Showing papers in "Journal of The American Society of Echocardiography in 2013"

Normal ranges of left ventricular strain: a meta-analysis.

Abstract: Background The definition of normal values of left ventricular global longitudinal strain (GLS), global circumferential strain, and global radial strain is of critical importance to the clinical application of this modality. The investigators performed a meta-analysis of normal ranges and sought to identify factors that contribute to reported variations. Methods MEDLINE, Embase, and the Cochrane Library database were searched through August 2011 using the key terms "strain," "speckle tracking," "left ventricle," and "echocardiography" and related phrases. Studies were included if the articles reported left ventricular strain using two-dimensional speckle-tracking echocardiography in healthy normal subjects, either in the control group or as a primary objective of the study. Data were combined using a random-effects model, and effects of demographic, hemodynamic, and equipment variables were sought in a meta-regression. Results The search identified 2,597 subjects from 24 studies. Reported normal values of GLS varied from −15.9% to −22.1% (mean, −19.7%; 95% CI, −20.4% to −18.9%). Normal global circumferential strain varied from −20.9% to −27.8% (mean, −23.3%; 95% CI, −24.6% to −22.1%). Global radial strain ranged from 35.1% to 59.0% (mean, 47.3%; 95% CI, 43.6% to 51.0%). There was significant between-study heterogeneity and inconsistency. The source of variation was sought between studies using meta-regression. Blood pressure, but not age, gender, frame rate, or equipment, was associated with variation in normal GLS values. Conclusions The narrowest confidence intervals from this meta-analysis were for GLS and global circumferential strain, but individual studies have shown a broad range of strain in apparently normal subjects. Variations between different normal ranges seem to be associated with differences in systolic blood pressure, emphasizing that this should be considered in the interpretation of strain.

American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography.

Abstract: Allan L. Klein, MD, FASE, Chair, Suhny Abbara, MD, Deborah A. Agler, RCT, RDCS, FASE, Christopher P. Appleton, MD, FASE, Craig R. Asher, MD, Brian Hoit, MD, FASE, Judy Hung, MD, FASE, Mario J. Garcia, MD, Itzhak Kronzon, MD, FASE, Jae K. Oh, MD, FASE, E. Rene Rodriguez, MD, Hartzell V. Schaff, MD, Paul Schoenhagen,MD, Carmela D. Tan,MD, and Richard D.White, MD,Cleveland and Columbus, Ohio; Boston, Massachusetts; Weston, Florida; Scottsdale, Arizona; Rochester, Minnesota; Bronx and New York, New York

Focused cardiac ultrasound: recommendations from the American Society of Echocardiography.

Abstract: 1. Why is a guideline needed? 567 2. Definitions 568 a. What is FCU? 568 b. Terminology 568 3. Differentiation of FCU and ‘‘Limited TTE’’ 568 a. Examination Expectations 569 b. Equipment 570 c. Image Acquisition 570 d. Image Interpretation 570 e. Billing 571 4. Considerations for Successful Use of FCU as an Adjunct to Physical Examination 571 a. Personnel 571 b. Equipment 571 c. Potential Limitations of FCU 572 5. FCU Scope of Practice 573 a. FCU When Echocardiography is Not Promptly Available 573 b. FCU When Echocardiography is Not Practical 574

Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.

Abstract: Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

Echocardiography in Pulmonary Arterial Hypertension: from Diagnosis to Prognosis

Abstract: Pulmonary arterial hypertension is most often diagnosed in its advanced stages because of the nonspecific nature of early symptoms and signs. Although clinical assessment is essential when evaluating patients with suspected pulmonary arterial hypertension, echocardiography is a key screening tool in the diagnostic algorithm. It provides an estimate of pulmonary artery pressure, either at rest or during exercise, and is useful in ruling out secondary causes of pulmonary hypertension. In addition, echocardiography is valuable in assessing prognosis and treatment options, monitoring the efficacy of specific therapeutic interventions, and detecting the preclinical stages of disease.

Independent and incremental value of deformation indices for prediction of trastuzumab-induced cardiotoxicity.

Abstract: Background: Assessment of left ventricular systolic function is necessary during trastuzumab-based chemotherapy because of potential cardiotoxicity. Deformation indices have been proposed as an adjunct to clinical risk factors and ejection fraction (EF), but the optimal parameter and optimal cutoffs are undefined. The aim of this study was to determine the best means of early detection of subsequent reduction of EF in patients with breast cancer treated with trastuzumab. Methods: Eighty-one consecutive women (mean age, 50 6 11 years) receiving trastuzumab were prospectively studied, 37 of whom received concurrent anthracyclines. Conventional echocardiographic indices (mitral annular systolic [s 0 ] and diastolic [e 0 ] velocities) and myocardial deformation indices (global longitudinal peak systolic strain [GLS], global longitudinal peak systolic strain rate [GLSR-S], and global longitudinal early diastolic strain rate [GLSR-E]) were measured at baseline and at 6 and 12 months. Cardiotoxicity was defined as a >10% decline as a percentage of baseline EF in 12 months. Results: In the 24 patients (30%) who later developed cardiotoxicity, myocardial deformation indices decreased at 6 months (GLS, P 0) of 0.77 (95% confidence interval, 0.33‐1.22; P = .036). Conclusions: GLS is an independent early predictor of later reductions in EF, incremental to usual predictors in patients at risk for trastuzumab-induced cardiotoxicity. (J Am Soc Echocardiogr 2013;26:493-8.)

