Showing papers in "Journal of The American Society of Echocardiography in 2011"

Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications: Endorsed by the Japanese Society of Echocardiography

Abstract: Echocardiographic imaging is ideally suited for the evaluation of cardiac mechanics because of its intrinsically dynamic nature. Because for decades, echocardiography has been the only imaging modality that allows dynamic imaging of the heart, it is only natural that new, increasingly automated techniques for sophisticated analysis of cardiac mechanics have been driven by researchers and manufacturers of ultrasound imaging equipment.Several such technique shave emerged over the past decades to address the issue of reader's experience and inter measurement variability in interpretation.Some were widely embraced by echocardiographers around the world and became part of the clinical routine,whereas others remained limited to research and exploration of new clinical applications.Two such techniques have dominated the research arena of echocardiography: (1) Doppler based tissue velocity measurements,frequently referred to as tissue Doppler or myocardial Doppler, and (2) speckle tracking on the basis of displacement measurements.Both types of measurements lend themselves to the derivation of multiple parameters of myocardial function. The goal of this document is to focus on the currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardial dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated backscatter analysis. This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses,briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use.

EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease

Abstract: The introduction of devices for transcatheter aortic valve implantation, mitral repair, and closure of prosthetic paravalvular leaks has led to a greatly expanded armamentarium of catheter-based approaches to patients with regurgitant as well as stenotic valvular disease. Echocardiography plays an essential role in identifying patients suitable for these interventions and in providing intra-procedural monitoring. Moreover, echocardiography is the primary modality for post-procedure follow-up. The echocardiographic assessment of patients undergoing transcatheter interventions places demands on echocardiographers that differ from those of the routine evaluation of patients with native or prosthetic valvular disease. Consequently, the European Association of Echocardiography in partnership with the American Society of Echocardiography has developed the recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease. It is intended that this document will serve as a reference for echocardiographers participating in any or all stages of new transcatheter treatments for patients with valvular heart disease.

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate use criteria for echocardiography

Abstract: The American College of Cardiology Foundation (ACCF), in partnership with the American Society of Echocardiography (ASE) and along with key specialty and subspecialty societies, conducted a review of common clinical scenarios where echocardiography is frequently considered. This document combines and updates the original transthoracic and transesophageal echocardiography appropriateness criteria published in 2007 (1) and the original stress echocardiography appropriateness criteria published in 2008 (2). This revision reflects new clinical data, reflects changes in test utilization patterns,and clarifies echocardiography use where omissions or lack of clarity existed in the original criteria.The indications (clinical scenarios)were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of the original appropriate use criteria (AUC).The 202 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9,to designate appropriate use(median 7 to 9), uncertain use(median 4 to 6), and inappropriate use (median 1 to 3). Ninety-seven indications were rated as appropriate, 34 were rated as uncertain, and 71 were rated as inappropriate. In general,the use of echocardiography for initial diagnosis when there is a change in clinical status or when the results of the echocardiogram are anticipated to change patient management were rated appropriate. Routine testing when there was no change in clinical status or when results of testing were unlikely to modify management were more likely to be inappropriate than appropriate/uncertain.The AUC for echocardiography have the potential to impact physician decision making,healthcare delivery, and reimbursement policy. Furthermore,recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Abstract: Christopher A. Troianos, MD, Gregg S. Hartman, MD, Kathryn E. Glas, MD, MBA, FASE, Nikolaos J. Skubas, MD, FASE, Robert T. Eberhardt, MD, Jennifer D. Walker, MD, and Scott T. Reeves, MD,MBA, FASE, for the Councils on Intraoperative Echocardiography and Vascular Ultrasound of the American Society of Echocardiography, Pittsburgh, Pennsylvania; Lebanon, New Hampshire; Atlanta, Georgia; New York, New York; Boston, Massachusetts; and Charleston, South Carolina

American Society of Echocardiography recommendations for quality echocardiography laboratory operations.

Abstract: Michael H. Picard, MD, FASE, David Adams, RDCS, FASE, S. Michelle Bierig, RDCS, MPH, FASE, JohnM.Dent,MD,FASE, Pamela S.Douglas,MD,FASE,LindaD.Gillam,MD,FASE,AndrewM.Keller,MD,FASE, David J. Malenka, MD, FASE, Frederick A. Masoudi, MD, MSPH, Marti McCulloch, RDCS, FASE, Patricia A. Pellikka, MD, FASE, Priscilla J. Peters, RDCS, FASE, Raymond F. Stainback, MD, FASE, G.Monet Strachan, RDCS, FASE, andWilliam A. Zoghbi,MD, FASE, Boston, Massachusetts; Durham,North Carolina; St. Louis, Missouri; Charlottesville, Virginia; New York, New York; Danbury, Connecticut; Lebanon, New Hampshire; Denver, Colorado; Houston, Texas; Rochester, Minnesota; Pennsauken, New Jersey; San Diego, California

