Showing papers in "European Journal of Echocardiography in 2013"
TL;DR: It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing regurgitation, and to integrate the quantification of the regurgitations, assessment of the valve anatomy and function, as well as the consequences of valvular disease on cardiac chambers.
Abstract: Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Echocardiography has become the primary non-invasive imaging method for the evaluation of valvular regurgitation. The echocardiographic assessment of valvular regurgitation should integrate the quantification of the regurgitation, assessment of the valve anatomy and function, as well as the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation thus largely integrates the results of echocardiography. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing regurgitation.
1,263 citations
TL;DR: The use of PHHE after brief bedside training in the form of a tutorial greatly improved the clinical diagnosis of medical students and junior doctors, over and above history, physical examination, and ECG findings.
Abstract: Aims While patient history taking and physical examination remain the cornerstones of patient evaluation in clinical practice, there has been a decline in the accuracy of the latter. Pocket-size hand-held echocardiographic (PHHE) devices have recently been introduced and could potentially improve the diagnostic accuracy of both medical students and junior doctors. The amount of training required to achieve optimal results remains a matter of debate. We hypothesized that the use of PHHE after limited training in the form of a tutorial can improve the clinical diagnosis even in the hands of medical students and inexperienced physicians.
Methods and results Five final-year medical students and three junior doctors without prior echocardiographic experience participated in a standardized 2 h PHHE bedside tutorial. Subsequently, they assessed 122 cardiology patients using history, physical examination, ECG and PHHE. Their final clinical diagnosis was compared against that of a consultant clinician's and also expert in echocardiography. A total of 122 PHHE were performed of which 64 (53%) by final-year medical students and 58 (47%) by junior doctors. Mean ± SD for diagnostic accuracy after history, physical examination, and ECG interpretation was 0.49 ± 0.22 (maximum = 1), whereas the addition of PHHE increased its value to 0.75 ± 0.28 ( Z = −7.761, P <0.001). When assessing left ventricular systolic dysfunction by means of history and physical examination, specificity was 84.9% and sensitivity only 25.9%, whereas after including findings from PHHE, these figures rose to 93.6 and 74.1%, respectively.
Conclusion The use of PHHE after brief bedside training in the form of a tutorial greatly improved the clinical diagnosis of medical students and junior doctors, over and above history, physical examination, and ECG findings.
187 citations
TL;DR: In a large series of patients operated within the last decade, MVr resulted in a low incidence of long-term LV dysfunction, and a GLS of >-19.9% demonstrated to be a major independent predictor ofLong- term LV dysfunction after adjustment for parameters currently implemented into guidelines.
Abstract: Aims Despite a successful surgical procedure and adherence to current recommendations, postoperative left ventricular (LV) dysfunction after mitral valve repair (MVr) for organic mitral regurgitation (MR) may still occur. New approaches are therefore needed to detect subclinical preoperative LV dysfunction. LV global longitudinal strain (GLS), assessed with speckle-tracking echocardiographic analysis, has been proposed as a novel measure to better depict latent LV dysfunction. The aim of this study was to investigate the value of GLS to predict long-term LV dysfunction after MVr.
Methods and results A total of 233 patients (61% men, 61 ± 12 years) with moderate–severe organic MR who underwent successful MVr between 2000 and 2009 were included. Echocardiography was performed at baseline and long-term follow-up (34 ± 20 months) after MVr. LV dysfunction at follow-up was defined as LV ejection fraction (EF) −19.9% were predictors of long-term LV dysfunction. By multivariate analysis, GLS remained an independent predictor of LV dysfunction (odds ratio 23.16, 95% confidence interval: 6.53–82.10, P < 0.001), together with LVESD.
Conclusion In a large series of patients operated within the last decade, MVr resulted in a low incidence of long-term LV dysfunction. A GLS of >−19.9% demonstrated to be a major independent predictor of long-term LV dysfunction after adjustment for parameters currently implemented into guidelines.
181 citations
TL;DR: Emergency echocardiography recommendations from the European Association of Cardiovascular Imaging recommendations.
Abstract: Emergency echocardiography : the European Association of Cardiovascular Imaging recommendations
158 citations
TL;DR: The use of MAPSE measurement is still especially helpful to evaluate LV systolic function in case of poor sonographic windows, since good imaging quality is required for most of the modern echocardiographic techniques with the exception of tissue Doppler imaging.
Abstract: Mitral annular plane systolic excursion (MAPSE) has been suggested as a parameter for left ventricular (LV) function. This review describes the current clinical application and potential implications of routinely using MAPSE in patients with various cardiovascular diseases. Reduced MAPSE reflects impaired longitudinal function and thus provides complementary information to ejection fraction (EF), which represents the global result of both longitudinal and circumferential contraction. Reduced long-axis deformation results from dysfunctional or stressed longitudinal myofibres due to endo- (and potentially epi-) cardial ischaemia, fibrosis, or increased wall stress. In patients with aortic stenosis, reduced MAPSE is suggestive of subendocardial fibrosis. Moreover, reduced MAPSE could be used as a sensitive early marker of LV systolic dysfunction in hypertensive patients with normal EF, where compensatory increased circumferential deformation might mask the reduced longitudinal deformation. In addition, reduced MAPSE was associated with poor prognosis in patients with heart failure, atrial fibrillation and post-myocardial infarction as well as in patients with severe aortic stenosis undergoing aortic valve replacement. Despite of the routine use of newer and more refined echocardiographic technologies nowadays, such as strain-rate imaging, speckle-tracking imaging, and 3D echocardiography, the use of MAPSE measurement is still especially helpful to evaluate LV systolic function in case of poor sonographic windows, since good imaging quality is required for most of the modern echocardiographic techniques with the exception of tissue Doppler imaging.
150 citations
TL;DR: WSS in the ascending aorta was significantly altered in individuals with BAVs compared with TAV, suggesting that the significantly higher shear forces may have an impact on the development of aortic dilation in patients with B AVs.
