Association class, worsening ejection fraction, or cardiovascular death) was analyzed and adjusted using Cox proportional hazards regression. Ischemic patients hazard ratio (HR) was 28, 95% CI, 17-44, P < .0005, for subsequent heart failure compared with negative DST patients. Nonischemic, positive DSTs were highly predictive (HR = 4.2; 95% CI, 1.6-11.0; P = .001); while high E/e'pre was not predictive (HR = 1.3; 95% CI, 0.7-2.4; P = .49) of future heart failure events. Conclusions DST differentiates heart failure prognosis in patients with induced diastolic dysfunction. Ischemia predictably portends the worst heart failure outcomes, and nonischemic, positive diastolic stress tests predicted more events compared with negative tests. These prognostic data support and add to the recommendations of the 2016 guidelines.

    更新日期:2019-08-01
  • How Does Regional Hypertrophy Affect Strain Measurements With Different Speckle-Tracking Methods?
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-31
    Monica Dobrovie, Stėphanie Bėzy, Serkan Ünlü, Bidisha Chakraborty, Aniela Petrescu, Jürgen Duchenne, Ahmed Salem Beela, Jens-Uwe Voigt
    更新日期:2019-08-01
  • Age- and Gender-Specific Prognostic Cutoff Values of Coronary Flow Velocity Reserve in Vasodilator Stress Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-31
    Lauro Cortigiani, Quirino Ciampi, Alberto Lombardo, Fausto Rigo, Francesco Bovenzi, Eugenio Picano

    Purpose Coronary flow velocity reserve (CFVR) of the left anterior descending artery is useful for risk stratification during stress echocardiography (SE) as an add-on to regional wall motion abnormalities (RWMA). We sought to provide sex- and age-specific prognostic cutoff values for CFVR. Methods A total of 5,577 patients (2,284 women; 110 age ≥ 85 years) who underwent dipyridamole SE with evaluation of RWMA and CFVR were enrolled in a multicenter prospective SE registry. Death and myocardial infarction were the clinical end points. Results During 20 months' median follow-up, 649 events (236 deaths, 413 infarctions) occurred: 288 in women and 38 in patients ≥85 years. At receiver operating characteristics analysis, the best prognostic cutoff value for CFVR was similar for men (2.03) and women (2.02) and consistent across all age strata (<45 years: 2.03; 45-54 years: 2.04; 45-64 years: 2.03; 65-74 and 75-84 years: 2.0) except for patients >85 years, who showed 1.90 as the optimal value. Independent predictors of mortality or myocardial infarction were RWMA (hazard ratio [HR] = 5.42), reduced CFVR (HR = 3.26), resting ejection fraction (HR = 0.98), smoking habit (HR = 1.41), age (HR = 1.02), and prior percutaneous coronary intervention (HR = 1.20) in patients age <85 years; and RWMA (HR = 5.42), smoking habit (HR = 3.24), and resting ejection fraction (HR = 0.97) in those age ≥85 years. CFVR added a prognostic contribution over clinical parameters, resting ejection fraction, and stress-induced RWMA in all age and sex groups except men >85 years. Conclusions A sex-independent value of CFVR ≤2.0 provides the optimal prognostication across all age groups, except for those ≥85 years in whom a cutoff ≤1.90 is needed. Risk stratification is more effective for all age groups when CFVR is combined with RWMA.