Early Detection of Left Atrial Strain Abnormalities by Speckle-Tracking in Hypertensive and Diabetic Patients with Normal Left Atrial Size

Abstract: Background Systemic hypertension and type 2 diabetes mellitus are associated with impaired left atrial (LA) function, but whether LA functional abnormalities also occur in patients with hypertension and diabetes who have normal LA sizes is unknown. The aim of this study was to explore LA strain using speckle-tracking echocardiography in patients with hypertension or diabetes and normal LA size. Methods LA strain was studied by speckle-tracking echocardiography in 155 patients with hypertension or diabetes with LA volume indexes 2 (83 with hypertension, 34 with diabetes, and 38 with both diabetes and hypertension) and 36 age-matched controls. The following indexes were measured: peak atrial longitudinal strain, time to peak atrial longitudinal strain, atrial longitudinal strain during early diastole and late diastole, and peak LA strain rate during ventricular systole, early diastole, and late diastole. Results Peak atrial longitudinal strain was lower in patients with hypertension (29.0 ± 6.5%) and those with diabetes (24.7 ± 6.4%) than in controls (39.6 ± 7.8%) and further reduced in patients with diabetes and hypertension (18.3 ± 5.0%) ( P P Conclusions LA deformation mechanics are impaired in patients with hypertension or diabetes with normal LA size. The coexistence of both conditions further impairs LA performance in an additive fashion. Speckle-tracking echocardiography may be considered a promising tool for the early detection of LA strain abnormalities in these patients.

Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training Writing group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC)

Abstract: Luc Mertens, MD, PhD, FASE, FESC, Istvan Seri, MD, PhD, HonD, Jan Marek, MD, PhD, FESC, Romaine Arlettaz, MD, Piers Barker, MD, FASE, Patrick McNamara, MD, MB, FRCPC, Anita J. Moon-Grady, MD, Patrick D. Coon, RDCS, FASE, Shahab Noori, MD, RDCS, John Simpson, MD, FRCP, FESC, Wyman W. Lai, MD, MPH, FASE, Toronto, Ontario, Canada; Los Angeles and San Francisco, California; London, United Kingdom; Zurich, Switzerland; Durham, North Carolina; Philadelphia, Pennsylvania; New York, New York

American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with hypertrophic cardiomyopathy: Endorsed by the American Society of Nuclear Cardiology, Society for Cardiovascular Magnetic Resonance, and Society of Cardiovascular Computed Tomography.

Abstract: Sherif F. Nagueh, MD, FASE, Chair,* S. Michelle Bierig, RDCS, FASE,* Matthew J. Budoff, MD, Milind Desai, MD,* Vasken Dilsizian, MD, Benjamin Eidem, MD, FASE,* Steven A. Goldstein, MD,* Judy Hung, MD, FASE,* Martin S. Maron, MD, Steve R. Ommen, MD,* and Anna Woo, MD,*Houston, Texas; St. Louis, Missouri; Los Angeles, California; Cleveland, Ohio; Baltimore, Maryland; Rochester, Minnesota; Washington, District of Columbia; Boston, Massachusetts; Toronto, Ontario, Canada

New Equations and a Critical Appraisal of Coronary Artery Z Scores in Healthy Children

Abstract: Background The aim of this study was to find the best model to obtain valid and normally distributed Z scores for coronary artery (CA) diameters in a large, heterogeneous population of healthy children. Methods Echocardiography was performed on 1,033 healthy children. Several regression models were tested with height, weight, body surface area, and aortic valve diameter. The computed Z scores were tested for normal distribution and stability. Results CA diameter was best predicted using regression with the square root of body surface area. The weighted least squares method yielded normally distributed and very stable Z -score estimates for all CA segments. In prepubertal children, aortic valve diameter was also a valid predictor of CA diameter. Conclusions This study shows two valid methods to estimate Z scores for CA size in children of all ages. Such Z scores are important for risk stratification in patients with Kawasaki disease.

Diastolic dysfunction in patients with type 2 diabetes mellitus: is it really the first marker of diabetic cardiomyopathy?

Abstract: Background Diastolic dysfunction is considered the first marker of diabetic cardiomyopathy. However, preclinical systolic alteration was also recently described by strain, but its association with diastolic dysfunction has never been investigated. Methods One hundred fourteen patients with type 2 diabetes mellitus (DM) with controlled blood pressure and without overt heart disease were prospectively enrolled and compared with 88 age-matched controls. All subjects underwent comprehensive echocardiography, including diastolic evaluation according to current recommendations and speckle-tracking imaging. The prevalence of diastolic dysfunction, the determinants of diastolic parameters, and the association between preclinical systolic and diastolic dysfunctions were studied. Results Diastolic parameters were altered in patients compared with controls, with lower E/A ratios, longer mitral deceleration and isovolumic relaxation times, and higher E/e′ ratio. Diastolic dysfunction occurred in 47% of patients with DM (33% and 14% with grade I and II diastolic dysfunction, respectively) and systolic alteration (longitudinal strain ≥ −18%) in 32% of patients. Whereas longitudinal systolic strain was independently associated with DM and gender, diastolic parameters were influenced by many factors, including age, rate-pressure product, history of hypertension, and body mass index. Systolic alteration occurred in 28% of patients with DM with normal diastolic function and in 35% with diastolic dysfunction. Conclusions Diastolic dysfunction diagnosed according to current recommendations is frequent in patients with DM but is also influenced by other factors. Systolic strain alteration may exist despite normal diastolic function, indicating that diastolic dysfunction should not be considered the first marker of a preclinical form of diabetic cardiomyopathy.

