Showing papers in "European Journal of Echocardiography in 2006"

Recommendations for chamber quantification

Abstract: Quantification of cardiac chamber size, ventricular mass and function ranks among the most clinically important and most frequently requested tasks of echocardiography. Over the last decades, echocardiographic methods and techniques have improved and expanded dramatically, due to the introduction of higher frequency transducers, harmonic imaging, fully digital machines, left-sided contrast agents, and other technological advancements. Furthermore, echocardiography due to its portability and versatility is now used in emergency rooms, operating rooms, and intensive care units. Standardization of measurements in echocardiography has been inconsistent and less successful, compared to other imaging techniques and consequently, echocardiographic measurements are sometimes perceived as less reliable. Therefore, the American Society of Echocardiography, working together with the European Association of Echocardiography, a branch of the European Society of Cardiology, has critically reviewed the literature and updated the recommendations for quantifying cardiac chambers using echocardiography. This document reviews the technical aspects on how to perform quantitative chamber measurements of morphology and function, which is a component of every complete echocardiographic examination.

Evaluation of right ventricular volume and function by 2D and 3D echocardiography compared to MRI.

Abstract: Aims: Radionuclide techniques, and recently MRI, have been used for clinical evaluation of right ventricular (RV) volumes function (RVEF) and volumes; but with the introduction of 3D echocardiography, new echocardiographic possibil- ities for RV evaluation independent of geometrical assumptions have emerged. This study compared classic and new echocardiographic and radionuclide estimates, including gated blood pool single-photon emission computed tomography (SPECT) of RV size and function to RV volumes, and ejection fraction (RVEF) measured by magnetic resonance imaging (MRI). Methods and results: Thirty-four subjects with (a) prior inferior ST-elevation myo- cardial infarction (n ¼ 17), (b) a history of pulmonary embolism and persistent dys- pnea (n ¼ 7) or (c) normal subjects (n ¼ 10) had 2D and 3D echocardiography, SPECT and MRI within 24 h. End-diastolic volume and peak tricuspid regurgitation velocity were increased in patients with a history of pulmonary embolism compared to healthy subjects,

Tako-Tsubo cardiomyopathy: new insights into the possible underlying pathophysiology.

Abstract: Tako-Tsubo cardiomyopathy is characterised by an atypical distribution of left ventricular (LV) dysynergy with apical ballooning and compensatory basal hyperkinesis. Coronary angiography is normal. Several substrates have been put forward to explain the underlying pathophysiology such as raised catecholamine levels (due to physical or emotional stress), multivessel epicardial coronary spasm or diffuse microvascular spasm. However, the pathophysiology has not yet been fully clarified. We present a series of cases whose findings could explain the mechanism underlying this syndrome. Four consecutives patients, all female, were admitted with the clinical features typical of Tako-Tsubo syndrome. In all, severe widespread transient LV mid-apical a/dyskinesia was associated with a mid-cavity dynamic obstruction which resolved prior to the resolution of the LV wall motion abnormalities. In all cases the dynamic LV obstruction was related to localised mid-ventricular septal thickening. After improvement in wall motion, a low-dose strain/strain rate dobutamine stress-echocardiography (DSE) was performed to determine the underlying ischaemic substrate. This provoked an LV mid-cavity gradient at peak dose in all. Regional deformation changes during DSE showed the affected myocardium to have the typical response diagnostic of regional stunning. Conclusion We postulate that an important unrecognised factor in the development of Tako-Tsubo cardiomyopathy is the presence of abnormal myocardial functional architecture (such as localised mid-ventricular septal thickening), which in the presence of dehydration and/or raised catecholamine levels due to physical or emotional stress, leads the development of a severe transient LV mid-cavity obstruction. This effectively sub-divides the LV into two functionally different chambers with a marked increase in wall stress in the high pressure distal apical chamber. This, in combination with the abnormal high circulating catecholamine levels, induces widespread sub-endocardial ischaemia which is unrelated to a specific coronary artery territory. With rehydration/fall in catecholamine levels the interventricular gradient resolves and distal function recovers. Low dose SR/S DSE confirms that the distal ischaemic substrate is myocardial stunning.

Tissue Doppler imaging and conventional echocardiography after anthracycline treatment in adults: early and late alterations of left ventricular function during a prospective study.

Abstract: Aim of the study: To evaluate the short and long-term effects of anthracycline chemotherapy in adults using conventional echocardiography and pulsed tissue Doppler imaging (TDI). Methods and results: Twenty patients were included of which 16 had a complete follow up. They underwent an echocardiography before chemotherapy, 1e3 months and 3.5 G 0.6 years after the treatment. We recorded pulsed TDI at the mitral annulus, the basal segments of the left ventricular (LV) lateral and posterior walls; peak velocities in systole (Sm), early (Em) and late diastole and the isovolumic relaxation time (IVRT) were measured. The cumulative dose of doxorubicin was 211 G 82 g/m 2 . Early after anthracycline therapy, we observed changes in the diastolic LV function with a decrease of the mitral E peak velocity and TDI Em. At the late control, diastolic changes were more pronounced and associated with an alteration of the systolic function (LV ejection fraction and Sm). Four patients had a LV ejection fraction !50%; in these patients we observed a mitral annulus IVRT !80 ms at the early control; this could be of interest to predict later impairment of the LV ejection fraction.