Noninvasive evaluation of right atrial pressure.

Abstract: In current practice, right atrial pressure (RAP) is an essential component in the hemodynamic assessment of patients and a requisite for the noninvasive estimation of the pulmonary artery pressures. RAP provides an estimation of intravascular volume, which is a critical component for optimal patient care and management. Increased RAP is associated with adverse outcomes and is independently related to all-cause mortality in patients with cardiovascular disease. Although the gold standard for RAP evaluation is invasive monitoring, various techniques are available for the noninvasive evaluation of RAP. Various echocardiographic methods have been suggested for the evaluation of RAP, consisting of indices obtained from the inferior vena cava, systemic and hepatic veins, tissue Doppler parameters, and right atrial dimensions. Because the noninvasive evaluation of RAP involves indirect measurements, multiple factors must be taken into account to provide the most accurate estimate of RAP. The authors review the data supporting current guidelines, identifying areas of agreement, conflict, limitation, and uncertainty.

Basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.

Abstract: Scott T Reeves, MD, FASE, Alan C Finley, MD, Nikolaos J Skubas, MD, FASE, Madhav Swaminathan, MD, FASE, William S Whitley, MD, Kathryn E Glas, MD, FASE, Rebecca T Hahn, MD, FASE, Jack S Shanewise, MD, FASE, Mark S Adams, BS, RDCS, FASE, and Stanton K Shernan, MD, FASE, for the Council on Perioperative Echocardiography of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists, Charleston, South Carolina; New York, New York; Durham, North Carolina; Atlanta, Georgia; Boston, Massachusetts

Current state of three-dimensional myocardial strain estimation using echocardiography.

Abstract: With the developments in ultrasound transducer technology and both hardware and software computing, real-time volumetric imaging has become widely available, accompanied by various methods of assessing three-dimensional (3D) myocardial strain, often referred to as 3D speckle-tracking echocardiographic methods. Indeed, these methods should provide cardiologists with a better view of regional myocardial mechanics, which might be important for diagnosis, prognosis, and therapy. However, currently available 3D speckle-tracking echocardiographic methods are based on different algorithms, which introduce substantial differences between them and make them not interchangeable with each other. Therefore, it is critical that each 3D speckle-tracking echocardiographic method is validated individually before being introduced into clinical practice. In this review, the authors discuss differences and similarities of the currently available 3D strain estimation approaches and provide an overview of the current status of their validation.

Noninvasive assessment of pulmonary vascular resistance by Doppler echocardiography.

Abstract: Background The ratio of tricuspid regurgitation velocity (TRV) to the time-velocity integral of the right ventricular outflow tract (TVI RVOT ) has been studied as a reliable measure to distinguish elevated from normal pulmonary vascular resistance (PVR). The equation TRV/TVI RVOT × 10 + 0.16 (PVR echo ) has been shown to provide a good noninvasive estimate of PVR. However, its role in patients with significantly elevated PVR (> 6 Wood units [WU]) has not been conclusively evaluated. The aim of this study was to establish the validity of the TRV/TVI RVOT ratio as a correlate of PVR. The role of TRV/TVI RVOT was also compared with that of a new ratio, TRV 2 /TVI RVOT , in patients with markedly elevated PVR (>6 WU). Methods Data from five validation studies using TRV/TVI RVOT as an estimate of PVR were compared with invasive PVR measurements (PVR cath ). Multiple linear regression analyses were generated between PVR cath and both TRV/TVI RVOT and TRV 2 /TVI RVOT . Both PVR echo and a new derived regression equation based on TRV 2 /TVI RVOT : 5.19 × TRV 2 /TVI RVOT - 0.4 (PVR echo2 ) were compared with PVR cath using Bland-Altman analysis. Logistic models were generated, and cutoff values for both TRV/TVI RVOT and TRV 2 /TVI RVOT were obtained to predict PVR > 6 WU. Results One hundred fifty patients remained in the final analysis. Linear regression analysis between PVR cath and TRV/TVI RVOT revealed a good correlation ( r = 0.76, P Z = 0.92). There was a better correlation between PVR cath and TRV 2 /TVI RVOT ( r = 0.79, P Z = −0.01) in the entire cohort as well as in patients with PVR > 6 WU. Moreover, PVR echo2 compared better with PVR cath than PVR echo using Bland-Altman analysis in the entire cohort and in patients with PVR > 6 WU. TRV 2 /TVI RVOT and TRV/TVI RVOT both predicted PVR > 6 WU with good sensitivity and specificity. Conclusions TRV/TVI RVOT is a reliable method to identify patients with elevated PVR. In patients with TRV/TVI RVOT > 0.275, PVR is likely > 6 WU, and PVR echo2 derived from TRV 2 /TVI RVOT provides an improved noninvasive estimate of PVR compared with PVR echo .

Assessment of left atrial deformation and synchrony by three-dimensional speckle-tracking echocardiography: comparative studies in healthy subjects and patients with atrial fibrillation.

