Showing papers in "Journal of The American Society of Echocardiography in 2009"

Recommendations for the evaluation of left ventricular diastolic function by echocardiography

Abstract: Recommendations for the evaluation of left ventricular diastolic function by echocardiography

Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice

Abstract: Abbreviations: AR aortic regurgitation, AS aortic stenosis, AVA aortic valve area, CSA cross sectional area, CWD continuous wave Doppler, D diameter, HOCM hypertrophic obstructive cardiomyopathy, LV left ventricle, LVOT left ventricular outflow tract, MR mitral regurgitation, MS mitral stenosis, MVA mitral valve area, DP pressure gradient, RV right ventricle, RVOT right ventricular outflow tract, SV stroke volume, TEE transesophageal echocardiography, T1/2 pressure half-time, TR tricuspid regurgitation, TS tricuspid stenosis, V velocity, VSD ventricular septal defect, VTI velocity time integral

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound. A Report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association

Abstract: A Report From the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, Endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography

Echocardiographic Epicardial Fat: A Review of Research and Clinical Applications

Abstract: Epicardial fat plays a role in cardiovascular diseases. Because of its anatomic and functional proximity to the myocardium and its intense metabolic activity, some interactions between the heart and its visceral fat depot have been suggested. Epicardial fat can be visualized and measured using standard two-dimensional echocardiography. Standard parasternal long-axis and short-axis views permit the most accurate measurement of epicardial fat thickness overlying the right ventricle. Epicardial fat thickness is generally identified as the echo-free space between the outer wall of the myocardium and the visceral layer of pericardium and is measured perpendicularly on the free wall of the right ventricle at end-systole. Echocardiographic epicardial fat thickness ranges from a minimum of 1 mm to a maximum of almost 23 mm. Echocardiographic epicardial fat thickness clearly reflects visceral adiposity rather than general obesity. It correlates with metabolic syndrome, insulin resistance, coronary artery disease, and subclinical atherosclerosis, and therefore it might serve as a simple tool for cardiometabolic risk prediction. Substantial changes in echocardiographic epicardial fat thickness during weight-loss strategies may also suggest its use as a marker of therapeutic effect. Echocardiographic epicardial fat measurement in both clinical and research scenarios has several advantages, including its low cost, easy accessibility, rapid applicability, and good reproducibility. However, more evidence is necessary to evaluate whether echocardiographic epicardial fat thickness may become a routine way of assessing cardiovascular risk in a clinical setting.

Age-specific reference intervals for indexed left ventricular mass in children.

Abstract: Background In older children, one of the standards for indexing left ventricular mass (LVM) is height raised to an exponential power of 2.7. The purpose of this study was to establish a normal value for the pediatric age group and to determine how, if at all, LVM/height 2.7 varies in children. Methods M-mode echocardiography was performed in 2,273 nonobese, healthy children (1,267 boys, 1,006 girls; age range 0-18 years). Curves were constructed for the 5th, 10th, 25th, 50th, 75th, 90th, and 95th quantiles of LVM/height 2.7 . Results In children aged > 9 years, median LVM/height 2.7 ranged from 27 to 32 g/m 2.7 and had little variation with age. However, in those aged 2.7 varied significantly, and percentiles for newborns and infants were approximately double the levels for older children and adolescents: the 95th percentile ranged from 80 g/m 2.7 for newborns to 40 g/m 2.7 for 11-year-olds. Conclusion For patients aged > 9 years, quantiles of LVM/height 2.7 vary little, and values > 40 g/m 2.7 in girls and > 45 g/m 2.7 in boys can be considered abnormal (ie, > 95th percentile). However, for patients aged 2.7 must be compared with percentile curves, which are provided. This variation in LVM/height 2.7 in younger children indicates that a better indexing method is needed for this age group. Nevertheless, these data are valuable in that they provide normal values with which patient data can be compared.

Right Ventricular Function in Infants, Children and Adolescents: Reference Values of the Tricuspid Annular Plane Systolic Excursion (TAPSE) in 640 Healthy Patients and Calculation of z Score Values

Abstract: Background Tricuspid annular plane systolic excursion (TAPSE) is an echocardiographic measurement to assess right ventricular systolic function in adults. The aim of this study was to determine growth-related changes in TAPSE to establish references values. Methods A prospective study was conducted in a group of 640 healthy pediatric patients (age range, 1 day to 18 years; body surface area range, 0.12-2.25 m 2 ). The effects of age and body surface area on TAPSE were determined. Results TAPSE ranged from a mean of 0.91 cm ( z score ± 3, 0.56-1.26 cm) in neonates to 2.47 cm ( z score ± 3, 1.84-3.10 cm) in 18-year-olds. TAPSE values showed positive correlations with age and body surface area. There was no significant difference in TAPSE values between female or male children. Conclusion In this study, z scores of TAPSE values were calculated and percentile charts were established to serve as reference data for ready application in patients with congenital heart disease in the future.