Feasibility of strain and strain rate imaging for the assessment of regional left atrial deformation: A study in normal subjects

Abstract: Aims: There are no data on the use of Myocardial Velocity Imaging (MVI) to study the left atrium (LA) wall deformation. The aims of this study were to assess the feasibility of measuring regional longitudinal strain/strain rate (3/SR) profiles in the LA wall, to define the normal values and to validate these measurements. Methods and results: MVI data were recorded in 40 healthy young individuals using a GE Vivid7 for the lateral, anterior and inferior LA walls. The peak 3/SR values and total3valuesduringthecontractile,reservoirandconduitLAphases weremeasured. For the LA lateral wall, the total 3 values were correlated with the LA volumetric indicators (LA active emptying fraction: LA AEF; LA expansion index: LA EI; and LA passive emptying fraction: LA PEF). The correlations were significant for all three periods: contractile (total 3 vs. LA AEF, rZ� 0.78, P!0.001), reservoir (total 3 vs. LA EI, rZ0.43, P!0.01) and conduit (total 3 vs. LA PEF, rZ� 0.46, P!0.005). Conclusion: SR/3 imaging for the quantification of longitudinal myocardial LA deformation was shown to be feasible and the normal values were reported and validated. These data may improve the understanding of the LA pathophysiology. a 2005 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.

Mitral annular motion as a surrogate for left ventricular function: correlation with brain natriuretic peptide levels.

Abstract: Background: Pulsed-wave (PW) Doppler tissue velocities of the mitral annulus correlate well with Left Ventricular (LV) diastolic(D) and systolic(S) functions. Brain natriuretic peptide (BNP) levels have been shown to be elevated in patients with symptomatic LV dysfunction (Dys) and correlate to the severity of symptoms and prognosis. Objectives: To validate the accuracy of mitral annular motion (MAM) assessed by Doppler Tissue Imaging (DTI) & M-mode Echocardiography (MME) as a surrogate for determination of LV function in comparison with BNP. Methods: A series of 133 patients with a variety of cardiac pathologies referred for echocardiography and 20 healthy age & sex matched volunteers as a control group were included the study. Ejection fraction (EF) of LV, Doppler recordings of the mitral inflow, MME and PWDTI data (from each of 4 mitral annular sites, inferior, anterior, septum and lateral) were obtained. Mean peak (S) MAM velocity (Sm), mean annular early (D) velocity (Em) by PWDTI and mean mitral annular plane (S) excursion (MAPSE) by MME were calculated by averaging of values measured at each annular site. BNP levels were measured by a rapid immunoassay and blinded to cardiologist making the assessment of LV function. Results: MAPSE ! 12 mm determined by MME has 90% sensitivity, 88% specificity & 89% accuracy for detection of LVEF !50%, while these values were 94%, 93% & 94% respectively for (Sm) ! 8 cm/s determined by PWDTI. BNP level O 75 pg/ml has 98% sensitivity, 90% specificity & 97% accuracy for detection of LV Dys either (S,D, or both). BNP levels were significantly higher in patients with combined (S & D) Dys. Than those with only (S) Dys, the later group had significantly higher BNP levels than those with only (D) Dys. (1054.5 G 202.3 pg/ml vs. 500 G 39.9 pg/ml & 500 G 39.9 pg/ml vs. 215.3 G 100.9 pg/ml respectively, P ! 0.001) & each were significantly

New generation 3-dimensional echocardiography for left ventricular volumetric and functional measurements: Comparison with cardiac magnetic resonance

Abstract: Aims: Non-invasive assessment of left ventricular (LV) structure and func- tion is important in the evaluation of cardiac patients. This study was designed to test the accuracy and reproducibility of new generation 3-dimensional echocardiography (3DE) in measuring volumetric and functional LV indices as compared with current ''gold standard'' of non-invasive cardiac imaging, cardiac magnetic resonance (CMR). Methods and results: Sixty-four subjects with good acoustic windows, including 40 cardiac patients with LV ejection fraction (EF) 45% and 10 normal volunteers underwent 3DE using a commercially available Philips Sonos 7500 scanner equipped with a matrix phase-array x4 xMATRIX transducer, and CMR on a 1.5 T Signa CV/i scanner (GE Medical Systems). Volumetric assessment was performed with analytical 4D-LV-Analysis software (TomTec) for 3DE and MRI-Mass software (Medis) for CMR. We found no significant differences in LV end-diastolic volume (EDV), end-systolic volume (ESV) and EF with excellent correlations between the indices measured using 3DE and CMR (r ¼ 0.97, r ¼ 0.98, and r ¼ 0.94, respectively). BlandeAltman analysis showed bias of 7 ml for EDV, 3 ml for ESV and � 1% for EF with 3DE with corresponding limits of agreement (2SD) of 28 ml, 22 ml and 10%, respectively. Intraobserver and interobserver variabilities were for EDV: 3% and 4% (3DE) vs 2% and 2% (CMR), for ESV: 3% and 6% (3DE) vs 2% and 3% (CMR), and for EF: 4% and 4% (3DE) vs 2% and 4% (CMR), respectively.