Abstract: Aims We compared flow and wall shear stress (WSS) patterns in the ascending aorta of individuals with either bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) using four-dimensional cardiovascular magnetic resonance (4D-CMR). BAV are known to be associated with dilation and dissection of the ascending aorta. However, the cause of vessel disease in patients with BAVs is unknown. Inborn connective tissue disease and also dilation secondary to increased WSS because of altered blood flow patterns in the ascending aorta are discussed as causes for dilation of the aorta. WSS can be estimated non-invasively by 4D-CMR.
Methods and results Eighteen, otherwise, healthy individuals with functionally normal BAVs were compared prospectively with an age- and sex-matched control group of healthy individuals with TAV. Blood flow data were obtained by 4D-CMR visualization and WSS was calculated with specific software tools. Eighty-five per cent of the individuals with BAVs showed a high-grade helical flow pattern in the ascending aorta compared with 6% of the individuals with TAV. WSS in the ascending aorta was significantly altered in individuals with BAVs compared with TAV.
Conclusion WSS and flow patterns in the ascending aorta in patients with BAVs without concomitant valve or vessel disease are significantly different compared with TAV. The significantly higher shear forces may have an impact on the development of aortic dilation in patients with BAVs.
144 citations
TL;DR: Despite equivalent LVSVs, HF patients with mild LV remodelling demonstrate altered diastolic flow routes through the LV and impaired preservation of inflow KE at pre-systole compared with healthy subjects, which may prove useful as subclinical markers of LV dysfunction.
Abstract: Aims Patients with mild heart failure (HF) who are clinically compensated may have normal left ventricular (LV) stroke volume (SV). Despite this, altered intra-ventricular flow patterns have been recognized in these subjects. We hypothesized that, compared with normal LVs, flow in myopathic LVs would demonstrate a smaller proportion of inflow volume passing directly to ejection and diminished the end-diastolic preservation of the inflow kinetic energy (KE).
Methods and results In 10 patients with dilated cardiomyopathy (DCM) (49 ± 14 years, six females) and 10 healthy subjects (44 ± 17 years, four females), four-dimensional MRI velocity and morphological data were acquired. A previously validated method was used to separate the LV end-diastolic volume (EDV) into four flow components based on the blood's locations at the beginning and end of the cardiac cycle. KE was calculated over the cardiac cycle for each component. The EDV was larger ( P = 0.021) and the ejection fraction smaller ( P < 0.001) in DCM compared with healthy subjects; the SV was equivalent (DCM: 77 ± 19, healthy: 79 ± 16 mL). The proportion of the total LV inflow that passed directly to ejection was smaller in DCM ( P = 0.000), but the end-diastolic KE/mL of the direct flow was not different in the two groups (NS).
Conclusion Despite equivalent LVSVs, HF patients with mild LV remodelling demonstrate altered diastolic flow routes through the LV and impaired preservation of inflow KE at pre-systole compared with healthy subjects. These unique flow-specific changes in the flow route and energetics are detectable despite clinical compensation, and may prove useful as subclinical markers of LV dysfunction.
138 citations
TL;DR: Assessment of the final infarct size by CMR 3 months after a STEMI provides strong independent prognostic information incremental to known risk factors including the LVEF, and may help to improve the risk stratification of STEMI patients.
Abstract: Aims Tailored heart failure treatment and risk assessment in patients following ST-segment elevation myocardial infarction (STEMI) is mainly based on the assessment of the left ventricular (LV) ejection fraction (EF). Assessment of the final infarct size in addition to the LVEF may improve the prognostic evaluation. To evaluate the prognostic importance of the final infarct size measured by cardiovascular magnetic resonance (CMR) in patients with STEMI.
Methods and results In an observational study the final infarct size was measured by late gadolinium enhancement CMR 3 months after initial admission in 309 patients with STEMI. The clinical endpoint was a composite of all-cause mortality and admission for heart failure. During the follow-up period of median 807 days (IQR: 669–1117) 35 events (5 non-cardiac deaths, 3 cardiac deaths, and 27 admissions for heart failure) were recorded. Patients with a final infarct size ≥median had significantly higher event rates than patients with a final infarct size
135 citations
TL;DR: In this article, the authors used two-dimensional speckle-tracking echocardiography (2D-STE) and three-dimensional echico-cardiography (3DE) to define normative reference values of RA volumes and function.
Abstract: Aims Right atrial (RA) size predicts the outcome in some pathological conditions but reference values for RA volumes and myocardial function remain to be defined. Thus, we used two-dimensional speckle-tracking echocardiography (2D-STE) and three-dimensional echocardiography (3DE) to define normative reference values of RA volumes and function.
Methods and results Two hundreds healthy volunteers (43 ± 15 years, range 18–75; 44% men) underwent two-dimensional echocardiography (2DE) to obtain RA volumes and longitudinal strain (LS) of RA wall using 2D-STE, and 3DE to measure maximal ( V max), minimal, and preA volumes to calculate total, passive, and active emptying volumes (TotEV, PassEV, and ActEV) and emptying fractions (TotEF, PassEF, and ActEF). Three-dimensional echocardiography volumes ( V max, 52 ± 15 mL vs. 41 ± 14 mL), EVs (TotEV, 33 ± 10 mL vs. 24 ± 9 mL), and EFs (TotEF, 63 ± 9 vs. 58 ± 9%) were larger than 2DE ones (all P < 0.0001). Indexed 3D volumes were significantly larger in men than in women. RA TotEF correlated with total LS ( r = 0.24, P = 0.025) and PassEF with positive LS (LSpos; r = 0.34, P < 0.0001). Ageing was associated with a decrease in passive (LSpos, r = −041; PassEV, r = −0.26; PassEF, r = −0.38; all P < 0.0001) and an increase in active RA function (negative LS, r = 0.34; ActEV, r = 0.25; all P < 0.0001; and ActEF, r = 0.15; P = 0.035) in order to maintain TotEV ( r = −0.14, P = 0.05).
Conclusion Our study provides normative values for RA volumes and function measured by 3DE and 2D-STE in a relatively large cohort of healthy subjects with a wide age range. These data will help clinicians to identify RA remodelling and dysfunction.
