Showing papers in "Journal of The American Society of Echocardiography in 2010"

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography

Abstract: on Statement: Society of Echocardiography is accreditedby theAccreditationCouncil for edical Education to provide continuingmedical education for physicians. n Society of Echocardiography designates this educational activity for of 1.0 AMA PRA Category 1 Credits . Physicians should only claim credit te with the extent of their participation in the activity. CCI recognize ASE’s certificates and have agreed to honor the credit hours registry requirements for sonographers. Society of Echocardiography is committed to ensuring that its educational ll sponsored educational programs are not influencedby the special interests ation or individual, and itsmandate is to retain only those authors whose fists canbeeffectively resolved tomaintain thegoals andeducational integrity y. While a monetary or professional affiliation with a corporation does not fluence an author’s presentation, the Essential Areas and policies of the ire that any relationships that could possibly conflict with the educational activity be resolved prior to publication and disclosed to the audience. f faculty and commercial support relationships, if any, have been indicated. ience: is designed for all cardiovascular physicians and cardiac sonographers with erest and knowledge base in the field of echocardiography; in addition, reschers, clinicians, intensivists, and other medical professionals with a spein cardiac ultrasound will find this activity beneficial.

Recommendations for quantification methods during the performance of a pediatric echocardiogram: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council.

Abstract: n Society of Echocardiography designates this educational activity for of 15 AMA PRA Category 1 Credits Physicians should only claim credit te with the extent of their participation in the activity CCI recognize the ASE’s certificates and have agreed to honor the credit their registry requirements for sonographers n Society of Echocardiography is committed to ensuring that its educan and all sponsored educational programs are not influenced by the special y corporation or individual, and itsmandate is to retain only those authors ial interests can be effectively resolved to maintain the goals and educaty of the activity Although amonetary or professional affiliationwith a cors not necessarily influence an author’s presentation, the Essential Areas and e ACCME require that any relationships that could possibly conflict with al value of the activity be resolved prior to publication and disclosed to Disclosures of faculty and commercial support relationships, if any, dicated ience: is designed for all cardiovascular physicians and cardiac sonographers with erest and knowledge base in the field of echocardiography; in addition, reschers, clinicians, intensivists, and other medical professionals with a spein cardiac ultrasound will find this activity beneficial

Assessment of Myocardial Mechanics Using Speckle Tracking Echocardiography: Fundamentals and Clinical Applications

Abstract: The authors summarize the recent developments in speckle-tracking echocardiography (STE), a relatively new technique that can be used in conjunction with two-dimensional or three-dimensional echocardiography for resolving the multidirectional components of left ventricular (LV) deformation. The tracking system is based on grayscale B-mode images and is obtained by automatic measurement of the distance between 2 pixels of an LV segment during the cardiac cycle, independent of the angle of insonation. The integration of STE with real-time cardiac ultrasound imaging overcomes some of the limitations of previous work in the field and has the potential to provide a unified framework to more accurately quantify the regional and global function of the left ventricle. STE holds promise to reduce interobserver and intraobserver variability in assessing regional LV function and to improve patient care while reducing health care costs through the early identification of subclinical disease. Following a brief overview of the approach, the authors pool the initial observations from clinical studies on the development, validation, merits, and limitations of STE.

Focused Cardiac Ultrasound in the Emergent Setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians

Abstract: The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac evaluation of symptomatic patients. The technologic miniaturization and improvement in transducer technology, as well as the implementation of educational curriculum changes in residency training programs and specialty practice, have facilitated the integration of focused cardiac ultrasound into practice by specialties such as emergency medicine. In the emergency department, focused cardiac ultrasound has become a fundamental tool to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions by the emergency physician.

Safety of Transesophageal Echocardiography

Abstract: Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.

Left atrial strain measured by two-dimensional speckle tracking represents a new tool to evaluate left atrial function.

Abstract: Background Left atrial (LA) strain (e) and e rate (SR) analysis by two-dimensional speckle tracking can represent a new tool to evaluate LA function. To assess its potential value, the authors addressed whether LA e and SR measured in normal subjects correlates with other Doppler echocardiographic parameters that evaluate LA function and left ventricular function. Methods Sixty-four healthy subjects were studied. LA e and SR were calculated with the reference point set at the P wave, which enabled the recognition of peak negative e (e neg peak ), peak positive e (e pos peak ), and the sum of those values, total LA e (e tot ), corresponding to LA contractile, conduit, and reservoir function, respectively. Similarly, peak negative SR (LA SR late neg peak ) during LA contraction, peak positive SR (LA SR pos peak ) at the beginning of LV systole, and peak negative SR (LA SR early neg peak ) at the beginning of LV diastole were identified. Results Global LA e pos peak , e neg peak , and e tot were 23.2 ± 6.7%, −14.6 ± 3.5%, and 37.9 ± 7.6%, respectively. Global LA SR pos peak , SR early neg peak , and SR late neg peak were 2.0 ± 0.6 s −1 , −2.0 ± 0.6 s −1 , and −2.3 ± 0.5 s −1 , respectively. The above-described variables derived from analysis of global LA e and LA SR correlated significantly with Doppler echocardiographic indexes that evaluated the same phase of the cardiac cycle or the same component of the LA function, including indexes derived from mitral inflow, pulmonary vein velocities, tissue Doppler, and LA volumes. Global LA e pos peak , LA e tot , and LA SR early neg peak also correlated significantly with age or body mass index. Global LA SR late neg peak also correlated significantly with age. Conclusions LA e analysis is a new tool that can be used to evaluate LA function. Further studies are warranted to determine the utility of LA e in disease states.