Global and regional left ventricular function assessment with 16-detector row CT: Comparison with echocardiography and cardiovascular magnetic resonance

Abstract: function; MDCT; Echocardiography; CMR Abstract Aims: To compare multidetector row computed tomography (MDCT) global and regional left ventricular (LV) function assessment with echocardiography and cardiovascular magnetic resonance (CMR). Methods and results: In 25 patients, who were referred for noninvasive angiography with 16-detector row CT, LV function assessment was also performed. A subsequent echocardiogram was performed, and in a subgroup of patients, CMR examination was completed to evaluate LV function. For global function assessment, the LV ejection fraction (LVEF) was calculated. Regional LV function was scored using a 17-segment model and a 4-point scoring system. MDCT agreed well with echocardiography for the assessment of LVEF (rZ 0.96; bias 0.54%; p ! 0.0001) and regional LV function (kZ 0.78). Eight patients had no contra-indications and gave informed consent for CMR examination. A fair correlation between MDCT and CMR was demonstrated in the assessment of LVEF (rZ 0.86; bias 1.5%; p !0.01). Regional LV function agreement between MDCT and CMR was good (kZ 0.86).

Comparison of transthoracic echocardiography using second harmonic imaging, transcranial Doppler and transesophageal echocardiography for the detection of patent foramen ovale in stroke patients

Abstract: Aims The comparison of three imaging methods to determine which is the most accurate and reliable for the detection of right-to-left shunt. Methods and results One hundred and seven patients who were hospitalized for stroke underwent: a transthoracic echocardiography (TTE) using second harmonic, a transcranial Doppler (TCD) and a transesophageal echocardiography (TEE) from August 2003 to April 2004. All studies were recorded on a videotape and were studied by a physician blinded to the study. With TTE and TEE, we found 44 (41%) patent foramen ovales. All contrast tests were positive with TCD for these 44 patients. For two patients, the contrast test was positive only with TTE and TCD. We found four false negative contrast tests with TTE. Among the 63 patients who had a negative contrast test with TEE and TTE, the results were the same with TCD for 59 of them; we were not able to determine a cause for the four positive tests. Conclusion This study confirms that transesophageal echocardiography has limitations in the diagnosis of patent foramen ovale. In this study, the negative predictive value of transcranial Doppler was excellent. Therefore, this examination is able to exclude a patent foramen ovale with a high level of confidence.

Abnormal pulmonary vascular responses in patients registered with a systemic autoimmunity database: Pulmonary Hypertension Assessment and Screening Evaluation using stress echocardiography (PHASE-I)

Abstract: Patients with autoimmune disease, and in particular limited systemic sclerosis (CREST syndrome), are at risk of developing pulmonary artery hypertension (PAH) which is associated with a poor prognosis. With improvements in therapy offering improved survival and functional capacity, there has been an emphasis on screening to identify patients at risk. Assessment of patients during exercise may enable early identification of patients with this condition. Aims and methods We aimed to assess the ability of exercise stress echocardiography to evaluate the change in pulmonary artery pressure in 51 patients with autoimmune disease (systemic lupus erythamatosus (SLE), limited systemic sclerosis (LSS or “CREST”) and diffuse systemic sclerosis (DSS)). Systolic pulmonary artery pressure (sPAP) was estimated using interrogation of the tricuspid incompetence jet before and after exercise. PAH was classified as normal, mild, moderate or severe using echocardiographic assessment of sPAP. Results We were able to estimate pre-exercise and post-exercise sPAP in 92% and 90% of patients, respectively. Pulmonary pressures rose or remained unchanged in all screened individuals, with a mean rise during stress of 14.1mmHg (±1.1). Pulmonary artery pressure rose significantly in each of three subgroups ( p <0.05). Stress echocardiography demonstrated PAH (using a cut-off of >35mmHg) in 59% of all individuals with systemic autoimmunity. Conclusion Stress echocardiography is a useful tool in identifying individuals with autoimmune disease who may have underlying pulmonary arterial disease that may be amenable to therapy. We noted a consistent elevation in sPAP across all autoimmune subtypes, suggesting an abnormal pulmonary vascular response to exercise exists in these patients.