127 citations
TL;DR: The assessment necessary to determine eligibility for the MitraClip procedure is described, including accurate assessment of MR and detailed analysis of MV morphology by 2D and 3D echocardiography.
Abstract: Worldwide, there have been more than 6500 MitraClip procedures performed to treat either functional or degenerative mitral regurgitation (MR). The MitraClip procedure is the only available percutaneous device available to reduce MR by creating a double mitral valve (MV) orifice and decreasing MV annular diameter. As the mitral leaflets cannot be assessed by fluoroscopy, procedural success is dependent upon echocardiographic guidance. In this review, we describe the assessment necessary to determine eligibility for the MitraClip procedure. This includes accurate assessment of MR and detailed analysis of MV morphology by 2D and 3D echocardiography. In addition, each of the intraprocedural steps involved in the deployment of this device and the guidance of these steps by 2D and 3D echo are described in detail, along with the use of echo to detect procedural complications. Thus the focus of this review is on the peri-interventional echocardiographic assessment before, during, and after the MitraClip procedure.
121 citations
TL;DR: An overview of the currently available imaging techniques that enable flow visualization, as well as its present and future applications based on the available literature and on-going works are provided.
Abstract: Non-invasive cardiovascular imaging initially focused on heart structures, allowing the visualization of their motion and inferring its functional status from it. Colour-Doppler and cardiac magnetic resonance (CMR) have allowed a visual approach to intracardiac flow behaviour, as well as measuring its velocity at single selected spots. Recently, the application of new technologies to medical use and, particularly, to cardiology has allowed, through different algorithms in CMR and applications of ultrasound-related techniques, the description and analysis of flow behaviour in all points and directions of the selected region, creating the opportunity to incorporate new data reflecting cardiac performance to cardiovascular imaging. The following review provides an overview of the currently available imaging techniques that enable flow visualization, as well as its present and future applications based on the available literature and on-going works.
TL;DR: Most cases of stent malapposition with a short S–V distance, thrombus, tissue prolapse, or minor stent edge dissection improved during the follow-up, and these OCT-detected minor abnormalities may not require additional treatment.
Abstract: Thirty-five patients treated with 40 drug-eluting stents underwent serial optical coherence tomography (OCT) imaging immediately after PCI and at the 8-month follow-up. Among a total of 73 929 struts in every frame, 431 struts (26 stents) showed malapposition immediately after PCI. Among these, 49 remained malapposed at the follow-up examination. The mean distance between the strut and vessel wall (S-V distance) of persistent malapposed struts on post-stenting OCT images was significantly longer than that of resolved malapposed struts (342+99 vs. 210+49 mm; P , 0.01). Based on receiver-operating characteristic curve analysis, an S-V distance ≤260 m mo n post-stenting OCT images was the corresponding cut-off point for resolved malapposed struts (sensitivity: 89.3%, specificity: 83.7%, area under the curve ¼ 0.884). Additionally, 108 newly appearing malapposed struts were observed on follow-up OCT, probably due to thrombus dissolution or plaque regression. Thrombus was observed in 15 stents post-PCI. Serial OCT analysis revealed persistent thrombus in 1 stent, resolved thrombus in 14 stents, and late-acquired thrombus in 8 stents. Tissue prolapse observed in 38 stents had disappeared at the follow-up. All eight stent edge dissections were repaired at the follow-up. Conclusion Most cases of stent malapposition with a short S-V distance, thrombus, tissue prolapse, or minor stent edge dissec- tion improved during the follow-up. These OCT-detected minor abnormalities may not require additional treatment.
TL;DR: The preliminary data suggest that the persistence of vortex from late diastole into IC is a haemodynamic measure of coupling between diastoles and systole and shows association with adverse clinical outcomes seen in HF patients.
Abstract: This study investigated the incremental role of echocardiographic-contrast particle image velocimetry (Echo-PIV) in patients with heart failure (HF) for measuring changes in left ventricular (LV) vortex strength (VS) during phases of a cardiac cycle. Echo-PIV was performed in 42 patients, including 23 HF patients and 19 controls. VS was measured as a fluid-dynamic parameter that integrates blood flow rotation over a given area and correlated with non-invasively derived indices of LV mechanical performance. In comparison with early and late diastole, the VS was higher during isovolumic contraction (IC) for control and HF patients with the preserved ejection fraction (P ¼ 0.002 and P ¼ 0.01, respectively), but not for HF patients with the reduced ejection fraction (P ¼ 0.41). On multivariable regression analysis, the VS during IC (VSIC) was independently related to late-diastolic VS and LV longitudinal strain (R 2 ¼ 0.63, P , 0.001 and P ¼ 0.003, re- spectively). Patients in whom diastolic VS was augmented during IC showed a higher LV stroke volume (P ¼ 0.01), stroke work (P ¼ 0.02), and mechanical efficiency (P ¼ 0.008). Over a median follow-up period of 2.9 years, eight (34%) HF patients were hospitalized for decompensated HF. In comparison with the rest, these eight patients showed markedly reduced longitudinal strain (P ¼ 0.002), and lower change in VS (P ¼ 0.004). Conclusion Our preliminary data suggest that the persistence of vortex from late diastole into IC is a haemodynamic measure of coupling between diastole and systole. The change in VS is correlated with LV mechanical performance and shows association with adverse clinical outcomes seen in HF patients.
TL;DR: By adding a PHHE examination to standard care, medical residents were able to obtain reliable information of important cardiovascular structures in patients admitted to a non-university medical department.
Abstract: Aims To study the feasibility and reliability of pocket-size hand-held echocardiography (PHHE) by medical residents with limited experience in ultrasound.