Utility of Right Ventricular Free Wall Speckle-Tracking Strain for Evaluation of Right Ventricular Performance in Patients with Pulmonary Hypertension

Abstract: Background The objectives of this study were to test the utility of right ventricular (RV) speckle-tracking strain as an assessment tool for RV function in patients with pulmonary hypertension (PH) compared with conventional echocardiographic parameters and to investigate the relationship of the findings obtained with RV speckle-tracking strain with the hemodynamic parameters of RV performance. Methods Forty-five prospective consecutive patients with PH were studied. RV free wall longitudinal speckle-tracking strain (RV-free) and RV septal wall longitudinal speckle-tracking strain (RV-septal) were calculated by averaging each of three regional peak systolic strains along the entire right ventricle. The conventional echocardiographic parameters—RV fractional area change, RV myocardial performance index, tricuspid annular plane systolic excursion, and tricuspid annular peak systolic velocity—were also studied. For comparison, 22 age-matched volunteers with normal ejection fractions were studied. Results RV-free in patients with PH was significantly lower than that in normal controls, but RV-septal in the two groups was similar. Importantly, multivariate analysis revealed that RV-free was an independent echocardiographic predictor of hemodynamic RV performance items, including mean pulmonary artery pressure (β = −0.844, P = .001) and pulmonary vascular resistance (β = −0.045, P r = 0.60, r = 0.56, and r = 0.49, respectively, P r = 0.68, P Conclusions RV-free has the potential to allow for noninvasive follow-up of patients with PH.

Diagnostic Accuracy of a Hand-Held Ultrasound Scanner in Routine Patients Referred for Echocardiography

Abstract: Background The aim of this study was to investigate the imaging capabilities of recent hand-held ultrasound scanners. Methods Three hundred forty-nine patients were scanned with hand-held ultrasound (HAND) and high-end echocardiography (HIGH). Segmental endocardial border delineation was scored (2 = good, 1=poor, 0=invisible) to describe image quality. Assessments of left ventricular (LV) dimensions, regional and global LV function, and grades of valve disease were compared. Results The mean endocardial visibility grades were 1.6 ± 0.5 with HAND and 1.7 ± 0.4 with HIGH ( P P r = 0.99, P P Conclusions Handheld echocardiography was feasible and missed no relevant findings. Given the future implementation of spectral Doppler capabilities, this handheld scanner can safely be used in clinical routine.

Reference Values for Myocardial Two-Dimensional Strain Echocardiography in a Healthy Pediatric and Young Adult Cohort

Abstract: Background The accurate evaluation of intrinsic myocardial contractility in children with or without congenital heart disease (CHD) has turned out to be a challenge. Two-dimensional strain echocardiographic (2DSTE) imaging or two-dimensional speckle-tracking echocardiographic imaging appears to hold significant promise as a tool to improve the assessment of ventricular myocardial function. The aim of this study was to estimate left ventricular myocardial systolic function using 2DSTE imaging in a large cohort consisting of healthy children and young adults to establish reference strain values. Methods Transthoracic echocardiograms were acquired in 195 healthy subjects (139 children, 56 young adults) and were retrospectively analyzed. Longitudinal, circumferential, and radial peak systolic strain values were determined by means of speckle tracking. Nonlinear regression analysis was performed to assess the effect of aging on these 2DSTE parameters. Results There was a strong, statistically significant second-order polynomial relation ( P Conclusion This is the first report to establish age-dependent reference values per cardiac segment for myocardial strain in all three directions assessed using 2DSTE imaging in a large pediatric and young adult cohort. There is a need to use age-specific reference values for the adequate interpretation of 2DSTE measurements.

Reproducibility and inter-vendor variability of left ventricular deformation measurements by three-dimensional speckle-tracking echocardiography.