Effects of cardiac resynchronization therapy on the mechanisms underlying functional mitral regurgitation in congestive heart failure

Abstract: Aims: Functional mitral regurgitation (FMR) improvement induced by cardiac resynchronization therapy (CRT) has been related to left ventricular (LV) remodeling reversal and contractility enhancement. The effects induced by the changes of LV synchronicity indexes on FMR severity have not been investigated. Methods and results: In 30 patients with CRT for heart failure (HF) and QRS O 130 ms, LV function parameters, FMR severity as mitral jet regurgitation/ left atrial area ratio (JA/LAA) and standard deviation (SD) of the time to the systolic peak velocity at 6-basal and mid-LV segments as asynchrony indexes were evaluated (echo/tissue Doppler) before and 6 months after implant. At follow- up, 15 patients resulted responders to LV reverse remodeling with R15% end- systolic volume (ESV) and LV systolic function improvement. Improvement of FMR with R15% JA/LAA reduction was observed in 19 patients, 7 were nonresponders to LV reverse remodeling. In patients with R15% JA/LAA reduction a significant decrease of LV asynchrony indexes was observed as compared to patients without R15% JA/LAA reduction in whom LV asynchrony indexes were increased. Reduction of LV mid-segmental asynchrony was the variable most strongly related to JA/LAA reduction (r 2 Z 0.697, P! 0.01), with good agreement between observed and predicted values (only 1 patient outside the mean G 2SD).

Pulsed tissue Doppler and strain imaging discloses early signs of infiltrative cardiac disease: a study on patients with familial amyloidotic polyneuropathy.

Abstract: BACKGROUND: Familial amyloidotic polyneuropathy (FAP) is a hereditary systemic amyloidosis with cardiac involvement. As early identification of the cardiac involvement is of major clinical interest ...

Two-dimensional acoustic pattern derived strain parameters closely correlate with one-dimensional tissue Doppler derived strain measurements

Abstract: Background: Two-dimensional strain echocardiography (2D-SE) calcu- lates tissue velocities via frame-to-frame tracking of unique acoustic markers within the image and provides strain parameters in two dimensions. Novel 2D-SE software allows semi-automated strain measurements and increased averaging capabilities optimizing signalenoise ratio. Aim: We tested whether 2D-SE and the currently used and well-validated tissue Doppler derived strain echocardiography (TD-SE) yield similar information in the clinical setting. Methods and results: We performed 2D-SE and TD-SE on 17 patients with amyloid cardiomyopathy and 10 age-matched healthy volunteers. Single walls from standard apical views (2- and 4-chamber) were acquired at high frame rates (w200 fps). Offline analysis was performed by observers blinded to clinical data using the EchoPAC program with custom 2D-SE software. Longitudinal strain rate and strain from the basal, mid and apical segments of the septal and lateral walls were determined by each method (TD-SE and 2D-SE). Ejection fraction was O0.55 in healthy volunteers and ranged from 0.30 to 0.80 in cardiomyopathy group. A total of 54 walls (162 segments) were examined. Acceptable quality strain data was available in 92% and 85% segments by 2D-SE and TD-SE, respectively. Two- dimensional strain echocardiography values correlated closely with TD-SE values (rZ 0.94 and 0.96 for strain rate and strain, respectively).

The BNP assay does not identify mild left ventricular diastolic dysfunction in asymptomatic diabetic patients

Abstract: Aims We examined the usefulness of BNP for screening for left ventricular (LV) diastolic dysfunction in a sample of type 2 diabetic patients, without structural heart disorder, who have never presented symptoms or signs of heart failure (HF). Methods and results Seventy-six consecutive patients admitted to the Outpatient Diabetes Clinic were studied. Blood samples were analyzed using the Triage BNP fluorescence immunoassay (Biosite Diagnostics, La Jolla, CA, USA). Echocardiography examinations were performed, with no knowledge of the BNP value. A total of 39 patients out of 76 (51%) were diagnosed with LV diastolic dysfunction and 23 (30%) with LV hypertrophy. Of the patients with LV diastolic dysfunction, impaired relaxation and pseudonormal pattern accounted for 97 and 3% of the cases, respectively. BNP levels among subjects with LV diastolic dysfunction (26±22pg/ml, n =39) were not significantly different from patients with normal LV function (24±23pg/ml, n =37pg/ml; Mann–Whitney U -test, Z =−0.4, n.s.). Conclusions Our data confirm alarmingly high prevalence of LV diastolic dysfunction in asymptomatic individuals with diabetes. Identification of patients with preclinical diabetic cardiomyopathy should be a research and clinical priority. BNP levels cannot be used to detect mild LV diastolic dysfunction in this subset of patients, which requires Doppler echocardiography to be detected.