Abstract: Background The aim of this study was to examine whether left atrial (LA) strain and synchrony can be assessed using three-dimensional (3D) speckle-tracking echocardiography (STE) and how 3D STE parameters are modified by atrial fibrillation (AF). Methods LA peak ventricular systolic longitudinal strain (LSs), circumferential strain (CSs), and area strain (ASs) and LA peak pre–atrial contraction longitudinal strain, circumferential strain (CSa), and area strain were determined using 3D STE, and SDs of times to peaks of regional LA strain were calculated as indices of LA dyssynchrony. Three-dimensional speckle-tracking was able to measure LA strain in 75 of the 77 healthy subjects and in all 47 patients with AF (31 with paroxysmal AF [PAF] and 16 with permanent AF). Results The mean time for analysis with 3D STE was 18% shorter than with two-dimensional (2D) STE ( P P = .044), LSs ( P = .040), ASs ( P = .007), and CSa ( P = .020) were independent predictors of PAF. Conclusions Three-dimensional speckle-tracking enables the measurement of both LA strain and synchrony with excellent reproducibility. Three-dimensional LA strain appears to be beneficial compared with 2D LA strain for identifying patients with PAF.

Comprehensive Analysis of Left Ventricular Geometry and Function by Three-Dimensional Echocardiography in Healthy Adults

Abstract: Background Recent European Association of Echocardiography and American Society of Echocardiography guidelines on three-dimensional echocardiography state that normal values of left ventricular (LV) parameters for age and body size remain to be established. Methods In 226 consecutive healthy subjects (125 women; age range, 18–76 years), comprehensive three-dimensional echocardiographic analyses of LV parameters were performed, and values were compared with those obtained by conventional echocardiography. Results Upper reference values (mean + 2 SDs) for three-dimensional LV end-diastolic and end-systolic volumes were 85 and 34 mL/m 2 in men and 72 and 28 mL/m 2 in women, respectively. Indexing LV volumes to body surface area did not eliminate gender differences. Lower reference values (mean − 2 SDs) for ejection fraction were 54% in men and 57% in women and for stroke volume were 25 and 24 mL/m 2 , respectively. Upper reference values for LV mass were 97 g/m 2 in men and 90 g/m 2 in women and for end-diastolic sphericity index were 0.49 and 0.48, respectively. Significant age dependency of LV parameters was identified and reported across age groups. Three-dimensional echocardiographic LV volumes were larger, ejection fraction was similar, and LV stroke volume and mass were significantly smaller in comparison with the corresponding values obtained by conventional echocardiography. Conclusions The investigators report a comprehensive analysis of LV geometry and function using three-dimensional echocardiography in a relatively large cohort of healthy Caucasian subjects with a wide age range. These may serve to establish age-specific and gender-specific reference ranges, which are crucial for the routine implementation of three-dimensional echocardiography to detect LV remodeling and dysfunction in clinical practice.

Reproducibility of speckle-tracking-based strain measures of left ventricular function in a community-based study.

Abstract: Background The reproducibility of echocardiographic measurements of myocardial strain, performed in a community-based setting, has not been reported previously. Methods The reproducibility of left ventricular strain measurements was examined in two samples of 20 participants each from the Offspring Cohort of the Framingham Heart Study (mean age, 63 ± 9 years; 59% women). Two-dimensional speckle-tracking-based measurements of global peak left ventricular strain in systole were performed in the apical four-chamber, apical two-chamber, and midventricular parasternal short-axis views. Results Interobserver intraclass correlation coefficients were ≥0.84 for all global strain measurements, with average coefficients of variation of ≤4% for global longitudinal and circumferential strain and Conclusions Excellent reproducibility of global longitudinal and circumferential strain measurements and very good reproducibility of global transverse and radial strain measurements were observed. Taken together, these findings demonstrate the reproducibility of performing echocardiographic strain measurements in a large, epidemiologic community-based setting.

The Why and How of Z Scores

Abstract: 38 The use of echocardiographic measurements to detect disease and predict outcomes can be confounded by a number of nondisease factors, including the effect of body size, that contribute to the variance of these measurements. The process of normal growth is associated with a nearly 200-fold increase in normal left ventricular enddiastolic volume (EDV) from premature infants up to large adolescents, making it imperative to account for changes in body size in pediatrics. Although this issue is often ignored in adult echocardiography, the sensitivity and specificity of parameters of left ventricular size are significantly improved when adjustment for body size in adults is performed. The article by Mawad et al. in this issue of JASE addresses an important aspect of this process, although it is likely a topic that is unfamiliar to most echocardiographers, even those in pediatric cardiology who rely heavily on Z scores. The concept of Z scores itself is often unfamiliar to adult echocardiographers. What is a Z score? Normative anatomic data are often presented as nomograms, a graphic representation of the mean values and one or more percentile curves, perhapsmost familiar to clinicians as the common height and weight curves used to track growth in children. Instead of percentiles, the distance from the mean value can be expressed as the standard deviation (SD), which has similar information content but is more easily interpreted for values outside the normal range. The number of SDs from the mean is termed the Z score, also known as the normal deviate or a standard score. Ameasurement that is 2 SDs above themean (the 97.7th percentile) has a Z score of 2, whereas a measurement that is 2 SDs below the mean (the 2.3rd percentile) has aZ score of 2. The use of Z scores dramatically simplifies clinical interpretation, because the clinician need not remember the age-specific or body surface area (BSA)–specific normal range for a variety of echocardiographic measurements. Instead, all variables have a mean of 0 and a normal range of 2 to +2, regardless of age or BSA. In addition, interpretation of change over time is simplified, because cardiovascular structures remain at the same Z score over time in normal subjects, despite changes in body size. Longitudinal change in the size of a cardiovascular structure that is more or less than expected for growth is easily recognized as change in Z score over time. Statistical analysis of research results is similarly facilitated and indeed enhanced by using Z scores. The analytic power added through the use of Z scores is often underappreciated and can be illustrated through an example. A common study design is to attempt to control for the effects of age and body size by selecting controls matched for age and body size and then performing a paired comparison of change over time in subjects versus controls. However, the sensitivity of this type of study design to detect therapeutic effects is diminished when there is significant variation in body size in the sample. Consider, for example, a hypothetical clinical trial of a therapy for dilated

Detection of right-to-left atrial communication using agitated saline contrast imaging: experience with 1162 patients and recommendations for echocardiography.