Abstract: Background Myocardial deformation measurements using two-dimensional speckle-tracking echocardiography (STE) are known to vary among vendors. The intervendor agreement of three-dimensional (3D) deformation indices has not been studied. The goals of this study were to determine the intervendor agreement of 3D STE–based measurements of left ventricular (LV) deformation parameters to investigate the intrinsic variability of these measurements and identify the sources of intervendor differences. Methods Real-time full-volume images obtained in 30 subjects with normal LV systolic function using two vendors' equipment (V1 and V2) on the same day were analyzed by two independent observers using two software packages (S1 and S2). Agreement between three technique combinations (V1/S1, V2/S2, and V1/S2) and their intrinsic reproducibility (interobserver and intraobserver agreement) were assessed using intraclass correlation coefficients. Parameters of LV deformation included global longitudinal strain, twist, 3D displacement, and 3D strain and its radial, longitudinal, and circumferential components. Results For all three combinations, intertechnique agreement was poor (intraclass correlation coefficient Conclusions Three-dimensional STE–derived LV deformation parameters are highly vendor dependent, and the discordance levels are beyond intrinsic measurement variability of any of the tested combinations of imaging equipment and analysis software. This intervendor discordance must be taken into account when interpreting 3D deformation data.

Pulmonary artery acceleration time provides an accurate estimate of systolic pulmonary arterial pressure during transthoracic echocardiography.

Abstract: Background: Transthoracic echocardiographic estimates of peak systolic pulmonary artery pressure are conventionally calculated from the maximal velocity of the tricuspid regurgitation (TR) jet. Unfortunately, there is insufficient TR to determine estimated peak systolic pulmonary artery pressure (EPSPAP) in a significant numberofpatients.Todate,intheabsenceofTR,nononinvasivemethodofderivingEPSPAPhasbeendeveloped. Methods: Five hundred clinically indicated transthoracic echocardiograms were reviewed over a period of 6 months. Patients with pulmonic stenosis were excluded. Pulsed-wave Doppler was used to measure pulmonary artery acceleration time (PAAT) and right ventricular ejection time. Continuous-wave Doppler was used to measurethepeakvelocityofTR(TRVmax),andEPSPAPwascalculated as4TRVmax 2 +10mmHg(toaccount for right atrial pressure). The relationship between PAAT and EPSPAP was then assessed. Results:Adequateimagingtomeasure PAATwasavailablein 99.6%ofpatients(498of500),but25.3%(126of 498) had insufficient TR to determine EPSPAP, and 1 patient had significant pulmonic stenosis. Therefore, 371 were included in the final analysis. Interobserver variability for PAAT was 0.97. There were strong inverse correlations between PAAT and TRVmax (r = 0.96), the right atrial/right ventricular pressure gradient (r = 0.95), and EPSPAP (r=0.95). The regression equation describing the relationship between PAAT and EPSPAP was log10(EPSPAP) = 0.004 (PAAT) + 2.1 (P < .001). Conclusions: PAAT is routinely obtainable and correlates strongly with both TRVmax and EPSPAP in a large population of randomly selected patients undergoing transthoracic echocardiography. Characterization of the relationship between PAAT and EPSPAP permits PAAT to be used to estimate peak systolic pulmonary artery pressure independent of TR, thereby increasing the percentage of patients in whom transthoracic echocardiography can be used to quantify pulmonary artery pressure. (J Am Soc Echocardiogr 2011;24:687-92.)

The right ventricle of the endurance athlete: the relationship between morphology and deformation

Abstract: Introduction It is well established that endurance exercise results in cardiac adaptation including eccentric hypertrophy of the left ventricle which can complicate the differential diagnosis of the athletic heart from some cardiac pathologies that may pre-dispose to sudden cardiac death. The impact of physiological conditioning on RV structure and function, and a similar diagnostic challenge with arrhythmogenic right ventricular cardiomyopathy (ARVC), has received less attention. A recent guideline paper from the American Society of Echocardiography (ASE) has provided a range for normal RV dimensions and functional deformation. These guidelines suggest the RV inflow (RVI) should be 36 mm or 21 mm/m 2 is a major criterion for the diagnosis of ARVC and furthermore longitudinal RV deformation has been shown to be impaired in these patients. In view of this, the aims of this study are twofold: To provide a range of absolute values for RV dimensions in 102 endurance athletes as well as providing a range of data indexed for body surface area (BSA). To provide normal athlete data for indices of RV strain (ɛ) and strain rate (SR). Methods and Results One hundred and two (102) endurance athletes (86 males and 16 females) with a broad age range (mean ± SD age (range)=36 ± 11 (21–71) years) volunteered and were consecutively enrolled in the study. All subjects were either endurance runners or cyclists and were scanned at peak condition. Echocardiography provided measurements of RVI, RV length, RVOT and RV diastolic area (RVDarea). A 2D strain technique was utilised to provide indices of RVɛ and systolic and diastolic SR. The values for RVI ranged from 30 to 55 mm with 57% of the population having values greater than the normal range. Proximal RVOT ranged from 26 to 49 mm with 40% of the population above the normal range. 28% of the population had RVOT values greater than the proposed “major criteria” for ARVC. RV length ranged from 70 to 110 mm and RVDarea from 13 to 38 cm 2 with values falling above ASE cut-offs in 69% and 59% of the population, respectively. When indexed (ratio scaling) for BSA proximal RVOT ranged from 13 to 25 mm/m 2 with 6% of the population meeting the major criteria for ARVC. Peak RVɛ ranged from −18 to −41% and peak RV SRS′ from −0.75 to −2.65 l/s, consistent with normal ranges proposed by the ASE. RV diastolic deformation indices displayed marked individual variability with a dominant SRE′ (mean ± SD=2.0±0.61 l/s) and smaller SRA′ (1.25±0.56 l/s). Conclusion RV dimensions in endurance athletes are higher than those proposed as “normal” and likewise may be consistent with the criteria for ARVC. Despite this enlargement, RV function in endurance athletes is preserved and therefore the role of RV strain imaging may provide additional diagnostic value in differentiating physiological from pathological adaptation.