Accuracy of right ventricular volumes and function determined by three-dimensional echocardiography in comparison with magnetic resonance imaging: a meta-analysis study.

Abstract: Background Determining right ventricular (RV) function is challenging because of the complex anatomy of the right ventricle. Three-dimensional echocardiography (3DE) has achieved better estimation, but underestimations of volumes and ejection fraction (EF) has often been reported, and no previous study has synthesized these data. The investigators performed a meta-analysis on the bias and examined the related factors. Methods Studies comparing RV volumes and/or EF between 3DE and magnetic resonance imaging were eligible. A meta-analysis was performed to evaluate the systematic bias. The related bias was investigated using univariate and multivariate regression analysis. Results Twenty-three studies including 807 subjects revealed underestimation of RV volumes ( P P = .03). Larger volumes and EF were associated with more underestimation. Older patient age was associated with overestimation of volumes and underestimation of EF. Conclusions This meta-analysis found underestimation of RV volumes and EF by 3DE and factors affecting the bias. These data provide a more detailed basis for improving the accuracy of 3DE for further clinical application.

Differences of myocardial systolic deformation and correlates of diastolic function in competitive rowers and young hypertensives: a speckle-tracking echocardiography study.

Abstract: Background The aim of this study was to compare speckle-tracking echocardiography–derived left ventricular (LV) systolic mechanics and their relationships with LV diastolic properties in young patients with hypertension and in young competitive athletes in relation to their respective alterations of LV structure. Methods Nineteen sedentary controls, 22 top-level rowers, and 18 young newly diagnosed, never-treated patients with hypertension, all male, underwent Doppler echocardiography including pulsed tissue Doppler of the mitral annulus and speckle-tracking echocardiography. Peak longitudinal strain was calculated in apical long-axis, four-chamber, and two-chamber views, and values of the three views were averaged (global longitudinal strain [GLS]). Regional circumferential and radial strain were calculated at the LV basal, middle, and apical levels, and values were averaged (global circumferential strain and global radial strain). LV torsion was determined as the net difference in the mean rotation between the apical and basal levels. Results The three groups were comparable for age, whereas body mass index and blood pressure were higher in patients with hypertension, and heart rate was lower in rowers. LV mass index was higher in rowers and in patients with hypertension than in controls, without differences in relative wall thickness, ejection fraction, and midwall shortening. Left atrial volume index was greater in rowers than in controls and patients with hypertension. Annular systolic velocity (s′) ( P P P P P Conclusions The hearts of young patients with hypertension are characterized by reduced GLS, whereas global circumferential strain, global radial strain, and torsion are similar to those of athletes' hearts. The extent of GLS is strongly associated with LV diastolic function, independently of afterload changes and the degree of LV hypertrophy.

Timing and magnitude of regional right ventricular function: a speckle tracking-derived strain study of normal subjects and patients with right ventricular dysfunction.

Abstract: Background The aim of this study was to evaluate the timing and magnitude of global and regional right ventricular (RV) function by means of speckle tracking–derived strain in normal subjects and patients with RV dysfunction. Methods Peak longitudinal systolic strain (PLSS) and time to PLSS in 6 RV segments (the basal, mid, and apical segments of the RV free wall and septum) were obtained in 100 healthy volunteers and 76 patients with RV dysfunction by tracking speckles inside the myocardium using grayscale images. Global PLSS and time to PLSS were based on the average of the 6 regional values. Results There was a significant and close correlation between RV contractility as measured by PLSS and tricuspid annular plane systolic excursion ( r = −0.83, P P P P = .038). Conclusions Speckle tracking not only makes it possible to quantify global RV function but also illustrates the physiology of RV contraction and the pattern of activation at regional level. Speckle tracking–derived strain could become an important new means of assessing and following up patients with impaired RV function and increased pulmonary pressure.

Dynamic assessment of right ventricular volumes and function by real-time three-dimensional echocardiography: a comparison study with magnetic resonance imaging in 100 adult patients.