Methods and results A total of 199 patients admitted to a non-university medical department were examined with PHHE. Six out of 14 medical residents were randomized to use a focused protocol and examine the heart, pericardium, pleural space, and abdominal large vessels. Diagnostic corrections were made and findings were confirmed by standard diagnostics. The median time consumption for the examination was 5.7 min. Each resident performed a median of 27 examinations. The left ventricle was assessed to satisfaction in 97% and the pericardium in all patients. The aortic and atrioventricular valves were assessed in at least 76% and the abdominal aorta in 50%, respectively. Global left-ventricular function, pleural, and pericardial effusion showed very strong correlation with reference method (Spearman's r ≥ 0.8). Quantification of aortic stenosis and regurgitation showed strong correlation with r = 0.7. Regurgitations in the atrioventricular valves showed moderate correlations, r = 0.5 and r = 0.6 for mitral and tricuspid regurgitation, respectively, similar to dilatation of the left atrium ( r = 0.6) and detection of regional dysfunction ( r = 0.6). Quantification of the abdominal aorta (aneurysmatic or not) showed strong correlation, r = 0.7, while the inferior vena cava diameter correlated moderately, r = 0.5.
Conclusion By adding a PHHE examination to standard care, medical residents were able to obtain reliable information of important cardiovascular structures in patients admitted to a medical department. Thus, focused examinations with PHHE performed by residents after a training period have the potential to improve in-hospital diagnostic procedures.
TL;DR: In this paper, the authors used the Kaplan-Meier method to identify independent predictors of MACE in patients with suspected myocardial ischaemia, and found that the largest added value was conferred by com- bining stress MBF to SDS, while the lowest stressMBF tertile group (MBF,1.8 mL/min/g) had the highest MACE rate.
Abstract: Westudiedtherespectiveaddedvalueofthequantitativemyocardialbloodflow(MBF)andthemyocardialflowreserve (MFR)asassessedwith 82 Rbpositronemissiontomography(PET)/CTinpredictingmajoradversecardiovascularevents (MACEs) in patients with suspected myocardial ischaemia. Methods and results Myocardialperfusionimageswereanalysedsemi-quantitatively(SDS,summeddifferencescore)andquantitatively(MBF, MFR) in 351 patients. Follow-up was completed in 335 patients and annualized MACE (cardiacdeath, myocardial infarc- tion, revascularization, or hospitalization for congestive heart failure or de novo stable angor) rates were analysed with theKaplan-Meiermethodin318patientsafterexcluding17patientswithearlyrevascularizations(,60 days).Independ- ent predictors of MACEs were identified by multivariate analysis. During a median follow-up of 624 days (inter-quartile range 540-697), 35 MACEs occurred. An annualized MACE rate was higher in patients with ischaemia (SDS .2) (n ¼ 105) than those without (14% (95% CI ¼ 9.1-22%) vs. 4.5% (2.7-7.4%), P , 0.0001). The lowest MFR tertile group (MFR ,1.8) had the highest MACE rate (16% (11-25%) vs. 2.9% (1.2-7.0%) and 4.3% (2.1-9.0%), P , 0.0001). Similarly, the lowest stress MBF tertile group (MBF ,1.8 mL/min/g) had the highest MACE rate (14% (9.2-22%)vs.7.3%(4.2-13%)and1.8%(0.6-5.5%),P ¼ 0.0005).QuantitationwithstressMBForMFRhadasignificant independentprognosticpower inadditionto semi-quantitativefindings.The largest addedvaluewas conferredbycom- bining stress MBF to SDS. This holds true even for patients without ischaemia. Conclusion Perfusionfindingsin 82 RbPET/CTarestrongMACEoutcomepredictors.MBFquantificationhasanaddedvalueallowing
TL;DR: Children with newly diagnosed ALL showed decline of systolic and diastolic function during treatment with anthracyclines using cardiac biomarkers and myocardial 2D strain echocardiography and cTnT was not a predictor for abnormal strain at T = 2.
Abstract: Aims The aim of this study was to investigate myocardial 2D strain echocardiography and cardiac biomarkers in the assessment of cardiac function in children with acute lymphoblastic leukaemia (ALL) during and shortly after treatment with anthracyclines.
Methods and results Cardiac function of 60 children with ALL was prospectively studied with measurements of cardiac troponin T (cTnT) and N-terminal-pro-brain natriuretic peptide (NT-pro-BNP) and conventional and myocardial 2D strain echocardiography before start ( T = 0), after 3 months ( T = 1), and after 1 year ( T = 2), and were compared with 60 healthy age-matched controls. None of the patients showed clinical signs of cardiac failure or abnormal fractional shortening. Cardiac function decreased significantly during treatment and was significantly decreased compared with normal controls. Cardiac troponin T levels were abnormal in 11% of the patients at T = 1 and were significantly related to increased time to global peak systolic longitudinal strain at T = 2 ( P = 0.003). N-terminal-pro-brain natriuretic peptide levels were abnormal in 13% of patients at T = 1 and in 20% at T = 2, absolute values increased throughout treatment in 59%. Predictors for abnormal NT-pro-BNP at T = 2 were abnormal NT-pro-BNP at T = 0 and T = 1, for abnormal myocardial 2D strain parameters at T = 2 cumulative anthracycline dose and z-score of the diastolic left ventricular internal diameter at baseline.
Conclusion Children with newly diagnosed ALL showed decline of systolic and diastolic function during treatment with anthracyclines using cardiac biomarkers and myocardial 2D strain echocardiography. N-terminal-pro-brain natriuretic peptide levels were not related to echocardiographic strain parameters and cTnT was not a predictor for abnormal strain at T = 2 . Therefore, the combination of cardiac biomarkers and myocardial 2D strain echocardiography is important in the assessment of cardiac function of children with ALL treated with anthracyclines.
TL;DR: After completion of the NORRE Study, uniform reference limits according to age, gender, and anthropometric parameters will be available to standardize the quantitative interpretation of echocardiography.