Association of decreased left atrial strain and strain rate with stroke in chronic atrial fibrillation.

Abstract: Background The objective of this study was to investigate myocardial deformation of the left atrium (LA) assessed by two-dimensional speckle tracking echocardiography in patients with permanent atrial fibrillation (AF) and its value for risk stratification for stroke. Methods We recruited 66 consecutive patients with permanent AF who were referred to our echocardiography laboratory for evaluation. These patients were divided into two groups according to the presence of previous stroke or not. Results Peak positive longitudinal strain (LASp) during atrial filling, peak strain rate in the reservoir phase of LA (LASRr), and peak strain rate in the conduit phase (LASRc) were identified from LA strain and strain rate curves. The ratio of peak early filling velocity (E) of mitral inflow to early diastolic annulus velocity (E') of the medial annulus (E/E') was calculated. LASp (10.44% ± 4.2% vs. 15.69% ± 5.1%, P 001), LASRr (1.09 ± 0.27 1/s vs. 1.37 ± 0.32 1/s, P = .001), and LASRc (−1.28 ± 0.38 1/s vs. −1.62 ± 0.43 1/s, P = .002) were significantly lower in patients with AF with stroke than those without stroke. By multivariate analysis controlling for age, LA volume index, and left ventricular ejection fraction, LASp (OR 0.787, 95% CI, 0.639–0.968, P = .023) and LASRr (OR 0.019, 95% CI, 0.001–0.585, P = .023) were independently associated with stroke but not LASRc, E', and E/E' ratio. Conclusion Decreased LASp and LASRr were independently associated with stroke in patients with permanent AF.

Assessment of myocardial deformation in children using Digital Imaging and Communications in Medicine (DICOM) data and vendor independent speckle tracking software.

Abstract: Background Analysis of myocardial deformation from data stored in Digital Imaging and Communications in Medicine format using vendor-independent software may be useful for clinical and research purposes but has not been evaluated in children. Methods Grayscale images were prospectively acquired on Vivid 7 (GE Healthcare) and iE33 (Philips Medical Systems) ultrasound systems in 49 children. Digital Imaging and Communications in Medicine and raw data were analyzed using vendor-independent software (Cardiac Performance Analysis, Tomtec Imaging Systems) and vendor-specific software (EchoPAC and QLAB) and results compared. In addition, vendor-independent software using images at 30 frames/sec were compared with images at the higher acquisition frame rate. Results Measurement of short-axis radial and circumferential strain (e) and apical four-chamber longitudinal e by vendor-independent software was possible in >92% of the children. Intraobserver and interobserver coefficients of variation for global circumferential and longitudinal e ranged from 7.1% to 15.3% and for radial e from 23.9% to 30.2%. Strain values were somewhat higher when using GE images at acquisition frame rates compared with e values using GE images stored at 30 frames/sec. Strain values obtained by vendor-independent software were comparable with those obtained by vendor-specific software for longitudinal e and higher for circumferential e. Radial e values obtained by vendor-independent software were lower than e values by EchoPAC and higher than e values by QLAB. Conclusions Vendor-independent software–derived e is feasible and potentially valuable for measuring myocardial deformation in research and in multicenter studies using images from different ultrasound systems, especially for longitudinal deformation. However, a systematic bias for circumferential e and a high variability in radial e measurements remain concerns.

Left Atrial Systolic and Diastolic Dysfunction in Heart Failure with Normal Left Ventricular Ejection Fraction