Abstract: Background The aim of this study was to validate a novel real-time three-dimensional echocardiographic (RT3DE) analysis tool for the determination of right ventricular volumes and function in unselected adult patients. Methods A total of 100 consecutive adult patients with normal or pathologic right ventricles were enrolled in the study. A dynamic polyhedron model of the right ventricle was generated using dedicated RT3DE software. Volumes and ejection fractions were determined and compared with results obtained on magnetic resonance imaging (MRI) in 88 patients with adequate acquisitions. Results End-diastolic, end-systolic, and stroke volumes were slightly lower on RT3DE imaging than on MRI (124.0 ± 34.4 vs 134.2 ± 39.2 mL, P P = .02; and 58.8 ± 18.4 vs 64.5 ± 24.1 mL, P P = .57). Correlation coefficients on Bland-Altman analysis were r = 0.84 (mean difference, 10.2 mL; 95% confidence interval [CI], −31.3 to 51.7 mL) for end-diastolic volume, r = 0.83 (mean difference, 4.5 mL; 95% CI, −23.8 to 32.9 mL) for end-systolic volume, r = 0.77 (mean difference, 5.7 mL; 95% CI, −24.6 to 36.0 mL) for stroke volume, and r = 0.72 (mean difference, 0.4%; 95% CI, −14.2% to 15.1%) for ejection fraction. Conclusion Right ventricular volumes and ejection fractions as assessed using RT3DE imaging compare well with MRI measurements. RT3DE imaging may become a time-saving and cost-saving alternative to MRI for the quantitative assessment of right ventricular size and function.

Echocardiographic particle image velocimetry: a novel technique for quantification of left ventricular blood vorticity pattern.

Abstract: Background In this study, the functionality of echocardiographic particle imaging velocimetry (E-PIV) was compared with that of digital particle imaging velocimetry (D-PIV) in an in vitro model. In addition, its capability was assessed in the clinical in vivo setting to obtain the ventricular flow pattern in normal subjects, in patients with dilated cardiomyopathy, and in patients with mechanical and bioprosthetic mitral valves. Methods A silicon sac simulating the human left ventricle in combination with prosthetic heart valves, controlled by a pulsed-flow duplicator, was used as the in vitro model. Particle-seeded flow images were acquired (1) using a high-speed camera from the mid plane of the sac, illuminated by a laser sheet for D-PIV, and (2) using a Siemens Sequoia system at a frame rate of 60 Hz for E-PIV. Data analysis was performed with PIVview software for D-PIV and Omega Flow software for E-PIV. E-PIV processing was then applied to contrast echocardiographic image sets obtained during left ventricular cavity opacification with a lipid-shelled microbubble agent to assess spatial patterns of intracavitary flow in the clinical setting. Results The velocity vectors obtained using both the E-PIV and the D-PIV methods compared well for the direction of flow. The streamlines were also found to be similar in the data obtained using both methods. However, because of the superior spatial resolution of D-PIV, some smaller scale details were not revealed by E-PIV. The application of E-PIV to the human heart resulted in reproducible flow patterns in echocardiographic images taken within different time frames or by independent examiners. Conclusions The E-PIV technique appears to be capable of evaluating the major flow features in the ventricles. However, the bounded spatial resolution of ultrasound imaging limits the small-scale features of ventricular flow to be revealed.

Global Longitudinal Strain as a Major Predictor of Cardiac Events in Patients with Depressed Left Ventricular Function: A Multicenter Study

Abstract: BACKGROUND: The risk stratification of patients with left ventricular (LV) dysfunction can be performed using echocardiographic parameters such as the ejection fraction (EF) Recently, new technologies based on deformation measurements have been shown to identify early myocardial dysfunction before EF decrease Consequently, tools such as two-dimensional strain have been incorporated into echocardiographic systems, allowing for fast, reliable, and reproducible calculation of longitudinal components of LV systolic deformation The hypothesis in this study was that as a more sensitive marker of LV dysfunction, longitudinal strain would allow for the risk stratification of patients with heart failure METHODS: This multicenter study included 147 patients with heart failure with LV EFs ≤ 45% (mean age, 64 ± 14 years; 74% men; mean LV EF, 299 ± 89%) Conventional echocardiographic parameters as well as global and segmental longitudinal strain were measured and compared with these values in a control population Patients were monitored for cardiac events, defined as a composite criterion, over 12 months RESULTS: Clinical events were observed in 20% of patients during the 12-month follow-up period On receiver operating characteristic curve analysis, global longitudinal strain had the highest prognostic value (area under the curve, 083) and the highest combination of sensitivity (73%) and specificity (83%), using a cutoff value of -7% CONCLUSION: Strain assessment is highly feasible and reliable in patients with LV dysfunction and allows for cardiovascular risk stratification in patients with heart failure with greater accuracy than LV EF

Circumferential and Longitudinal Strain in 3 Myocardial Layers in Normal Subjects and in Patients with Regional Left Ventricular Dysfunction

Abstract: Background The left ventricle is not homogenous and is composed of 3 myocardial layers. Until recently, magnetic resonance imaging has been the only noninvasive technique for detailed evaluation of the left ventricular (LV) wall. The aim of this study was to analyze strain in 3 myocardial layers using speckle-tracking echocardiography. Methods Twenty normal subjects and 21 patients with LV dysfunction underwent echocardiography. Short-axis (for circumferential) and apical (for longitudinal strain) views were analyzed using modified speckle-tracking software enabling the analysis of strain in 3 myocardial layers. Results In normal subjects, longitudinal and circumferential strain was highest in the endocardium and lowest in the epicardium. Longitudinal endocardial and mid layer strain was highest in the apex and lowest in the base. Epicardial longitudinal strain was homogenous over the left ventricle. Circumferential 3-layer strain was highest in the apex and lowest in the base. In patients with LV dysfunction, strain was lower, with late diastolic or double peak. Conclusions Three-layer analysis of circumferential and longitudinal strain using speckle-tracking imaging can be performed on a clinical basis and may become an important method for the assessment of real-time, quantitative global and regional LV function.