Disagreement between tissue Doppler imaging and conventional pulsed wave Doppler in the measurement of myocardial performance index

Abstract: Aim: Myocardial performance index (MPI) is usually measured with pulsed wave Doppler (PWD). Our aim was to assess the degree of agreement be- tween PWD and a method based on tissue Doppler imaging (TDI). Methods and results: Seventy-five patients with prior myocardial infarction and 20 healthy subjects underwent measurement of time intervals and MPI with PWD and pulsed TDI at septal and lateral sides of mitral annulus. MPI and TDI-MPI at septal side showed the best intraclass correlation coefficient (ICC Z 0.54; p ! 0.0005). Ninety-five percent interval of agreement ranged from 0.27 to 0.22. These differ- ences were attributed to discrepancies in isovolumic contraction and relaxation times. In the healthy group the results were similar (ICC Z 0.44), although the 95% interval of agreement was lower (from 0.13 to 0.12). Conclusions: The agreement between PWD and TDI in the measurement of MPI is only moderate. This should be taken into account in the interpretation of studies

New reference values for echocardiographic dimensions of healthy Dutch children

Abstract: Aim: To renew the echocardiographic reference values of heart dimensions in healthy children.

Baseline echocardiographic characteristics of heart failure patients enrolled in a large European multicentre trial (CArdiac REsynchronisation Heart Failure study).

Abstract: Aims: Information on the prevalence and clinical, electrocardiographic and echocardiographic inter-relationships of mechanical dyssynchrony among patients with heart failure (HF) and left ventricular systolic dysfunction derives mainly from relatively small studies. The CARE-HF trial provides the opportunity to address these issues in a large population of patients with advanced HF. Methods and results: The CARE-HF trial enrolled patients with New York Heart Association (NYHA) class III or IV HF, with a QRS duration � 120 ms, left ventricular (LV) ejection fraction (EF) � 35% and LV end diastolic diameter � 30 mm/m (height in m). Patients underwent a thorough echocardiographic evaluation, which included assessment of LV structure, systolic function, mitral inflow pattern, right ventricular (RV) dimensions and function, and interventricular mechanical delay (IVMD) as an index of interventricular dyssynchrony. Echocardiographic measurements were made in a Core Laboratory to ensure consistent quantitative analysis. Of the 813 patients enrolled, 735 had a baseline echocardiographic examination suitable for measurement. Overall patients had advanced LV dysfunction (mean EF 25.5%) but few had a restrictive mitral filling pattern (18%) and both the mean RV

Noncompaction of ventricular myocardium involving both ventricles.

Abstract: Aim: We aimed to present a case with ventricular myocardial noncom- paction involving both ventricles. Methods and results: Noncompaction of ventricle is a rare and unclassified congen- ital cardiac malformation is due to an arrest in intrauterine endomyocardial mor- phogenesis. We presented a ventricular myocardial noncompaction case involving both left and right ventricles. The physical examination of this case is consistent with mitral regurgitation and the echocardiographic findings are consistent with noncompaction of ventricular myocardium involving both ventricles with left ven- tricular systolic failure. Conclusion: Transthoracic echocardiography is a useful clinical tool for diagnosing noncompaction of both the right and left ventricular myocardium. The LVNC defini- tion can also be utilized for RVNC, which this diagnosis has never been reported in a Turkish patient. a 2005 Published by Elsevier Ltd on behalf of The European Society of Cardiology.

Dynamic LV obstruction in apical ballooning syndrome: the chicken or the egg

Abstract: Please see page 53 for the article by Merli et al. (doi: 10.1016/j.euje.2005.08.003 ) to which this editorial pertains. Between 1990 and 2001 several cases of a new heart syndrome have been reported in Japan, all in Japanese journals. This syndrome consisted of acute onset, transient left ventricular apical wall motion abnormalities with chest symptoms, electrocardiographic changes and minimal myocardial enzymatic release mimicking acute myocardial infarction in patients without significant stenosis on coronary angiogram. It was named “Tako-tsubo” – shaped cardiomyopathy due to its unique “short neck round – flask” – like left ventricular apical ballooning resembling the Tako-Tsubo (Japanese for octopus pot or trap) of Japan. These reports received little or no attention in Western literature, until in 2001 a series of 88 patients were published,1 retrospectively enrolled from cardiovascular institutes of Angina Pectoris–Myocardial Infarction investigations in Japan. In addition to describing symptoms and electrocardiographic and hemodynamic findings, this publication suggested that emotional or physical stress might play a key role in this acute cardiomyopathy since in a majority of cases a preceding aggravation of underlying disorders or acute emotional and physical problems could be identified. Because until then virtually all reports had been confined to Japanese patients, many Western cardiologists believed that it concerned a geographically restricted cardiovascular syndrome, if not a misinterpretation of rare cases of aborted anterior myocardial infarction or variant angina. But in 2003, a first European series of 13 white patients were described,2 underscoring that this syndrome also exists outside Japan. Again the complete recovery of left ventricular function within three weeks was reported, despite the sometimes dramatic initial presentation. It was now obvious that clinicians in the Western world should also be aware of the existence of this syndrome because this syndrome mimicking acute myocardial infarction may inadvertently expose patients to futile …

Doppler myocardial imaging in adult male rats: reference values and reproducibility of velocity and deformation parameters.