Abstract: Background The authors hypothesized that in patients with heart failure with normal left ventricular (LV) ejection fraction (HFNEF), the same fibrotic processes that affect the subendocardial layer of the left ventricle could also alter the subendocardial fibers of the left atrium. Consequently, these fibrotic alterations, together with chronically elevated LV filling pressures, would lead to both systolic and diastolic subendocardial dysfunction of the left atrium (i.e., impaired left atrial [LA] longitudinal systolic and diastolic function) in patients with HFNEF. Methods Patients with HFNEF and a control group consisting of asymptomatic patients with LV diastolic dysfunction (LVDD) matched by age, gender, and LV ejection fraction were studied using two-dimensional speckle-tracking echocardiography. Results A total of 420 patients were included (119 with HFNEF and 301 with asymptomatic LVDD). LA longitudinal systolic (LA late diastolic strain rate) and diastolic (LA systolic strain and strain rate) function was significantly more impaired in patients with HFNEF (LA late diastolic strain rate, −1.17 ± 0.63 s −1 ; LA systolic strain, 19.9 ± 7.3%; LA systolic strain rate, 1.17 ± 0.46 s −1 ) compared with those with asymptomatic LVDD (−1.80 ± 0.70 s −1 , 30.8 ± 11.4%, and 1.67 ± 0.59 s −1 , respectively) (all P values Conclusions In patients with HFNEF, LA subendocardial systolic and diastolic dysfunction is common and possibly associated with the same fibrotic processes that affect the subendocardial fibers of the left ventricle and to a lesser extent with elevated LV filling pressures. Furthermore, these findings suggest that LA longitudinal systolic and diastolic dysfunction could be related to reduced functional capacity during effort in patients with HFNEF.

Three-dimensional speckle tracking echocardiography for automatic assessment of global and regional left ventricular function based on area strain.

Abstract: Objective We evaluated the ability of a novel automatic index based on area strain to reliably quantify global and regional left ventricular (LV) function and accurately identify wall motion (WM) abnormalities using three-dimensional speckle tracking echocardiography. Methods A total of 140 consecutive patients underwent two- and three-dimensional echocardiography. Segmental WM assessment by area strain was compared with visual assessment of two-dimensional images by two experienced echocardiographers. For global LV function assessment, area strain was validated against LV ejection fraction (EF) and wall motion score index (WMSI). Observer reliability was assessed in all patients, whereas test–retest reliability was evaluated in a subgroup of 50 randomly selected patients. Normal reference values of area strain were determined in 56 healthy subjects. Results Agreement of WM scores between area strain and visual assessment was found in 94% of normal, 55% of hypokinetic, and 91% of akinetic segments ( κ -coefficient 0.88). Sensitivity, specificity, and accuracy of area strain to distinguish abnormal segments from normal segments were 91%, 96%, and 94%, respectively. In regard to global LV function assessment, area strain was highly correlated with EF and WMSI ( r = 0.91 and 0.88, respectively). Observer and test–retest reliability of area strain for quantitative assessment of global and regional LV function were good to excellent (all intraclass correlation coefficients ≥0.77). Intraobserver and interobserver reliability of semiquantitative segmental WM analysis by area strain ( κ -coefficients 0.87 and 0.73) were comparable to visual assessment by experienced echocardiographers (0.85 and 0.69, respectively). Conclusion Area strain represents a promising novel automatic index that may provide an accurate and reproducible alternative to current echocardiographic standards for quantitative assessment of global and regional LV function. Area strain seems to adequately identify regional wall motion abnormalities compared with the clinical standard of visual assessment by experienced echocardiographers.

Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure.

Abstract: Background The rapid detection of left ventricular systolic dysfunction (LVSD) is an important step in the clinical management of patients admitted with acute decompensated heart failure, because it allows the initiation of treatment specific to LVSD and avoidance of contraindicated therapies. The aim of this study was to determine whether internal medicine residents with limited ultrasound training could use hand-carried ultrasound (HCU) to identify LVSD. Methods Fifty patients admitted with acute decompensated heart failure were imaged from the parasternal window at the bedside with an HCU device by residents blinded to all clinical data, who had undergone limited cardiac ultrasound training (20 practice studies). Ejection fraction (EF) on HCU was graded as >40% or Results The average formal EF was 32 ± 16% (range, 7%–70%), with 66% of patients having EFs Conclusions Residents with limited training in cardiac ultrasound were able to identify LVSD in patients with acute decompensated heart failure with superior accuracy compared with clinical, physical exam, lab, and electrocardiographic findings and an average of 22 hours before the results of formal echocardiography were available.

Epicardial Fat: An Additional Measurement for Subclinical Atherosclerosis and Cardiovascular Risk Stratification?

Abstract: Background The value of epicardial adipose tissue (EAT) thickness as determined by echocardiography in cardiovascular risk assessment is not well understood. The aim of this study was to determine the associations between EAT thickness and Framingham risk score, carotid intima media thickness, carotid artery plaque, and computed tomographic coronary calcium score in a primary prevention population. Methods Patients presenting for cardiovascular preventive care ( n = 356) who underwent echocardiography as well as carotid artery ultrasound and/or coronary calcium scoring were included. Results EAT thickness was weakly correlated with Framingham risk score. The prevalence of carotid plaque was significantly greater in those with EAT thickness ≥5.0 mm who either had low Framingham risk scores or had body mass indexes ≥25 kg/m 2 , compared with those with EAT thickness Conclusion EAT thickness ≥5.0 mm may identify an individual with a higher likelihood of having detectable carotid atherosclerosis.