Abstract: Background Right-to-left shunting via a patent foramen ovale (PFO) has a recognized association with embolic events in younger patients. The use of agitated saline contrast injection (ASCi) for detecting atrial shunting is well documented, but the optimal technique is not well described. The purpose of this study was to assess the efficacy and safety of transthoracic echocardiographic (TTE) ASCi for the assessment of right-to-left atrial communication in a large cohort of patients. Methods A retrospective review was undertaken of 1,162 consecutive patients who underwent TTE ASCi, of whom 195 had also undergone clinically indicated transesophageal echocardiography. ASCi shunt results were compared with color flow imaging, and the role of provocative maneuvers (PM) was assessed. Results Four hundred three TTE studies (35%) had paradoxical shunting seen during ASCi. Of these, 48% were positive with PM only. There was strong agreement between TTE ASCi and reported transesophageal echocardiographic findings (99% sensitivity, 85% specificity), with six false-positive and two false-negative results. In hindsight, the latter were likely due to suboptimal right atrial opacification and the former to transpulmonary shunting. TTE color flow imaging was found to be insensitive (22%) for the detection of a PFO compared with TTE ASCi. Conclusions TTE color flow imaging is too insensitive for PFO screening. TTE ASCi, however, is simple and highly accurate for the detection of right-to-left atrial communication, on the proviso that a dedicated protocol, including correctly implemented PM, is followed. It is recommended that TTE ASCi with PM be considered the primary diagnostic tool for the detection of PFO in clinical practice.

American Society of Echocardiography: Remote Echocardiography with Web-Based Assessments for Referrals at a Distance (ASE-REWARD) Study.

Abstract: Background Developing countries face the dual burden of high rates of cardiovascular disease and barriers in accessing diagnostic and referral programs. The aim of this study was to test the feasibility of performing focused echocardiographic studies with long-distance Web-based assessments of recorded images for facilitating care of patients with cardiovascular disease. Methods Subjects were recruited using newspaper advertisements and were prescreened by paramedical workers during a community event in rural north India. Focused echocardiographic studies were performed by nine sonographers using pocket-sized or handheld devices; the scans were uploaded on a Web-based viewing system for remote worldwide interpretation by 75 physicians. Results A total of 1,023 studies were interpreted at a median time of 11:44 hours. Of the 1,021 interpretable scans, 207 (20.3%) had minor and 170 (16.7%) had major abnormalities. Left ventricular systolic dysfunction was the most frequent major abnormality (45.9%), followed by valvular (32.9%) and congenital (13.5%) defects. There was excellent agreement in assessing valvular lesions (κ = 0.85), whereas the on-site readings were frequently modified by expert reviewers for left ventricular function and hypertrophy (κ = 0.40 and 0.29, respectively). Six-month telephone follow-up in 71 subjects (41%) with major abnormalities revealed that 57 (80.3%) had improvement in symptoms, 11 (15.5%) experienced worsening symptoms, and three died. Conclusions This study demonstrates the feasibility of performing sonographer-driven focused echocardiographic studies for identifying the burden of structural heart disease in a community. Remote assessment of echocardiograms using a cloud-computing environment may be helpful in expediting care in remote areas.

Feasibility and Reproducibility of Systolic Right Ventricular Strain Measurement by Speckle Tracking Echocardiography in premature infants

Abstract: Background Right ventricular (RV) systolic function is an important prognostic determinant of cardiopulmonary pathologies in premature infants. Measurements of dominant RV longitudinal deformation are likely to provide a sensitive measure of RV function. An approach for image acquisition and postacquisition processing is needed for reliable and reproducible measurements of myocardial deformation by two-dimensional (2D) speckle-tracking echocardiography. The aims of this study were to determine the feasibility and reproducibility of 2D speckle-tracking echocardiographic measurement of RV peak global longitudinal strain (pGLS) and peak global longitudinal strain rate in premature infants and to establish methods for acquiring and analyzing strain. Methods The study was designed in two phases: (1) a training phase to develop methods of image acquisition and postprocessing in a cohort of 30 premature infants (born at 28 ± 1 weeks) and (2) a study phase to prospectively test in a separate cohort of 50 premature infants (born at 27 ± 1 weeks) if the methods improved the feasibility and reproducibility of RV pGLS and peak global longitudinal strain rate measurements to a clinically significant level, assessed using Bland-Altman analysis (bias, limits of agreement, coefficient of variation, and intraclass correlation coefficient). Results Strain imaging was feasible from 84% of the acquisitions using the methods developed for optimal speckle brightness and frame rate for RV-focused image acquisition. There was high intraobserver (bias, 3%; 95% limits of agreement, −1.6 to +1.6; coefficient of variation, 2.7%; intraclass correlation coefficient, 0.97; P = .02) and interobserver (bias, 7%; 95% limits of agreement, −4.8 to +4.73; coefficient of variation, 3.9%; intraclass correlation coefficient, 0.93; P r = 0.97 [ P r = 0.93 [ P Conclusions This study demonstrates high clinical feasibility and reproducibility of RV pGLS and RV peak global longitudinal strain rate measurements by 2D speckle-tracking echocardiography in premature infants and offers methods for image acquisition and data analysis for systolic strain imaging that can provide a reliable assessment of global RV function.