Two-dimensional speckle-tracking echocardiography of the left atrium: feasibility and regional contraction and relaxation differences in normal subjects.

Abstract: Background Increased left atrial (LA) size and reduced global contractility are related to adverse cardiac events. The potential incremental value of assessing regional LA contractility is unknown. To assess the feasibility of measuring this variable angle, independent 2-dimensional speckle-tracking strain echocardiography (2D-SpTr) was used to measure regional LA strain (ɛ) and strain rate (SR) in normal individuals of various ages. Methods From standard apical views, 2D-SpTr was used on 84 normal subjects to measure longitudinal velocity, ɛ, and SR in 13 LA segmental regions. The values obtained from the different atrial regions were compared with each other and corresponding LA volumes before and after LA contraction. Results Regional LA ɛ and SR could be measured in 77 of 84 normal subjects (94%). A consistent pattern of differences in LA regional function was noted with the annular regions, and particularly the inferior wall having a larger average peak velocity and ɛ and SR values in comparison with the mid and superior LA segments. Peak ɛ and SR during LA contraction had only a modest correlation with LA volumes. Conclusion The angle-independent technique of 2D-SpTr tracking can analyze regional LA ɛ and SR in 94% of normal subjects. Regional differences in LA contractility are consistently present. The annular regions, and especially the inferior wall have the highest values for LA ɛ and SR. The significance of these findings and their possible use in identifying disease states will require further study.

Comprehensive Evaluation of Left Ventricular Strain Using Speckle Tracking Echocardiography in Normal Adults: Comparison of Three-Dimensional and Two-Dimensional Approaches

Abstract: Objective The two-dimensional speckle tracking (2DT) method is based on the measurements of strain on two-dimensional (2D) images, ignoring actual three-dimensional (3D) myocardial movements. We sought to investigate the feasibility of the newly developed three-dimensional speckle tracking (3DT) method to assess longitudinal, circumferential, and radial strain values, and then compared the data with those measured by 2DT. Methods Echocardiographic examinations were performed in 46 volunteers. In the apical 3D volumetric images, 3 vectors of the strains were analyzed in 16 myocardial segments. 2D longitudinal strain was assessed in apical 4-, 3-, and 2-chamber views, and circumferential and radial strains were measured in parasternal short-axis view. Results The average time for 3D image acquisition and 3D strain analysis by 3DT was significantly shorter than for 2DT. Longitudinal strain value by 3DT was significantly smaller than by 2DT (−17.4% ± 5.0% vs −19.9% ± 6.7%, P P Conclusion 3DT is a simple, feasible, and reproducible method to measure longitudinal, circumferential, and radial strains. The discordant results between 3DT and 2DT may be explained by the 3D cardiac motion that has been ignored in current 2DT.

Assessment of the right ventricle by echocardiography: a primer for cardiac sonographers.

Abstract: The assessment of right ventricular (RV) structure and function by echocardiography has been improved by advancements that include Doppler tissue imaging, strain imaging, and three-dimensional imaging. Doppler tissue imaging and strain imaging can be useful for the assessment of regional RV systolic and diastolic function. Three-dimensional imaging has been reported to determine RV volumes and ejection fraction, which have previously been cumbersome to measure with conventional two-dimensional echocardiography. This article addresses the role of conventional and newer methods of echocardiography to assist sonographers in understanding the technical considerations, limitations, and pitfalls of image acquisition and analysis of RV structure and function.