Usefulness of a New Miniaturized Echocardiographic System in Outpatient Cardiology Consultations as an Extension of Physical Examination

Abstract: Background The aim of this study was to assess the usefulness of a new miniaturized echocardiographic system (MS) to perform bedside echocardiography in initial outpatient cardiology consultations, in addition to physical examination. Methods One hundred eighty-nine patients referred for initial cardiology outpatient consultations at two tertiary hospitals in two countries were studied. Each patient was submitted to physical examination followed by MS assessment. Scanning time, the number of examinations with abnormal results after physical examination and the MS, and the information obtained by physical examination alone and followed by the MS (in terms of its importance in reaching a diagnosis, in the necessity of performing routine echocardiography, and in the decision to release the patient from the outpatient clinic) were assessed. Results The scanning time with the MS was 180 ± 86 seconds. Its use after physical examination led to diagnoses in 141 patients (74.6%) and to an additional 37 patients (19.6%) being released from the outpatient clinic. After physical examination followed by MS assessment, only 64 patients (33.9%) were sent to the echocardiography lab. The MS modified the decision of whether to send a patient to the echocardiography lab, with referral determined by the MS in 27 patients (14.3%) and no referral determined by the MS in 58 patients (30.7%). Conclusions The new MS caused a negligible increase in the duration of consultations. It showed additive clinical value over physical examination, increasing the number of diagnoses, reducing the use of unnecessary routine echocardiography, increasing the number of adequate echocardiographic studies, and determining a large number of releases from the outpatient clinic.

Pericardial rather than epicardial fat is a cardiometabolic risk marker: an MRI vs echo study.

Abstract: Background Several studies using echocardiography identified epicardial adipose tissue (EPI) as an important cardiometabolic risk marker. However, validation compared with magnetic resonance imaging (MRI) or computed tomography has not been performed. Moreover, pericardial adipose tissue (PERI) has recently been shown to have some correlation with cardiovascular disease risk factors. The aims of this study were to validate echocardiographic analyses compared with MRI and to evaluate which cardiac fat depot (EPI or PERI) is the most appropriate cardiovascular risk marker. Methods Forty-nine healthy subjects were studied (age range, 25–68 years; body mass index, 21–40 kg/m 2 ), and PERI and EPI fat depots were measured using echocardiography and MRI. Findings were correlated with MRI visceral fat and subcutaneous fat, blood pressure, insulin sensitivity, triglycerides, cholesterol, insulin, glucose, and 10-year coronary heart disease risk. Results Most cardiac fat was constituted by PERI (about 77%). PERI thickness by echocardiography was well correlated with MRI area ( r = 0.36, P = .009), and independently of the technique used for quantification, PERI was correlated with body mass index, waist circumference, visceral fat, subcutaneous fat, blood pressure, insulin sensitivity, triglycerides, cholesterol, glucose, and coronary heart disease risk. On the contrary, EPI thicknesses correlated only with age did not correlate significantly with MRI EPI areas, which were found to correlate with age, body mass index, subcutaneous fat, and hip and waist circumferences. Conclusions Increased cardiac fat in the pericardial area is strongly associated with features of the metabolic syndrome, whereas no correlation was found with EPI, indicating that in clinical practice, PERI is a better cardiometabolic risk marker than EPI.

Global left atrial strain correlates with CHADS2 risk score in patients with atrial fibrillation.

Abstract: Background The aim of this cross-sectional study was to explore the association between echocardiographic parameters and CHADS 2 score in patients with nonvalvular atrial fibrillation (AF). Methods Seventy-seven subjects (36 patients with AF, 41 control subjects) underwent standard two-dimensional, Doppler, and speckle-tracking echocardiography to compute regional and global left atrial (LA) strain. Results Global longitudinal LA strain was reduced in patients with AF compared with controls ( P 2 score ≥ 2; odds ratio, 0.86; P = .02). LA strain indexes showed good interobserver and intraobserver variability. In sequential Cox models, the prediction of hospitalization and/or death was improved by addition of global LA strain and indexed LA volume to CHADS 2 score ( P = .003). Conclusions LA strain is a reproducible marker of dynamic LA function and a predictor of stroke risk and cardiovascular outcomes in patients with AF.

Mechanistic Insights into Ischemic Mitral Regurgitation: Echocardiographic and Surgical Implications

Abstract: Ischemic mitral regurgitation is a common complication of the healing phase of myocardial infarction. A number of mechanisms have been invoked in its pathogenesis, including alterations of papillary muscle position, annular dynamics, and intraventricular synchrony. The echocardiographic hallmark of ischemic mitral regurgitation is systolic tethering of the mitral valve leaflets away from the annular plane. A number of leaflet tethering parameters have been described (tenting height and area, leaflet angles) that provide insight into the mechanism of tethering as well as prognostic information about the durability of mitral valve repair. Restrictive annuloplasty and coronary artery revascularization promote reverse remodeling and remain the most common surgical treatment. Innovative subannular therapies and a number of percutaneous interventions are under investigation.