Abstract: Aim: Limited data are available about the use of Doppler myocardial im- aging (DMI) in small animals. We intend to provide reference values for velocity, strain and strain rate in a large group of healthy rats and studied the reproducibility and repeatability of these parameters.

Gender and age related differences in left ventricular function and geometry with focus on the long axis

Abstract: Aims: To study age and gender related alterations in left ventricular (LV) long axis function. Methods: Eighty-two healthy individuals from the general population in three age groups were investigated. LV long axis and short axis function and dimensions were studied with echocardiographic M-mode and two-dimensional technique. Results: The most prominent age related differences were observed in LV long axis function, whereas only minor alterations in short axis function were noticed. Both systolic and diastolic long axis function decreased with advancing age; maximal systolic velocity (rZ 0.61, p !0.0001), maximal early diastolic filling velocity (rZ 0.87, p! 0.0001). The length of the long axis decreased with age, while the relative contraction amplitude was maintained. LV global and short axis measure- ments revealed significant differences between genders, males having generally larger dimensions, even when correcting for body surface area. Females exhibited a more pronounced remodelling process with advancing age. Conclusion: Functional age related changes in LV function are more prominent in the long axis, while differences between genders are more pronounced in short axis and in volume measurements. These findings might be of importance when remodelling processes are evaluated, as these appear to be different in men and women and also age related.

Stress echocardiography is superior to exercise ECG in the risk stratification of patients presenting with acute chest pain with negative Troponin.

Abstract: Objective To compare exercise electrocardiography (ExECG) and stress echocardiography (SE) in the risk stratification of patients presenting to hospital with cardiac-sounding chest pain, non-diagnostic ECGs and negative cardiac Troponin. Methods Patients presenting with acute chest pain were prospectively randomised to early ExECG or SE. A post-test likelihood of CAD was determined by the pre-test likelihood and the result of the stress test. Patients with a low post-test likelihood of CAD were discharged; those with a high post-test probability were considered for coronary angiography. All others were managed according to standard hospital protocols. Results A total of 302 patients underwent either ExECG or SE. SE identified significantly more patients with a low post-test probability of CAD (80% vs 31%, p <0.0001) and significantly fewer patients with an intermediate post-test likelihood of CAD compared to ExECG (3% vs 47%; p <0.0001). Significantly fewer patients undergoing SE were referred for further tests to exclude or refute the diagnosis of CAD (16% vs 52%; p <0.0001). In total, 36 (12%) had flow limiting CAD demonstrated by coronary angiography. Significant CAD was seen in fewer patients with a positive ExECG than with a positive SE (56% vs 84% ( p =0.12)). Event rates were low for both modalities in patients with low post-test probability (3.5% for SE vs 5.1% for ExECG; p =ns) though the number of patients identified as low risk was higher if SE was performed. Conclusion Despite negative cardiac Troponin, 12% of patients with acute chest pain had significant CAD. SE is superior to ExECG in discriminating between those patients with a low and intermediate risk of CAD and correctly identified patients with significant CAD, as well as conferring an excellent prognosis in those considered low risk. SE significantly reduces the requirement for further tests to diagnose CAD compared to ExECG.

Quadricuspid aortic valve: A rare etiology of aortic regurgitation

Abstract: Quadricuspid aortic valve is a rare cause of aortic insufficiency. We report two unusual cases of this valvular pathology associated with a dilatation of the aortic root. The mechanism leading to this valve incompetence is incompletely understood and is discussed in regard to these cases.

Additive value of contrast echocardiography for the diagnosis of noncompaction of the left ventricular myocardium.

Abstract: Noncompaction of the left ventricular myocardium is a rare and unclassified cardiomyopathy that remains frequently overlooked, even by experienced echocardiographers. This fact may be due to non-optimal imaging of the lateral and apical myocardium, and/or insufficient disease awareness by echocardiographers. We report a case of a young man with heart failure and severe left ventricular dysfunction, previously diagnosed of ischemic etiology, in which the contrast enhancement of left ventricular endocardium allowed us to reach the correct diagnosis of isolated left ventricular noncompaction.

Triphasic mitral inflow velocity with mid-diastolic flow: the presence of mid-diastolic mitral annular velocity indicates advanced diastolic dysfunction.

