Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography : An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

http://www.jse.gr.jp/2016_LVDiastolicFunction.pdf

Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The American Society for Testing and Materials (ASTM) is an independent organization devoted to the development of standards.

American Society for Testing and Materials

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Echocardiographic assessment of left ventricular (LV) diastolic function is an integral part of the routine evaluation of patients presenting with symptoms of dyspnea or heart failure. The 2009 American Society of Echocardiography (ASE) and European Association of Echocardiography (now European Association of Cardiovascular Imaging [EACVI]) guidelines for diastolic function assessment were comprehensive, including several two-dimensional (2D) and Doppler parameters to grade diastolic dysfunction and to estimate LV filling pressures.1 Notwithstanding, the inclusion of many parameters in the guidelines was perceived to render diastolic function assessment too complex, because several readers have interpreted the guidelines as mandating all the listed parameters in the document to fall within specified values before assigning a specific grade. The primary goal of this update is to simplify the approach and thus increase the utility of the guidelines in daily clinical practice.

LV diastolic dysfunction is usually the result of impaired LV relaxation with or without …

Purpose
The LUX-Lung 3 study investigated the efficacy of chemotherapy compared with afatinib, a selective, orally bioavailable ErbB family blocker that irreversibly blocks signaling from epidermal growth factor receptor (EGFR/ErbB1), human epidermal growth factor receptor 2 (HER2/ErbB2), and ErbB4 and has wide-spectrum preclinical activity against EGFR mutations. A phase II study of afatinib in EGFR mutation-positive lung adenocarcinoma demonstrated high response rates and progression-free survival (PFS).

Patients and Methods
In this phase III study, eligible patients with stage IIIB/IV lung adenocarcinoma were screened for EGFR mutations. Mutation-positive patients were stratified by mutation type (exon 19 deletion, L858R, or other) and race (Asian or non-Asian) before two-to-one random assignment to 40 mg afatinib per day or up to six cycles of cisplatin plus pemetrexed chemotherapy at standard doses every 21 days. The primary end point was PFS by independent review. Secondary end points included tumor response, overall survival, adverse events, and patient-reported outcomes (PROs).

Results
A total of 1,269 patients were screened, and 345 were randomly assigned to treatment. Median PFS was 11.1 months for afatinib and 6.9 months for chemotherapy (hazard ratio [HR], 0.58; 95% CI, 0.43 to 0.78; P = .001). Median PFS among those with exon 19 deletions and L858R EGFR mutations (n = 308) was 13.6 months for afatinib and 6.9 months for chemotherapy (HR, 0.47; 95% CI, 0.34 to 0.65; P = .001). The most common treatmentrelated adverse events were diarrhea, rash/acne, and stomatitis for afatinib and nausea, fatigue, and decreased appetite for chemotherapy. PROs favored afatinib, with better control of cough, dyspnea, and pain.

Conclusion
Afatinib is associated with prolongation of PFS when compared with standard doublet chemotherapy in patients with advanced lung adenocarcinoma and EGFR mutations.

Phase III study of afatinib or cisplatin plus pemetrexed in patients with metastatic lung adenocarcinoma with EGFR mutations