Real-time three-dimensional transesophageal echocardiography adds value to transcatheter aortic valve implantation.

Abstract: Background Successful transcatheter aortic valve implantation (TAVI) mandates comprehensive, accurate multimodality imaging. Echocardiography is involved at all key stages and, with the advent of real-time three-dimensional (3D) transesophageal echocardiography, is uniquely placed to enable periprocedural monitoring. The investigators describe a comprehensive two-dimensional (2D) and 3D echocardiographic protocol, and the additional benefits of 3D TEE, within a high-volume TAVI program. Methods TAVI was performed with 2D and 3D transesophageal echocardiographic and fluoroscopic guidance in consecutive high-risk patients with symptomatic severe aortic stenosis. The role of TEE, including the additive value of 3D TEE, was examined, and procedural and echocardiographic outcomes were evaluated. A 3D sizing transcatheter heart valve (THV) strategy was used, except as mandated by study protocol. Results Procedural success was achieved in 99% of 256 patients (mean age, 82.9 ± 7.1 years, mean logistic European System for Cardiac Operative Risk Evaluation score, 21.6 ± 11.2%; mean aortic valve area, 0.63 ± 0.19 cm 2 ), with no procedural deaths. Acceptable 2D and 3D transesophageal echocardiographic images were achieved in all patients. Aortic valve annular dimensions by 2D transthoracic echocardiography, 2D TEE, and 3D TEE were 21.6 ± 1.9 mm, 22.5 ± 2.2 mm ( P P = .004 vs 2D TEE), respectively. The 2D THV sizing strategy would have changed THV selection in 23% of patients, downsizing in most. Three-dimensional TEE provided superior spatial visualization and anatomic orientation and optimized procedural performance. Postprocedural mild, moderate, and severe paravalvular aortic regurgitation was observed in 24%, 3%, and 0% of patients, respectively, with no or trace transvalvular aortic regurgitation in 95%. A second valve was successfully deployed in five patients, and TEE detected five other periprocedural complications. Conclusions A systematic, comprehensive echocardiographic protocol, incorporating the additional benefits of 3D TEE, has a vital role within a TAVI program and, combined with a 3D THV sizing strategy, contributes to excellent outcomes.

Prognostic value of right ventricular two-dimensional global strain in patients referred for cardiac surgery.

Abstract: Background Right ventricular (RV) function is a strong predictor of patient outcome after cardiac surgery. Limited studies have compared the predictive value of RV global longitudinal strain (RV-GLS) with tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change (RVFAC) in this setting. Methods The study included 250 patients (66 ± 13 years old, LVEF = 52% ± 12%) referred for cardiac surgery (EuroSCORE-II = 4.8% ± 8.0%). RV function before surgery was assessed by RV-GLS by using speckle-tracking analysis (3-segment from the RV free wall), RVFAC and TAPSE was compared with postoperative outcome defined by 1-month mortality. Results Overall, 19 patients (7.6%) had RVFAC −21% (35% with normal RVFAC ≥ 35%). Postoperative death ( n = 25) was higher in patients with abnormal RV-GLS > −21% (22% vs 3%; P P = .007), and RVFAC P = .001). Mortality was 3% in patients with preserved RV-GLS. In patients with preserved RVFAC ≥ 35% but abnormal RV-GLS, mortality was similar to that of those with RVFAC P = .12). Among RV systolic indexes, only RV-GLS was associated with patient outcome by multivariate analysis adjusted to EuroSCORE-II and cardiopulmonary bypass duration. Conclusions RV-GLS is a sensitive marker of RV dysfunction and correlates with postoperative mortality.

Implementation of Echocardiography Core Laboratory Best Practices: A Case Study of the PARTNER I Trial

Abstract: Background Multicenter clinical trials use echocardiographic core laboratories to ensure expertise and consistency in the assessment of imaging eligibility criteria, as well as safety and efficacy end points. The aim of this study was to report the real-world implementation of guidelines for best practices in echocardiographic core laboratories, including their feasibility and quality results, in a large, international multicenter trial. Methods Processes and procedures were developed to optimize the acquisition and analysis of echocardiograms for the Placement of Aortic Transcatheter Valves (PARTNER) I trial of percutaneous aortic valve replacement for aortic stenosis. Comparison of baseline findings in the operative and nonoperative cohorts and reproducibility analyses were performed. Results Echocardiography was performed in 1,055 patients (mean age, 83 years; 54% men) The average peak and mean aortic valve gradients were 73 ± 24 and 43 ± 15 mm Hg, and the average aortic valve area was 0.64 ± 0.20 cm 2 . The average ejection fraction was 52 ± 13% by visual estimation and 53 ± 14% by biplane planimetry. The mean left ventricular mass index was 151 ± 42 g/m 2 . The inoperable cohort had lower left ventricular mass and mass indexes and tended to have more severe mitral regurgitation. Core lab reproducibility was excellent, with intraclass correlation coefficients ranging from 0.92 to 0.99 and κ statistics from 0.58 to 0.85 for key variables. The image acquisition quality improvement process brought measurability to >85%, which was maintained for the duration of the study. Conclusions This real-world echocardiographic core lab experience in the PARTNER I trial demonstrates that a high standard of measurability and reproducibility can result from extensive quality assurance efforts in both image acquisition and analysis. These results and the echocardiographic data reported here provide a reference for future studies of aortic stenosis patients and should encourage the wider use of echocardiography in clinical research.