Abstract: BACKGROUND: Availability of normative reference values for cardiac chamber dimensions, volumes, mass, and function is a prerequisite for the accurate application of echocardiography for both clinical and research purposes. However, due to the lack of consistency in current echocardiographic 'reference values', their use for clinical decision-making remains questionable. AIMS: The aim of the 'Normal Reference Ranges for Echocardiography Study (NORRE Study)' is to obtain a set of 'normal values' for cardiac chamber geometry and function in a large cohort of healthy Caucasian individuals aged over a wide range of ages (25-75 years) using both conventional and advanced echocardiographic techniques. METHODS: The NORRE Study is a large prospective, observational multicentre study in which transthoracic echocardiographic studies will be acquired in 22 laboratories accredited by the European Association of Cardiovascular Imaging and in one laboratory in the USA accredited by ICAEL. The final sample size has been estimated in 1100 normal subjects in whom M-mode, 2D, and 3D imaging, colour Doppler, pulsed-wave Doppler, pulsed-wave tissue Doppler, and colour tissue Doppler imaging data will be obtained. All studies will be sent to a central echocardiographic core laboratory for quantitative analysis. Multiple studies will be performed for reproducibility analysis. CONCLUSION: After completion of the NORRE Study, uniform reference limits according to age, gender, and anthropometric parameters will be available to standardize the quantitative interpretation of echocardiography.
TL;DR: Apart from Lε, the inter-vendor agreement of Rε, Cε and Aε measured with Artida and VividE9 was poor, and Reference values should be specific for each system and baseline and follow-up data in longitudinal studies should be obtained using the same 3D STE platform.
Abstract: Aims Since there is insufficient data available about the inter-vendor consistency of three-dimensional (3D) speckle-tracking (STE) measurements, we undertook this study to (i) assess the inter-vendor consistency of 3D LV global strain values obtained using two different scanners; (ii) identify the sources of inter-vendor inconsistencies, if any; and (iii) compare their respective intrinsic variability.
Methods and results Sixty patients (38 ± 12 years, 64% males) with a wide range of LV end-diastolic volumes (from 74 to 205 ml) and ejection fractions (from 17 to 70%) underwent two 3D LV data set acquisitions using VividE9 and Artida ultrasound systems. Global longitudinal (Lɛ), radial (Rɛ), circumferential (Cɛ) and area (Aɛ) strain values were obtained offline using the corresponding 3D STE softwares. Despite being significantly different, Lɛ showed the closest values between the two platforms (bias = 1.5%, limits of agreement (LOA) from −2.9 to −5.9%, P < 0.05). Artida produced significantly higher values of both Cɛ and Aɛ than VividE9 (bias = 6.6, LOA: −14.1 to 0.9%, and bias = 6.0, LOA = −28.2–8.6%, respectively, P < 0.001). Conversely, Rɛ values obtained with Artida were significantly lower than those measured using VividE9 platform (bias = −24.2, LOA: 1.5–49.9, P < 0.001). All strain components showed good reproducibility (intra-class correlation coefficients: 0.82–0.98), except for Rɛ by Artida, which showed only a moderate reproducibility.
Conclusion Apart from Lɛ, the inter-vendor agreement of Rɛ, Cɛ and Aɛ measured with Artida and VividE9 was poor. Reference values should be specific for each system and baseline and follow-up data in longitudinal studies should be obtained using the same 3D STE platform.
Cedars-Sinai Medical Center1, University of Erlangen-Nuremberg2, Wayne State University3, University of California, Los Angeles4, Erasmus University Rotterdam5, Yonsei University6, Beaumont Hospital7, University of Ottawa8, Cornell University9, Innsbruck Medical University10, Ludwig Maximilian University of Munich11, University of Zurich12, Seoul National University Hospital13, University of British Columbia14, Emory University15
TL;DR: Amongst patients with suspected CAD referred for CCTA, individuals with increased BMI have greater prevalence, extent, and severity of CAD that is not fully explained by the presence of traditional risk factors.
Abstract: Aims Obesity is associated with the presence of coronary artery disease (CAD) risk factors and cardiovascular events. We examined the relationship between body mass index (BMI) and the presence, extent, severity, and risk of CAD in patients referred for coronary computed tomographic angiography (CCTA).
Methods and results We evaluated 13 874 patients from a prospective, international, multicentre registry of individuals without known CAD undergoing CCTA. We compared risk factors, CAD findings, and risk of all-cause mortality and non-fatal myocardial infarction (MI) amongst individuals with underweight (18.5–20.0 kg/m2), normal (20.1–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2) BMI. The mean follow-up was 2.4 ± 1.2 years with 143 deaths and 193 MIs. Among underweight, normal weight, overweight, and obese individuals, there was increasing prevalence of diabetes (7 vs.10% vs. 12 vs. 19%), hypertension (37 vs. 40% vs. 46 vs. 59%), and hyperlipidaemia (48 vs. 52% vs. 56 vs. 56%; P < 0.001 for trend). After multivariable adjustment, BMI was positively associated with the prevalence of any CAD [odds ratio (OR) 1.25 per +5 kg/m2, 95% confidence interval (CI): 1.20–1.30, P < 0.001] and obstructive (≥50% stenosis) CAD (OR: 1.13 per +5 kg/m2, 95% CI: 1.08–1.19, P < 0.001); a higher BMI was also associated with an increased number of segments with plaque (+0.26 segments per +5 kg/m2, 95% CI: 0.22–0.30, P < 0.001). Larger BMI categories were associated with an increase in all-cause mortality ( P = 0.004), but no difference in non-fatal MI. After multivariable adjustment, a higher BMI was independently associated with increased risk of MI (hazards ratio: 1.28 per +5 kg/m2, 95% CI: 1.12–1.45, P < 0.001).
Conclusions Amongst patients with suspected CAD referred for CCTA, individuals with increased BMI have greater prevalence, extent, and severity of CAD that is not fully explained by the presence of traditional risk factors. A higher BMI is independently associated with increased risk of intermediate-term risk of myocardial infarction.
TL;DR: The OCT morphological characteristics of DES restenotic tissue varied at different time-points, and OCT images in early DES ISR might be associated with delayed arterial healing, and neoatherosclerosis might contribute to late catch-up phenomenon (L-ISR and VL- ISR) after DES implantation.