Reference Values for Right Ventricular Volumes and Ejection Fraction With Real-Time Three-Dimensional Echocardiography: Evaluation in a Large Series of Normal Subjects

Abstract: Background The quantification of right ventricular (RV) size and function is of diagnostic and prognostic importance. Recently, new software for the analysis of RV geometry using three-dimensional (3D) echocardiographic images has been validated. The aim of this study was to provide normal reference values for RV volumes and function using this technique. Methods A total of 245 subjects, including 15 to 20 subjects for each gender and age decile, were studied. Dedicated 3D acquisitions of the right ventricle were obtained in all subjects. Results The mean RV end-diastolic and end-systolic volumes were 49 ± 10 and 16 ± 6 mL/m 2 respectively, and the mean RV ejection fraction was 67 ± 8%. Significant correlations were observed between RV parameters and body surface area. Normalized RV volumes were significantly correlated with age and gender. RV ejection fractions were lower in men, but differences across age deciles were not evident. Conclusion The current study provides normal reference values for RV volumes and function that may be useful for the identification of clinical abnormalities.

Comparison between Different Speckle Tracking and Color Tissue Doppler Techniques to Measure Global and Regional Myocardial Deformation in Children

Abstract: Background Myocardial deformation parameters obtained by speckle-tracking echocardiography (STE) and color Doppler tissue imaging (CDTI) using two different ultrasound systems and three different software packages were compared. Methods Apical four-chamber, short-axis grayscale, and color Doppler tissue images were prospectively acquired using Vivid 7 and iE33 ultrasound systems in 34 children and then analyzed using EchoPAC and QLAB (STE) and SPEQLE (CDTI). Results Measurement of myocardial deformation was feasible for all three modalities. Longitudinal strain (e) measurements showed the lowest intraobserver and interobserver variability (intraobserver and interobserver coefficients of variation, 9% and 8% for EchoPAC, 5% and 6% for QLAB, and 14% and 16% for SPEQLE). In addition, longitudinal e had a small bias and narrow limits of agreement when comparing different techniques. The coefficients of variation of circumferential e by EchoPAC and QLAB were 12% and 11% (intraobserver) and 9% and 13% (interobserver), respectively. Circumferential e by STE had a small systematic bias but relatively narrow limits of agreement. The reproducibility of radial e measurements using STE was low, while CDTI e provided better performance (intraobserver and interobserver coefficients of variation for radial posterior e, 12% and 24% for EchoPAC, 39% and 56% for QLAB, and 12% and 14% for SPEQLE). Radial e was on average 50% lower using QLAB compared with EchoPAC and SPEQLE. Systolic strain rate values obtained by STE were lower compared with CDTI-derived values. The limits of agreement for strain rate values among the three modalities were wide, and intraobserver and interobserver variability was poor for all three modalities. Conclusions Some deformation measurements (e.g., longitudinal and circumferential e) are comparable among different ultrasound machines and software packages, whereas others are significantly different (e.g., radial e and strain rate). This study stresses the need for an industry standard for these techniques.

Echocardiographic Indexes for the Non-Invasive Evaluation of Pulmonary Hemodynamics

Abstract: Ultrasound imaging has continuously developed over recent years, leading to the development of several novel echocardiographic indexes. Among these, of particular interest are those that focus on pulmonary hemodynamics, because they not only improve both sensitivity and specificity in the echocardiographic evaluation of pulmonary pressures (systolic, mean, and diastolic), but can also be used to estimate other pulmonary hemodynamic parameters, such as pulmonary vascular resistance, pulmonary capillary wedge pressure, and pulmonary capacitance and impedance. Such parameters can provide important diagnostic and prognostic information in patients with heart failure, chronic obstructive pulmonary disease, and pulmonary arterial hypertension and in every patient with suspected pulmonary impairment. In this review, the authors present a comprehensive overview of the echocardiographic indexes involved in pulmonary hemodynamic evaluation and discuss the applications of these indexes in the clinical setting.

Impaired myocardial radial function in asymptomatic patients with type 2 diabetes mellitus: a speckle-tracking imaging study.