Left atrial function by two-dimensional speckle-tracking echocardiography in patients with severe organic mitral regurgitation: Association with guidelines-based surgical indication and postoperative (long-term) survival

Abstract: Background Left atrial (LA) mechanics in patients with severe mitral regurgitation (MR) remain largely unexplored. The aim of the present evaluation was to assess the effect of severe MR on LA function, its potential relation with conventional surgical indications, and long-term postoperative survival. Methods Two-dimensional speckle-tracking strain and volumetric indices of LA reservoir, conduit, and contractile function were assessed in 121 patients with severe MR and 70 controls. Patients were divided according to the presence ( n = 46) or absence ( n = 75) of one or more guidelines-based criteria for mitral surgery (symptoms, left ventricular ejection fraction ≤ 60%, left ventricular end-systolic diameter ≥ 40 mm, atrial fibrillation, or systolic pulmonary arterial pressure >50 mm Hg). Results In patients with severe MR compared with controls, significant LA reservoir and contractile dysfunction was observed, which was more pronounced in patients with mitral surgery indication ( P P P = .02), regardless the symptomatic status before surgery. LA reservoir strain, on top of mitral surgery indications, provided incremental predictive value for postoperative survival. Conclusions Impaired LA reservoir strain in patients with severe organic MR relates to long-term survival after mitral valve surgery, independently of and incremental to current guidelines-based indications for mitral surgery.

A Review and Critique of the Statistical Methods Used to Generate Reference Values in Pediatric Echocardiography

Abstract: Several articles have proposed echocardiographic reference values in normal pediatric subjects, but adequate validation is often lacking and has not been reviewed. The aim of this study was to review published reference values in pediatric two-dimensional and M-mode echocardiography with a specific focus on the adequacy of the statistical and mathematical methods used to normalize echocardiographic measurements. All articles proposing reference values for transthoracic pediatric echocardiography were reviewed. The types of measurements, the methods of normalization, the regression models used, and the methods used to detect potential bias in proposed reference values were abstracted. The detection of residual associations, residual heteroscedasticity, and departures from the normal distribution theory predictions were specifically analyzed. Fifty-two studies met the inclusion criteria. Most authors (87%) used parametric normalization to account for body size, but their approaches were very heterogeneous. Linear regression and indexing were the most common models. Heteroscedasticity was often present but was mentioned in only 27% of studies. The absence of residual heteroscedasticity and residual associations between the normalized measurements and the independent variables were mentioned in only 9% and 22% of the studies, respectively. Only 14% of studies documented that the distribution of the residual values was appropriate for Z score calculation or that the proportion of subjects falling outside the reference range was appropriate. Statistical suitability of the proposed reference ranges was often incompletely documented. This review underlines the great need for better standardization in echocardiographic measurement normalization.

Validation Study of the Accuracy of Echocardiographic Measurements of Systemic Blood Flow Volume in Newborn Infants

Abstract: Background The echocardiographic assessment of circulatory function in sick newborn infants has the potential to improve patient care. However, measurements are prone to error and have not been sufficiently validated. Phase-contrast magnetic resonance imaging (MRI) provides highly validated measures of blood flow and has recently been applied to the newborn population. The aim of this study was to validate measures of left ventricular output and superior vena caval flow volume in newborn infants. Methods Echocardiographic and MRI assessments were performed within 1 working day of each other in a cohort of newborn infants. Results Examinations were performed in 49 infants with a median corrected gestational age at scan of 34.43 weeks (range, 27.43–40 weeks) and a median weight at scan of 1,880 g (range, 660–3,760 g). Echocardiographic assessment of left ventricular output showed a strong correlation with MRI assessment ( R 2 = 0.83; mean bias, −9.6 mL/kg/min; limits of agreement, −79.6 to +60.0 mL/kg/min; repeatability index, 28.2%). Echocardiographic assessment of superior vena caval flow showed a poor correlation with MRI assessment ( R 2 = 0.22; mean bias, −13.7 mL/kg/min; limits of agreement, −89.1 to +61.7 mL/kg/min; repeatability index, 68.0%). Calculating superior vena caval flow volume from an axial area measurement and applying a 50% reduction to stroke distance to compensate for overestimation gave a slightly improved correlation with MRI ( R 2 = 0.29; mean bias, 2.6 mL/kg/min; limits of agreement, −53.4 to +58.6 mL/kg/min; repeatability index, 54.5%). Conclusions Echocardiographic assessment of left ventricular output appears relatively robust in newborn infant. Echocardiographic assessment of superior vena caval flow is of limited accuracy in this population, casting doubt on the utility of the measurement for diagnostic decision making.

Right atrial and ventricular adaptations to training in male Caucasian athletes: an echocardiographic study.