To evaluate whether the extracellular volume fraction (ECV) measured using cardiac magnetic resonance (CMR) imaging can detect myocardial tissue changes in dilated cardiomyopathy (DCM) without late gadolinium enhancement (LGE). Forty-one DCM patients and 10 healthy volunteers underwent pre- and post-T1 mapping using a modified Look-Locker Inversion recovery sequence, LGE, and cine MRI on a 3-T CMR system. LGE-MR findings were used to divide DCM patients into two groups: Group A had no apparent LGE, and Group B had LGE apparent in at least one segment. The ECV of the left ventricle (LV) myocardium (16 segments) was calculated in the short-axis view as follows: ECV = [(ΔR1 of myocardium/ΔR1 of LV blood pool)] × (1 − hematocrit), where R1 = 1/T1, ΔR1 = post-contrast R1 − pre-contrast R1. The LV ejection fraction (LVEF) was obtained from cine MRI images. The mean myocardial ECV in LGE (−) segments in Group A + B was compared to that of controls. The mean myocardial ECV in Group A was compared to that of LGE (−) segments in Group B. The correlation between LV systolic function and the mean myocardial ECV of the whole myocardium was evaluated in all groups. Among the 41 DCM patients, 22 were in Group A, and 19 were in Group B. The mean ECV of DCM patents (n = 41, 568 segments, 30.7 % ± 5.9) was significantly higher (P < 0.001) than that of the control group (n = 10, 157 segments, 25.6 % ± 3.2). The ECV was inversely related to LVEF in Group A (r = −0.551, P = 0.008), Group B (r = −0.525, P = 0.021), and Group A + B (r = −0.550, P < 0.001). The ECV measured by MRI could be a useful parameter in evaluating diffuse myocardial changes in DCM patients.

/pdf/extracellular-volume-fraction-in-dilated-cardiomyopathy-4nkim5d22z.pdf

Extracellular volume fraction in dilated cardiomyopathy patients without obvious late gadolinium enhancement: comparison with healthy control subjects

Various factors, such as the volumetric fraction of constituents, mineralogy, and pore fluids, affect heat flow in granular materials. Although the stress applied on granular materials controls the formation of major pathways for heat flow, few studies have focused on a detailed investigation of its significance with regard to the thermal conductivity and anisotropy of the materials. This paper presents a numerical investigation of the stress-induced evolution of anisotropic thermal conductivity of dry granular materials with supplementary experimental results. Granular materials under a variety of stress conditions in element testing are analyzed by the three-dimensional discrete element method, and quantitative variations in their anisotropic effective thermal conductivity are calculated via the network model and conductivity tensor measurements. Results show that the directional development of contact area and fabric under anisotropic stress conditions leads to the evolution of anisotropy in thermal conductivity. The anisotropy induced in thermal conductivity by shear stress is higher than that induced by compressive stress because shear stress causes more significant changes in microstructural configurations and boundary conditions. The shear-stress-induced evolution of anisotropy between principal thermal conductivities depends on dilatancy as well as shearing mode, and the shear-driven discontinuity localizes the conductivity. Factors involved in the stress-induced evolution and their implications on the thermal conductivity characterization are discussed.

Stress-induced evolution of anisotropic thermal conductivity of dry granular materials

MDCT of pulmonary embolism after percutaneous vertebroplasty.

Aims

Despite the prognostic importance of ventricular filling and ventricular–arterial interaction in patients with advanced systolic heart failure, the structural determinants of these parameters have not been fully studied. We aimed to investigate whether patterns of late gadolinium enhancement (LGE) on cardiac magnetic resonance affect ventricular elastic properties or performance in patients with non-ischaemic dilated cardiomyopathy (DCM).



Methods and results

Patients (n = 49) with markedly reduced systolic function (left ventricular (LV) ejection fraction <35%) due to longstanding non-ischaemic DCM underwent contrast-enhanced cardiac magnetic resonance after comprehensive echo-Doppler evaluations. The single beat-derived end-diastolic elastance, end-systolic elastance, arterial elastance, and dyssynchrony indices were measured by echo. On the basis of LGE patterns, patients could be divided into three groups: non-LGE (n = 18), non-midwall LGE (n = 13), and midwall LGE (n = 18). The midwall LGE group had lower LV systolic longitudinal velocity (4.6 ± 1.7 for non-LGE vs. 4.3 ± 1.2 for non-midwall LGE vs. 3.5 ± 1.0 cm/s for midwall LGE, P = 0.025), higher end-diastolic elastance index (0.41 ± 0.21 vs. 0.46 ± 0.31 vs. 0.85 ± 0.51 respectively, P = 0.008), and a more impaired ventriculoarterial coupling index (3.14 ± 1.53 vs. 2.88 ± 1.94 vs. 5.52 ± 3.18, P = 0.006) than other subgroups.