Real-Time Three-Dimensional Transesophageal Echocardiography in the Intraoperative Assessment of Mitral Valve Disease

Abstract: Background The aims of this study were to evaluate the feasibility of real-time 3-dimensional (3D) transesophageal echocardiography in the intraoperative assessment of mitral valve (MV) pathology and to compare this novel technique with 2-dimensional (2D) transesophageal echocardiography. Methods Forty-two consecutive patients undergoing MV repair for mitral regurgitation (MR) were studied prospectively. Intraoperative 2D and 3D transesophageal echocardiographic (TEE) examinations were performed using a recently introduced TEE probe that provides real-time 3D imaging. Expert echocardiographers blinded to 2D TEE findings assessed the etiology of MR on 3D transesophageal echocardiography. Similarly, experts blinded to 3D TEE findings assessed 2D TEE findings. Both were compared with the anatomic findings reported by the surgeon. Results At the time of surgical inspection, ischemic MR was identified in 12% of patients, complex bileaflet myxomatous disease in 31%, and specific scallop disease in 55%. Three-dimensional TEE image acquisition was performed in a short period of time (60 ± 18 seconds) and was feasible in all patients, with optimal (36%) or good (33%) imaging quality in the majority of cases. Three-dimensional TEE imaging was superior to 2D TEE imaging in the diagnosis of P1, A2, A3, and bileaflet disease ( P Conclusions Real-time 3D transesophageal echocardiography is a feasible method for identifying specific MV pathology in the setting of complex disease and can be expeditiously used in the intraoperative evaluation of patients undergoing MV repair.

Echocardiography-guided interventions.

Abstract: A major advantage of echocardiography over other advanced imaging modalities (magnetic resonance imaging, computed tomographic angiography) is that echocardiography is mobile and real time. Echocardiograms can be recorded at the bedside, in the cardiac catheterization laboratory, in the cardiovascular intensive care unit, in the emergency room-indeed, any place that can accommodate a wheeled cart. This tremendous advantage allows for the performance of imaging immediately before, during, and after various procedures involving interventions. The purpose of this report is to review the use of echocardiography to guide interventions. We provide information on the selection of patients for interventions, monitoring during the performance of interventions, and assessing the effects of interventions after their completion. In this document, we address the use of echocardiography in commonly performed procedures: transatrial septal catheterization, pericardiocentesis, myocardial biopsy, percutaneous transvenous balloon valvuloplasty, catheter closure of atrial septal defects (ASDs) and patent foramen ovale (PFO), alcohol septal ablation for hypertrophic cardiomyopathy, and cardiac electrophysiology. A concluding section addresses interventions that are presently investigational but are likely to enter the realm of practice in the very near future: complex mitral valve repairs, left atrial appendage (LAA) occlusion devices, 3-dimensional (3D) echocardiographic guidance, and percutaneous aortic valve replacement. The use of echocardiography to select and guide cardiac resynchronization therapy has recently been addressed in a separate document published by the American Society of Echocardiography and is not further discussed in this document. The use of imaging techniques to guide even well-established procedures enhances the efficiency and safety of these procedures.

Correlation between left ventricular end-diastolic pressure and peak left atrial wall strain during left ventricular systole.

Abstract: Objective Left atrial (LA) reservoir function is determined by integration of LA relaxation and left ventricular (LV) systolic function, and LV diastolic dysfunction increases LA volume at end systole. This study investigates the effect of LV end-diastolic pressure on LA wall tension during LV systole. Methods A total of 101 stable patients with sinus rhythm undergoing cardiac catheterization were studied. LA wall extension during LV systole was evaluated as LA wall strain in the longitudinal direction obtained using two-dimensional ultrasound speckle tracking imaging. LV end-diastolic pressure and LV end-systolic and end-diastolic volumes were obtained in cardiac catheterization, and LV ejection fraction was determined. Results Peak LA wall strain during LV systole had a significant inverse correlation with LV end-diastolic pressure ( r = − 0.76, P r = − 0.64, P Conclusion Elevated LV end-diastolic pressure is associated with a decrease of peak LA wall strain in the longitudinal direction during LV systole. In patients with peak LA wall strain during LV systole of less than 30%, the majority had elevated LV end-diastolic pressure, while most patients with peak LA wall strain during LV systole 45% or higher had normal LV end-diastolic pressures. In patients whose LV ejection fraction is 50% or more, when peak LA wall strain during LV systole is between 30% and 44%, it is not possible to predict LV end-diastolic pressure from peak LA wall strain measures.

Echocardiographic imaging in clinical trials: American Society of Echocardiography Standards for echocardiography core laboratories: endorsed by the American College of Cardiology Foundation.

Abstract: Pamela S. Douglas, MD, FASE, Chair, Jeanne M. DeCara, MD, Richard B. Devereux, MD, Shelly Duckworth, RDCS, Julius M. Gardin, MD, FASE, Wael A. Jaber, MD, Annitta J. Morehead, RDCS, FASE, Jae K. Oh, MD, FASE, Michael H. Picard, MD, FASE, Scott D. Solomon, MD, Kevin Wei, MD, and Neil J. Weissman, MD, FASE, Durham, North Carolina; Chicago, Illinois; New York, New York; Hackensack, New Jersey; Cleveland, Ohio; Rochester, Minnesota; Boston, Massachusetts; Portland, Oregon; Washington, DC

Three-dimensional-wall motion tracking: a new and faster tool for myocardial strain assessment: comparison with two-dimensional-wall motion tracking.