Abstract: Mitral inflow filling pattern usually consists of 2 forward flow velocities in sinus rhythm: early rapid filling (E) and late filling with atrial contraction (A). However, additional mid-diastolic flow velocity may be present resulting in triphasic mitral inflow filling pattern. When mitral inflow is triphasic, mitral annulus velocity recorded by tissue Doppler imaging (TDI) frequently demonstrates a mid-diastolic component (L'). The significance of L' has not been explored previously. The purpose of this study was to explore possible mechanisms and clinical implications of triphasic mitral inflow with or without L' using TDI and proBNP. Of 9004 patients who underwent transthoracic echocardiography from March to November 2003, 83 (0.9%) patients (33 male, 50 female; mean age, 63+/-10 years) with a triphasic mitral inflow velocity pattern, including mid-diastolic flow velocity of at least 0.2m/s, and sinus rhythm were prospectively identified in our clinical echocardiography laboratory. Peak velocity of E, mid-diastolic (L), and A, and deceleration time (DT) of the E wave velocity were measured. Diastolic mitral annular velocities were measured at the septal corner of the mitral annulus by TDI from the apical 4-chamber view. ProBNP was measured at the time of echocardiogram using a quantitative electrochemiluminescence immunoassay. Mean heart rate was 54+/-6 beats/min (range, 40-67). Mean left ventricular (LV) ejection fraction (EF) was 64+/-13% and LV systolic dysfunction (EF<40%) was present in only 6 (7%). Patients were classified into 2 groups: group 1 (n=47) included those who had L' and group 2 (n=36) included those without L'. Group 1 patients had significantly higher peak velocity (35+/-14 vs 26+/-6 cm/s, p=0.0002) and TVI (35+/-14 vs 26+/-6 cm/s, p=0.0002) of L, E/E' (18+/-8 vs 14+/-6, p=0.02), and left atrial volume index (42+/-14 vs 34+/-10 ml/m(2), p=0.0037). E' (4.7+/-1.3 vs 6.2+/-2.3 cm/s, p=0.001) and A' (6.2+/-2.0 vs 8.6+/-3.4 cm/s, p=0.0006) were significantly lower in group 1 compared with those of group 2. ProBNP was significantly higher in group 1 (847+/-1461 vs 438+/-1039 pmol/l, p=0.0012) and it was above normal in all except in 1 patient of group 1. In conclusion, the presence of L' in subjects with triphasic mitral inflow velocity pattern with mid-diastolic flow is associated with higher E/E', elevated proBNP and enlarged left atrium indicating advanced diastolic dysfunction with elevated filling pressures. This unique mitral annular velocity pattern should be helpful in identifying the patients with advanced diastolic dysfunction and increased LV filling pressures.

481 Should routine echocardiography be performed in all patients with stroke

Abstract: Background: Cardiogenic embolism accounts for 15% to 30% of ischemic strokes. Echocardiography is frequently being used as a screening test for sources of cardiac embolism in patients with stroke. However, the value of routine use of echocardiography for this task remains controversial. We evaluated the diagnostic yield of echocardiography in unselected patients with acute ischemic stroke. Methods: Consecutive patients with ischemic stroke or a transient ischemic attack were included in the study. Transthoracic echocardiography was performed in all patients, complemented by transesophageal echocardiography in selected patients. Results: In all, 807 echocardiographic examinations (743 transthoracic and 64 transesophageal) were performed in 775 consecutive patients. A potential cardiac source of embolism (CSE) was found in 144 (18%) of the patients. The most frequent potential causes of cardiac embolism included atrial fibrillation (7%) and patent foramen ovale (6%). Results were more likely to have impact on therapeutic decisions in younger patients. Numbers needed to test for detection of CSE increased 10-fold from 6 in patients younger than 50 years to 62 in patients aged 70 years and older. Conclusion: Echocardiography may provide important information on the cause of ischemic stroke. However, echocardiographic screening for a CSE is not warranted in all patients. In patients with younger than 50 years with stroke, echocardiography has a higher diagnostic yield and should routinely be performed. In older patients routine echocardiography results in a high rate of unspecific findings, and should be applied selectively, targeted at specific clinical questions. Key Words: Stroke— echocardiography— diagnosis—patent foramen ovale— embolism—accuracy—sensativity—specificity— human. © 2007 by National Stroke Association

Intracardiac pseudotumor caused by mitral annular calcification

Abstract: The current report describes a rare case of a pseudotumor in the left ventricle. Transthoracic and transesophageal echocardiography demonstrated a round, echodense, mobile mass attached to the posterior mitral leaflet and annulus. At surgical exploration caseous annular calcification of the posterior mitral leaflet was diagnosed. After resection of the mass, successful mitral valvular plasty was performed. Review of the literature indicated that mitral annular calcification is associated with an increased risk of stroke. Optimal treatment may be surgery, especially when valve plasty can be performed, although randomized trials are currently lacking.