    更新日期:2019-08-01
  • Challenges With Left Ventricular Functional Parameters: The Pediatric Heart Network Normal Echocardiogram Database
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-24
    Peter C. Frommelt, L. LuAnn Minich, Felicia L. Trachtenberg, Karen Altmann, Joseph Camarda, Meryl S. Cohen, Steven D. Colan, Andreea Dragulescu, Michele A. Frommelt, Tiffanie R. Johnson, John P. Kovalchin, Lina Lin, Joseph Mahgerefteh, Arni Nutting, David A. Parra, Gail D. Pearson, Ricardo Pignatelli, Ritu Sachdeva, Holly Taylor

    Background The reliability of left ventricular (LV) systolic functional indices calculated from blinded echocardiographic measurements of LV size has not been tested in a large cohort of healthy children. The objective of this study was to estimate interobserver variability in standard measurements of LV size and systolic function in children with normal cardiac anatomy and qualitatively normal function. Methods The Pediatric Heart Network Normal Echocardiogram Database collected normal echocardiograms from healthy children ≤18 years old distributed equally by age, gender, and race. A core lab used two-dimensional echocardiograms to measure LV dimensions from which a separate data coordinating center calculated LV volumes and systolic functional indices. To evaluate interobserver variability, two independent expert pediatric echocardiographic observers remeasured LV dimensions on a subset of studies, while blinded to calculated volumes and functional indices. Results Of 3,215 subjects with measurable images, 552 (17%) had a calculated LV shortening fraction (SF) < 25% and/or LV ejection fraction (EF) < 50%; the subjects were significantly younger and smaller than those with normal values. When the core lab and independent observer measurements were compared, individual LV size parameter intraclass correlation coefficients were high (0.81-0.99), indicating high reproducibility. The intraclass correlation coefficients were lower for SF (0.24) and EF (0.56). Comparing reviewers, 40/56 (71%) of those with an abnormal SF and 36/104 (35%) of those with a normal SF based on core lab measurements were calculated as abnormal from at least one independent observer. In contrast, an abnormal EF was less commonly calculated from the independent observers’ repeat measures; only 9/47 (19%) of those with an abnormal EF and 8/113 (7%) of those with a normal EF based on core lab measurements were calculated as abnormal by at least one independent observer. Conclusions Although blinded measurements of LV size show good reproducibility in healthy children, subsequently calculated LV functional indices reveal significant variability despite qualitatively normal systolic function. This suggests that, in clinical practice, abnormal SF/EF values may result in repeat measures of LV size to match the subjective assessment of function. Abnormal LV functional indices were more prevalent in younger, smaller children.

    更新日期:2019-07-25
  • Impact of Right Ventricular Geometry and Left Ventricular Hypertrophy on Right Ventricular Mechanics and Clinical Outcomes in Hypoplastic Left Heart Syndrome
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-24
    Assami Rösner, Tara Bharucha, Adam James, Luc Mertens, Mark K. Friedberg

    Background Right ventricular (RV) function is a major determinant of survival in hypoplastic left heart syndrome (HLHS). However, the relation of RV geometry to myocardial mechanics and their relation to transplant-free survival are incompletely characterized. Methods We retrospectively studied 48 HLHS patients from the Hospital for Sick Children, Toronto, (median age, 2.2; interquartile range, 3.62 years) at different surgical stages. Patients were grouped by the presence (n = 23) or absence (n = 25) of RV “apical bulging” defined as a sigmoid-shaped septum with the RV leftward apical segment contiguous with the left ventricular (LV) lateral wall. Regional and global RV strain were measured using speckle-tracking echocardiography, and regional strains were analyzed for patterns and peak values. These were compared between HLHS anatomical subtypes and between patients with versus without apical bulging. We further investigated the association between RV geometry and dysfunction with the outcomes of heart failure, death, or transplant. Results RV global (–7.3% ± 2.8% vs –11.2% ± 4.4%; P = .001), basal septal (–3.8% ± 3.2% vs –11.4% ± 5.8%; P = .0001) and apicolateral (–5.1% ± 3.5% vs –8.0% ± 5.8%, P = .001) longitudinal strain were lower in patients with versus without apical bulging, respectively. Apical bulging was equally prevalent in all HLHS anatomical variants. Twenty of 22 (91%) patients with apical bulging displayed hypertrophy of the LV apical and lateral segments. Death or transplantation were approximately equal in both groups but related to reduced RV global strain in patients with (seven of seven) and not in those without apical bulging (two of eight; P = .022). Conclusions These results suggest that the finding of apical bulging is related to the presence of a hypertrophied hypoplastic LV, with a negative impact on regional and global RV function. Therefore, analysis of RV and LV geometry and mechanics may aid in the assessment and prognostication of this high-risk population.