Abstract: Background Two-dimensional (2D) wall motion–tracking echocardiography (WMT) is a useful method to measure myocardial strain, but it is very limited because acquisition and analysis are time consuming. Three-dimensional (3D) WMT is a new method that might improve diagnostic usefulness and reduce study times. The aims of this study were to compare results on 2D and 3D WMT and to compare the times for the acquisition and analysis of regional myocardial strain between the two methods. Methods Measurements of the radial and longitudinal strain of every left ventricular (LV) segment and the time for acquisition and analysis were obtained using 3D and 2D WMT. Results Thirty patients were enrolled (mean age, 57.2 ± 19.6 years; 60% men). Three-dimensional WMT provided complete radial and longitudinal LV strain information, similar to 2D WMT ( P = NS), but it was less time consuming: the times for acquisition and analysis were 14.0 ± 1.9 minutes with 2D WMT and 5.1 ± 1.1 minutes with 3D WMT ( P Conclusions Three-dimensional WMT provides a faster, more complete, and similar analysis to assess LV longitudinal and radial strain compared with 2D WMT. Thus, 3D WMT is a potential clinical bedside tool for quantifying myocardial strain.

Use of Real Time Three-Dimensional Transesophageal Echocardiography in Intracardiac Catheter Based Interventions

Abstract: Background Real-time three-dimensional (RT3D) echocardiography is a recently developed technique that is being increasingly used in echocardiography laboratories. Over the past several years, improvements in transducer technologies have allowed development of a full matrix-array transducer that allows acquisition of pyramidal-shaped data sets. These data sets can be processed online and offline to allow accurate evaluation of cardiac structures, volumes, and mass. More recently, a transesophageal transducer with RT3D capabilities has been developed. This allows acquisition of high-quality RT3D images on transesophageal echocardiography (TEE). Percutaneous catheter-based procedures have gained growing acceptance in the cardiac procedural armamentarium. Advances in technology and technical skills allow increasingly complex procedures to be performed using a catheter-based approach, thus obviating the need for open-heart surgery. Methods The authors used RT3D TEE to guide 72 catheter-based cardiac interventions. The procedures included the occlusion of atrial septal defects or patent foramen ovales (n = 25), percutaneous mitral valve repair (e-valve clipping; n=3), mitral balloon valvuloplasty for mitral stenosis (n = 10), left atrial appendage obliteration (n = 11), left atrial or pulmonary vein ablation for atrial fibrillation (n = 5), percutaneous closures of prosthetic valve dehiscence (n = 10), percutaneous aortic valve replacement (n = 6), and percutaneous closures of ventricular septal defects (n = 2). In this review, the authors describe their experience with this technique, the added value over multiplanar two-dimensional TEE, and the pitfalls that were encountered. Results The main advantages found for the use RT3D TEE during catheter-based interventions were (1) the ability to visualize the entire lengths of intracardiac catheters, including the tips of all catheters and the balloons or devices they carry, along with a clear depiction of their positions in relation to other cardiac structures, and (2) the ability to ability to demonstrate certain structures in an "en face" view, which is not offered by any other currently available real-time imaging technique, enabling appreciation of the exact nature of the lesion that is undergoing intervention. Conclusion RT3D TEE is a powerful new imaging tool that may become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based procedures.

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Assessments of Right Ventricular Volume and Function Using Three-Dimensional Echocardiography in Older Children and Adults With Congenital Heart Disease: Comparison With Cardiac Magnetic Resonance Imaging

Abstract: Background The utility of three-dimensional echocardiography (3DE) for right ventricular (RV) assessment is uncertain in older children and adults with congenital heart disease (CHD), in whom the right ventricle is often dilated and dysfunction is common. Methods RV assessments using 3DE were compared with manual tracing and automated border detection (ABD) with magnetic resonance imaging (MRI) as the reference method. Twenty-eight of 54 consecutive patients (52%; median age, 17 years) with CHD had adequate three-dimensional echocardiographic data sets for analysis. Results There were wide ranges of RV size (mean RV end-diastolic volume index, 143 ± 43 mL/m 2 ) and function (mean RV ejection fraction [EF], 48 ± 10%) on MRI. End-diastolic volume was underestimated on 3DE by 20% ( P P P = .03). The mean analysis time for ABD was 5 minutes, compared with 19 minutes for manual tracing ( P Conclusion Approximately half the patients with CHD had adequate three-dimensional echocardiographic images. Three-dimensional echocardiography accurately estimated EF but underestimated volume, particularly when the right ventricle was dilated. ABD minimally underestimated EF but offered a significant reduction in analysis time.