Abstract: Background Diabetic cardiomyopathy has been characterized by an early impairment of left ventricular (LV) longitudinal function as opposed to preserved LV radial function. Methods Conventional echocardiography and longitudinal (e L ) and radial (e R ) systolic strain assessed by speckle-tracking imaging were obtained in 114 type 2 diabetic patients and 88 age-matched controls. Results LV ejection fraction was similar in diabetic patients and controls. The presence of subclinical LV systolic dysfunction in diabetic patients was demonstrated by lower values of midwall fractional shortening (18% ± 3% vs 20% ± 3%, P = .006), e L (-19% ± 3% vs –22% ± 2%, P 001), and e R (50% ± 16% vs 56% ± 12%, P = .003) compared with controls. On multivariate analysis, factors predicting strain values were diabetes ( P = .001) and gender ( P = .001) for e L and diabetes ( P = .003) for e R . Conclusion Diabetic patients without overt heart disease display subclinical alteration of both radial and longitudinal LV systolic function even after adjustment for blood pressure, age, and body mass index.

Three-Dimensional Echocardiographic Assessment of Right Ventricular Volume and Function in Adult Patients With Congenital Heart Disease: Comparison With Magnetic Resonance Imaging

Abstract: Background The aim of this study was to evaluate the accuracy of three-dimensional (3D) ultrasound compared with the standard magnetic resonance imaging method in determining right ventricular (RV) volumes and function in adult patients with congenital heart disease and chronic, severe pulmonary regurgitation (PR). Methods Twenty-five patients with severe PR secondary to either pulmonary valvotomy or tetralogy of Fallot repair were evaluated using 3D ultrasound and MRI. Results The mean RV ejection fractions were 42 ± 8% on 3D ultrasound and 44 ± 7% on MRI ( r = 0.89, P r = 0.88 and r = 0.89, respectively). Conclusions Three-dimensional ultrasound was comparable with MRI in determining RV size and function in most patients with complex congenital heart disease. It will be important to study 3D US in a larger population of patients with TOF, which will be possible only through multi-center collaboration.

Validation of conventional and simplified methods to calculate projected valve area at normal flow rate in patients with low flow, low gradient aortic stenosis: the multicenter TOPAS (True or Pseudo Severe Aortic Stenosis) study.

Abstract: Background It has been previously demonstrated that a new index of aortic stenosis (AS) severity derived from dobutamine stress echocardiography (DSE), the projected aortic valve area (AVA) at a normal transvalvular flow rate (AVA proj ), is superior to traditional Doppler echocardiographic indices to discriminate true severe from pseudosevere low-gradient AS. The objectives of this study were to prospectively validate the diagnostic and prognostic value of AVA proj in a large series of patients and to propose a new clinically applicable simplified method to estimate AVA proj . Methods AVA proj was calculated in 142 patients with low-flow AS using 2 methods. In the conventional method, AVA was plotted against mean transvalvular flow (Q) at each stage of DSE, and AVA at a standardized flow rate of 250 ml/s was projected from the slope of the regression line fitting the plot of AVA versus Q: AVA proj = AVA rest + slope × (250 − Q rest ). In the simplified method, using this equation, the slope of the regression line was estimated by dividing the DSE-induced change in AVA from baseline to the peak stage of DSE by the change in Q. Results There was a strong correlation between AVA proj calculated by the two methods ( r = 0.95, P proj demonstrated similar performance in discriminating true severe from pseudosevere AS (percentage of correct classification of AVA proj ≤ 1 cm 2 , 94% and 92%, respectively) and were superior to traditional dobutamine stress echocardiographic indices (percentage of correct classification, 60%-77%). Both conventional and simplified AVA proj correlated well with valve weight ( r = 0.52 and r = 0.58, respectively), whereas traditional dobutamine stress echocardiographic indices did not. In the 84 patients who were treated medically, conventional AVA proj ≤ 1.2 cm 2 (hazard ratio, 1.65; P = .02) and simplified AVA proj ≤ 1.2 cm 2 (hazard ratio, 2.70; P Conclusion In patients with low-flow AS, AVA proj better predicts underlying AS severity and patient outcomes than traditional dobutamine stress echocardiographic indices. Simplified AVA proj is easier to calculate than conventional AVA proj , facilitating the use of AVA proj in clinical practice.

Clinical value of real-time three-dimensional echocardiography for right ventricular quantification in congenital heart disease: validation with cardiac magnetic resonance imaging.

Abstract: Background The objective of this study was to test the feasibility, accuracy, and reproducibility of the assessment of right ventricular (RV) volumes and ejection fraction (EF) using real-time three-dimensional echocardiographic (RT3DE) imaging in patients with congenital heart disease (CHD), using cardiac magnetic resonance (CMR) as a reference. Methods RT3DE data sets and short-axis cine CMR images were obtained in 62 consecutive patients (mean age, 26.9 ± 10.4 years; 65% men) with various CHDs. RV volumetric quantification was done using semiautomated 3-dimensional border detection for RT3DE images and manual tracing of contours in multiple slices for CMR images. Results Adequate RV RT3DE data sets could be analyzed in 50 of 62 patients (81%). The time needed for RV acquisition and analysis was less for RT3DE imaging than for CMR ( P P r = 0.93, r = 0.91, and r = 0.74, respectively, P Conclusion In the majority of unselected patients with complex CHD, RT3DE imaging provides a fast and reproducible assessment of RV volumes and EF with fair to good accuracy compared with CMR reference data when using current commercially available hardware and software. Further studies are warranted to confirm our data in similar and other patient populations to establish its use in clinical practice.