    更新日期:2019-07-25
  • Intervendor Discordance of Fetal and Neonatal Myocardial Tissue Doppler and Speckle-Tracking Measurements
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-24
    Olga Patey, Julene S. Carvalho, Basky Thilaganathan

    Background Fetal and neonatal studies report a wide range of cardiac parameters derived by pulsed-wave Doppler tissue imaging (DTI) and two-dimensional speckle-tracking echocardiographic (STE) imaging. The use of different ultrasound systems and their vendor-specific software compromises the ability to compare echocardiographic findings among various studies. The aim of this study was to evaluate intervendor reproducibility as well as intra- and interobserver repeatability of DTI and STE measurements in normal-term fetuses and neonates. Methods A prospective study was conducted of term fetuses (n = 196) from uncomplicated pregnancies assessed days before the onset of labor and a few hours after birth. Fetal and neonatal DTI and STE parameters were obtained and analyzed using vendor-specific software on three ultrasound systems: Toshiba Aplio MX versus GE Vivid E9 and GE Vivid E9 versus Philips EPIQ. A reproducibility study in fetuses and neonates (n = 118) was performed by systematic scanning with head-to-head comparison. Results DTI reproducibility showed moderate to good correlation, with good agreement for fetuses and neonates on Toshiba versus GE (intraclass correlation coefficient [ICC] = 0.4–0.8). Correlation of DTI measurements on GE versus Philips was poor to moderate for fetuses (ICC = 0.1–0.6) and moderate to good for neonates (ICC = 0.5–0.8), with wider limits of agreement. Fetal and neonatal STE parameters revealed very poor correlation (ICC = 0.1–0.3) and agreement among ultrasound vendors. Intra- and interobserver repeatability demonstrated good to excellent correlation of all fetal and neonatal DTI and STE measurements, with good agreement irrespective of the ultrasound platform used. Conclusions These findings demonstrate reliable assessment of fetal and neonatal DTI and STE measurements when performed on the same ultrasound platform, whereas ultrasound machines and software from different vendors give significantly divergent estimates of DTI and STE parameters in fetuses and neonates. These intervendor discrepancies have significant clinical and research implications and should be considered when interpreting and comparing study findings, establishing reference standards, or performing systematic reviews.

    更新日期:2019-07-25
  • Advanced Protocol for Three-Dimensional Transesophageal Echocardiography Guidance Implementing Real-Time Multiplanar Reconstruction for Transcatheter Mitral Valve Repair by Direct Annuloplasty
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-15
    Martin Geyer, Efthymios Sotiriou, Alexander R. Tamm, Tobias F. Ruf, Felix Kreidel, Yang Yang, Tilman Emrich, Andres Beiras-Fernandez, Tommaso Gori, Thomas Münzel, Eberhard Schulz, Ralph Stephan von Bardeleben

    Transcatheter direct annuloplasty has been introduced as a novel interventional treatment option for severe mitral valve regurgitation. Until now, only one direct annuloplasty device (Edwards Cardioband) has been commercially available, being implanted in more than 250 patients worldwide. Yet this procedure poses greater challenges regarding optimal fluoroscopic and echocardiographic guidance compared with edge-to-edge repair: correct localization and orientation of the anchors upon penetration into the fibrous mitral annulus tissue and the basal left ventricular myocardium are preconditions for an optimal result and essential to avoid damage of the neighboring structures (atrioventricular node, circumflex artery, coronary sinus). Real-time single-beat multiplanar reconstruction has become available as an additional imaging tool for three-dimensional transesophageal echocardiography in most recent echo machines. In this review, we introduce a three-dimensional transesophageal echocardiography–based imaging protocol implementing real-time multiplanar reconstruction for transcatheter direct annuloplasty procedures, which optimizes and also simplifies echocardiographic guidance during the implantation. The advanced echocardiographic protocol might also help to expedite implantation times and potentially increase the safety of the procedure. In this “how-to” article, we describe in detail this novel approach for optimized guidance and compare its advantages and challenges to “conventional” echocardiographic imaging for transcatheter mitral valve repair.