Abstract: Background The aim of this study was to investigate the systolic and diastolic properties of the right cardiac chambers (the right ventricle and right atrium) among different subsets of athletes to unveil potential variations in right ventricular and right atrial remodeling secondary to different training modes. Methods A cohort of Caucasian male top-level athletes ( n = 108; 80 endurance athletes [EAs], mean age, 31.2 ± 10.4 years; 28 strength-trained athletes [SAs], mean age, 27.4 ± 5.7 years) and untrained controls ( n = 26; mean age, 26.6 ± 5.6 years) ( P = .327) were prospectively enrolled. Conventional echocardiographic parameters, including transtricuspid inflow, Doppler tissue imaging, and two-dimensionally derived peak systolic longitudinal strain and strain rate indices of the right ventricle and right atrium, were calculated. Results EAs had greater internal right ventricular and right atrial dimensions compared with SAs and controls. There were no significant differences concerning strain between groups (−23.1 ± 3.7% in EAs vs −25.1 ± 3.2% in SAs vs −23.1 ± 3.5% in controls, P = .052), with SAs presenting higher global systolic strain rates (−1.42 ± 0.22 sec −1 in SAs vs −1.21 ± 0.21 sec −1 in EAs vs −1.2 ± 0.28 sec −1 in controls, P = .016), as well as greater right atrial strain rate systolic and diastolic components. Training volume (highly vs moderately trained athletes) did not significantly influence deformation parameters. No significant differences concerning diastolic transtricuspid inflow and Doppler tissue imaging indices were also noted among different athlete groups and controls. Conclusions Despite the existence of right geometric alterations in athletes participating in different sport disciplines, few meaningful differences in deformation and diastolic function exist.

Nomograms for blood flow and tissue Doppler velocities to evaluate diastolic function in children: a critical review.

Abstract: Interest in diastolic function in children has increased recently. However, the strengths and limitations of published pediatric nomograms for echocardiographic diastolic parameters have not been critically evaluated, especially in the neonatal population. A literature search was performed within the National Library of Medicine using the keywords normal/reference values, power Doppler/tissue Doppler velocities, and children/neonates. The search was further refined by adding the keywords diastolic function, myocardial, mitral/tricuspid inflow, pulmonary vein, and Tei index. Thirty-three published studies evaluating diastolic function in normal children were included in this review. In many studies, sample sizes were limited, particularly in terms of neonates. There was heterogeneity in the methodologies to perform and normalize measurements and to express normalized data (Z scores, percentiles, and mean values). Although most studies adjusted measurements for age, classification by specific age subgroups varied, and few addressed the relationships of measurements to body size and heart rate (especially with higher neonatal heart rates). Although reference values were reproducible in older children, they varied significantly in neonates and infants. Pediatric diastolic nomograms are limited by small sample sizes and inconsistent methodologies for the performance and normalization of measurements, with few data on neonates. Some studies do reveal reproducible patterns in diastolic function in older children. A comprehensive pediatric nomogram of diastolic function involving a large population of normal infants and older children and using standardized methodology is warranted and would have tremendous impact in the care of children with acquired and congenital heart disease.

Frequent Periodic Leg Movement During Sleep Is Associated With Left Ventricular Hypertrophy and Adverse Cardiovascular Outcomes

Abstract: Background Sleep disturbance caused by obstructive sleep apnea is recognized as a contributing factor to adverse cardiovascular outcomes. However, the effect of restless legs syndrome, another common cause of fragmented sleep, on cardiac structure, function, and long-term outcomes is not known. The aim of this study was to assess the effect of frequent leg movement during sleep on cardiac structure and outcomes in patients with restless legs syndrome. Methods In our retrospective study, patients with restless legs syndrome referred for polysomnography were divided into those with frequent (periodic movement index > 35/hour) and infrequent (≤35/hour) leg movement during sleep. Long-term outcomes were determined using Kaplan-Meier and logistic regression models. Results Of 584 patients, 47% had a periodic movement index > 35/hour. Despite similarly preserved left ventricular ejection fraction, the group with periodic movement index > 35/hour had significantly higher left ventricular mass and mass index, reflective of left ventricular hypertrophy (LVH). There were no significant baseline differences in the proportion of patients with hypertension, diabetes, hyperlipidemia, prior myocardial infarction, stroke or heart failure, or the use of antihypertensive medications between the groups. Patients with frequent periodic movement index were older, predominantly male, and had more prevalent coronary artery disease and atrial fibrillation. However, on multivariate analysis, periodic movement index > 35/hour remained the strongest predictor of LVH (odds ratio, 2.45; 95% confidence interval, 1.67–3.59; P 35/hour had significantly higher rates of heart failure and mortality over median 33-month follow-up. Conclusions Frequent periodic leg movement during sleep is an independent predictor of severe LVH and is associated with increased cardiovascular morbidity and mortality.

Calcification of the Mitral Valve and Annulus: Systematic Evaluation of Effects on Valve Anatomy and Function

Abstract: Background Mitral annular calcification (MAC) is common in chronic kidney disease. It is associated with cardiovascular events and can cause valvular dysfunction, but it has not been systematically characterized. The aim of this prospective study was to assess the prevalence and distribution of MAC, its effects on leaflet motion, and its association with mitral stenosis and mitral regurgitation (MR) in a hemodialysis population. Methods Echocardiograms were obtained in 75 consecutive hemodialysis outpatients. MAC extent and distribution were graded semiquantitatively using two-dimensional and three-dimensional echocardiography. Associations with the presence and severity of mitral stenosis and MR were explored. Results The mean age was 60 ± 14 years; 60% were men, and 87% were African American. MAC was present in 64% (moderate to severe in 48%). Calcium extended more than halfway onto the leaflet in 37% and beyond the annulus in 40%. Leaflet motion was restricted in 37%. Mitral stenosis was present in 28%, and the extent of calcification was associated with mean mitral valve gradient ( P P = .04). Three-dimensional analysis suggested an uneven distribution of annular calcium; the middle and lateral anterior segments were less often calcified than the anterior-medial or posterior segments. Calcification in any annular segment was highly associated with restricted motion of the attached leaflet segment. Conclusions MAC is common and often extensive in hemodialysis patients. Calcium may be unevenly distributed among the annular segments. When present, annular calcification reduces the angle of leaflet opening and can cause valvular dysfunction.