Echocardiographic tissue deformation imaging quantifies abnormal regional right ventricular function in arrhythmogenic right ventricular dysplasia/cardiomyopathy.

Abstract: Background The aim of this study was to determine the accuracy of new quantitative echocardiographic strain and strain-rate imaging parameters to identify abnormal regional right ventricular (RV) deformation associated with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). Methods A total of 34 patients with ARVD/C (confirmed by Task Force criteria) and 34 healthy controls were prospectively enrolled. Conventional echocardiography, including Doppler tissue imaging (DTI), was performed. Doppler and two-dimensional strain-derived velocity, strain, and strain rate were calculated in the apical, mid, and basal segments of the RV free wall. Results RV dimensions were significantly increased in patients with ARVD/C (RV outflow tract 19.3 ± 5.2 mm/m 2 vs 14.1 ± 2.2 mm/m 2 , P 2 vs 18.8 ± 2.4 mm/m 2 , P Conclusions DTI and two-dimensional strain-derived parameters are superior to conventional echocardiographic parameters in identifying ARVD/C. This novel technique may have additional value in the diagnostic workup of patients with suspected ARVD/C.

Effects of aging on left atrial function assessed by two-dimensional speckle tracking echocardiography.

Abstract: Background Aging affects left atrial (LA) function, which can be assessed by two-dimensional (2D) speckle tracking echocardiography (STE). The aim of this study was to determine (1) the feasibility and accuracy of measuring LA volume with 2DSTE and (2) the effects of aging on LA function. Methods 2DSTE of the LA was acquired from the apical 4-chamber view (frame rate: 63 ± 11 /sec, iE33) using prototype speckle tracking software (QLAB, Philips Medical Systems, Andover, MA) in 140 healthy volunteers (3-79 years, 74 men). LA wall was tracked on a frame-by-frame basis, and LA volume waveforms were generated. Maximum LA volume (LAVmax) and minimal LA volume (LAVmin), and the LA volume before atrial contraction (LAVpre-a) were measured. Passive emptying percent of total emptying (LA conduit function) and active emptying percent of total emptying (booster function) were calculated as ([LAVmax-LAVpre-a]/[LAVmax-LAVmin]) × 100 and ([LAVa-LAVmin]/[LAVmax-LAVmin]) × 100. Results Adequate LA volume waveforms were obtained in all subjects. A good correlation was obtained between speckle tracking-derived LA volume measurements and manually traced LA volume measurements of the identical 2D image (LAVmax: r = 0.93, P .001, LAVmin: r = 0.88, P .001, LAVpre-a: r = 0.92, P .001). Passive and active emptying indices had a significant age dependency ( r = 0.80, P .001). Overall, passive emptying accounted for 67% of the total LA emptying ranging from 83% in the youngest to 42% in the oldest decade. Conclusion Aging significantly affects LA conduit and booster function. 2DSTE can effectively and easily measure LA volume and has a potential for the noninvasive assessment of LA function.

Utility of tissue Doppler and strain rate imaging in the early detection of trastuzumab and anthracycline mediated cardiomyopathy.