    更新日期:2019-07-16
  • Changes in Left Ventricular Global Longitudinal Strain after Transcatheter Aortic Valve Implantation according to Calcification Burden of the Thoracic Aorta
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-13
    Tea Gegenava, E. Mara Vollema, Alexander van Rosendael, Rachid Abou, Laurien Goedemans, Frank van der Kley, Arend de Weger, Nina Ajmone Marsan, Jeroen J. Bax, Victoria Delgado

    Background After transcatheter aortic valve replacement (TAVR), changes in left ventricular (LV) function are partly influenced by the vascular afterload. The burden of thoracic aorta calcification is a component of vascular afterload. Objective To assess changes in LV systolic function measured with global longitudinal strain (GLS) in relation to the burden of thoracic aorta calcification in patients with severe aortic stenosis treated with TAVR. Methods Calcification of the thoracic aorta was estimated on noncontrast computed tomography in 210 patients (50% male, 80 ± 7 years) undergoing TAVR. Conventional and speckle-tracking echocardiography were performed at baseline (prior to TAVR) and 3-6 months and 12 months after TAVR. Patients were divided according to tertiles of calcification burden of the thoracic aorta. Results At baseline, patients within the first tertile of thoracic aorta calcification (0-1,395 Hounsfield Units, HU) had better LV systolic function (LV ejection fraction [LVEF], 47% ± 9%; and LV GLS, –15% ± 5%) as compared with the second tertile (1,396-4,634 HU; LVEF, 46% ± 10%; and LV GLS, –14% ± 4%), and the third tertile (>4,634 HU; LVEF, 44% ± 10%; and LV GLS, –12% ± 4%). During follow-up, patients within tertile 1 of calcification of thoracic aorta achieved significantly better LV systolic function and larger regression of LV mass at 12 months of follow-up than patients within the other tertiles. This pattern was more pronounced in patients with reduced LVEF at baseline. Conclusions After TAVR, LVEF and GLS improves and LV mass index is reduced significantly at 3-6 and 12 months of follow-up. Patients within the lowest burden of thoracic aorta calcification achieved the best values of LVEF and LV GLS at 1-year follow-up.

    更新日期:2019-07-14
  • Changes in Left Ventricular Mass and Geometry in the Older Adults: Role of Body Mass and Central Obesity
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-13
    Tetz C. Lee, Zhezhen Jin, Shunichi Homma, Koki Nakanishi, Mitchell S.V. Elkind, Tatjana Rundek, Aylin Tugcu, Kenji Matsumoto, Ralph L. Sacco, Marco R. Di Tullio