168 Isovolumic acceleration measured by tissue Doppler echocardiography is preload independent in healthy subjects

Abstract: BACKGROUND Isovolumic acceleration (IVA) as assessed by Tissue Doppler Imaging (TDI) has been proposed as a measure of left ventricular (LV) contractility. IVA is believed to be less dependent on preload than previously proposed estimates. IVA has been measured at different locations, and studies have shown conflicting results. OBJECTIVES We investigated the impact of increased preload on modern echocardiographic estimates of contractility, including IVA performed at different locations, in healthy volunteers. METHODS Seventeen young healthy individuals (male 13, age 31(+/- 9) years) with no prior history of cardiovascular or metabolic diseases had a Doppler and Tissue Doppler echocardiographic study performed at baseline and after a rapid infusion of 30 ml/kg of bodyweight of isotonic saline. Results are given as mean +/- standard deviation (SD), differences tested by paired t-test. RESULTS Echocardiographic parameters used to determine changes in preload, altered significantly. E/e' increased both at the lateral (5 +/- 1 vs 7 +/- 1 P < 0.01) and at the septal side of the annulus (7 +/- 2 vs 9 +/- 2, P < 0.01). Afterload remained unchanged. IVA was unchanged regardless of the measurement location: in the basal free wall (1.21 +/- 0.58 vs 0.98 +/- 0.41, not significant (NS)) or in the mitral annulus (1.18 +/- 0.56 vs 1.15 +/- 0.33, NS). Peak systolic strain, measured at the basal segment of LV septum, increased significantly (15.4 +/- 5.0 vs 20.7 +/- 5, P < 0.05), while all other measurements for strain or strain rate (SR) remained unchanged. CONCLUSION IVA is unchanged following significant increases in preload in healthy subjects, and thus is a potentially useful measure of global LV contractility.

571 Importance of the echocardiographic evaluation of right ventricular function in patients with AL amyloidosis

Abstract: BACKGROUND Patients with AL amyloidosis often present with signs of congestive heart failure. AIM This study was prospectively designed to assess the significance of RV dysfunction in AL amyloidosis. METHODS AND RESULTS Seventy-four patients with biopsy proven AL amyloidosis underwent a thorough echocardiographic evaluation. A tricuspid annular plane systolic excursion (TAPSE)<17 mm was taken as marker of RV dysfunction. Plasma NT-proBNP determinations were performed in all cases. RV function was normal in 60 patients and reduced in 14 patients. Patients with RV dysfunction had thicker left ventricular (LV) walls (p<0.01), lower LV end-diastolic volumes (p<0.01), lower LV ejection fraction (p<0.01) and more frequently a restrictive LV filling pattern (p<0.01). RV dimensions and RV free wall thickness were not significantly different in the two groups. A thick interventricular septum and a reduced TAPSE were associated with high NT-proBNP levels (both p<0.01). Seven patients died during a median follow-up period of 19 months; TAPSE<17 mm was the only echocardiographic parameter associated with poor survival. CONCLUSION In patients with AL amyloidosis, RV dysfunction is associated with more severe involvement of the left ventricle, higher plasma levels of NT-proBNP and with poor prognosis.

Impaired myocardial function in newly onset type 2 diabetes associates with arterial stiffness.

Abstract: Aim The aim of this study was to evaluate myocardial function using pulsed and color-coded tissue Doppler imaging (TDI) and vascular wall elasticity using whole-body impedance cardiography (ICG) in patients with newly diagnosed Type 2 diabetes mellitus (DM2), and to compare the measurements with those of healthy controls. Methods Systolic (SBP) and diastolic (DBP) blood pressure and glycocylated hemoglobin (HbA1c) were measured in 49 men (mean age 52.3±5.6 years, duration of DM2 1.8 years), and 15 healthy male control subjects (48.3±7.4 years). Mitral annular peak systolic (Svm), early (Evm), and late (Avm) diastolic velocities as well as myocardial peak systolic (Sv), early (Ev) and late diastolic (Av) velocity from middle segments of the anterior, inferior and lateral wall and the inferior septum were measured by TDI. ICG at rest was used to measure cardiac index (CI) and pulse wave velocity (PWV). Results The patients had higher body mass index (BMI 29.1±3.7 vs. 25.2±2.4kg/m2, p =0.000) and SBP (142±15 vs. 120±7mmHg, p =0.005) than the controls, CI was comparable (2.8±0.5 vs. 2.8±0.6l/min/m2). The patients had lower age adjusted myocardial Sv (3.8±1.1 vs. 4.8±1.1cm/s, p =0.002) and Ev (4.6±1.6 vs. 6.2±1.7cm/s, p =0.011), and also mitral annulus peak early diastolic velocity (Evm 7.8±1.9 vs. 10.4±2.6cm/s, p =0.001). In diabetic patients PWV (14.2±2.7 vs. 10.0±1.7m/s, p =0.002) was higher. Age ( r =−0.39, p =0.001), BMI ( r =−0.44, p =0.000) and PWV ( r =−0.52, p =0.000) correlated significantly with Evm. PWV correlated with age ( r =0.50, p =0.000), SBP ( r =0.67, p =0.000), and HBA1c ( r =0.36, p =0.010). In stepwise regression analysis, PWV ( β =−0.39, p =0.000) was the major determinant of Evm. Conclusion Myocardial function is impaired in asymptomatic patients with newly detected DM2 consistent with diabetic heart muscle disease. Arterial stiffness is strongly related to myocardial dynamics, and both may have the same pathophysiologic background.