Abstract: Background Trastuzumab provides considerable therapeutic benefits in the adjuvant setting of breast cancer. However, its use is limited by an elevated incidence of cardiotoxicity when used in combination with doxorubicin. Although Myocet (liposomal encapsulated doxorubicin) is less cardiotoxic, its cardiac safety profile with trastuzumab is not well known. The aim of this study was to determine if sensitive indices of left ventricular (LV) dysfunction, specifically Doppler tissue imaging (DTI), would be useful for addressing the early detection of trastuzumab and anthracycline–mediated cardiotoxicity. Methods In an acute murine model, wild-type C57Bl/6 mice (n = 60) received one of the following drug regimens: (1) control, (2) doxorubicin, (3) Myocet, (4) trastuzumab, (5) doxorubicin plus trastuzumab, or (6) Myocet plus trastuzumab. DTI-derived peak endocardial systolic velocity, strain rate, and LV ejection fraction were measured serially for 5 days. On day 5, the hearts, lungs, and livers were removed for histopathologic and Western blot analyses. Results Mice treated with Myocet plus trastuzumab demonstrated minimal cardiotoxicity compared with those treated with doxorubicin plus trastuzumab. Progressive LV dilatation and LV systolic dysfunction were observed by day 4 of treatment with doxorubicin plus trastuzumab, compared with preserved LV ejection fraction in the remaining groups. DTI parameters decreased within 24 hours in the doxorubicin alone and doxorubicin plus trastuzumab groups and predicted early mortality. The survival rate was only 20% at day 5 of the experiment in the doxorubicin plus trastuzumab group, whereas 100% of mice receiving trastuzumab, Myocet, or Myocet plus trastuzumab survived the 5 days. Conclusion DTI can detect early LV dysfunction prior to alterations in conventional echocardiographic indices and predicts early mortality in mice receiving doxorubicin plus trastuzumab.

An alternative echocardiographic method to estimate mean pulmonary artery pressure: diagnostic and clinical implications.

Abstract: Background The aim of this study was to evaluated an alternative echocardiographic method to calculate mean pulmonary arterial pressure (MPAP). Methods One hundred two patients were studied with simultaneous right-heart catheterization (RHC) and echocardiography. MPAP was calculated by adding the right ventricular–right atrial mean systolic gradient to right atrial pressure. Results The mean difference between MPAP calculated using this method and RHC-derived MPAP was −1.6 mm Hg, less than that of traditional systolic pulmonary arterial pressure (SPAP; −6.4 mm Hg) and MPAP estimated using the pulmonary regurgitation method (−13.9 mm Hg). The median absolute percentage difference of the MPAP calculations relative to RHC was significantly less with this method than with the pulmonary regurgitation method (18% vs 71%; P P = .30). Conclusion MPAP calculated using the proposed method is as accurate as SPAP calculation and less variable than previous methods, thus allowing widespread clinical use.

Assessment of atrial electromechanical delay, diastolic functions, and left atrial mechanical functions in patients with type 1 diabetes mellitus.

Abstract: Objective The aim of this study was to evaluate atrial electromechanical coupling obtained by tissue Doppler imaging (TDI), left and right ventricular diastolic functions, and left atrial (LA) mechanical functions in patients with type 1 diabetes mellitus (DM-1). Methods A total of 43 patients with DM-1 (age 19.6 ± 6.8 years) and 42 age- and gender-matched controls (age 19.5 ± 6.4 years) were included. Atrial electromechanical coupling was measured with TDI and corrected for heart rate. P-wave dispersion (Pd) was calculated from the 12-lead electrocardiograms. Systolic and diastolic functions in both ventricles were assessed using conventional echocardiography and TDI. Myocardial performance index was calculated with TDI. LA maximal, minimal, and pre-systolic volumes were measured according to the biplane area-length method. LA mechanical function parameters were calculated. Results Intra- and interatrial electromechanical delays and Pd were significantly higher in patients with DM-1 compared with controls ( P = .02, P P = 0.005, respectively). A-wave velocity and isovolumic relaxation time were higher and E/A ratio was lower in patients with DM-1 ( P = .03, P = .03, and P = .003, respectively). According to TDI, systolic velocities and myocardial performance index values of both ventricles were comparable. Diastolic filling velocities of the left ventricle, including E m global, A m global, E m /A m ratio, and right ventricular A m , were different between groups ( P = .03, P = .02, P P = .02, respectively). LA passive emptying fraction was decreased, and LA active emptying volume and LA active emptying fraction were increased in patients with DM-1 ( P = .02, P = .001, and P P P = .007, P P = .002, respectively), and was negatively correlated with E m /A m ratio and LA passive emptying fraction ( P P = .001, respectively). In multivariate analyses, age and DM-1 were independent predictors of interatrial electromechanical delay ( P = .001 and P Conclusion This study shows that intra- and interatrial electromechanical delays are prolonged diastolic functions of both ventricles and that LA mechanical functions are impaired in patients with DM-1. Age and the presence of DM-1 were independent factors of the interatrial electromechanical delay.