Left Ventricular Hypertrophy Causes Different Changes in Longitudinal, Radial, and Circumferential Mechanics in Patients with Hypertension: A Two-Dimensional Speckle Tracking Study

Abstract: Background Systolic reserve is an important compensatory mechanism against increasing afterload. Although longitudinal systolic dysfunction with preserved ejection fraction has been reported in hypertensive hearts, radial and circumferential function has not been fully examined. The aim of this study was to investigate three-directional systolic function and its relationships with left ventricular geometry in asymptomatic hypertensive patients using two-dimensional speckle-tracking imaging. Methods Echocardiographic evaluations were performed in 74 hypertensive patients and 55 age-matched control subjects. Results Longitudinal strain was significantly reduced in the hypertrophy groups compared with that in control subjects (concentric, −15.1 ± 4.0%; eccentric, −15.9 ± 4.4%; control, −18.9 ± 3.3%; P P Conclusion Hypertrophic remodeling attenuates compensatory augmentation of radial systolic function and is associated with latent longitudinal systolic dysfunction.

Left Atrial Volume by Real-Time Three-Dimensional Echocardiography: Validation by 64-Slice Multidetector Computed Tomography

Abstract: Background Left atrial (LA) enlargement has been acknowledged as a significant predictor of cardiovascular morbidity and mortality. Methods To evaluate the accuracy of two-dimensional and three-dimensional echocardiography for determining LA volume, LA volume measurements by echocardiography were compared with those measured by 64-slice multidetector computed tomography (MDCT) as a reference standard. Results Fifty-seven consecutive patients (mean age, 66 ± 11 years; 59% men) referred to echocardiography and MDCT on the same day were prospectively evaluated. LA volume by three-dimensional echocardiography was correlated closely with that by MDCT ( r = 0.95, P r = 0.86, P Conclusions LA volume assessment by three-dimensional echocardiography was correlated closely with that measured by MDCT, albeit with an 8% underestimation. Three-dimensional echocardiography is a feasible noninvasive method to evaluate LA volume.

Comparative Accuracy of Two- and Three-Dimensional Transthoracic and Transesophageal Echocardiography in Identifying Mitral Valve Pathology in Patients Undergoing Mitral Valve Repair: Initial Observations

Abstract: Background Identification of mitral regurgitation (MR) mechanism and pathology are crucial for surgical repair. The aim of the present investigation was to evaluate the comparative accuracy of real-time three-dimensional (3D) transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) with two-dimensional (2D) TEE and TTE in diagnosing the mechanism of MR compared with the surgical standard. Methods Forty patients referred for surgical mitral valve repair were studied; 2D and 3D echocardiography with both TTE and TEE were performed preoperatively. Two independent observers reviewed the studies for MR pathology, functional or organic. In organic disease, the presence and localization of leaflet prolapse and/or flail were noted. Surgical findings served as the gold standard. Results There was 100% agreement in identifying functional versus organic MR among all four modalities. Overall, 2D TTE, 2D TEE, and 3D TEE performed similarly in identifying a prolapse or a flail leaflet; 3D TEE had the best agreement in identifying anterior leaflet prolapse, and it also showed an advantage for segmental analysis. Three-dimensional TTE was less sensitive and less accurate in identifying flail segments. Conclusion All modalities were equally reliable in identifying functional MR. Both 2D TEE and 3D TEE were comparable in diagnosing MR mechanism, while 3D TEE had the advantage of better localizing the disease. With current technology, 3D TTE was the least reliable in identifying valve pathology.

Differential effects of coronary artery stenosis on myocardial function: the value of myocardial strain analysis for the detection of coronary artery disease.

Abstract: Background Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this study was to assess the predictive value of two-dimensional longitudinal strain in the detection of longitudinal LV dysfunction and the identification of coronary artery disease (CAD) in patients hospitalized with angina. Methods Two-dimensional strain software was extended to allow the analysis of numerous longitudinal strain traces in the entire left ventricle and generate a histogram of peak systolic strain (PSS) values for the left ventricle and for each coronary territory. In each histogram, the value of the 10% worst strain values (PSS 10% ) was determined. Global strain, segmental PSS, and PSS 10% were analyzed in 97 patients hospitalized with angina and had normal LV function, who underwent coronary angiography, and 51 patients with low probability of CAD. Echocardiography was performed 2.9 ± 2 days after admission. Results Sixty-nine patients had significant CAD on coronary angiography. Significant differences were observed in all strain parameters between patients with and without CAD. PSS 10% showed the best accuracy in detecting CAD, with an area under the receiver operating characteristic curve of 0.85. The areas under the curve for global strain and segmental PSS were 0.80 and 0.76, respectively. The optimal cutoff for PSS 10% was −13.9%, with sensitivity and specificity of 86% and 75%, respectively. PSS 10% was better than segmental PSS in the detection of CAD in each coronary territory. Conclusions In patients hospitalized with angina who have significant CAD on coronary angiography, longitudinal systolic function is impaired. Histogram analysis improved the accuracy of longitudinal strain analysis in detecting global and regional impaired function.