Abstract: Aims Restenosis of drug-eluting stents (DESs) might be different from that of bare metal stent restenosis in diverse ways including mechanisms and time course; however, these have not been fully examined To gain insight into the mechanisms and time course of DES restenosis, we evaluated the characteristics of restenotic lesions of first generation DES using optical coherence tomography (OCT)
Methods and results We compared the morphological characteristics of early in-stent restenosis ( 3 years: VL-ISR, n = 21) OCT qualitative restenotic tissue analysis included the assessment of tissue structure [homogeneous or four types of heterogeneous intima (thin-cap fibroatheroma (TCFA)-like, layered, patchy or speckled pattern)], the presence of the peri-strut low intensity area (PLIA), microvessels, disruption with cavity, and intraluminal material and was performed at every 1 mm slice of the entire stent length In addition to a greater trend for heterogeneous intima at the later phase, TCFA-like pattern image, intra-intima microvessels were increased from the early to the very late phase On the other hand, the speckled pattern image was decreased from the early to the very late phase
Conclusion The OCT morphological characteristics of DES restenotic tissue varied at different time-points OCT images in early DES ISR might be associated with delayed arterial healing, and neoatherosclerosis might contribute to late catch-up phenomenon (L-ISR and VL-ISR) after DES implantation
TL;DR: GLS has an incremental value over LVEF for risk stratification in patients referred for cardiac surgery and is an independent predictor for early postoperative mortality, after adjustment to EuroSCORE.
Abstract: Aims Global longitudinal strain (GLS) seems accurate for detecting subclinical myocardial dysfunction, and may therefore be used to improve risk stratification for cardiac surgery.
Methods and results Longitudinal strain (by two-dimensional speckle tracking) was computed in 425 patients [mean age 67 ± 13 years, 69% male, left ventricular ejection fraction (LVEF) 51 ± 13%] referred for cardiac surgery [isolated coronary artery bypass graft (CABG) ( n = 155), aortic valve surgery ( n = 174), mitral surgery ( n = 96)]. GLS (global-ɛ) was assessed for predicting early postoperative death. Despite a fair correlation between LVEF and global strain ( r = −0.73, P −16%): −12.8 ± 1.7%, range −15% to −8%. In patients with preserved LVEF, NT-proBNP level (983 vs. 541 pg/mL, P = 0.03), heart failure symptoms (NYHA class, 2.2 ± 0.9 vs. 1.9 ± 0.9, P = 0.02), and the need for prolonged (>48 h) inotropic support after surgery (33.3 vs. 21.2%, P = 0.03) were greater when global-ɛ was impaired. Importantly, despite similar EuroSCORE (9.7 ± 12 vs. 7.7 ± 9%, P = 0.2 for EuroSCORE I and 4.2 ± 6.2 vs. 3.4 ± 4.9%, P = 0.4 for EuroSCORE II), the rate of postoperative death was 2.4-fold (11.8 vs. 4.9%, P = 0.04) in patients with preserved LVEF when global-ɛ was impaired. Multivariate analysis showed that global-ɛ is an independent predictor for early postoperative mortality [odds ratio = 1.10 (1.01–1.21)] after adjustment to EuroSCORE.
Conclusion GLS has an incremental value over LVEF for risk stratification in patients referred for cardiac surgery.
TL;DR: The applied CMR method was feasible and accurate in normal and regurgitant valves, and may potentially have an impact on diagnosis, improvement of surgical techniques and design of annular prostheses.
Abstract: AIMS To explore the potentiality of cardiovascular magnetic resonance (CMR) in the quantitative evaluation of mitral valve annulus (MVA) and tricuspid valve annulus (TVA) morphology and dynamics METHODS AND RESULTS CMR was performed in 13 normal subjects and 9 patients with mitral (n = 7) or tricuspid regurgitation (n = 2), acquiring cine-images in 18 radial long-axis planes passing through the middle of MVA or TVA A novel algorithm was used to obtain dynamic three-dimensional (3D) reconstruction of MVA and TVA Analysis was feasible in all cases, allowing accurate 3D annular reconstruction and tracking The 3D area increased from systole [MVA, median = 100 cm(2) (first quartile = 86, third quartile = 114); TVA, 112 cm(2) (88-132)] to diastole [MVA, 106 cm(2) (94, 117); TVA, 119 cm(2) (92-135)], with TVA larger than MVA While the longest diameter showed similar systolic and diastolic values, the shortest diameter elongated from systole [MVA, 30 mm (29-33); TVA, 33 mm (31-36)] to diastole [MVA, 31 mm (29-32); TVA, 36 mm (33-39)] Also, TVA became more circular than MVA TVA showed lower peak systolic excursion in the septal [159 mm (130-185)] and anterior regions [179 mm (122-207)] compared with the posterior [219 mm (186-240)] segment Values in MVA were smaller than in TVA, slightly higher in anterior [112 mm (95-130)] than in posterior [124 mm (102-146)] segments Valvular regurgitation was associated with enlarged, flattened, and more circular annuli CONCLUSION The applied method was feasible and accurate in normal and regurgitant valves, and may potentially have an impact on diagnosis, improvement of surgical techniques and design of annular prostheses
TL;DR: Usual indices of RV function are associated with ventricular-arterial coupling rather than with Ventricular contractility in a model of chronic pressure overload.
Abstract: AIMS: To investigate the physiological correlates of indices of RV function in a model of chronic pressure overload. METHODS AND RESULTS: Chronic pulmonary hypertension (PH) was induced in piglets by ligation of the left pulmonary artery (PA) followed by weekly embolization of right lower lobe arteries for 5 weeks (the PH group, n = 11). These animals were compared with sham-operated animals (controls, n = 6). At 6 weeks, a subgroup of five PH pigs underwent surgical reperfusion of the left lung and four others were followed until 12 weeks without treatment. Right ventricular function was assessed using echocardiography and conductance catheter measurements. At 6 weeks, mean PA pressure was higher in PH group compared with controls (35 ± 9 vs. 14 ± 2 mmHg, P < 0.01). Although RV elastance (Ees) increased at 6 weeks in the PH group (0.55 ± 0.09 vs. 0.38 ± 0.05mmHg/mL, P < 0.001), ventricular-arterial coupling measured by the ratio of Ees on PA elastance (Ea) was decreased (0.68 ± 0.17 vs. 1.18 ± 0.18, P < 0.001). There was a strong direct relationship between Ees/Ea and indices of RV function, while relationship between Ees and indices of RV function was moderate. Changes in indices of RV function with time and after left lung reperfusion were associated with changes in Ees/Ea. CONCLUSION: Usual indices of RV function are associated with ventricular-arterial coupling rather than with ventricular contractility in a model of chronic pressure overload.