Accuracy and Reproducibility of Strain by Speckle Tracking in Pediatric Subjects with Normal Heart and Single Ventricular Physiology: A Two-Dimensional Speckle-Tracking Echocardiography and Magnetic Resonance Imaging Correlative Study

Abstract: Background Myocardial strain is a sensitive measure of ventricular systolic function. Two-dimensional speckle-tracking echocardiography (2DSE) is an angle-independent method for strain measurement but has not been validated in pediatric subjects. The aim of this study was to evaluate the accuracy and reproducibility of 2DSE-measured strain against reference tagged magnetic resonance imaging–measured strain in pediatric subjects with normal hearts and those with single ventricles (SVs) of left ventricular morphology after the Fontan procedure. Methods Peak systolic circumferential strain and longitudinal strain (LS) in segments ( n = 16) of left ventricles in age-matched and body surface area–matched 20 healthy and 12 pediatric subjects with tricuspid atresia after the Fontan procedure were measured by 2DSE and tagged magnetic resonance imaging. Average (global) and regional segmental strains measured by the two methods were compared using Spearman's and Bland-Altman analyses. Results Global strains measured by 2DSE and tagged magnetic resonance imaging demonstrated close agreements, which were better for LS than circumferential strain and in normal left ventricles than in SVs (95% limits of agreement, +0.0% to +3.12%, −2.48% to +1.08%, −4.6% to +1.8%, and −3.6% to +1.8%, respectively). There was variability in agreement between regional strains, with wider limits in apical than in basal regions in normal left ventricles and heterogeneity in SVs. Strain values were significantly ( P Conclusions Strains measured by 2DSE agree with strain measured by magnetic resonance imaging globally but vary regionally, particularly in SVs. Global strain may be a more robust tool for cardiac functional evaluation than regional strain in SV physiology. The reliability of 2DSE-measured strain is affected by the frame rate, the nature of strain, and ventricular geometry.

Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa (MAIVF): A Comprehensive Review

Abstract: Pseudoaneurysm in the region of the fibrous body between the mitral and aortic valve, the mitral-aortic intervalvular fibrosa (MAIVF), is a rare complication. The authors provide a comprehensive review of all relevant English-language articles published from 1966 to December 2009. Pseudoaneurysm of the MAIVF was identified in 88 patients in the medical literature and one from the authors' institution (total reported cases, 89). Endocarditis and aortic valve surgery were the most frequently associated causative factors. Symptoms and signs of infection, chest pain, heart failure or shortness of breath, and cerebrovascular accidents accounted for 77% of clinical presentations. The formation of a fistulous tract, coronary artery compression, and death were important described complications. Patients with ring abscesses in the MAIVF region and those with prosthetic aortic valves and histories of endocarditis are at higher risk for developing pseudoaneurysm of the MAIVF. Transesophageal echocardiography was able to identify all cases in which it was used. Surgical correction is the treatment of choice.

Left Atrial Dysfunction as a Correlate of Heart Failure Symptoms in Hypertrophic Cardiomyopathy

Abstract: Background Hypertrophic cardiomyopathy (HCM) represents a generalized myopathic process affecting both ventricular and atrial myocardium. We aimed to assess left atrial (LA) function by two-dimensional speckle tracking echocardiography and its relation with left ventricular (LV) function and clinical status in patients with HCM. Methods We prospectively enrolled 37 consecutive patients with HCM and 37 normal subjects with similar age and gender distribution. Longitudinal LV strain (e) and LA e and strain rate (Sr) parameters (systolic, early diastolic, and late diastolic during atrial contraction) were assessed. Results Peak LAe and LA Sr parameters were significantly lower in patients compared with controls ( P ≤ . 001 for all). In patients, all LA function parameters correlated with LVe ( P 003 for all). Indexed LA volume, LA function parameters, and mitral regurgitation degree were the main correlates of New York Heart Association class; late diastolic strain rate during atrial contraction was the only independent predictor of symptomatic status. Conclusion In patients with HCM, LA function is significantly reduced and related to LV dysfunction. Moreover, LA booster pump function emerged as an independent correlate of heart failure symptoms in this setting.