Systolic and Diastolic Function Assessment in Fabry Disease Patients Using Speckle-Tracking Imaging and Comparison with Conventional Echocardiographic Measurements

Abstract: Background Fabry cardiomyopathy is characterized by progressive left ventricular hypertrophy (LVH) associated with diastolic dysfunction and is the most common cause of death in Fabry disease (FD). However, LVH is not present in all subjects, particularly early in disease progression and in female patients. Direct assessment of myocardial deformation by strain and strain rate (SR) analysis may be sensitive to detect subclinical Fabry cardiomyopathy independent of the presence of LVH. Methods Systolic (longitudinal, circumferential, and radial systolic strain and SR) and diastolic (SR during isovolumic relaxation [SR IVR ] and early diastole and strain at peak transmitral E wave) function was assessed in 16 patients with FD using two-dimensional speckle-tracking echocardiography. In addition, mean S′ and E′ mitral annular velocities by Doppler tissue imaging were measured. Diastolic filling indices, including E/SR IVR and E/E′ ratios, were calculated. The patients were compared with 24 healthy age-matched and gender-matched controls. Results All 16 patients with FD had normal left ventricular ejection fractions, and nine patients had LVH. Compared with controls, patients with FD had reduced longitudinal systolic strain ( P P = .007), while there were no differences in circumferential systolic strain and S′. Diastolic function assessment showed reduced longitudinal early diastolic SR ( P = .001), SR IVR ( P IVR ( P P = .006), E′ ( P = .021), and E/E′ ratio ( P IVR ( P IVR ( P = .025) remained significantly different between patients with FD and controls, with sensitivity of 94% and specificity of 92% for SR IVR of 0.235 sec −1 (area under the receiver operating characteristic curve, 0.953). Conclusions Strain and SR analysis is useful in identifying patients with FD with reduced myocardial function, with longitudinal systolic strain and diastolic isovolumic SR being superior to the other echocardiographic measurements of myocardial contraction and relaxation and independent of LVH.

Proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography applied for tricuspid regurgitation quantification.

Abstract: Background The two-dimensional (2D) proximal isovelocity surface area (PISA) method has known technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions and has already been validated for mitral regurgitation assessment. The aim of this study was to apply this novel method in patients with chronic tricuspid regurgitation (TR). Methods Ninety patients with chronic TR were enrolled. EROA and regurgitant volume (Rvol) were assessed using transthoracic 2D and 3D PISA methods. Quantitative Doppler and 3D transthoracic planimetry of EROA were used as reference methods. Results Both EROA and Rvol assessed using the 3D PISA method had better correlations with the reference methods than using conventional 2D PISA, particularly in the assessment of eccentric jets. On the basis of 3D planimetry–derived EROA, 35 patients had severe TR (EROA ≥ 0.4 cm 2 ). Among these 35 patients, 25.7% ( n = 9) were underestimated as having nonsevere TR (EROA ≤ 0.4 cm 2 ) using the 2D PISA method. In contrast, the 3D PISA method had 94.3% agreement (33 of 35) with 3D planimetry in classifying severe TR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.92 and 0.88 respectively. Conclusions TR quantification using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Estimation of Pulmonary Pressures and Diagnosis of Pulmonary Hypertension by Doppler Echocardiography: A Retrospective Comparison of Routine Echocardiography and Invasive Hemodynamics

Abstract: Background To date, Doppler echocardiography is the most widespread and well-recognized technique for the noninvasive evaluation of systolic pulmonary artery pressure (sPAP). However, recent studies have reported reservations about the relevance of Doppler echocardiography or the tool's reliability in the diagnosis and follow-up of patients with pulmonary hypertension (PH). Thus, the aim of this dedicated retrospective study was to address the questions of Doppler echocardiography's relevance and accuracy for PH diagnosis in the routine activity of a conventional echocardiography department. Methods Institutional databases were used to extract and analyze the records of 310 patients who underwent both hemodynamic and echocardiographic investigations within a single hospitalization period. Results Despite an underestimation of absolute Doppler sPAP values compared with measurements on right heart catheterization, data analysis revealed a strong correlation ( r = 0.80, P n = 310). Targeting a mean pulmonary pressure on right heart catheterization of 25 mm Hg for the definition of PH, receiver operating characteristic curve analysis demonstrated a strong association between sPAP and PH diagnosis (area under the curve, 0.82; n = 155). The cutoff obtained for sPAP was 38 mm Hg, and when applied on a second-test subgroup population ( n = 155), sensitivity, specificity, and accuracy were 88%, 83%, and 86%, respectively. When patients with examination intervals of n = 115), sensitivity and specificity reached 89% and 89%, respectively. No combination of parameters produced an improvement on the initial results. Conclusions In the real-world practice of a conventional echocardiography department, Doppler echocardiography is associated with high accuracy, sensitivity, and specificity for PH evaluation, thus confirming its major position as a primary noninvasive tool.