TL;DR: RLS and RLS evaluation provides an accurate assessment of global myocardial function and of the presence of segments with transmural extent of necrosis, with several potential clinical implications.
Abstract: Aims Global and regional longitudinal strain (GLS–RLS) assessed by two-dimensional speckle tracking echocardiography (2D-STE) are considered reliable indexes of left-ventricular (LV) function and myocardial viability in chronic ischaemic patients when compared with delayed-enhanced cardiac magnetic resonance (DE-CMR). In the present study, we tested whether GLS and RLS could also identify early myocardial dysfunction and transmural extent of myocardial scar in patients with acute ST elevation myocardial infarction (STEMI) and relatively preserved LV function.
Methods and results Twenty STEMI patients with LVEF ≥40%, treated with PPCI within 6 h from symptoms onset, underwent DE-CMR and 2D-echocardiography for 2D-STE analysis 6 ± 2 days after STEMI. Wall motion score index (WMSI) and LV ejection fraction (LVEF) were calculated by both methods. Infarct size and transmural extent of necrosis were assessed by CMR. GLS and RLS were obtained by 2D-STE. Mean GLS of the study population was −14 ± 3.3, showing a significant correlation with both LVEF and WMSI, by CMR ( r = −0.86, P = 0.001, and r = 0.80, P = 0.001, respectively) and time-to-PCI ( r = 0.66, P = 0.038). A weaker correlation was found between GLS and LVEF and WMSI assessed by 2D-echo ( r = −0.65, P = 0.001, and r = 0.53, P = 0.013, respectively). RLS was significantly lower in DE-segments when compared with normal myocardium ( P < 0.0001). A cut-off value of RLS of −12.3% by receiver-operating characteristic (ROC) curves identified DE-segments (sensitivity 82%, specificity 78%), whereas a cut-off value of −11.5% identified transmural extent of DE (sensitivity 75%, specificity 78%).
Conclusion Our findings indicate that RLS and GLS evaluation provides an accurate assessment of global myocardial function and of the presence of segments with transmural extent of necrosis, with several potential clinical implications.
TL;DR: This study suggests that LS is useful for the identification of perivalvular infection in patients with a suspicion of PVE and inconclusive transoesophageal echocardiography (TEE).
Abstract: Aims In patients with a suspicion of prosthetic valve endocarditis (PVE), detection of perivalvular infection can be difficult based only on echocardiography. The aim of this retrospective study was to test the interest of radiolabelled leucocyte scintigraphy (LS) for the detection of perivalvular infection in patients with a suspicion of PVE and inconclusive transoesophageal echocardiography (TEE).
Methods and results LS was performed in 42 patients. The results of LS were classified as positive in the cardiac area (intense or mild), or negative. Macroscopical aspects and bacteriology were obtained from patients who underwent cardiac surgery ( n = 10). Clinical outcome was collected in patients treated medically ( n = 32).
Among patients with intense signal with LS who underwent surgery ( n = 6), five had an abscess confirmed during intervention and one, post-operatively. Patients with intense accumulation of radiolabelled leucocytes with scintigraphy and treated medically ( n = 3) had a poor outcome: death ( n = 1); prosthetic valve dehiscence ( n = 1); and recurrent endocarditis ( n = 1). Among patients with mild activity with LS ( n = 5), one patient developed a large prosthetic valve dehiscence during the follow-up. The remaining four patients were treated medically and did not present any recurrent endocarditis after a median follow-up of 14 months. No abscess was detected in patients with negative LS who underwent surgery ( n = 4). Among the patients with negative LS treated medically ( n = 24), none presented recurrent endocarditis after a mean follow-up of 15 ± 16 months. Patient management was influenced by the results of LS in 12 out of 42 patients (29%).
Conclusion This study suggests that LS is useful for the identification of perivalvular infection in patients with a suspicion of PVE and inconclusive TEE.
TL;DR: Whether adenosine stress myocardial perfusion imaging by Dual Source CT enables non-invasive quantification of regional MBF in an animal model with various degrees of coronary flow reduction is determined.
Abstract: Aims Only few preliminary experimental studies demonstrated the feasibility of adenosine stress CT myocardial perfusion imaging to calculate the absolute myocardial blood flow (MBF), thereby providing information whether a coronary stenosis is flow limiting. Therefore, the aim of our study was to determine whether adenosine stress myocardial perfusion imaging by Dual Source CT (DSCT) enables non-invasive quantification of regional MBF in an animal model with various degrees of coronary flow reduction.
Methods and results In seven pigs, a coronary flow probe and an adjustable hydraulic occluder were placed around the left anterior descending coronary artery to monitor the distal coronary artery blood flow (CBF) while several degrees of coronary flow reduction were induced. CT perfusion (CT-MBF) was acquired during adenosine stress with no CBF reduction, an intermediate (15–39%) and a severe (40–95%) CBF reduction. Reference standards were CBF and fractional flow reserve measurements (FFR). FFR was simultaneously derived from distal coronary artery pressure and aortic pressure measurements. CT-MBF decreased progressively with increasing CBF reduction severity from 2.68 (2.31–2.81)mL/g/min (normal CBF) to 1.96 (1.83–2.33) mL/g/min (intermediate CBF-reduction) and to 1.55 (1.14–2.06)mL/g/min (severe CBF-reduction) (both P < 0.001). We observed very good correlations between CT-MBF and CBF ( r = 0.85, P < 0.001) and CT-MBF and FFR ( r = 0.85, P < 0.001).
Conclusion Adenosine stress DSCT myocardial perfusion imaging allows quantification of regional MBF under various degrees of CBF reduction.
TL;DR: In STEMI patients, impaired LA fractional change is independently associated with outcome and provide incremental prognostic information to established predictors including LAmax and other known predictors.