Independent predictors of survival in primary systemic (Al) amyloidosis, including cardiac biomarkers and left ventricular strain imaging: an observational cohort study

Abstract: Background The prognostic value of Doppler myocardial imaging, including myocardial velocity imaging, strain, and strain rate imaging, in patients with primary (AL) amyloidosis is uncertain. The aim of this longitudinal study was to identify independent predictors of survival, comparing clinical data, hematologic and cardiac biomarkers, and standard echocardiographic and Doppler myocardial imaging measures in a cohort of patients with AL amyloidosis. Methods A total of 249 consecutive patients with AL amyloidosis were prospectively enrolled. The primary end point was all-cause mortality, and during a median follow-up period of 18 months, 75 patients (30%) died. Clinical and electrocardiographic data, biomarkers (brain natriuretic peptide and cardiac troponin T) and standard echocardiographic and longitudinal systolic and diastolic Doppler myocardial imaging measurements for 16 left ventricular segments were tested as potential independent predictors of survival. Results Age (hazard ratio [HR], 1.03; P = .03), New York Heart Association class III or IV (HR, 2.47; P = .01), the presence of pleural effusion (HR, 1.79; P = .08), brain natriuretic peptide level (HR, 1.29; P = .01), ejection time (HR, 0.99; P = .13), and peak longitudinal systolic strain of the basal anteroseptal segment (HR, 1.05; P = .02) were independent predictors in the final model. Conclusions Multivariate survival analysis identified independent predictors of clinical outcome in patients with AL amyloidosis: New York Heart Association class III or IV, presence of pleural effusion, brain natriuretic peptide level > 493 pg/mL, ejection time

Outcomes of Patients with Stress-Induced Cardiomyopathy Diagnosed by Echocardiography in a Tertiary Referral Hospital

Abstract: Background Because stress-induced cardiomyopathy (SIC) is increasingly being observed during routine daily practice, we sought to explore the clinical features and factors that determine the outcome of SIC in a tertiary referral hospital. Methods Patients with typical left ventricular (LV) takotsubo (apical ballooning) or inverted takotsubo on 2-dimensional echocardiography were prospectively enrolled, and their clinical data were analyzed. Results Over a 63-month period, 56 consecutive patients (median age and interquartile range=64 years [52-74 years]) were identified. Women comprised 79% (44/56) of all patients. The triggering events were acute medical illness, including sepsis and hypoxemia in 29 patients (52%, group A), in-hospital surgery/procedure in 17 patients (30%, group B), and emotional stress in 10 patients (18%, group C). Chest pain was more frequently observed in group C (50%) than in groups A (14%) and B (6%) ( P = .021), whereas dyspnea was the presenting symptom in groups A and B. Typical takotsubo and inverted takotsubo were observed in 48 and 8 patients, with a median ejection fraction of 33%. Other abnormalities included dynamic LV outflow tract obstruction (n = 2), LV thrombus (n = 2), and right ventricular dysfunction (n = 12). Nine deaths (16%) occurred during hospitalization. The groups did not differ in mortality. The Acute Physiology and Chronic Health Evaluation II score (odds ratio 1.405; 95% confidence interval, 1.091-1.810; P = .009) and absence of LV function recovery within 1 week (ejection fraction P = .036) were independent factors associated with mortality. During clinical follow-up up to 6 months, 3 more patients died, 2 of whom had recurrences of SIC. Conclusions SIC in a tertiary referral hospital was mainly associated with physical stressors and characterized by diverse clinical presentations, high mortality, and occasional fatal recurrences.

Prospective Assessment of Fetal Cardiac Function With Speckle Tracking in Healthy Fetuses and Recipient Fetuses of Twin-to-Twin Transfusion Syndrome

Abstract: Background The aim of this study was to assess speckle tracking–derived fetal cardiac function in a normal population and in recipient fetuses of twin-to-twin transfusion syndrome (TTTS). Methods A case-control study was conducted of 59 uncomplicated singleton pregnancies and 17 recipient fetuses of TTTS. Peak systolic strain, strain rate, velocity, and displacement were calculated, corrected for gestational age, and compared between patients with TTTS and controls. Results The feasibility of speckle tracking was 83% in controls but only 61% in patients with TTTS. Myocardial velocity and displacement increased over gestation, and regional differences were present within each wall and between walls. Strain and strain rate were stable within each wall but were higher in the right ventricle than in the left ventricle and septum. Right ventricular strain was decreased in patients with TTTS compared with controls (0.75 ± 0.34 vs 1.00 ± 0.37 multiples of the median, P = .04). Conclusion The feasibility of speckle tracking is low when imaging conditions are challenging, but it can identify right ventricular failure in selected patients with TTTS.

Left ventricular myocardial velocities and deformation indexes in top-level athletes

Abstract: Background The aim of this study was to define the range of left ventricular (LV) velocities and deformation indexes in highly trained athletes, analyzing potential differences induced by different long-term training protocols. Methods Standard echocardiography, pulsed-wave tissue Doppler echocardiography, and two-dimensional strain echocardiography of the interventricular septum and lateral wall were performed in 370 endurance athletes and 280 power athletes. Using pulsed-wave tissue Doppler, the following parameters of myocardial function were assessed: systolic peak velocities (S m ), early (E m ) and late (A m ) diastolic velocities, and the E m /A m ratio. By two-dimensional strain echocardiography, peaks of regional systolic strain and LV global longitudinal strain were calculated. Results LV mass index and ejection fraction did not significantly differ between the two groups. However, power athletes showed an increased sum of wall thicknesses ( P P m and E m /A m at both the septal and lateral wall levels were higher in endurance athletes. By two-dimensional strain echocardiography, myocardial deformation indexes were comparable between the two groups. E m /A m ratios ≥ 1 were found in the overall population, while 90 % of athletes had an E m ≥ 16 cm/sec, S m ≥ 10 cm/sec, and global longitudinal strain ≤ −16%. Multivariate analyses evidenced independent positive association between Em peak velocity and LV end-diastolic volume ( P P Conclusions This study describes the full spectrum of systolic and diastolic myocardial velocities and deformation indexes in a large population of competitive athletes.