Conclusion

Patients with midwall LGE had a higher ventricular stiffness index and more impaired ventriculoarterial coupling when compared with other non-ischaemic DCM patients.

https://onlinelibrary.wiley.com/doi/pdf/10.1093/eurjhf/hfp050

Patterns of late gadolinium enhancement are associated with ventricular stiffness in patients with advanced non-ischaemic dilated cardiomyopathy.

Purpose To investigate the diagnostic utility of dual-energy computed tomography (CT)-based monochromatic imaging for myocardial delayed enhancement (MDE) assessment in patients with cardiomyopathy. Materials and Methods The institutional review board approved this prospective study, and informed consent was obtained from all participants who were enrolled in the study. Forty patients (27 men and 13 women; mean age, 56 years ± 15 [standard deviation]; age range, 22-81 years) with cardiomyopathy underwent cardiac magnetic resonance (MR) imaging and dual-energy CT. Conventional (120-kV) and monochromatic (60-, 70-, and 80-keV) images were reconstructed from the dual-energy CT acquisition. Subjective quality score, contrast-to-noise ratio (CNR), and beam-hardening artifacts were compared pairwise with the Friedman test at post hoc analysis. With cardiac MR imaging as the reference standard, diagnostic performance of dual-energy CT in MDE detection and its predictive ability for pattern classification were compared pairwise by using logistic regression analysis with the generalized estimating equation in a per-segment analysis. The Bland-Altman method was used to find agreement between cardiac MR imaging and CT in MDE quantification. Results Among the monochromatic images, 70-keV CT images resulted in higher subjective quality (mean score, 3.38 ± 0.54 vs 3.15 ± 0.43; P = .0067), higher CNR (mean, 4.26 ± 1.38 vs 3.93 ± 1.33; P = .0047), and a lower value for beam-hardening artifacts (mean, 3.47 ± 1.56 vs 4.15 ± 1.67; P < .0001) when compared with conventional CT. When compared with conventional CT, 70-keV CT showed improved diagnostic performance for MDE detection (sensitivity, 94.6% vs 90.4% [P = .0032]; specificity, 96.0% vs 94.0% [P = .0031]; and accuracy, 95.6% vs 92.7% [P < .0001]) and improved predictive ability for pattern classification (subendocardial, 91.5% vs 84.3% [P = .0111]; epicardial, 94.3% vs 73.5% [P = .0001]; transmural, 93.0% vs 77.7% [P = .0018]; mesocardial, 85.4% vs 69.2% [P = .0047]; and patchy. 84.4% vs 78.4% [P = .1514]). For MDE quantification, 70-keV CT showed a small bias 0.1534% (95% limits of agreement: -4.7013, 5.0080). Conclusion Dual-energy CT-based 70-keV monochromatic images improve MDE assessment in patients with cardiomyopathy via improved image quality and CNR and reduced beam-hardening artifacts when compared with conventional CT images. © RSNA, 2017 Online supplemental material is available for this article.

/pdf/utility-of-dual-energy-ct-based-monochromatic-imaging-in-the-3a06tl511m.pdf

Young Jin Kim

Papers

Extracellular volume fraction in dilated cardiomyopathy patients without obvious late gadolinium enhancement: comparison with healthy control subjects

Stress-induced evolution of anisotropic thermal conductivity of dry granular materials

MDCT of pulmonary embolism after percutaneous vertebroplasty.

Patterns of late gadolinium enhancement are associated with ventricular stiffness in patients with advanced non-ischaemic dilated cardiomyopathy.

Utility of Dual-Energy CT-based Monochromatic Imaging in the Assessment of Myocardial Delayed Enhancement in Patients with Cardiomyopathy