    Background Left ventricular (LV) hypertrophy is an independent risk factor for cardiovascular outcomes. There are limited data about modifiable factors associated with progression of LV hypertrophy in older adults. Our objective is to describe the changes in LV mass and geometry over time in a predominantly older multiethnic cohort and to identify possible predictors of changes over time. Methods We analyzed data from participants in the Northern Manhattan Study who underwent serial echocardiographic studies, comparing the baseline and the most recent echocardiograms. We recorded changes in LV mass and geometry and correlated them with baseline characteristics using linear regression models. Results There were 826 participants (mean age, 64.2 ± 8.0 years) included in the analysis (time between measurements, 8.5 ± 2.7 years). Overall, LV mass index increased from 45.0 ± 12.7 to 50.3 ± 14.6 g/m2.7 (P < .001). There were 548 participants (66.3%) with LV mass increase; 258 individuals (31.2%) showed worsening LV geometry. Multivariable analysis showed that change in LV mass index was independently associated with baseline LV mass index (β estimate, −17.000 [standard error, 1.508]; P < .001), hypertension (2.094 [0.816], P = .011), body mass index (0.503 [0.088], P < .001), and waist-to-hip ratio (1.031 [0.385], P = .008). Both waist-to-hip ratio and waist-to-height ratio remained significantly associated with LV mass increase even after adjusting for body mass index (P = .008 and P = .036, respectively). Conclusions Regardless of race/ethnicity, LV mass progressed over time in older adults. We also observed that worsening geometry was frequent. Assessment of central obesity in the older population is important because indicators of central obesity add prognostic value over body mass index for the risk of LV mass increase.

    更新日期:2019-07-13
  • ST-Segment Elevation Myocardial Infarction in Patients With Chronic Obstructive Pulmonary Disease: Prognostic Implications of Right Ventricular Systolic Dysfunction as Assessed with Two-Dimensional Speckle-Tracking Echocardiography
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-13
    Laurien Goedemans, Georgette E. Hoogslag, Rachid Abou, Martin J. Schalij, Nina Ajmone Marsan, Jeroen J. Bax, Victoria Delgado

    Background Right ventricular (RV) systolic function in patients admitted with ST-segment elevation myocardial infarction (STEMI) with chronic obstructive pulmonary disease (COPD) and its impact on prognosis have not been characterized. The present study aims to compare the prevalence of RV systolic dysfunction in COPD versus non-COPD patients with STEMI and evaluate the prognostic implications. Methods One hundred seventeen STEMI patients with COPD with transthoracic echocardiography performed within 48 hours of admission were retrospectively selected. Matched on age, gender, and infarct size (determined by cardiac biomarkers and left ventricular ejection fraction [LVEF]), 207 non-COPD patients were selected. RV dysfunction was defined based on tricuspid annular plane systolic excursion <17 mm (TAPSE), tricuspid annular systolic velocity <6 cm/s (S′), RV fractional area change <35% (FAC), and RV longitudinal free wall strain (FWSL) measured with speckle-tracking echocardiography >–20%. Patients were followed for the occurrence of all-cause mortality. Results RV assessment was feasible in 112 COPD and 199 non-COPD patients (mean age, 69 ± 10; 74% male; mean, LVEF 47% ± 8%). Patients with COPD had significantly lower RV FAC (38% ± 11% vs 40% ± 9%; P = .04), equal TAPSE and S′ (17.9 ± 3.7 vs 18.1 ± 3.8 mm, P = .72; and 8.4 ± 2.2 vs 8.5 ± 2.2 cm/sec, P = .605, respectively) and more impaired RV FWSL (–21.1% ± 6.6% vs –23.4% ± 6.5%, P = .005), compared with patients without COPD. RV dysfunction was more prevalent in patients with COPD, particularly when assessed with RV FWSL (46% vs 32%; P = .021). During a median follow-up of 30 (interquartile range 1.5-44) months, 49 patients died (16%). Multivariate models stratified for COPD status showed that RV FWS >–20% was independently associated with 5-year all-cause mortality (hazard ratio, 2.05; 95% CI, 1.12-3.76; P = .020), after adjusting for age, diabetes, peak troponin level, and LVEF. Interestingly, RV FAC < 35%, S′< 6 cm/sec, and TAPSE < 17 mm were not independently associated with survival. Conclusion In a STEMI population with relatively preserved LVEF, COPD patients had significantly worse RV FWSL compared with patients without COPD. Moreover, RV FWSL > –20% was independently associated with worse survival. In contrast, conventional parameters were not associated with survival.