A Framework for Systematic Characterization of the Mitral Valve by Real-Time Three-Dimensional Transesophageal Echocardiography

Abstract: Because of the complex anatomy of the mitral valve, detailed imaging is a challenge. Transesophageal echocardiography (TEE) using two-dimensional echocardiography provides the backbone for the structural evaluation of the mitral valve. Interventional and surgical procedures on the mitral valve demand precise and sophisticated imaging for guidance and support. Three-dimensional (3D) transthoracic echocardiography and 3D transesophageal echocardiography (TEE) are now being used with increasing frequency to provide more comprehensive evaluations of the structure and function of the mitral valve complex. In this review, the authors present a framework for the application of 3D TEE in the evaluation of patients with structural or functional mitral valve disease, outline an examination protocol, and address the advantages and limitations of the current platform for 3D TEE. Real-time 3D TEE has the real potential to become the main imaging tool for the guidance of surgical and interventional procedures on the mitral valve. Although 3D TEE provides impressive images of the mitral valve, it now must be demonstrated, through scientific studies, that these beautiful images add clinical value to the management of patients with mitral valve disease.

Left Atrial Volume Index: A Predictor of Adverse Outcome in Patients With Hypertrophic Cardiomyopathy

Abstract: Background Despite the relatively benign course for the majority of patients with hypertrophic cardiomyopathy (HCM), this disease may cause sudden cardiac death and progressive heart failure (HF). The aim of this study was to investigate useful parameters for predicting adverse outcomes of HCM, including echocardiographic parameters, cardiac magnetic resonance (CMR), and clinical markers. Methods Eighty-one patients with nonapical HCM (51 men; mean age, 57 ± 14 years) who underwent CMR and echocardiography were prospectively evaluated. Cardiovascular events were defined as hospitalization for worsening HF, stroke, or cardiovascular death. Results During the mean follow-up period of 41 ± 17 months, there were 17 cardiovascular events (5 deaths, 7 hospitalizations for worsening HF, and 5 strokes). Univariate analysis showed that older age, atrial fibrillation, elevated E/E′ ratio, increased left atrial (LA) volume index, presence of mitral regurgitation grade > 2, New York Heart Association class III or IV, and late gadolinium enhancement ≥ 6% were associated with cardiovascular events. In multivariate Cox regression analysis, increased LA volume index was found to be an independent predictor of cardiovascular events (for each 5 mL/m 2 increase, hazard ratio, 1.28; 95% confidence interval, 1.10-1.48; P 2 increase, hazard ratio, 1.44; 95% confidence interval, 1.12-1.83; P Conclusion LA volume index is independently associated with adverse outcomes in patients with HCM and provides additional prognostic information.

Prognostic Significance of Left Atrial Volume Dilatation in Patients with Hypertrophic Cardiomyopathy

Abstract: To evaluate the prognostic role of left atrial (LA) volume in hypertrophic cardiomyopathy (HCM), LA volume was measured at baseline and during follow-up in 140 patients with HCM. Unfavorable outcome, defined as occurrence of sudden death, heart transplantation, or invasive reduction of obstruction, developed in 16 patients. In patients with enlarged LA volume (>27 mL/m 2 ), there was an increased risk for unfavorable outcome ( P = .0152). Patients with normal LA volume at baseline in whom volume increased more than 3 mL per year (fast dilating LA volume) had a worse prognosis than patients with normal and stable volume ( P P = not significant). LA volume dilated at baseline, fast dilating LA volume, and New York Heart Association functional class were independent predictors of unfavorable outcome development (odds ratio: 11.453; P = .021, P = 2.019, P = .020, respectively). The assessment of LA volume at baseline and during follow-up adds information regarding prognosis in patients with HCM.

Role of Echocardiography in the Diagnosis of Constrictive Pericarditis

Abstract: The clinical recognition of constrictive pericarditis (CP) is important but challenging. In addition to Doppler echocardiography, newer echocardiographic techniques for deciphering myocardial deformation have facilitated the noninvasive recognition of CP and its differentiation from restrictive cardiomyopathy. In a patient with heart failure and a normal ejection fraction, echocardiographic demonstration of exaggerated interventricular interdependence, relatively preserved left ventricular longitudinal deformation, and attenuated circumferential deformation is diagnostic of CP. This review is a concise update on the pathophysiology and hemodynamic features of CP, the transmural and torsional mechanics of CP, and the merits and pitfalls of the various echocardiographic techniques used in the diagnosis of CP.