Abstract: Aims The left atrium (LA) transfers blood to the left ventricle in a complex manner. LA function is characterized by passive emptying (LA passive fraction), active emptying (LA ejection fraction), and total emptying (LA fractional change). Despite this complexity, the clinical relevance of the LA is based almost exclusively on LA maximal volume (LAmax), which may not glean the full prognostic potential. Cardiovascular magnetic resonance (CMR) is considered the most accurate method for studying LA function and size. The aim of the present study was to evaluate the prognostic importance of LA function in patients following ST elevation myocardial infarction (STEMI).
Methods and results In 199 patients, a CMR scan was performed within 1–3 days after STEMI to measure LAmax and minimal volume (LAmin) and LA function. The incidence of death, re-infarction, stroke, and admission for heart failure [major adverse cardiac event (MACE)] were registered during the follow-up period [2.3 years (inter-quartile range: 2.0–2.5)]. A total of 40 patients (20%) met the clinical endpoint of MACE during follow-up. In a Cox regression analysis adjusting for known risk factors, LA fractional change remained independently associated with MACE [adjusted hazard ratio: 0.66 (95% confidence interval: 0.46–0.95)]. LAmax, LAmin, or LA passive fraction was not independently associated with MACE. Furthermore, LA fractional change provided incremental prognostic value to LAmax and other known predictors (Wald χ 2 31.0 vs. 39.9, P = 0.016).
Conclusion In STEMI patients, impaired LA fractional change is independently associated with outcome and provide incremental prognostic information to established predictors including LAmax.
TL;DR: Results suggest that CMR guidance may represent a clinically useful tool for CRT, and lead placement was possible in the CMR target region in most patients with an AHR comparable with the best achieved in any CS branch.
Abstract: CMR-derived anatomical models and dyssynchrony maps were created for 20 patients. The CMR targets (three latest activated segments with ,50% scar) were overlaid on to live fluoroscopy. Acute haemodynamic response (AHR) to LV pacing was assessed using an intra-ventricular pressure wire. Chronic CRT response (end-systolic volume reduc- tion ≥15%) was assessed 6 months post-implantation. All patients underwent successful CMR-guided LV lead place- ment. A CMR target segment was paced in 75% of patients. The mean change in LVdP/dtmax for the CMR target was +14.2+ 12.5 vs. +18.7+ 11.9% for the best AHR in any segment and +12.0+ 13.8% for the segment based on coronary sinus (CS) venography. Using CMR guidance, the acute responder rate was 60 vs. 50% on the basis of ven- ography. At 6 months 60% of patients were echocardiographic responders. Of the echocardiographic responders, 92% were successfully paced in a CMR target segment compared with only 50% of non-responders (P ¼ 0.04). Conclusion CMR guidance compared well when validated against the AHR. Lead placement was possible in the CMR target region in most patients with an AHR comparable with the best achieved in any CS branch. The chronic response was significantly better in patients paced in a CMR target segment. These results suggest that CMR guidance may represent a clinically useful tool for CRT.
TL;DR: Echocardiographic quantitation of myocardial deformation has been one of the most significant developments in this field over the last decade, with important applications in basicMyocardial mechanics, ischaemic heart disease, cardiomyopathies, valvularHeart disease, diastolic function, and in detecting pre-clinical myocardials dysfunction.
Abstract: Echocardiographic quantitation of myocardial deformation has been one of the most significant developments in our field over the last decade, with important applications in basic myocardial mechanics, ischaemic heart disease, cardiomyopathies, valvular heart disease, diastolic function, and in detecting pre-clinical myocardial dysfunction such as in cardiotoxicity in cancer chemotherapy and valvular regurgitation. Unfortunately, several investigators have documented a relatively poor reproducibility when strain is calculated using echocardiographic equipment from different vendors, an issue that threatens widespread clinical application of this important new technology.
Recognizing the critical need for standardization in strain imaging, in 2010, the leaders of the European Association of Echocardiography (now the European Association of Cardiovascular Imaging, EACVI), and the American Society of Echocardiography (ASE) invited technical representatives from all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. Table 1 lists the society and vendor representatives on this committee, which met for the first time at EuroEcho in Copenhagen in December, 2010.This brief …
TL;DR: Septal interstitial expansion is seen in adults late after atrial redirection surgery for TGA and may have a role in the development of RV systolic impairment.
Abstract: Aims After atrial redirection surgery (Mustard–Senning operations) for transposition of the great arteries (TGA), the systemic right ventricle (RV) suffers from late systolic failure with high morbidity and mortality. Mechanisms of late RV failure are poorly characterized. We hypothesized that diffuse interstitial expansion representing diffuse fibrosis is greater in systemic RVs of patients following Mustard–Senning surgery and that it would be associated with other markers of heart failure and disease severity.
Methods and results We used equilibrium contrast cardiovascular magnetic resonance (CMR) imaging to quantify extracellular volume (ECV) in the septum and RV free wall of 14 adults presenting to a specialist clinic late after surgery for TGA (8 Mustard, 6 female, median age 33). These were compared with 14 age-and sex-matched healthy volunteers. Patients were assessed with a standardized CMR protocol, NT-brain natriuretic peptide (NT-proBNP), and cardiopulmonary exercise (CPEX) testing.
The mean septal ECV was significantly higher in patients than controls (0.254 ± 0.036 vs. 0.230 ± 0.032; P = 0.03). NT-proBNP positively related to septal ECV ( P = 0.04; r = 0.55). The chronotropic index (CI) during CPEX testing negatively related to the ECV ( P = 0.04; r = −0.58). No relationship was seen with other CMR or CPEX parameters. R.V free wall ECV was difficult to measure (heavy trabeculation, sternal wires, blood pool in regions of interest) with high and poor inter-observer reproducibility: this analysis was abandoned.
Conclusion Septal interstitial expansion is seen in adults late after atrial redirection surgery for TGA. It correlates well with NT-proBNP and CI and may have a role in the development of RV systolic impairment. Measuring interstitial expansion in the RV free wall is difficult using this methodology.