    更新日期:2019-07-13
  • The Relationship of Capillary Blood Flow Assessments with Real Time Myocardial Perfusion Echocardiography to Invasively Derived Microvascular and Epicardial Assessments
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-03
    David Barton, Feng Xie, Edward O'Leary, Ioannis Chatzizisis, Gregory Pavlides, Thomas R. Porter

    Background The basis for abnormal microvascular flow responses to demand stress in coronary artery disease (CAD) is affected by resistance changes at both the epicardial stenosis level and within the downstream capillary network. We hypothesized that abnormal microvascular perfusion (MVP) responses during demand stress in patients with intermediate coronary stenoses occur when fractional flow reserve (FFR) across the epicardial stenosis is normal, because of increased microvascular resistance. Methods In 49 coronary arteries of 41 patients with intermediate stenoses (40%-80%) who were referred for both coronary angiography and demand stress MVP assessment, invasive coronary hemodynamics were obtained across the stenosis to measure FFR, coronary flow reserve (CFR), and hyperemic microvascular resistance (HMR) during adenosine infusion. MVP in each coronary artery territory (CAT) during demand stress was evaluated by an independent expert reviewer blinded to clinical and angiographic data. Results Thirty-four of the 49 CATs with intermediate stenoses exhibited abnormal MVP. Although the sensitivity of MVP was high for detecting abnormal FFR (100%), FFR < 0.8 was observed in only 15 of the 34 vessels that exhibited abnormal MVP (positive predictive value 44%). However, HMR was abnormal in 32 of 34 vessels (94%) with abnormal MVP (positive predictive value, 94%). Conclusions Although abnormal MVP has high sensitivity for detecting abnormal FFR, MVP is frequently abnormal when FFR is normal. In a large percentage of these patients, invasive assessments of microvascular resistance are abnormal.

    更新日期:2019-07-04
  • Global Left Ventricular Myocardial Work Efficiency in Healthy Individuals and Patients with Cardiovascular Disease
    J. Am. Soc. Echocardiog. (IF 6.111) Pub Date : 2019-07-03
    Mohammed El Mahdiui, Pieter van der Bijl, Rachid Abou, Nina Ajmone Marsan, Victoria Delgado, Jeroen J. Bax

    Background Global left ventricular (LV) myocardial work efficiency, the ratio of constructive to wasted work in all LV segments, reflects the efficiency by which mechanical energy is expended during the cardiac cycle. Global LV myocardial work efficiency can be derived from LV pressure-strain loop analysis incorporating both noninvasively estimated blood pressure recordings and echocardiographic strain data. The aim of this study was to characterize global LV myocardial work efficiency in healthy individuals and patients with cardiovascular (CV) risk factors or overt cardiac disease. Methods We retrospectively included healthy individuals without structural heart disease or CV risk factors, who were selected from an ongoing database of normal individuals, and matched for age and sex with (1) individuals without structural heart disease but with CV risk factors, (2) postinfarct patients without heart failure, and (3) heart failure patients with reduced ejection fraction (HFrEF). Global LV myocardial work efficiency was estimated with a proprietary algorithm from speckle-tracking strain analyses, as well as noninvasive blood pressure measurements. Results In total, 120 individuals (44% male, 53 ± 13 years) were included (n = 30 per group). In healthy individuals without structural heart disease or CV risk factors, global LV myocardial work efficiency was 96.0% (interquartile range, 95.0%-96.3%). Myocardial efficiency of the LV did not differ significantly between individuals without structural heart disease and those with CV risk factors (96.0% vs 96.0%; P = .589). Global LV myocardial work efficiency, however, was significantly decreased in postinfarct patients (96.0% vs 93.0%, P < .001) and in those with HFrEF (96.0% vs 69.0%; P < .001). Conclusions While global LV myocardial work efficiency was similar in normal individuals and in those with CV risk factors, it was decreased in postinfarct and HFrEF patients. The global LV myocardial work efficiency values presented here show distinct patterns in different cardiac pathologies.

    更新日期:2019-07-04
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