Prognostic Value of Left Ventricular End-Systolic Volume Index as a Predictor of Heart Failure Hospitalization in Stable Coronary Artery Disease: Data from the Heart and Soul Study

Abstract: Objective: Left ventricular (LV) end-systolic volume indexed to body surface area (ESVI) is a simple yet powerful echocardiographic marker of LV remodeling that can be measured easily. The prognostic value of ESVI and its merit relative to other markers of LV remodeling in patients with coronary heart disease are unknown. Methods: We examined the association of ESVI with hospitalization for heart failure (HF) and mortality in a prospective study of patients with coronary heart disease. Results: Of the 989 participants, 110 (11%) were hospitalized for HF during 3.6 1.1 years of follow-up. Among participants in the highest ESVI quartile (25 mL/m 2 ), 67 of 248 (27%) developed HF compared with 8 of 248 (3%) among those in the lowest quartile. The association between ESVI and HF hospitalization persisted after adjustment for potential confounders (hazard ratio 5.0, 95% confidence interval, 1.5-16.9; P .01). Conclusion: ESVI 25 mL/m 2 is an independent predictor of hospitalization for HF in patients with stable coronary heart disease. (J Am Soc Echocardiogr 2009;22:190-197.)

Application of appropriateness criteria in outpatient transthoracic echocardiography.

Abstract: Background Appropriateness criteria were applied to outpatient transthoracic echocardiographic (TTE) studies. Methods Indications were rated as appropriate, inappropriate, or unclassifiable, considering provider-stated indications, previous TTE studies, symptom changes, and patient-stated indications. Clinically important new or unexpected findings were recorded. Results Of 368 TTE studies, 206 (56%) were appropriate, 31 (8%) were inappropriate, and 131 (35%) were unclassifiable. Appropriateness was not correlated with patient or provider demographics. In 288 cases with prior TTE studies, there were 92 (32%) important new findings and 63 (22%) unexpected findings, of which 20% were from inappropriately ordered and 31% from unclassifiable TTE studies. Appropriateness was not associated with new (odds ratio, 1.23; 95% confidence interval, 0.48-3.18) or unexpected (odds ratio, 1.15; 95% confidence interval, 0.38-3.52) findings. Provider type and level of training were not correlated with new or unexpected findings. Conclusions Many indications for TTE studies were unclassifiable. A high percentage of inappropriately ordered TTE studies yielded important information. Care must be taken in judging the value of TTE studies solely on the basis of appropriateness criteria.

Comparison of left ventricular ejection fraction and left ventricular global strain as determinants of infarct size in patients with acute myocardial infarction

Abstract: Background The aim was to compare left ventricular ejection fraction (LVEF) and left ventricular (LV) global strain by speckle tracking as predictors of final infarct size. Methods LV global strain and LVEF by echocardiography were assessed in the acute phase and after revascularization in 39 patients with ST-elevation myocardial infarction treated with thrombolysis. Results After revascularization, global strain and LVEF correlated well with infarct size measured by contrast-enhanced cardiac magnetic resonance. A cutoff value of −15.0% for global strain had a sensitivity of 90% and a specificity of 86% to identify myocardial infarcts larger than 20%. Interobserver variability, expressed by intraclass correlation coefficients, for global strain and LVEF was 0.91 and 0.72, respectively. Conclusions LV global strain is a more precise diagnostic predictor of large infarcts compared with LVEF and is more reproducible. Global strain measured after revascularization demonstrates advantages over LVEF in the evaluation of LV injury in patients with ST-elevation myocardial infarction.

Left Atrial Volume Provides Independent Prognostic Value in Patients With Chagas Cardiomyopathy

Abstract: Background Heart failure is a severe clinical manifestation of Chagas disease. Left atrial volume (LAV), a marker of chronically elevated left ventricular (LV) filling pressure, is a predictor of prognosis in patients with heart failure and may be important in the assessment of risk in patients with Chagas disease. The aim of this study was to identify echocardiographic parameters of diastolic function predictors of survival in patients with Chagas cardiomyopathy. Methods A total of 192 patients with Chagas cardiomyopathy (mean age, 48.5 ± 12.1 years; 37% women) were prospectively enrolled. The end points were death and cardiac transplantation. Results Over a mean follow-up period of 33.8 months, LAV normalized for body surface area emerged as an independent predictor of survival (hazard ratio, 1.037 per 1 mL/m 2 change; 95% confidence interval, 1.018-1.056; P 51 mL/m 2 was associated with significant excess mortality (log-rank, P Conclusions LAV provides powerful prognostic information incrementally and independently to clinical data and conventional echocardiographic parameters in the prediction of survival. New York Heart Association functional class, LV ejection fraction, right ventricular function, the E/E′ ratio, and LAV index can be used to build a risk prediction model, which can be used clinically.