Diagnostic Value of Segmental Longitudinal Strain by Automated Function Imaging in Coronary Artery Disease without Left Ventricular Dysfunction

Abstract: Background The aim of this study was to investigate the role of segmental longitudinal strain for the diagnosis of coronary artery disease (CAD) assessed by automated function imaging. Methods One hundred fifty-two subjects (mean age, 63 ± 12 years; 77 men) referred for assessment of cardiac function under suspicion of CAD were recruited for this study. Patients with left ventricular dysfunction or with acute coronary syndromes were excluded. Results Peak systolic global longitudinal strain (GLS) was significantly decreased in patients with CAD. Peak segmental longitudinal strain difference (LSD) and its ratio to peak systolic GLS were significant higher in patients with CAD. The areas under receiver operating characteristic curves for the diagnosis of CAD were 0.813 for peak systolic GLS, 0.851 for the number of abnormal segments, 0.805 for peak segmental LSD, and 0.862 for the ratio of peak segmental LSD to peak systolic GLS. Using 1.0 as a cutoff point for the ratio of peak segmental LSD to peak systolic GLS, sensitivity was 77.3% and specificity 79.2%. Conclusions This study suggests that it may be possible to assess CAD with strain by automated function imaging, but further larger scale studies are needed to confirm this.

Role of M-mode technique in today's echocardiography.

Abstract: M-mode echocardiography is considered to be obsolete by many. The technique rarely is included in American Society of Echocardiography standards documents, except for M-mode measurements, which have limited value. The superior temporal resolution of M-mode echocardiography is frequently overlooked. Doppler recordings reflect blood velocity, whereas M-mode motion of cardiac structures reflect volumetric blood flow. The 2 examinations are hemodynamically complementary. In the current digital era, recording multiple cardiac cycles of two-dimensional echocardiographic images is no longer necessary. However, there are times when intermittent or respiratory changes occur. The M-mode technique is an effective and efficient way to record the necessary multiple cardiac cycles. In certain situations, M-mode recordings of the valves and interventricular septum can be particularly helpful in making a more accurate and complete echocardiographic cardiac assessment, thus helping to make the examination more cost-effective.

High Prevalence of Ultrasound Detected Carotid Atherosclerosis in Subjects with Low Framingham Risk Score: Potential Implications for Screening for Subclinical Atherosclerosis

Abstract: Background The cardiovascular (CV) risk assigned by the Framingham risk score (FRS) misses many subjects destined for CV events. Coronary artery calcification (CAC) as measured by computed tomography and carotid intima-media thickness (CIMT) and plaque assessment using B-mode ultrasound can identify subclinical atherosclerosis. The comparative relation of CAC and CIMT and carotid plaque after integration into the FRS is not established. The aim of this study was to develop a CV screening approach incorporating FRS, CAC, and CIMT. Methods The prevalence of subclinical atherosclerosis, defined as CAC score > 0, CIMT ≥ 75th percentile, or plaque ≥ 1.5 mm, was determined in the groups with low, intermediate, and high FRS among 136 asymptomatic subjects. The CIMT and CAC values were used to determine "vascular age" and "coronary calcium" age, respectively, with established nomograms. Results In the 103 low-risk (FRS 0, CIMT ≥ 75th percentile, plaque ≥ 1.5 mm, and CIMT ≥ 75th percentile or plaque ≥ 1.5 mm, respectively. In the 33 subjects with intermediate (n = 14) or high (n = 19) FRS, 70%, 81%, 87%, and 87% had CAC scores > 0, CIMT ≥ 75th percentile, plaque ≥ 1.5 mm, and CIMT ≥ 75th percentile or plaque ≥ 1.5 mm, respectively. Fifty-two percent of subjects with coronary calcium scores of zero had carotid plaque. Adjusted for FRS, body mass index was an independent predictor of abnormal CIMT in the low-FRS group, but not of abnormal CAC. Mean vascular CIMT age was significantly higher than coronary calcium age (61.6 ± 11.4 vs 58.3 ± 11.1 years, P = .001), and both were significantly higher than chronologic age (56.9 ± 10.1 years) ( P P 5% in more cases than CAC (42% vs 17%). Conclusion In asymptomatic patients without CV disease, CIMT and plaque assessment are more likely to revise FRS than CAC. Body mass index predicts increased CIMT in low-FRS subjects. These findings may have broad implications for screening in low-FRS subjects.